世界卫生组织关于卫生系统反应性测量的策略

反应性是WHO评价卫生系统运行绩效的三个内在目标之一,WHO对卫生系统反应性测量的基本策略是：（1）达到对反应性概念的理解和指导反应性测量的共识;（2）形成反应性测量可靠与有效的方法;（3）确保反应性资料收集的负担及费用经济有效;（4）促使反应性测量与反应性改善联系在一起。     

卫生系统反应性研究概况

卫生系统反应性是卫生系统的产出之一。《2000年世界卫生报告》将反应性作为评价卫生系统绩效的三大主要目标之一。本文对反应性的概念、构成、测量工具及评价方法等进行简单介绍,并对目前国内对于卫生系统反应性的研究现状进行了简要回顾和讨论。     

WHO关于卫生系统反应性的研究进展

WHO近年来对反应性的理论体系、测量工具不断进行修改和完善。笔者运用文献综述的方法对卫生系统反应性的研究进展进行系统的阐述,主要包括反应性测量维度的调整、反应性模型的评价以及情景问卷的引入。     

上海市卫生系统反应性初探

《2000年世界卫生报告》将反应性作为评价卫生系统绩效的三大主要目标之一。文章利用WHO的关键知情人调查（KIS）问卷首次对上海市卫生系统的反应性进行了初步的测量，并对KIS的测量、评价方法进行了初步的探讨。     

卫生系统反应性研究

自2000年世界卫生组织提出卫生系统反应性这一概念以来,世界各国对它的研究一直处于不断地修改和完善之中.文章在查阅大量文献的基础上,对卫生系统反应性的研究进展进行了阐述,主要包括卫生系统反应性的概念、构成、测量工具与评价方法、国内外研究现状以及现存的问题等方面.     

海军部队卫生系统反应性调查

目的调查海军某基地卫生系统反应性，为积圾维护和增进官兵健康，满足官兵合理需求，改进医疗服务提供参考依据。方法采用问卷调查方法，对海军某基地关键知情人（卫生机关领导及一般管理人员、预防保健人员、专业医务技术人员、门诊就医人员、住院患者）、师以下部队官兵等进行调查。结果70％以上调查对象认为医院反应性程度高（很好和好），反应性评价总得分为7．839。结论该部卫生系统反应性总体情况尚好，目前存在部分师以下部队官兵对卫生系统反应性评价尚不高的问题。卫生系统反应性是评价卫生系统绩效的较好方法。     

基于基尼系数的住院患者医疗机构反应性研究

目的分析住院患者对三级医疗机构反应性的水平与分布,为改善三级医疗机构的反应性提供科学依据。方法采取多阶段随机抽样的方法、借鉴WHO研制的反应性问卷对三级医疗机构的住院患者进行现场调查,利用基尼系数和Lorenz曲线测量反应性分布的公平性。结果住院患者对三级医疗机构的总体反应性评分为6.49分,8个子条目(尊严、自主性、保密性、交流、及时性、社会支持网络、基本设施服务质量、选择性)的评分分别为6.56、5.73、5.70、7.74、5.59、7.50、6.94、5.89;住院患者对三级医疗机构反应性分布的基尼系数为0.08,各条目分布的基尼系数在0.08~0.21之间。结论住院患者对三级医疗机构的反应性评价较差、但反应性分布的公平性较好;应合理配置优质医疗资源、完善分级诊疗制度、优化医疗保险定点机构管理、实现规范化与个性化的诊疗相结合,以改善三级医疗机构的反应性。     

郑州市卫生系统反应性评价及影响因素分析

目的 初步评价郑州市卫生系统反应性,探讨性别、年龄、婚姻、文化程度、职业、家庭收入等人口学特征与卫生系统反应性评分的相互关系。方法 用分层随机抽样的方法,抽取郑州市5家综合医院,采用世界卫生组织制订的〈居民健康和卫生系统反应性调查〉问卷进行调查。采用秩和检验方法对反应性进行初步评价,用典型相关分析方法探讨人口学特征和反应性评分之间的关系。结果 郑州市卫生系统反应性各方面中对基本环境的评价相对较低;人口学特征与卫生系统反应性评分之间呈典型相关,典型相关系数为0．286（P〈0．05）。结论 应进一步加强就医环境的改善,反应性各方面的提高是持续变化的过程。     

