摘要
研究背景
我国农村人口众多,农村卫生工作一直是政府工作的重点和难点。虽然我国农村卫生服务系统在过去的数十年里有了长足的发展,农村居民医疗保障体系逐步健全,但是,相对于整个国民经济的发展和居民对医疗卫生服务需求的不断提高,农村卫生资源远远无法满足农村居民防治疾病、维护健康的需要,农村居民疾病负担比较重,因病致贫、因病返贫的现象仍然困扰着相当地区的农村居民,如何提高我国农村地区的医疗服务水平,如何切实改善农村地区医疗环境,让农民能够踏实地用得上经济有效的卫生技术和诊疗手段是解决当下农村卫生问题的关键。因此,为农村地区提供符合当地需求、安全、有效、可接受性强、经济适用、符合社会伦理道德要求的卫生适宜技术日益受到社会关注。2008年《卫生部关于加强适宜卫生技术推广工作的指导意见》中明确指出“坚持依靠卫生科学技术进步,研究农村卫生技术需求,加强面向农村的卫生适宜技术推广工作,是全面贯彻我国卫生和科技工作方针,促进卫生科技成果转化,发展农村卫生服务的重要内容和关键环节,是提高基层医疗卫生技术水平和服务能力的重要措施”。2009年我国新医改方案再次强调“基层医疗卫生机构要使用适宜技术、适宜设备和基本药物,大力推广包括民族医药在内的中医药,为城乡居民提供安全有效和低成本的服务”。
近年来,我国医药卫生科技工作者研制了一大批卫生技术,并加入到了卫生部“面向农村和基层推广医药卫生适宜技术十年百项计划”的清单,如何在众多的卫生适宜技术中选择出适合于不同地区的技术,使之切实服务于我国农村居民、真正改善农村医疗卫生环境,是该计划首先要考虑和解决的问题。需求性是卫生适宜技术的重要特征之一,是农村卫生适宜技术评估和筛选的重要依据,也是影响后继技术推广效果的主要因素。因此,评估和筛选适合于我国农村基层推广应用的卫生技术,首先必须了解项目推广地区的卫生需求情况,这是保证筛选出农村地区真正急需、可行、适宜、有效的卫生技术的必要和首要步骤。由此,课题组首先进行了农村基层卫生需求调查研究,为卫生技术的进一步评估提供理论依据和方向参考。在充分了解农村基层卫生需求的前提下,选择合适的评估方法,对各项卫生适宜技术进行科学评估是确保筛选结果准确的必要步骤。本研究在选择卫生适宜技术评价方法时,首先选用了国际上公认的“金标准”—循证医学系统综述评价的方法,对各项卫生适宜技术逐一进行系统综述评价,以期形成完整的系统综述。基于我国农村基层医疗环境和我国农村卫生适宜技术特点,我们发现单纯依靠“金标准”-系统综述评价的方法不适用于我国现有的全部卫生适宜技术,因此,我们根据以往的研究结果,选择综合评分法进行卫生技术评估,选用的指标体系为应用较为成熟的基于层次分析法的综合评价指标体系。进一步研究发现,我国现有的卫生适宜技术中包括相当一部分疾病综合防治策略类技术,由于这一类技术主要是通过防治网络的建立或健康宣传等手段达到防病治病的目的,其技术特性等指标不易量化,因此,不适用于依据指标体系的评价方式,目前,对于这一类技术缺乏可参照的评价方法,通过理论考证和专家咨询,本研究设计采用定性评价的方法对这一类疾病综合防治策略类技术进行全面评估。最后,在充分考虑地方卫生需求的基础上,综合各种卫生技术评估结果,拟定适合于各项目的推广应用的卫生适宜技术清单。
研究目的
本研究的总体目标为根据需求研制综合性农村卫生适宜技术评估筛选方法,遴选农村卫生适宜技术清单,为卫生适宜技术推广服务。具体的研究目的包括：明确农村卫生适宜技术需求；研制综合性的农村卫生适宜技术评估筛选方法；提出农村卫生适宜技术清单；形成农村卫生适宜技术推广政策建议。
研究方法
在对农村基层卫生适宜技术需求展开调查的基础上,采用卫生技术评估的具体方法对我国农村适宜技术进行一系列评估筛选综合研究。主要研究范围为河南省、宁夏地区和山东省,主要研究对象为卫生部面向农村基层推广适宜技术“十年百项计划”第二轮第5至7批卫生适宜技术。
(1)农村卫生需求调查
本研究参考2005年各省人均国民生产总值,在17个项目省中抽取项目实施较好的宁夏、河南两省为调查范围,在每个省中抽取两个示范县。基线资料由总课题组统一提供,采取分层抽样的方法在县乡村三级医疗机构随机抽取基层医生为调查对象。调查工具主要为基线调查表和卫生适宜技术需求调查表,采取提前通知医院组织医生,调研员按时到达指定地点集中对符合条件的医生统一进行问卷调查的方法。资料的分析主要为描述性分析和单因素统计推断,建立Microsoft Access2003数据库,统计分析采用SPSS17.0软件。根据研究目的,依据国际疾病分类编码ICD-10对诊疗困难的疾病进行分类。
(2)农村卫生适宜技术的循证医学系统综述评价
本部分研究主要采用系统综述评价的方法具体评价第5至7批共20项适合做系统评估的卫生适宜技术,通过专家咨询和文献查阅等方法确定文献的纳入标准和排除标准,制定检索策略和证据质量评价标准。数据分析方法主要采用描述性分析和Meta分析,诊断性试验使用Meta-disc分析软件进行分析,应用灵敏度、特异性、阴阳性预测值以及拟合sROC曲线等指标合并统计量；干预性试验采用RevMan4.2软件进行Meta分析,数值变量和分类变量资料在进行合并统计量时,分别采用加权均数差和相对危险度、比值比。
