卫生政策系统评价方法探讨

获得高质量的证据是循证决策的关键,系统评价作为生产证据的方法已经在医学科学领域得到认可与应用,循证医学系统评价方法日渐完善,但由于卫生政策研究的范畴、方法、研究对象等的特殊性,导致循证医学系统评价方法无法直接在卫生政策领域应用。本研究在世界卫生组织卫生政策联盟的资金与技术支持下,从2006年开始进行卫生政策领域系统评价方法的学习与研究,探索出“两段式卫生政策系统评价方法”,并进行了实证研究。本文主要介绍该方法的关键技术,包括纳人研究的质量评价、数据整合和分析方法,并提出该方法需要进一步完善的方向。     

系统评价是发展中国家卫生系统循证研究的有效工具吗?

越来越多的卫生体制研究人员运用系统评价的方法来综合研究证据,促进全球和国家的卫生政策发展。然而,在卫生体制研究中开展卫生政策文献的系统评价面临方法学上的挑战。本文探讨了系统评价作为一种研究工具,在发展中国家卫生体制循证研究中的应用前景及局限性。文中首先简要介绍了系统评价方法及其在卫生研究领域过去数十年的发展,然后讨论了卫生体制研究作为系统科学的定义,并将其特点与医学研究相比较,最后讨论和分析了系统评价能否成为发展中国家卫生体制循证研究的有效工具。我们认为,系统评价可能会是卫生体制循证研究中解决特定政策问题的一种非常有用的工具,然而,在某些卫生体制及卫生政策问题的研究上,系统评价方法并不适用。     

通过改进挽留政策提高农村和边远地区卫生人力的可及性:WHO2010全球政策建议解读

农村和边远地区卫生人力资源不足是世界各国普遍关注的卫生问题之一,严重影响卫生公平的实现.对此,WHO提出全球政策建议——通过改进挽留政策提高农村和边远地区卫生人力的可及性.本文重点从循证医学方法学和指南制定角度,对该政策指南制定的关键步骤进行解读,主要包括背景及问题的提出、证据的检索与遴选、证据质量分级与推荐方案形成,从而进一步探讨卫生决策过程中如何正确认识、获得、评价与应用当前可得的研究证据,以及如何基于证据,利用GRADE系统做出科学可行的推荐,强调证据及GRADE系统在循证卫生决策中的重要作用.     

知证卫生决策工具之一——什么是知证决策

本文讨论以下3个问题：①什么是证据？②研究证据在知证卫生决策中有何作用？③什么是知证决策？知证卫生决策是一种决策方法,旨在保证基于最佳可及的研究证据做出决策。知证决策的特点是将系统、透明地获取和评价证据的方法引入决策全过程。虽不要求制定政策的整个过程系统和透明,但在制定政策的全过程,采用系统的步骤可以确保合理地查找、评价和使用相关研究。过程透明化旨在确保他人可以检查什么样的研究证据被用于支持决策并评价证据及其意义。知证决策帮助政策制定者了解这些过程。     

卫生决策中对系统评价的十大认识误区

随着循证实践的蓬勃开展,系统评价证据越来越被视为决策的可靠依据,特别是在时间紧急,任务重要,且干扰因素多的情况下,其优势更为凸显。但在非医学领域中,对循证实践及系统评价作用的认知还存在一定局限性,许多认识误区阻碍了系统评价方法在卫生决策领域的推广与使用。本文以健康干预实践证据为例,探讨系统评价在卫生决策领域的作用,力图澄清这些认识误区,推动系统评价的发展。     

循证医学与临床实践

目前循证医学方法学已广泛应用于临床医疗实践,指导、制定临床各科疾病的治疗方案,评价药物、治疗方案的有效性、适用性,以及为政府部门制定卫生政策、新药的研究、开发评价提供证据,并已形成了许多相关学科。介绍循证医学对临床医疗、中医药发展和药学研究的影响及其临床指导作用,提倡在临床医疗实践中,充分应用循证医学的原则与方法,为临床、科研、卫生决策、医学教育提供最佳证据,并应用最佳证据指导临床决策。     

循证医学与临床实践

目前循证医学方法学已广泛应用于临床医疗实践，指导、制定临床各科疾病的治疗方案，评价药物、治疗方案的有效性、适应性，以及为政府部门制定卫生政策、新药的研究、开发评价提供证据，并已形成了许多相关学科。介绍循证医学对临床医疗、中医药发展和药学研究的影响及其临床指导作用，提倡在临床医疗实践中，充分应用循证医学的原则与方法，为临床、科研、卫生决策、医学教育提供最佳证据，并应用最佳证据指导临床决策。     

