改進(jìn)美國(guó)老年人的健康和醫(yī)療衛(wèi)生英文文獻(xiàn)及翻譯

1、 improving the health and health care of older americansarlene bireman, william spectorintroduction as we enter the new millennium, the nation is confronted with the enormous challenge of preparing to meet the demands of an aging society. in the face of current demographic trends, increasing health

2、care costs, and concerns about the quality of health care, the financing and delivery of care for older people is a critical health care policy challenge figure 1 the conceptual framework of a patient-centered health policy early in the related discussions, we decided to focus our efforts on cost-ef

3、fective interventions that enhance functioning and health-related quality of life hrqol or prevent functional decline. with this decision, we focused on gaps in knowledge that influence the ability of health care services to improve functioning and hrqol including costs, financing, barriers to acces

4、s, organization and delivery of care, and clinical practice, as well as the interaction of these factors with individual patient characteristics and preferences, family, and community. figure 1 describes the conceptual framework we used. it includes a patient-centered rather than disease-specific fo

5、cus. this framework also recognizes the role of health policy in influencing patient outcomes. all of the arrows on our framework are bidirectional, recognizing the multiple, complex interrelationships that influence health and function in older people. a focused research effort to determine how the

6、 health care system can most cost-effectively prevent disability, reduce functional decline, and extend active life expectancy in older people can provide decisionmakers with the information needed to accelerate the decline in age-specific disability rates and to allocate limited resources efficient

7、ly delivering health care to an aging population an aging population, together with rising health care costs and rapid health system change, presents a major challenge in the delivery of health care to older americans. the changing composition of the population is already putting increasing pressure

8、 on the health care system. in 2011, 77 million baby boomers will begin to turn 65, and by 2025, the number of medicare beneficiaries is expected to reach 69.3 million, representing 20.6 percent of the u.s. population, with the old old?those over age 80?comprising the fastest growing segment of the

9、population. along with the increased numbers of older americans, the elder population is becoming increasingly diverse; it is expected that by the year 2030, one in four people over the age of 65 will be from a racial or ethnic minority. moreover, there is also concern that changes in fertility, wom

10、ens labor force participation, and increases in the divorce rate may reduce the ability of families to take care of older family members who have disabilities, placing even greater demands on public and social programs. because of these demographic trends, there is concern that health care costs for

11、 the elderly population will continue to grow dramatically. per capita expenditures for elderly living in the community were more than three times those of the nonelderly in 1996?$5,644 vs. $1,865?and are projected to increase to $7,674 in 1996 dollars by 2005. medicare and medicaid long-term care e

12、xpenditures are also projected to double by 2005.these projected increases in taxpayer-funded costs will place great pressure on these programs to reduce costs. consequently, there is apprehension that continuing and rising pressures to contain costs will adversely affect health care quality and acc

13、ess. furthermore, the rapid changes in the health care system that have already occurred have had significant effects on the care provided to elderly people. for example, previous efforts to control costs have resulted in an increase in medicare managed care, market instability, and shifting of care

14、 to ambulatory settings. there have also been significant changes in the provision and financing of long-term care, with growing use of community-based long-term care such as home care and assisted living communities. the role of institutions has also changed, with nursing homes being used more exte

15、nsively for subacute care. nursing homes are confronting many other changes, such as capitation and prospective payment for skilled nursing home care and quality measurement and reporting. there are many unanswered questions about the effect of these changes on quality and cost providing and financi

16、ng health care services for older people the unique challenges in providing and financing health care services for older people require a targeted research focus. caring for older people involves clinical complexities that are difficult to coordinate at the health system level and because of fragmen

17、ted financing, are also difficult to manage financially. aging results in both pathophysiologic and pharmacokinetic changes that must be addressed in clinical practice. comorbidity is common, presenting a challenge to clinical management. end-of-life decisionmaking grows in importance, focusing atte

