ตัวชี้วัดและการใช้ข้อมูลเชิงจุลภาคและมหภาค ในการประเมินผลลัพธ์ด้านสุขภาพ Health Outcome ศุภสิทธิ์ พรรณารุโณทัย คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร การประชุมระดมสมอง การจัดทำกรอบแนวคิดการประเมินผลลัพธ์ด้านสุขภาพ จากการนำนโยบายและยุทธศาสตร์ของกระทรวงสาธารณสุขไปสู่การปฏิบัติ ๒๕ กันยายน ๒๕๕๑ โรงแรมริชมอนด์ นนทบุรี

Scope Health data at micro and macro level Users of health data Health outcome Conclusion

Health insurance system People/patients B Providers DIRECT PAYMENTS HEALTH SERVICES CLAIMS REGULATION INSURANCE COVERAGE MONEY (TAXES OR PREMIUMS) MONEY PAYMENT (FEES, GLOBAL BUDGET) Professional bodies D CASEMIX C Purchasers REGULATION 17 7

The England NHS 2005

Health data at micro level Service flow: ambulatory visit, admission, laboratory investigation Finance flow: ABC for resource use, payment to provider, budget management Accountability flow: compliance to standard operating procedure, client satisfaction

Health data at macro level Service flow: annual utilization of services Finance flow: national health account, budget allocation Accountability flow: quality, efficiency, equity, social accountabilty of health systems

Users of health data Steps to capacity development in using data policy review policy implementation data + training + analysis + networking + policy making data + training + analysis + networking core data + training + analysis core data + training Steps to capacity development in using data WHO (2003) Human resources and national health systems: shaping the agenda for action

Defining a research question PICO for EBM Patient Intervention Comparison Outcome PICO for EBPH Population Intervention Comparison Outcome www.sph.uth.tmc.edu/charting/handouts/ebph_handouts/pico.pdf

Defining a research question A group of children come down with measles. The parents of these kids are concerned about the potential health risks of vaccinations and have decided not to vaccinate any of their kids. You need to develop an intervention that increases the likelihood that this group will vaccinate their kids P: children with measles I: program to increase vaccinations C: group not exposed O1: an increased rate of vaccinations? O2: a decreased rate of measles among the children of parents exposed to the intervention? www.sph.uth.tmc.edu/charting/handouts/ebph_handouts/pico.pdf

Defining a research question There is a section of town which has a high prevalence rate of obesity and diabetes. There are many churches in that area so you decide to work with the churches to develop a series of interventions to reduce both obesity and diabetes. One of the programs will target foods served at church-sponsored events which are mostly pot-luck P: members of a group of churches in a town I: program designed to improve types of foods served at church-sponsored events C: foods served before the intervention O: more nutritious foods served after the intervention? www.sph.uth.tmc.edu/charting/handouts/ebph_handouts/pico.pdf

Health outcomes Physical health Dissatisfaction Mental health Social health Spiritual health Dissatisfaction Discomfort Disease Disability Death

Health outcomes Direct vs. indirect Preclinical Clinical Surrogate: fasting blood sugar Final: diabetic retinopathy Preclinical Physiological Laboratory Clinical Subclinical Complication

Health outcomes Positive vs. negative outcome Subjective vs. objective Positive: survival Negative: adverse outcome, death Subjective vs. objective Quality of life Life cycle Birth and neonatal outcome Children and adolescent Adult and elderly

Health outcomes Short vs. long term Short term: Long term:

Psychoeducational programmes for coronary artery disease Outcomes Studies r (95% CI) MI recurrence at 1 to 10 y 16 0.03 (0.01 to 0.06) Systolic BP decrease at {0.1 to 2 y} 8 0.12 (0.06 to 0.18) Serum cholesterol level decrease at {0.1 to 2 y} 7 0.25 {0.20 to 0.30} Weight decrease at {0.1 to 2 y} 8 0.09 (0.03 to 0.15) Decrease in smoking at {0.1 to 2 y} 21 0.07 (0.03 to 0.10) *BP = blood pressure; MI = myocardial infarction. Gluckman R (2000) Evid. Based Med. 2000;5;83

Quality and Outcome Framework CHD 1 The practice can produce a register of patients with coronary heart disease. CHD 2 The percentage of patients with newly diagnosed angina who are referred for exercise testing and/or specialist assessment. CHD 3 The percentage of patients with coronary heart disease whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once.

Conclusion Define precise research question. Select relevant and practical outcome for answering the question.