贫困地区居民对县乡村医疗机构反应性评价

目的 考察贵州省农村居民对县、乡、村三级医疗机构反应性评价.方法 采用多阶段随机抽样方法,对贵州省4个县的1 006户家庭进行入户调查,对391例在县级医疗机构就诊和住院患者进行随机调查.结果 农村居民对县、乡、村三级医疗机构反应性评价较好的有服务态度、沟通与交流、基本环境条件;及时性次之;对自主性和保密性的要求及其满足程度较低;反应性的大部分指标仍有改进及提升空间.居民对县、乡级机构的保密性、自主性、费用查询的评价明显不同.结论 重视反应性对农村卫生系统绩效的促进作用;优先考虑与医疗机构功能相适应的医疗设施与设备建设和人才建设;发挥卫生服务供方在提高反应性上的主导作用.     

福州市社区卫生服务反应性的模糊综合评价

目的 对福州市社区卫生服务的反应性水平进行评估,为制定合理的管理策略提供依据.方法 采用自编的社区卫生服务反应性问卷进行调查,利用模糊评价方法进行综合评价.结果 福州市社区卫生服务反应性得分为47.20,处于一般和好之间;在反应性各要素中,最需要改进的前3位是尊严维护、及时关注及与患者交流.结论 福州市社区卫生服务在一定程度上满足了居民非技术方面卫生服务需求,但也还有很多需要改进的地方.     

卫生系统反应性——概念与测量

卫生系统反应性是卫生系统的产出之一,它是指医疗卫生机构对个体普遍合理期望的认知和适当的反应。卫生系统的反应性由七个方面组成,分为两个部分。第一部分为对个人的尊重,包括尊严、保密性和自主性三个方面;第二部分为以病人为中心,包括及时性、社会支持、基本设施质量和选择性四个方面,反应性一词往往被等同与病人满意度,反应性与病人的满意度和服务质量是有区别的,尽管它们之间有许多相同之处,它们的主要区别有：（1）范畴：病人的满意度主要体现在特定卫生服务环境下对医疗活动的反应,而反应性则是对整修卫生系统的评价。（2）范围：病人的满意度包括医疗和非医疗两个方面,而反应性仅指卫生系统的非医疗方面。（3）原理：病人的满意度是根据个人的期望和医疗活动经历,对已接受的服务进行的评价。测量卫生系统反应性的重要性主要表现在：（1）了解公众的合理期望是卫生系统管理的核心。（2）反应性是基础。因为它涉及到基本人权,反应性目标的核心就是保护和提高基本人权。（3）卫生系统不需要大量的投入即可改善反应性的部分指标。（4）在卫生系统的三个目标中,反应性的改善可能是最快捷的,因为他不需要大量投入,同时,干预措施的结果可立即显现,反应性的改善比健康的改善要快得多。     

对卫生系统反应性评价的几点不同看法

世界卫生组织在《2000年世界卫生报告》中将反应性作为卫生系统绩效评价的一个目标。由于涉及价值观，因此比较不同国家卫生系统反应性需要调节不同人群的期望差异。笔者认为，WHO进行的反应性评价存在一些不足，所得的结论不能反映各国卫生系统反应性的真实水平和分布，应对反应性的理论框架和测量作进一步的探讨。     

山东省两城市婚检机构反应性和满意度分析

目的:了解婚检者在接受婚检服务时的经历、体验和认知,分析婚检机构提供婚检服务的反应性和满意度水平并提出对策。方法:采用多阶段随机抽样方法,对山东省日照、潍坊两市2003年10月1日后登记结婚者进行问卷调查。结果:对婚检机构反应性和满意度的总体评价普遍不高,自主性、选择性、交流等方面存在较大问题。结论:今后要进一步规范服务,提高婚检机构服务质量,简化就诊流程,缩短就诊时间,同时要充分尊重婚检者的自主权。     

Internal consistency reliability is a poor predictor of responsiveness

Background  

Whether responsiveness represents a measurement property of health-related quality of life (HRQL) instruments that is distinct from reliability and validity is an issue of debate. We addressed the claims of a recent study, which suggested that investigators could rely on internal consistency to reflect instrument responsiveness.     

Measuring health status: What are the necessary measurement properties?