18、ntion on quality of life. family members often play an important role in providing and managing care, and require education, support, and assistance in these tasks. nevertheless, the majority of older people remain active and independent and the prevention of disability among this group of elders is

19、 critical. effective and efficient care for older people therefore requires new models of coordination among preventive, acute, chronic, rehabilitative, and long-term care services. furthermore, financing of care to older people is fragmented and improved models of care will depend on appropriate pa

20、yment models. improving the quality of care for older people is likely to have a substantial impact on their functional status and therefore their quality of life. the underuse of effective interventions, the overuse of interventions shown to be ineffective, and the misuse of others especially polyp

21、harmacy have all been well documented in the elderly. many doctors do not routinely assess the functional status of their older patients, nor do they have the knowledge and skills requisite for geriatric practice. quality measures are needed to assess the effectiveness of interventions to improve ca

22、re in these areas. while the unique constellation of issues confronting the elderly described here necessitates a targeted focus on older people, aging-related research shares common issues with research on improving care for the chronically ill and disabled; so there is a need to coordinate and col

23、laborate across research in all three of these areas using aging-related health services research to answer key questions aging-related health services research can provide answers to key questions about outcomes and effectiveness; cost, use, and access; and quality measurement and improvement for o

24、lder people. the issues addressed in general health services research e.g., optimal treatment, access to care, and the organization of care need to be addressed specifically with respect to the health needs of older people. health services research is uniquely able to address the multiple factors th

25、at impact upon health outcomes in the elderly such as comorbidity, patient beliefs, values and preferences, social support, and multiple sites and settings of care, as well as finance and policy factors. health services research is multidisciplinary and conducted collaboratively by clinicians, nurse

26、s, and social scientists. distinctive features of this research are its patient-centered focus and emphasis on studies related to imizing function and health-related quality of life. the basic sciences of health services research are essential to this endeavor: outcomes and effectiveness research, c

27、ost-effectiveness analysis, decision analysis, health status measurement, quality measurement and improvement, and health economics.改進(jìn)美國(guó)老年人的健康和醫(yī)療衛(wèi)生arlene bireman, william spector引言 當(dāng)我們進(jìn)入新世紀(jì)時(shí),美國(guó)這個(gè)國(guó)家正面臨著一個(gè)巨大的挑戰(zhàn),這就是如何應(yīng)對(duì)一個(gè)老齡化社會(huì)的需求。面對(duì)當(dāng)前的人口趨勢(shì)、日益增加的醫(yī)療成本以及對(duì)于醫(yī)療衛(wèi)生質(zhì)量的關(guān)注,為老年人口提供財(cái)政援助和醫(yī)療照顧就成了關(guān)鍵的醫(yī)療衛(wèi)生政策的挑戰(zhàn)。 圖1 以病人為

28、中心的衛(wèi)生政策的概念框架 在先前有關(guān)的討論中,我們決定將我們的努力重點(diǎn)放在成本?效益干預(yù)上。這種干預(yù)可以強(qiáng)化功能以及與健康相關(guān)的生活質(zhì)量,或可以防止功能的下降?；谶@樣的決定,我們集中關(guān)注一些知識(shí)上的鴻溝,這些鴻溝會(huì)影響旨在改善功能和與健康相關(guān)的生活質(zhì)量(包括成本、融資、進(jìn)入壁壘、醫(yī)療照顧的組織與提供、臨床實(shí)踐)的醫(yī)療服務(wù)能力,同時(shí)也會(huì)影響這些要素與單個(gè)病人的特征、偏好、家庭和社區(qū)的互動(dòng)。圖1描述了我們所采用的概念框架。它包括了以病人為核心而非以疾病為核心的關(guān)注重點(diǎn)。這樣的框架也承認(rèn)衛(wèi)生政策在影響病人效果方面的作用。這樣一項(xiàng)具有側(cè)重點(diǎn)的研究為的是確定醫(yī)療制度如何才最符合成本?效益要求的防止能力

