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预防、长寿和医疗改革

(2009-10-29 01:56:12)
标签:

胡德良

预防

心脏病

长寿

医疗改革

alfred

a.

bove

健康

分类: 医疗卫生

预防、长寿和医疗改革

阿尔弗雷德·A·博弗(Alfred A. Bove):医学博士、美国心脏病学会基金会会长

 Longevity, Prevention, and Health Care Reform

By Alfred A. Bove  胡德良 

 I want to discuss prevention in this month's President's Page, but I am hesitant to use the word "prevention" because there are some who say that prevention is too expensive and that we cannot afford a health system that is responsible for caring for people into their 90s. Prevention has taken on a significant role as a goal in health care reform discussions. Primary care providers point to prevention as one of their main advantages, and prevention is put forward as a major means of reducing health care costs. We have seen the evolution of entire industries aimed at keeping people healthy into old age—or, even better, at preventing aging in the first place.

 在本月的会长专版中,我想讨论一下预防的事情,但是我对使用“预防”这个词又感到犹豫不决,因为有人说预防的代价太昂贵,我们拿不出大量的资金来建立一个负责让人们活到90多岁的保健体制。然而,作为医疗改革讨论中的一个话题,预防起着重要的作用。主要的医疗保健单位把预防作为自己的主要优势之一,而且预防被推举为减少医疗花费的主要手段。我们已经看到,在整个医疗卫生事业的发展中,把目标定位在保持人们的健康老龄化,或者从更为理想的角度说,首先要控制人们的衰老进程。

 Prevention as it relates to longevity would enable people to participate in the workforce for more years, contributing their training and experience, and in general, one would expect high efficiency from these healthy middle-aged and older workers. Prevention and longevity in a different context relate to how most people envision their retirement as a time of travel and leisure. They do not usually consider it as a time of frequent hospital admissions and physician visits to maintain stability with a chronic disease.

 由于预防跟长寿相关,所以预防可以延长人们的工作年限,可以使他们把自己的技术和经验充分地贡献出来。总之,雇主期望这些健康的中老年人能够高效地工作。在不同的环境中,健康和长寿跟多数人对退休生活的展望有关:他们把退休后的时间看作是旅游休闲的时光,通常不会把这段时间看作是不断住院的时期,或者是为了稳定慢性病的病情而经常看医生的时期。

 However, in all of its permutations, prevention is clearly a process that involves the individual patient more than the physician. Indeed, a physician's contribution is focused primarily on medical therapies, while patients must be focused on maintaining a normal body weight, following healthy behaviors such as not smoking and foregoing excess alcohol or other drugs, exercising adequately, following a healthy diet, adhering to medication orders, and visiting their health care providers periodically for screening of early disease.

 然而无论如何变化,预防过程显然跟病人自己的关系更为密切,跟医生的关系倒不那么密切。的确,医生的作用主要是医治;而病人则必须注意保持正常的体重、按照健康的行为规范去行事,如:不吸烟、不过度饮酒、不过度使用其他药物、进行充分的锻炼、保持健康的饮食、用药遵守医嘱、定期去医疗保健单位进行检查以便有病早发现,等等。

 Cardiologists should encourage their patients to maintain healthy behavior and provide them with guidance on reducing cardiovascular disease (CVD) risk. Interestingly, I find that patients understand the concept of longevity better than the concept of prevention. Perhaps it is because longevity describes health maintenance goals with distant time horizons, while prevention sounds like medical therapy for the present only. Patients grasp that lowering blood pressure to normal levels and taking medication on a long-term basis will get them to their mid-80s in good health. This makes more sense conceptually than taking medicine to avoid a stroke.

 心脏病学家应该鼓励病人们保持健康的行为方式,为他们提供指导,以减少心血管疾病的患病风险。有趣的是,我发现人们对长寿的观念比对预防的观念理解得更为深刻。或许这是因为长寿描述了长期的保健目标,而预防听起来象只跟目前有关的医疗行为。病人们知道:把血压降到正常水平并长期服药,就能够使自己健康地活到八十五、六岁。从观念来讲,这样做比仅仅为了预防中风而服药更加有意义。

 The Cardiologist's Role

 心脏病学家的作用

 Trying to manage prevention in otherwise healthy people would overwhelm both cardiologists and primary care physicians. In their study of CVD history, Ford et al. (1)showed that 43% of the reduction in cardiovascular deaths was due to lifestyle changes, and 47% could be attributed to improved cardiovascular care. Yet, public campaigns still emphasize more immediate goals, and many people who start on prevention programs soon lose interest because they see no immediate effects. Often they need to take a medication for hyperlipidemia or hypertension, and because they see no apparent short-term advantage, they stop taking the medication.