The different measurement properties necessary for instruments whose goal is to detect differences between subjects at a single point in time (discriminative instruments) and those whose goal is to detect longitudinal change within subjects (evaluative instruments) is becoming increasingly recognized. Up to now, requirements for evaluative instruments have been presented as reproducibility, validity, and responsiveness (i.e. the ability to detect change over time). An alternative conceptualization would characterize any instrument as requiring two crucial measurement properties. One is validity, the other a high ratio of signal to noise. For discriminative instruments, the signal to noise ratio can be summarized in a reliability coefficient; for evaluative instruments, in a responsiveness index or coefficient. This formulation can simplify and clarify the understanding and teaching of issues in health status measurement.     

General practitioners' evaluation of community psychiatric services: responsiveness to change of the General Practitioner Experiences Questionnaire (GPEQ)

Background  

Instruments have been developed to assess professional views of the quality of care but have rarely been tested for responsiveness to change. The objective of this study was to test the responsiveness of the General Practitioner Experiences Questionnaire (GPEQ) for the measurement of Community Mental Health Centres in Norway.     

On assessing responsiveness of health-related quality of life instruments: Guidelines for instrument evaluation

A lack of clarity exists about the definition and adequate approach for evaluating responsiveness. An overview is presented of different categories of definitions and methods used for calculating responsiveness identified through a literature search. Twenty-five definitions and 31 measures were found. When applied to a general and a disease-specific quality of life questionnaire large variation in results was observed, partly explained by different goals of existing methods. Four major issues are considered to claim the usefulness of an evaluative health-related quality of life (HRQL) instrument. Their relation with responsiveness is discussed. The confusion about responsiveness arises mostly from a lack of distinction between cross-sectional and longitudinal validity and from a lack of distinction between responsiveness defined as the effect of treatment and responsiveness defined as the correlation of changes in the instrument with changes in other measures. All measures of what is currently called responsiveness can be looked at as measures of longitudinal validity or as measures of treatment effect. The latter ones tell us little about how well the instrument serves its purpose and are only of use in interpreting score changes. We therefore argue that the concept of responsiveness can be rejected as a separate measurement property of an evaluative instrument.     

A Patient-Reported Outcomes Measurement Information System Short Form for Measuring Physical Function During Geriatric Rehabilitation: Test-Retest Reliability,Construct Validity,Responsiveness, and Interpretability

ObjectivesTo study the test-retest reliability and measurement error, construct validity, responsiveness, interpretability, and floor/ceiling effects of a Patient-Reported Outcomes Measurement Information System (PROMIS) short form designed to measure physical function in geriatric rehabilitation patients (PROMIS-PF-GR).DesignProspective cohort.Setting and ParticipantsInpatient geriatric rehabilitation patients.MethodsWe evaluated the test-retest reliability by re-administering PROMIS-PF-GR 3 to 5 days after the admission measurement. The intraclass correlation coefficient (ICC) was calculated to determine test-retest reliability; an ICC of ≥0.70 was considered sufficient. Measurement error was established by calculating the standard error of measurement and smallest detectable change. Construct validity and responsiveness were determined by testing a priori formulated hypotheses (criterion: ≥75% hypothesis not rejected). Interpretability was evaluated by calculating the minimal important change using predictive modeling and a global rating as criterion for change. Floor/ceiling effects were established by calculating the percentage patients with the minimum/maximum raw score (criterion: ≤15%) at admission and discharge.ResultsA total of 207 patients participated in the study [mean ± standard deviation age (80 ± 8.3 years), 58% female]. More than one-half of patients (56%) reported to be improved during rehabilitation. The ICC was 0.79 (95% confidence interval 0.70–0.84), the standardized error of measurement was 3.8, and the smallest detectable change 10.6. None of the 4 hypotheses for construct validity were rejected; 2 out of 5 hypotheses for responsiveness were rejected. The minimal important change was 8.0 (95% confidence interval 4.1–12.5). No floor/ceiling effects were found.Conclusions and ImplicationsThe PROMIS-PG-GR showed sufficient test-retest reliability, measurement error, and construct validity. We did not find sufficient evidence for responsiveness, which may be due to the unexplained weak correlation between the PROMIS change score and the Global Rating Scale. We still recommend the use the PROMIS-PG-GR for measuring self-reported physical function in geriatric rehabilitation.