29、喪失、減少功能下降,延長(zhǎng)老年人積極生活的預(yù)期壽命。這些研究可以為決策者提供所需的信息,以加快因年齡原因而喪失能力的比例的下降,并能夠高效地對(duì)有限的資源進(jìn)行配置。 為老齡人口提供健康照顧 人口的不斷老化,再加上不斷提升的醫(yī)療衛(wèi)生成本,以及快速變化的醫(yī)療體制,向如何為美國(guó)的老年人口提供醫(yī)療衛(wèi)生提出了重要的挑戰(zhàn)。 人口年齡結(jié)構(gòu)的改變已經(jīng)給美國(guó)醫(yī)療制度造成了越來越大的壓力。進(jìn)入2011年,7700萬嬰兒潮時(shí)期出生的人口將進(jìn)入65歲的年齡段。到2025年,美國(guó)需要醫(yī)療福利的人口將達(dá)到6930萬,占美國(guó)總?cè)丝诘?0.6%。“老老齡人口”(年齡超過80歲的人口)將構(gòu)成美國(guó)人口增長(zhǎng)最快的部分。隨著美國(guó)老齡人口

30、的增加,老齡人口也變得更加分化了。據(jù)估計(jì),到2030年,超過65歲的人口中每四人中就會(huì)有一個(gè)來自少數(shù)族裔。另外,人們還關(guān)注到,隨著出生率的改變、婦女勞動(dòng)力的參與以及離婚率的上升,都會(huì)降低家庭照顧老年家庭成員的能力。當(dāng)這些老齡人口喪失自理能力時(shí),將對(duì)公共的和社會(huì)的項(xiàng)目提出更多的要求。由于這些人口趨勢(shì),人們?cè)絹碓疥P(guān)注到,老齡人口的醫(yī)療衛(wèi)生成本將會(huì)繼續(xù)快速增加。生活在社區(qū)中的老齡人口人均開支是1996年人口沒有老齡化的三倍。這一比例是5644美元比18651美元。這一數(shù)字到2005年增加到7674美元(按照1996年美元價(jià)格計(jì)算)。到2005年,醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助計(jì)劃方面的開支也將翻一番。這些由納稅

31、人負(fù)擔(dān)的計(jì)劃的增加必然會(huì)對(duì)要求削減開支計(jì)劃施加巨大的壓力。最后人們產(chǎn)生了一種憂慮,這就是,對(duì)于控制成本的不斷增加的壓力將會(huì)對(duì)醫(yī)療衛(wèi)生的質(zhì)量和獲得帶來負(fù)面的影響。 另外,早已發(fā)生的醫(yī)療制度的快速變革將對(duì)向老年人提供照顧帶來重要影響。比方說,先前的控制成本努力已經(jīng)導(dǎo)致醫(yī)療保險(xiǎn)制度中管理式醫(yī)療的增加,醫(yī)療市場(chǎng)的不穩(wěn)定性,并將會(huì)把醫(yī)療衛(wèi)生轉(zhuǎn)移到那些非住院的護(hù)理機(jī)構(gòu)。隨著越來越多地采取以社區(qū)為基礎(chǔ)的長(zhǎng)期護(hù)理辦法,比如家庭護(hù)理和社區(qū)生活援助等等,在長(zhǎng)期護(hù)理的提供和財(cái)政支持方面也發(fā)生了重要的變化,比如有經(jīng)驗(yàn)的護(hù)理院的資本化運(yùn)作和采取預(yù)先支付的方式等,當(dāng)然也要求相應(yīng)的質(zhì)量評(píng)估和報(bào)告。在質(zhì)量和成本方面的這些變革的效果如何,還存在著許多需要解答的問題。 為老年人提供醫(yī)療衛(wèi)生服務(wù)和融資 在為老齡人口提供醫(yī)療服務(wù)方面的特有挑戰(zhàn)要求圍繞具體目標(biāo)進(jìn)行專門研究。 對(duì)老