 让其他方面都健康的人们进行预防,使心脏病学家们和从事一线治疗的医生们都感到难以应付。厄尔·S·福特等人(在2007年7月出版的《新英格兰医学杂志》上发表论文,)证明心血管疾病的死亡率降低了,究其原因,43%是因为生活方式的改变,47%可能要归功于心血管疾病治疗水平的提高。然而,公众在保健运动中仍然注重立刻达到目的。由于不能够立即见效,很多人的预防计划开始之后不久就失去了兴趣。这些人通常需要服用治疗高血脂或高血压的药物,但是因为短期内看不到明显的益处,他们就停药了。

 However, cardiologists have a limited prevention role when it comes to seemingly healthy people. Despite the high number of asymptomatic people who have hypertension, many—particularly those who are 35 to 50 years old—will not make contact with a health care provider until they develop a cardiovascular event. By that time, it is too late for prevention. Cardiologists are most likely to be visited by patients seeking care for cardiac disorders. It is rare for an asymptomatic, young person to visit a cardiologist.

 然而对于表面看起来健康的人,心脏病学家们在预防方面所起的作用是有限的。尽管患有无症状高血压的人数量很多,可是许多人——尤其是那些介于35至50岁之间的病人,他们往往在发生心血管事件之后才跟医疗保健机构进行联系,但是到那个时候预防就太晚了。病人很可能为了治疗心脏病来找心脏病医生,没有症状的年轻人来看心脏病医生的情况很罕见。

 Prevention Costs and Health Care Reform

 预防的花费和医疗改革

 Studies that assess the cost for a quality life-year usually demonstrate excess cost for prevention if a statin or an antihypertensive medication is needed. With lifestyle changes alone (weight control, exercise, not smoking, and a balanced diet), the cost of prevention is very low. Health care economists indicate that a cost of $50,000 for a quality life-year would be an acceptable balance between outcome and cost. In most cases, statin use for prevention of atherosclerosis in individuals in the 40- to 50-year age range exceeds this number, and as a population benefit, cost would be prohibitive.

 通常,有关评估质量生命年花费的研究表明:如果需要一种斯他汀类药物或一种抗高血压的药物,那么预防的花费就会过多。单纯靠生活方式的改变(如:控制体重、进行锻炼、不吸烟和采取平衡饮食)来预防,花费是很低的。卫生经济学家们指出:权衡一下病情会造成的恶果和预防花费,每个质量生命年花掉5万美元还是可以接受的。在很多情况下,40至50岁年龄段的病人利用斯他汀类药物来预防动脉硬化症,花费都超过了这个数目。因此考虑到整个得病人群的利益,预防的花费是极高的。

 However, cost cannot be the only factor considered, particularly if we believe there is a societal imperative to provide good health into later life. Currently we have a moral imperative to provide good care for our patients, to diagnose and treat disease, to reduce morbidity and mortality, and to ensure a productive life for them into their 80s.

 然而花费不可能是唯一要考虑的因素,特别是如果我们相信让人们健康地活到晚年是一种社会需要,就更不能只考虑花费的问题了。目前从道义上来讲,我们也需要为我们的病人提供良好的医疗服务,为他们诊治疾病,减少他们的患病率和死亡率,保证他们在80多岁的时候仍能做出贡献。

 Many say that cost should not dominate in these decisions, and I agree. If providing good care means medication for controlling lipids and blood pressure or prescribing an antiplatelet agent to prevent stent thrombosis, the patient's well being should predominate over cost.

 很多人说,在作出这些决定时不应该让花费问题占主导地位,我同意这种说法。如果提供一种有效的预防意味着开出控制血脂和血压的药方,或者意味着开出一种抗血小板的药方来预防支架内血栓形成,那么占主导地位的应该是病人的利益,而不应该是花费问题。

 On the other hand, in the cases of therapies that have been proven to not add longevity, cost does become an important consideration. It is this concern over the cost of inappropriate therapies and tests that is a key element of the current health care reform debate.