(3)农村卫生适宜技术综合评分
采用分层抽样的方法抽取山东、河南和宁夏地区作为具体研究范围,每个项目省根据经济发展条件抽取2-3个县(或县级市),选取当地卫生医疗机构选取工作经验较丰富的业务骨干和专家,原则上是相应科室的全部资深专家(从医年限5年以上。主要调查工具包括专家基本情况表及卫生适宜技术综合评价表,选取基于层次分析法的综合评价指标体系作为本研究的指标体系,将本次待评价的卫生适宜技术分为内科、外科、妇产科、小儿科、五官科和公共卫生技术六个具体类别,具体赋值办法为集中组织专家、单独直接赋值。将录入的卫生技术单个指标评分数据库由Epidate数据格式转变为Visual FoxPro格式,同时建立卫生技术评分和评价指标数据库表,编写相应的Visual FoxPro程序,获得每一个专家对各项卫生技术间的综合评价,并进行一致性检验,根据各类技术的综合评价值,逐一计算各项技术的综合平均得分,按照各项技术的综合得分值对卫生技术按照类别进行统一排序。
(4)农村卫生适宜技术定性评价
专家的选择采取目的抽样和“滚雪球”抽样相结合的方法,由抽取的访谈人员推举对该研究有经验的其他专家加入访谈。访谈方式主要采取调查人员与指定专家一对一地进行个人深入访谈的具体模式。访谈内容和访谈提纲均提前通过专家咨询或小组讨论一致通过。访谈具体内容由各组访谈人员整理成册,统一编码,小组讨论和专家咨询结合对访谈内容进行进一步分析。
主要研究结果
1)充分了解农村卫生适宜技术需求
通过调查明确了县乡村主要健康问题、供方卫生技术需求和常见病技术需求；
通过有技术需求疾病和纳入本研究的卫生适宜技术做归类对比,发现本次评估筛选的技术能够满农村常见病卫生需求,进一步验证了本研究的方向正确,能够在需求性的基础上评估筛选卫生适宜技术；
部分地区存在潜在的、未得到满足的卫生技术需求,如职业病、精神类疾病。
2)通过我国农村卫生适宜技术系统综述、综合评分和定性评价的综合性评估方法,对待评卫生技术进行了全面评估,并结合卫生需求调查结果和各地经济发展等实际情况,提出各项目地拟推广应用的卫生适宜技术清单。
3)形成了以卫生需求为基础,以系统综述、综合评分和定性评价为具体步骤的综合性农村卫生适宜技术评估筛选方法,并提出我国农村卫生适宜技术推广政策建议。
4)各种评估方法研究结果：
①本研究所涉及的二十项卫生适宜技术的系统综述评价结果总体情况不佳,能够最终用Meta分析的方法进行分析的技术共计3项；能进入Meta分析具体实施环节分析得出部分关于效果等方面结论但是无法完成全部步骤的技术共计5项；经文献检索和文献质量评分无法进入Meta分析程序,但是能够得出部分结论的技术为7项；因无文献支持而无法进行分析的技术为5项。可见由于我国农村卫生适宜技术的自身特点和Meta分析的具体要求,仅应用Meta分析一种方法无法对所有项目进行评估,必须寻找其他评估方法互为补充、互为参考。
②各项技术分值相差不大,三个项目省分值较高或较低的技术具有共性(诊疗疾病的患病率较高或较低)；综合各地区评分结果,内、外科技术的赋值结果分布最为接近(准确度较高)；综合分值较高的技术与卫生需求调查中诊治常见病技术或急需的技术类别高度一致。
③针对基层常见病、多发病的诊疗技术受认可程度高；部分卫生技术所包含的治疗方案较陈旧、所需药物基层难以获得、技术要求操作水平高于基层医疗机构所能达到的水平,不宜推广；大多数技术推广存在困难,最主要为人员配置和资金不足；获得每项定性评价技术的推广结论和建议。
结论与政策建议
1.综合性卫生适宜技术评估筛选方法适用于我国农村地区卫生技术的筛选
本研究建立了以卫生需求为基础的综合性卫生适宜技术评估筛选方法,针对不同特征、不同类型的卫生适宜技术采用不同的方法进行评估,主要包括循证医学系统综述评价法、综合评分法和定性访谈法,几种方法互为补充,经实践证明,该方法科学可行、系统全面,能够为我国农村真正筛选出适宜的卫生技术。
2.我国农村卫生适宜技术基本能够满足农村基层常见病、多发病的诊治
本研究结果显示,农村基层常见病、多发病的诊疗技术均能在本次评估的技术清单中找到,而本次评估筛选出来适合推广的技术基本上涵盖了基层常见病、多发病的诊治范围,说明目前我幽农村卫生适宜技术基本能够满足农村常见病、多发病的诊治要求。
3.我国农村卫生适宜技术项目存在的不足
本研究通过农村卫生需求调查,以及对卫生部面向农村基层推广适宜技术“十年百项计划”第二轮计划第五至七批共37项西医范围的卫生适宜技术进行系统综述评价、综合评分和访谈研究,发现农村卫生适宜技术的筛选和推广过程中存在以下不足：
(1)部分卫生适宜技术本身存在不足
(2)现有技术适用范围区分有待明确
(3)卫生适宜技术不能完全满足农村基层卫生需求
(4)部分适宜技术在基层医疗机构的适宜性差
(5)政府投入相对不足
建议
