預(yù)防保健與就醫(yī)診療課件

預(yù)防保健與就醫(yī)診療臺灣家庭醫(yī)學(xué)醫(yī)學(xué)會秘書長李汝禮預(yù)防保健與就醫(yī)診療臺灣家庭醫(yī)學(xué)醫(yī)學(xué)會秘書長李汝禮1前言：醫(yī)師是做什麼的？醫(yī)生，古代稱大夫或郎中，指學(xué)習(xí)醫(yī)學(xué)或行醫(yī)的人，醫(yī)生也叫杏林，專指醫(yī)術(shù)精良，醫(yī)德高尚的醫(yī)家。華陀Hippocrates

前言：醫(yī)師是做什麼的？醫(yī)生，古代稱大夫或郎中，指學(xué)習(xí)醫(yī)學(xué)或行2民眾的健康醫(yī)療照護就醫(yī)診療(diseasetreatment)預(yù)防保?。杭膊☆A(yù)防(diseaseprevention)健康促進(healthpromotion)個人健康照護VS群體健康照護民眾的健康醫(yī)療照護就醫(yī)診療(diseasetreatmen3就醫(yī)診療S(SubjectiveData）：自覺癥狀徵候，包括主訴、現(xiàn)在病史、過去病史及個人史…。O(ObjectiveData)：檢查發(fā)現(xiàn)，包括診療發(fā)現(xiàn)及各種檢查報告…。A(Assessment)：診斷評估，即診斷(Diagnosis)或臆斷(Impression)。P(Plan)：治療計劃，包括各種處置、醫(yī)令或處方。就醫(yī)診療S(SubjectiveData）：自覺癥狀徵候4預(yù)防保健篩檢screening群眾篩檢vs個人病例發(fā)現(xiàn)(case-finding)諮詢介入(counselingintervention)疫苗接種(immunization)化學(xué)預(yù)防(chemoprophylaxis)預(yù)防保健篩檢screening5預(yù)防性健康照護的實證依據(jù)美國預(yù)防服務(wù)工作小組(U.S.PreventiveservicesTaskforce,USPSTF)加拿大預(yù)防性健康照謢工作小組(CanadianTaskForceonPreventiveHealthCare,CTFPHC)社區(qū)工作小組(CommunityTaskForce,CTF)預(yù)防性健康照護的實證依據(jù)美國預(yù)防服務(wù)工作小組(U.S.Pr6OverviewofProcessofRecommendationDevelopment

AHRQ:theAgencyforHealthcareResearchandQualityUSPSTF:U.S.PreventiveServicesTaskForceEPCs:Evidence-basedPractice

CentersOverviewofProcessofRecomme7ProceduresforDevelopingaRecommendationStatement

ProceduresforDevelopingaRe8AnalyticFrameworkwithKeyQuestions-1

AnalyticFrameworkwithKeyQu9AnalyticFrameworkwithKeyQuestions-21.DoesscreeningforXreduceMorbidityand/orMortality?

2.CanagroupathighriskforXbeidentifiedonclinicalgrounds?

3.Arethereaccurate(i.e.,sensitiveandspecific)screeningtestsavailable?

4.Aretreatmentsavailablethatmakeadifferenceinintermediateoutcomeswhenthediseaseiscaughtearly,ordetectedbyscreening?

AnalyticFrameworkwithKeyQu10AnalyticFrameworkwithKeyQuestions-35.Aretreatmentsavailablethatmakeadifferenceinmorbidityormortalitywhenthediseaseiscaughtearly,ordetectedbyscreening?

6.Howstrongistheassociationbetweentheintermediateoutcomesandpatientoutcomes?

7.Whataretheharmsofthescreeningtest?8.Whataretheharmsofthetreatment?

AnalyticFrameworkwithKeyQu11RecommendationGradeDefinitionsGradeDefinitionsAfterMay2007GradeDefinitionsPriortoMay2007RecommendationGradeDefinitio12GradeDefinitionsAfterMay2007-1GradeATheUSPSTFUSPSTFrecommendstheservice.Thereishighcertaintythatthenetbenefitissubstantial.Offerorprovidethisservice

GradeDefinitionsAfterMay2013GradeDefinitionsAfterMay2007-2GradeBTheUSPSTFrecommendstheservice.Thereishighcertaintythatthenetbenefitismoderateorthereismoderatecertaintythatthenetbenefitismoderatetosubstantial.Offerorprovidethisservice