Cicgrabe系统评价的基本方法

Cochrane系统评价是Cochrane协作网成员在Cochrane协作网统一工作手册的指导下所作的系统评价，是循证医学的临床实践指南，通过收集、汇总和评价原始临床研究结果，得出有关干预措施的综合结论，为临床实践和卫生决策提供真实、可靠的证据。与传统综述不同，他采用了科学、明确、可重复的研究方法以减少偏倚因素的影响。了解Cochrane系统评价的基本方法，对进行Cochrnae系统评价的研究人员有所帮助。     

Cochrane图书馆--循证医学的重要资料库

循证医学是指遵循科学依据的医学,提倡在临床实践中将个人经验、病人的需求与当前最佳科学依据结合起来进行医疗决策,倡导根据研究依据和个人经验处理病人.循证医学最可靠的证据来自按照特定方法收集所有质量可靠的随机对照试验(randomized controlled trial,RCT)后所作的系统评价(systematic review,SR).目前SR的结果正成为许多发达国家卫生决策的参考依据,影响着这些国家的医疗实践、卫生决策、医疗保险和医学教育,促进临床研究与实践进入一个全新的时代,即从经验医学到循证医学.     

非随机研究的系统评价

1 非随机化研究系统评价的必要性 循证医学强调利用最佳研究证据进行临床和医疗卫生决策。然而,所谓“最佳证据”是相对而言的,是根据决策者所能够得到的证据而言。在卫生资源相对匮乏的发展中国家,有时候要想获得高质量的研究证据是困难或不可及的,此时的卫生决策     

Bringing health services research to (and from) critical care

Health services research has the potential to improve the care provided to patients in critical care settings by informing the decisions of managers and policy makers who establish many of the rules within which critical care is provided. Living up to this potential requires health services researchers in critical care to enhance the relevance of their research for managerial and policy decision makers and to undertake initiatives to increase the uptake of this research by these decision makers. Researchers can begin by asking questions from the perspective of managers and policy makers, not just from the perspective of patients and clinicians. Researchers can also design studies that will generate valid and generalizable research findings that can be acted on by these decision makers, not just studies that describe a problem or test new methods to describe a problem. Health services research is, after all, an applied field. But researchers may not want to stop there: they can engage in coordinated efforts to facilitate the uptake of their re-search findings, and do so by drawing on our evolving understanding of what works best with these decision makers. Opportunities such as the relaunch of a journal that takes seriously the challenge of informing decision making do not come along often. We hope researchers will rise to the challenge. Copyright © 2002 by W.B. Saunders Company     

The clinical-economic trial: Promise,problems, and challenges

The clinical-economic trial is a study design that is appearing with greater frequency in medical and public health literature. Some experienced investigators view these trials with skepticism; to policy makers they represent a promising step in the control of rising health care costs. The success of clinical-economic trials in meeting the important goal of more rational and efficient use of health care resources will depend on the strengths and limitations of the research method. As part of a report to the Office of Technology Assessment of the U.S. Congress on new health care assessment techniques, we describe the reasons why economic data collection and analysis are being considered in clinical trials, identify and discuss various designs and methods for gathering economic trial data, and evaluate the strengths and limitations of different methods for providing sound data for decision making on appropriate use of health care interventions. Because of the potential significance and increasing visibility of such research, experts in research methods should give more attention to methodological research for clinical-economic trials. Future efforts should be directed at comparing different techniques for collecting data, examining the incremental value of precision in economic measurements and ensuring appropriate interpretation of data from clinical-economic trials.     

Producing systematic reviews of interventions in speech–language pathology: A framework for sustainability

Systematic reviews in the health and social sciences are increasingly recognized as a valuable scientific tool to support decision making by clinicians, managers, administrators, and policy makers. Numerous organizations have arisen to fulfill growing demand for high-integrity systematic reviews with practical applications, each with a unique model for their review production process. This paper presents the results of a purposive sample of current production models in use by organizations engaged in the production of systematic reviews to support evidence-based practice. This paper also evaluates elements of review production such as major review steps, evidence standards, resource use, and cost. The results provide a potential framework for organizing resources to conduct systematic reviews. Applying this framework, producers can identify key areas of systematic-review production with the best fit between individual production models and their organization's mission and policy environment.     

The limitations of 'evidence-based' public health

This paper examines how the concept of the 'evidence-based' approach has transferred from clinical medicine to public health and has been applied to health promotion and policy making. In policy making evidence has always been interpreted broadly to cover all types of reasoned enquiry and after some debate the same is now true for health promotion. Taking communities rather than individuals as the unit of intervention and the importance of context means that frequently randomized controlled trials are not appropriate for study of public health interventions. Further, the notion of a 'best solution' ignores the complexity of the decision making process. Evidence 'enlightens' policy makers shaping how policy problems are framed rather than providing the answer to any particular problem. There are lessons from the way that evidence-based policy is being applied in public health that could usefully be taken back into medicine.     