(1)重视和增加卫生适宜技术理论研究,提高农村卫生适宜技术文献质量鼓励基层医务工作者尤其是县级医疗机构的医生展开对适宜技术的理论研究,着重对技术的安全性和有效性等具体指标进行临床观察,并整理成高质量的文章,提高卫生适宜技术的文献质量,为科学地评价技术特点,以及技术的开展和终止提供有力的科学依据。
(2)建立健全农村卫生适宜技术制定标准
建立卫生适宜技术制定标准,根据农村卫生需求,制定适用于我国农村的卫生适宜技术。需要注意尽量使用农村地区可及的设备和药品。
(3)完善技术对于适用范围规定,根据需求增加技术种类
针对不同基层卫生机构的特点和技术需求,将适宜技术明确区分为适于县级医疗机构、适于乡镇卫生院和适于村卫生室等级别,因地制宜,不但有利于完善筛选体系,也提高推广应用的效率。
同时,根据农村地区卫生需求,增加针对如职业病、精神疾病等病种的诊疗新技术,同时增加慢性肺感染性疾病的诊疗技术。
(4)政府增加支持力度
增加政府或上级部门的支持力度,从经济、人员和组织协调三个方面分别给予适宜技术推广应用的支持和便利,才能真正保证卫生适宜技术真正适用于农村基层,保证技术的推广应用的长期性和可持续性。
There is a large population in rural areas of China, and rural health is a key point of the government's responsibility. The rural health service delivery system and medical insurance system have been improved dramatically during past decades, however, comparing with the social economic development and residents' increasing health demands, rural health resources can hardly satisfy rural residents' health needs. The burden of disease is heavy and the phenomenon of "disease-causing poverty" is widespread in a relative large area. Therefore, how to improve the medical skills and medical environments in rural areas so as to make the economical and efficient health technologies accessible to rural residents is the linchpin of solving the current rural health problems.
Therefore, the whole society pays more and more attentions to health appropriate technologies provided in rural areas which are local-demand-conforming, safe, effective, affordable, economical, and social moral conforming. In2008, the Ministry of Health issued a document which stated that as a linchpin of developing rural health system, health appropriate technologies should be studied and spread so as to improve the primary care system. In2009, the new health reform plan emphasized that the township health centers, village clinics, community health centers and stations should provide health appropriate technologies.
In recent years, many health technologies are created which are added into the list of "one hundred health appropriate technologies for rural areas program". The first step of this program is to select appropriate health technologies for different areas.