GradeDefinitionsAfterMay2014GradeDefinitionsAfterMay2007-3GradeCTheUSPSTFrecommendsagainstroutinelyprovidingtheservice.Theremaybeconsiderationsthatsupportprovidingtheserviceinanindividualpatient.Thereisatleastmoderatecertaintythatthenetbenefitissmall.Offerorprovidethisserviceonlyifotherconsiderationssupporttheofferingorprovidingtheserviceinanindividualpatient.GradeDefinitionsAfterMay2015GradeDefinitionsAfterMay2007-4GradeDTheUSPSTFrecommendsagainsttheservice.Thereismoderateorhighcertaintythattheservicehasnonetbenefitorthattheharmsoutweighthebenefits.Discouragetheuseofthisservice.GradeDefinitionsAfterMay2016GradeDefinitionsAfterMay2007-5GradeIStatement

TheUSPSTFconcludesthatthecurrentevidenceisinsufficienttoassessthebalanceofbenefitsandharmsoftheservice.Evidenceislacking,ofpoorquality,orconflicting,andthebalanceofbenefitsandharmscannotbedetermined.ReadtheclinicalconsiderationssectionofUSPSTFRecommendationStatement.Iftheserviceisoffered,patientsshouldunderstandtheuncertaintyaboutthebalanceofbenefitsandharms.

GradeDefinitionsAfterMay2017LevelsofCertaintyRegardingNetBenefit-1High：Theavailableevidenceusuallyincludesconsistentresultsfromwell-designed,well-conductedstudiesinrepresentativeprimarycarepopulations.Thesestudiesassesstheeffectsofthepreventiveserviceonhealthoutcomes.Thisconclusionisthereforeunlikelytobestronglyaffectedbytheresultsoffuturestudies.

LevelsofCertaintyRegarding18LevelsofCertaintyRegardingNetBenefit-2Moderate：Theavailableevidenceissufficienttodeterminetheeffectsofthepreventiveserviceonhealthoutcomes,butconfidenceintheestimateisconstrainedbysuchfactorsas:Thenumber,size,orqualityofindividualstudies.Inconsistencyoffindingsacrossindividualstudies.Limitedgeneralizabilityoffindingstoroutineprimarycarepractice.Lackofcoherenceinthechainofevidence.Asmoreinformationbecomesavailable,themagnitudeordirectionoftheobservedeffectcouldchange,andthischangemaybelargeenoughtoaltertheconclusion.

LevelsofCertaintyRegarding19LevelsofCertaintyRegardingNetBenefit-3Low：Theavailableevidenceisinsufficienttoassesseffectsonhealthoutcomes.Evidenceisinsufficientbecauseof:Thelimitednumberorsizeofstudies.Importantflawsinstudydesignormethods.Inconsistencyoffindingsacrossindividualstudies.Gapsinthechainofevidence.Findingsnotgeneralizabletoroutineprimarycarepractice.Lackofinformationonimportanthealthoutcomes.Moreinformationmayallowestimationofeffectsonhealthoutcomes.LevelsofCertaintyRegarding20GradeDefinitionsPriortoMay2007-1A—StronglyRecommended:

TheUSPSTFstronglyrecommendsthatcliniciansprovide[theservice]toeligiblepatients.TheUSPSTFfoundgoodevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitssubstantiallyoutweighharms.GradeDefinitionsPriortoMay21GradeDefinitionsPriortoMay2007-2B—Recommended:TheUSPSTFrecommendsthatcliniciansprovide[theservice]toeligiblepatients.TheUSPSTFfoundatleastfairevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitsoutweighharms.GradeDefinitionsPriortoMay22GradeDefinitionsPriortoMay2007-3C—NoRecommendation:TheUSPSTFmakesnorecommendationfororagainstroutineprovisionof[theservice].TheUSPSTFfoundatleastfairevidencethat[theservice]canimprovehealthoutcomesbutconcludesthatthebalanceofbenefitsandharmsistooclosetojustifyageneralrecommendation.GradeDefinitionsPriortoMay23GradeDefinitionsPriortoMay2007-4D—NotRecommended:TheUSPSTFrecommendsagainstroutinelyproviding[theservice]toasymptomaticpatients.TheUSPSTFfoundatleastfairevidencethat[theservice]isineffectiveorthatharmsoutweigh

benefits.GradeDefinitionsPriortoMay24GradeDefinitionsPriortoMay2007-5I—InsufficientEvidencetoMakeaRecommendation:

TheUSPSTFconcludesthattheevidenceisinsufficienttorecommendfororagainstroutinelyproviding[theservice].Evidencethatthe[service]iseffectiveislacking,ofpoorquality,orconflictingandthebalanceofbenefitsandharmscannotbedetermined.GradeDefinitionsPriortoMay25QualityofEvidence-1Good:

Evidenceincludesconsistentresultsfromwell-designed,well-conductedstudiesinrepresentativepopulationsthatdirectlyassesseffectsonhealthoutcomes.QualityofEvidence-1Good:26QualityofEvidence-2Fair:

Evidenceissufficienttodetermineeffectsonhealthoutcomes,butthestrengthoftheevidenceislimitedbythenumber,quality,orconsistencyoftheindividualstudies,generalizabilitytoroutinepractice,orindirectnatureoftheevidenceonhealthoutcomes.QualityofEvidence-2Fair:27QualityofEvidence-3Poor:

Evidenceisinsufficienttoassesstheeffectsonhealthoutcomesbecauseoflimitednumberorpowerofstudies,importantflawsintheirdesignorconduct,gapsinthechainofevidence,orlackofinformationonimportanthealthoutcomes.QualityofEvidence-3Poor:28http:///clinic/pocketgd.htm/clinic/poc29U.S.PreventiveServicesTaskForce

U.S.PreventiveServicesTask30預(yù)防保健與就醫(yī)診療課件31謝謝聆聽敬請指教！祝您健康、幸福！家醫(yī)學(xué)會李汝禮謝謝聆聽敬請指教！祝您健康、幸福！家醫(yī)學(xué)會李汝32預(yù)防保健與就醫(yī)診療臺灣家庭醫(yī)學(xué)醫(yī)學(xué)會秘書長李汝禮預(yù)防保健與就醫(yī)診療臺灣家庭醫(yī)學(xué)醫(yī)學(xué)會秘書長李汝禮33前言：醫(yī)師是做什麼的？醫(yī)生，古代稱大夫或郎中，指學(xué)習(xí)醫(yī)學(xué)或行醫(yī)的人，醫(yī)生也叫杏林，專指醫(yī)術(shù)精良，醫(yī)德高尚的醫(yī)家。華陀Hippocrates

前言：醫(yī)師是做什麼的？醫(yī)生，古代稱大夫或郎中，指學(xué)習(xí)醫(yī)學(xué)或行34民眾的健康醫(yī)療照護就醫(yī)診療(diseasetreatment)預(yù)防保?。杭膊☆A(yù)防(diseaseprevention)健康促進(healthpromotion)個人健康照護VS群體健康照護民眾的健康醫(yī)療照護就醫(yī)診療(diseasetreatmen35就醫(yī)診療S(SubjectiveData）：自覺癥狀徵候，包括主訴、現(xiàn)在病史、過去病史及個人史…。O(ObjectiveData)：檢查發(fā)現(xiàn)，包括診療發(fā)現(xiàn)及各種檢查報告…。A(Assessment)：診斷評估，即診斷(Diagnosis)或臆斷(Impression)。P(Plan)：治療計劃，包括各種處置、醫(yī)令或處方。就醫(yī)診療S(SubjectiveData）：自覺癥狀徵候36預(yù)防保健篩檢screening群眾篩檢vs個人病例發(fā)現(xiàn)(case-finding)諮詢介入(counselingintervention)疫苗接種(immunization)化學(xué)預(yù)防(chemoprophylaxis)預(yù)防保健篩檢screening37預(yù)防性健康照護的實證依據(jù)美國預(yù)防服務(wù)工作小組(U.S.PreventiveservicesTaskforce,USPSTF)加拿大預(yù)防性健康照謢工作小組(CanadianTaskForceonPreventiveHealthCare,CTFPHC)社區(qū)工作小組(CommunityTaskForce,CTF)預(yù)防性健康照護的實證依據(jù)美國預(yù)防服務(wù)工作小組(U.S.Pr38OverviewofProcessofRecommendationDevelopment

AHRQ:theAgencyforHealthcareResearchandQualityUSPSTF:U.S.PreventiveServicesTaskForceEPCs:Evidence-basedPractice

CentersOverviewofProcessofRecomme39ProceduresforDevelopingaRecommendationStatement

ProceduresforDevelopingaRe40AnalyticFrameworkwithKeyQuestions-1

AnalyticFrameworkwithKeyQu41AnalyticFrameworkwithKeyQuestions-21.DoesscreeningforXreduceMorbidityand/orMortality?

2.CanagroupathighriskforXbeidentifiedonclinicalgrounds?

3.Arethereaccurate(i.e.,sensitiveandspecific)screeningtestsavailable?

4.Aretreatmentsavailablethatmakeadifferenceinintermediateoutcomeswhenthediseaseiscaughtearly,ordetectedbyscreening?

AnalyticFrameworkwithKeyQu42AnalyticFrameworkwithKeyQuestions-35.Aretreatmentsavailablethatmakeadifferenceinmorbidityormortalitywhenthediseaseiscaughtearly,ordetectedbyscreening?

6.Howstrongistheassociationbetweentheintermediateoutcomesandpatientoutcomes?

7.Whataretheharmsofthescreeningtest?8.Whataretheharmsofthetreatment?