 另一方面,事实证明一些治疗方法不能延长病人的寿命,在这种情况下,花费确实成为一个值得考虑的重要问题。人们关心在不合适的治疗方案和实验方面所投入的花费问题,这个问题也正是目前医疗改革中争论的一个关键话题。

 Secondary Prevention and Continuity of Care

 二级预防及连续医护

 In the prevention of subsequent illness in patients who have CVD, which is considered secondary prevention, much of the effort involves continuity of care. Treatment of hypertension can be done with home monitoring and reporting. Heart failure is best stabilized over time with frequent communications by telephone or other means, and patients with arrhythmias and/or implanted devices need frequent surveillance to remain in a stable state of health. Patients with chronic coronary disease need medication, lifestyle changes, exercise programs, and frequent surveillance to maintain stable health.

 预防心血管疾病的再度发病,被认为是二级预防,为二级预防所进行的多半努力都跟连续医护有关。高血压的治疗可以伴随着家庭监视和家庭报告来进行;随着时间的推移,不断地通过电话或其他方式与医生进行沟通,这样最有利于心力衰竭患者的病情稳定;心律不齐患者、心脏器械植入患者和两种情况兼有的患者需要不断地进行监测,以维持稳定的健康状况;慢性冠心病患者需要药物治疗、改变生活方式、制定锻炼计划、不断地接受监测,以保持稳定的健康状况。

 However, at present, physicians are not reimbursed for providing either primary or secondary prevention programs. That said, prevention and continuity of care programs are performed using telephone, e-mail, or other Internet-based communication systems. When successful, these programs reduce morbidity, hospital days, emergency visits, and even regular office visits for which we are currently paid.

 然而,目前医生们没有因为提供了一级预防或二级预防计划而得到报酬。也就是说,预防和连续医护计划都是通过电话、电子邮件和其他基于互联网的通讯系统进行的。一旦这些计划进行得成功,发病率就会降低,住院天数就会减少,急诊病例就会减少,甚至正常的门诊就医数量也会减少,而这些我们通常都是可以得到报酬的。

 In this time of intense debate about health care reform, it is essential that we move the reimbursement system toward recognition of the value of continuity of care and prevention. Our goal of providing a program that fosters cardiovascular health for individual patients, and for the public at large, can be met with programs focused on these goals, but we cannot provide this service if there is no compensation.

 在这次有关医疗改革的激烈争论中,有必要将医疗行业的收费体制跟连续医护和预防结合起来。我们的目标是制定一个计划,促进心血管疾病患者的健康和全部公众的健康。我们所遇到的情况可能是,仅仅注重实现这些目标的系列计划,但是如果没有报酬的话,我们是无法提供这种服务的。

 In the health care debate, the American College of Cardiology has taken the position that there should be reimbursement for continuity of care by cardiologists. This argument also applies to the need to provide more reimbursement to primary care physicians. For patients with chronic CVD, we should take this role and should be compensated appropriately. If the mix of payments covers usual office visits, the needed procedures and tests, and continuity of care for primary and secondary prevention, we might reduce the dependency on tests for practice income and avoid the pressure for price controls that we know is an unsuccessful means of controlling health care costs. The health care reform debate should lead to legislation late in 2009, and the legislation should include meaningful payment reform that is aimed at improving health, instead of paying for sickness.

 在医疗保健的争论中,美国心脏病学会的所采取的立场是:心脏病学家应该通过连续医护而得到报酬。学会的论点还认为,需要为一线的医师提供更多的报酬。对于患有慢性心血管疾病的病人,我们应该担负起医护的任务,也应该得到相应的报酬。如果各种付费包括了平常的门诊收费、必要的手续费和检验费、为一级预防和二级预防而进行的连续医护费,那么我们医疗收入可能就会减少对检验费的依赖,或许就可以避免价格控制所带来的压力,而我们知道价格控制并不是控制医疗费的成功手段。到2009年年底,有关医疗改革的争论应该会导致立法的产生,这部立法应该包括具有影响意义的付费改革,付费改革的目标是:要为了改善健康状况而付费,并不是为了看病而付费。

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