Demand is a main characteristic of health appropriate technology, and the main standard of selecting and evaluating health appropriate technology, which is also the main factor to affect the spreading. Therefore, if we want to evaluate and select health appropriate technologies for rural areas, the first step is to know the demand in pilot areas, which is the main procedure to control the quality of evaluation. Hence, in our study, first we investigate the rural health demand to provide evidence for evaluation, then we select appropriate evaluating method which is the key to guarantee the correctness of the result.
About the evaluation method, first we select the international recognized "Golden Standard"-evidence-based systematic review. Considering the rural medical environment and the characteristics of health appropriate technology in China, it is not applicable to use systematic reviews to evaluate all health appropriate technologies, therefore, we select comprehensive score method, and the index system is based on analytic hierarchy process.
The result of further study shows that some of current health appropriate technologies are comprehensive disease prevention and therapy technologies, the main content of which are prevention and therapy network building or health promotion activities, and technical characteristics of them can't be measured, hence, we use qualitative method to evaluate them. In the end, based on consideration of local health demand, we refer to the health technologies evaluation results and make the list of health appropriate technologies which can be spread.
The total objective of this study is to find the comprehensive rural health appropriate technologies evaluation method, and make the list of health appropriate technologies which can be spread in each pilot area.
The specific objectives are as follows:find the comprehensive rural health appropriate technologies evaluation method; make the list of health appropriate technologies which can be spread in each pilot area; know rural health appropriate technologies evaluation direction and target; form the policy recommendation about rural health appropriate technology related programs.
Study Methods
First we investigate the rural health appropriate technology demand, then we adopt health technology assessment method to evaluate and select rural health appropriate technologies in China. The field survey sites are Henan province, Ningxia autonomous region, and Shandong province. The study objects are the fifth, sixth and seventh health appropriate technologies in the "one hundred health appropriate technologies for rural areas program" funded by Ministry of Health.
[1] Rural health demand survey
Considering GDP per capita of each province, we select Henan province and Ningxia autonomous region from the17program provinces, and two counties are selected from each province. The baseline materials are provided by our team, and we adopt stratified sampling method to select rural doctors randomly. The survey tools are baseline table and health appropriate technology demand survey table. First we inform hospitals to convene the doctors, then our interviewers interview the doctors at the same sites. The database is constructed using Microsoft Access2003, and descriptive analysis and single factor analysis are conducted with SPSS17.0.To achieve our study objective, we classify the complex diseases according to ICD-10.
[2] Evidenced-based systematic reviews of rural health appropriate technologies
In total,20health appropriate technologies are fit for systematic review. First we confirm the inclusion criteria and exclusion criteria through expert consultation method and paper analysis, then we make the search strategy and evidence quality evaluation standard. We adopt descriptive analysis and Meta analysis to analyze the data. We select indexes, such as sensitivity, specificity, positive and negative predicted value, sROC curve to analyze diagnosed trials by Meta-disc software; and we select weighted means difference, relative risk degree, and OR to analyze intervention trials by RevMan4.2software.
[3] Comprehensive Score of rural health appropriate technologies
Henan province, Ningxia autonomous region, and Shandong province are selected by stratified sample method, and two or three counties are selected from each province. Experienced doctors who have worked as a doctor more than five years are chosen and the tools are expert basic information table and health appropriate technology table. The comprehensive evaluation system based on analytic hierarchy process is selected and the index weight is conducted by experts. The health appropriate technologies are classified into six categories:internal medicine, surgery, gynecology and obstetrics, pediatrics, Ophthalmology and otolaryngology, and public health technologies. Each index score of each health appropriate technology is converted from Epidata data form into Visual FoxPro form. We construct the health technology evaluation score dataset and write relevant Visual FoxPro procedures. After each expert did the evaluation of each health appropriate technology, first we conduct consistency test, then calculate comprehensive average score, and make the order in each category in the end.
[4] Qualitative interview of rural health appropriate technology
When select the experts, we adopt purposive sampling and snowball sampling method. Interview pattern is face-to-face personal deep interview model. The interview content and outline are discussed and confirmed by expert consultation or group discussion in advance. The definite content of interview is analyzed into volume and coded uniformly.
Main Study Results:
[1] Through the rural health demand survey we grasp the demands of health appropriate technologies in rural.
The main health problems in rural are cleared. The technologies evaluated in the study are satisfied with the health demand in rural. They also recommended that the amount and type of public health technologies should be increased, as well as technologies aiming at occupational diseases.
[2] Based on rural health demand, considering the economic and actual situations fully in different regions and according to the results of the evaluation, we preliminarily protocol the rural health appropriate technologies to be spread for the17provinces and regions including Henan, Shandong and Ningxia.
