预防保健与就医诊疗课件

預防保健與就醫診療台灣家庭醫學醫學會秘書長李汝禮預防保健與就醫診療台灣家庭醫學醫學會秘書長李汝禮1前言：醫師是做什麼的？醫生，古代稱大夫或郎中，指學習醫學或行醫的人，醫生也叫杏林，專指醫術精良，醫德高尚的醫家。華陀Hippocrates

前言：醫師是做什麼的？醫生，古代稱大夫或郎中，指學習醫學或行2民眾的健康醫療照護就醫診療(diseasetreatment)預防保健：疾病預防(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療照護就醫診療(diseasetreatmen3就醫診療S(SubjectiveData）：自覺症狀徵候，包括主訴、現在病史、過去病史及個人史…。O(ObjectiveData)：檢查發現，包括診療發現及各種檢查報告…。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、醫令或處方。就醫診療S(SubjectiveData）：自覺症狀徵候4預防保健篩檢screening群眾篩檢vs個人病例發現(case-finding)諮詢介入(counselingintervention)疫苗接種(immunization)化學預防(chemoprophylaxis)預防保健篩檢screening5預防性健康照護的實證依據美國預防服務工作小組(U.S.PreventiveservicesTaskforce,USPSTF)加拿大預防性健康照謢工作小組(CanadianTaskForceonPreventiveHealthCare,CTFPHC)社區工作小組(CommunityTaskForce,CTF)預防性健康照護的實證依據美國預防服務工作小組(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预防保健与就医诊疗课件31謝謝聆聽敬請指教！祝您健康、幸福！家醫學會李汝禮謝謝聆聽敬請指教！祝您健康、幸福！家醫學會李汝32預防保健與就醫診療台灣家庭醫學醫學會秘書長李汝禮預防保健與就醫診療台灣家庭醫學醫學會秘書長李汝禮33前言：醫師是做什麼的？醫生，古代稱大夫或郎中，指學習醫學或行醫的人，醫生也叫杏林，專指醫術精良，醫德高尚的醫家。華陀Hippocrates

前言：醫師是做什麼的？醫生，古代稱大夫或郎中，指學習醫學或行34民眾的健康醫療照護就醫診療(diseasetreatment)預防保健：疾病預防(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療照護就醫診療(diseasetreatmen35就醫診療S(SubjectiveData）：自覺症狀徵候，包括主訴、現在病史、過去病史及個人史…。O(ObjectiveData)：檢查發現，包括診療發現及各種檢查報告…。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、醫令或處方。就醫診療S(SubjectiveData）：自覺症狀徵候36預防保健篩檢screening群眾篩檢vs個人病例發現(case-finding)諮詢介入(counselingintervention)疫苗接種(immunization)化學預防(chemoprophylaxis)預防保健篩檢screening37預防性健康照護的實證依據美國預防服務工作小組(U.S.PreventiveservicesTaskforce,USPSTF)加拿大預防性健康照謢工作小組(CanadianTaskForceonPreventiveHealthCare,CTFPHC)社區工作小組(CommunityTaskForce,CTF)預防性健康照護的實證依據美國預防服務工作小組(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