Bridging science to service: using Rehabilitation Research and Training Center program to ensure that research-based knowledge makes a difference

The challenge of bridging science to service is increasingly visible in the healthcare field, with emphasis on the influence of evidence-based knowledge on both policy and practice. Since its inception more than 40 years ago, the Rehabilitation Research and Training Center (RRTC) program has provided grants for both research and training activities designed to ensure that research knowledge is translated into practice. The RRTC program is unique in that its mission and funding have always required that both time and money be invested in the translation and dissemination of research-generated knowledge to users in the field, i.e., decision makers and practitioners. Boston University's Center for Psychiatric Rehabilitation has been an RRTC for more than 25 years and provides an example of the effect of the RRTC program in bridging science to service. The Center's mission as an RRTC has been to develop and transfer research knowledge to decision makers and practitioners who can then inform change and promote progress in mental health disability policy and practice. This article reviews five basic dissemination and utilization principles for overcoming the most common barriers to effective dissemination of evidence-based knowledge and provides examples of the Center's activities related to each principle. In addition, a knowledge-transfer framework developed by the Center to organize dissemination and utilization efforts is described.     

An example of the use of systematic reviews to answer an effectiveness question

Systematic reviews assist nurses, other health care providers, decision makers, and consumers in managing the explosion of health care information by synthesizing valid data and reporting the effects of interventions. Nurses are increasingly using systematic reviews to guide their practice and develop policy. The purpose of the article is to outline the steps involved in conducting a systematic review with examples taken from a systematic review titled "Strategies to Manage the Behavioral Symptoms Associated With Alzheimer's Disease." The steps of a systematic review include: (a) formulating a well-defined question, (b) developing relevance and validity tools, (c) conducting a comprehensive search to retrieve published and unpublished reports, (d) assessing the reports using relevance and validity tools, (e) data extraction, (f) synthesis of the findings, and (g) report writing. Understanding the steps involved in a systematic review will assist nurses in critically appraising reviews and in conducting their own reviews.     

W(h)ither complexity? The emperor's new toolkit? Or elucidating the evolution of health systems knowledge?

Rationale The outputs from vastly expanding health research and knowledge industry with a broadening range of approaches to the synthesis of knowledge provide an impetus to develop complex science and theory‐informed knowledge management in health care. Aims To stimulate debate in order to assist health care decision makers to move beyond framing certainty and evidence in purely reductionist terms. Objectives To locate health, health care and health knowledge systems research using a complex adaptive systems theory framework. Methods An conceptual analysis of pervading methodologies and ways of knowing in health systems research to elucidate a framework in order to inform health care decision making. Findings A living Tree of (Research) Knowledge is proposed, with theoretic and operational frameworks. Branches of the tree are linked to differing evolutionary and developmental processes in order to assist researchers in the ongoing self‐organizing of taxonomies, multiple methods and types of knowledge, recognizing the ‘lived’, developing and adaptive nature of our understandings. Conclusions It is challenging to determine whither the directions ‘knowledge’ creation and management should take in complex health systems, beyond a total reliance on reductionism. Yet quality will wither, if knowledge does not pertain to real world contexts.     

Recruiting and retaining a diverse workforce in nursing: from evidence to best practices to policy

Health policy makers, providers, clinicians, and social scientists are among those who have identified racial and ethnic diversification of the health care workforce as one strategy for solving the seemingly intractable problem of health disparities in the U.S. population. But evidence supporting the impact of such diversification on narrowing health disparities is lacking, thus making it unclear if the push for workforce diversification is empirically or politically driven. Moreover, data are largely derived from the study of physicians, making it difficult to generalize findings to nursing and other health professions. This article reviews the evidence that supports the impact of a diverse workforce on patient outcomes and delivery services. Assuming a positive social value in the absence of the data, the authors review the approaches that have been successful in diversifying the nursing workforce. The authors conclude with recommendations for research and policies, including best practices, for enhancing recruitment and retention of a diverse nursing workforce.     

Survival of nurse-managed centers: the importance of cost analysis

Despite the explosive growth in nurse-managed centers (NMC) in the past 20 years, most have been unable to achieve financial self-sufficiency, and many have closed. Combining costing techniques with outcome measures provides essential information needed by NMC for making operating decisions and for marketing NMC performance. These outcome data can be persuasive to policy makers and institutional decision makers and are crucial for NMC to improve their competitiveness in the health care market place.