AnalyticFrameworkwithKeyQu43RecommendationGradeDefinitionsGradeDefinitionsAfterMay2007GradeDefinitionsPriortoMay2007RecommendationGradeDefinitio44GradeDefinitionsAfterMay2007-1GradeATheUSPSTFUSPSTFrecommendstheservice.Thereishighcertaintythatthenetbenefitissubstantial.Offerorprovidethisservice

GradeDefinitionsAfterMay2045GradeDefinitionsAfterMay2007-2GradeBTheUSPSTFrecommendstheservice.Thereishighcertaintythatthenetbenefitismoderateorthereismoderatecertaintythatthenetbenefitismoderatetosubstantial.Offerorprovidethisservice

GradeDefinitionsAfterMay2046GradeDefinitionsAfterMay2007-3GradeCTheUSPSTFrecommendsagainstroutinelyprovidingtheservice.Theremaybeconsiderationsthatsupportprovidingtheserviceinanindividualpatient.Thereisatleastmoderatecertaintythatthenetbenefitissmall.Offerorprovidethisserviceonlyifotherconsiderationssupporttheofferingorprovidingtheserviceinanindividualpatient.GradeDefinitionsAfterMay2047GradeDefinitionsAfterMay2007-4GradeDTheUSPSTFrecommendsagainsttheservice.Thereismoderateorhighcertaintythattheservicehasnonetbenefitorthattheharmsoutweighthebenefits.Discouragetheuseofthisservice.GradeDefinitionsAfterMay2048GradeDefinitionsAfterMay2007-5GradeIStatement

TheUSPSTFconcludesthatthecurrentevidenceisinsufficienttoassessthebalanceofbenefitsandharmsoftheservice.Evidenceislacking,ofpoorquality,orconflicting,andthebalanceofbenefitsandharmscannotbedetermined.ReadtheclinicalconsiderationssectionofUSPSTFRecommendationStatement.Iftheserviceisoffered,patientsshouldunderstandtheuncertaintyaboutthebalanceofbenefitsandharms.

GradeDefinitionsAfterMay2049LevelsofCertaintyRegardingNetBenefit-1High：Theavailableevidenceusuallyincludesconsistentresultsfromwell-designed,well-conductedstudiesinrepresentativeprimarycarepopulations.Thesestudiesassesstheeffectsofthepreventiveserviceonhealthoutcomes.Thisconclusionisthereforeunlikelytobestronglyaffectedbytheresultsoffuturestudies.

LevelsofCertaintyRegarding50LevelsofCertaintyRegardingNetBenefit-2Moderate：Theavailableevidenceissufficienttodeterminetheeffectsofthepreventiveserviceonhealthoutcomes,butconfidenceintheestimateisconstrainedbysuchfactorsas:Thenumber,size,orqualityofindividualstudies.Inconsistencyoffindingsacrossindividualstudies.Limitedgeneralizabilityoffindingstoroutineprimarycarepractice.Lackofcoherenceinthechainofevidence.Asmoreinformationbecomesavailable,themagnitudeordirectionoftheobservedeffectcouldchange,andthischangemaybelargeenoughtoaltertheconclusion.

LevelsofCertaintyRegarding51LevelsofCertaintyRegardingNetBenefit-3Low：Theavailableevidenceisinsufficienttoassesseffectsonhealthoutcomes.Evidenceisinsufficientbecauseof:Thelimitednumberorsizeofstudies.Importantflawsinstudydesignormethods.Inconsistencyoffindingsacrossindividualstudies.Gapsinthechainofevidence.Findingsnotgeneralizabletoroutineprimarycarepractice.Lackofinformationonimportanthealthoutcomes.Moreinformationmayallowestimationofeffectsonhealthoutcomes.LevelsofCertaintyRegarding52GradeDefinitionsPriortoMay2007-1A—StronglyRecommended:

TheUSPSTFstronglyrecommendsthatcliniciansprovide[theservice]toeligiblepatients.TheUSPSTFfoundgoodevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitssubstantiallyoutweighharms.GradeDefinitionsPriortoMay53GradeDefinitionsPriortoMay2007-2B—Recommended:TheUSPSTFrecommendsthatcliniciansprovide[theservice]toeligiblepatients.TheUSPSTFfoundatleastfairevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitsoutweighharms.GradeDefinitionsPriortoMay54GradeDefinitionsPriortoMay2007-3C—NoRecommendation:TheUSPSTFmakesnorecommendationfororagainstroutineprovisionof[theservice].TheUSPSTFfoundatleastfairevidencethat[theservice]canimprovehealthoutcomesbutconcludesthatthebalanceofbenefitsandharmsistooclosetojustifyageneralrecommendation.GradeDefinitionsPriortoMay55GradeDefinitionsPriortoMay2007-4D—NotRecommended:TheUS