[3] The comprehensive method for assessment of the appropriate health technologies in rural in China is established.
[4] The main results in different methods of assessment of the appropriate health technologies
①The overall systematic review of the twenty health appropriate technologies involved in the study is not very good. Three technologies can be analyzed by Meta-analysis ultimately. Five technologies can enter the implementing procedure of Meta-analysis and draw conclusions about effectiveness, but they cannot complete all the procedures. Seven technologies can draw partial conclusions, though they cannot enter analyzing procedure of Meta-analysis because of literature searching and literature quality scoring. Five technologies cannot be analyzed for lack of literature support. For the characters of rural health appropriate technologies and the specific requirements of Meta-analysis, we cannot evaluate all the programs merely through Meta-analysis. Therefore we have to seek other evaluation methods to complement and refer.
②From the comprehensive scoring results of different technologies, we can see that there is little difference. between them. Among these six scoring results, internal medicine technologies and surgery technologies are almost the same. Selected health technologies with high scoring will be appropriate for rural basic institutions when they are coherent with the technologies for common diseases in the health demand survey.
③We find from the expert interviews that health technologies aiming at basic common diseases and frequently-occurring diseases can be approved and expected to spread by experts. Those having some problems itself cannot be accepted. Besides, the specific content of technologies need to pay attention to the availability of basic medicines and technologies. In a word, we can learn the relative information about rural health appropriate technologies from many aspects through qualitative interviews. We can also evaluate and select technologies about comprehensive curing strategy and provide reference for the following spread.
Conclusions
1. Comprehensive health appropriate technologies evaluating and selecting method is appropriate for rural China This study built comprehensive health appropriate technologies evaluating and selecting method based on health demand. This method can adopt different methods to evaluate technologies with different characters and types. It mainly includes evidence-based systematic review, comprehensive scoring method and qualitative interview and these methods complement each other. Proved by practice, the comprehensive evaluating and selecting method is scientific and systematic. It can select really appropriate technologies for rural China.
2. Health appropriate technologies in rural China can satisfy the diagnosing and curing of basic common diseases and frequently-occurring diseases substantially
As the study results show, the diagnosing and curing technologies of basic common diseases and frequently-occurring diseases in rural China all can be found in the list of technologies to be evaluated. Meanwhile, technologies selected to be spread cover the scope of basic common diseases and frequently-occurring diseases. These indicate that health appropriate technologies in rural China can satisfy the diagnosing and curing of basic common diseases and frequently-occurring diseases substantially at present.
3. Weaknesses of health appropriate technologies programs in rural China
According to rural health demand survey and the systematic review, comprehensive scoring and interview of37health appropriate technologies of western medicine which are included in the second round from group5to7of "one hundred health appropriate technologies for rural areas program" which is used by Ministry of Health to spread health appropriate technologies in rural China, we find that there are some weaknesses in the selecting and spreading processes which are as follows:
(1) Some health appropriate technologies have weaknesses themselves
(2) Existing technology applying scope need to be clarified
(3) Health appropriate technologies cannot satisfy the basic health demand of rural China
(4) A portion of health appropriate technologies are not so appropriate to basic medical institutions
(5) The government input is relatively insufficient
Suggest i ons
[1] Emphasize and increase theoretical researches of health appropriate technologies, and improve the quality of literatures on rural health appropriate technologies
Encourage basic medical workers especially the ones at county level to carry out theoretical researches of health appropriate technologies, to conduct clinical observation focusing on specific indicators such as the safety and validity of technologies and write high quality articles. Thus, improve the quality of literatures on health appropriate technologies and provide strong scientific evidences for the evaluation, spread and termination of health technologies.
[2] Establish and perfect the formulating standard of rural health appropriate technologies
Establish the formulating standard of health appropriate technologies and formulate health appropriate technologies applying to rural China. Pay attention to using equipments and medicines available for rural regions as far as possible.
[3] Improve the regulation of technology application, add more technologies based on health demand
Based on differences of health technology demand and characteristic in different health facilities, we should make lists for county-level hospitals, township health centers and village clinics respectively, which not only can improve the selection system, but also can improve the spread efficiency.
At the same time, to satisfy the health demand in rural areas, we should add more technologies in the field of occupational disease, mental disease, and chronic lung infection disease.
[4] Government input should be increased
The governments in each level should provide more resources, such as money, personnel and coordination, to facilitate the spread and application of health appropriate technologies, which can guarantee the effect and efficiency of health appropriate technology application in rural areas in the future.
引文
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