Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Lown Institute, Brookline, MA, USA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Lancet. 2017 Jul 8;390(10090):191-202. doi: 10.1016/S0140-6736(16)32586-7. Epub 2017 Jan 9.
The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective-ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
本系列前几篇论文概述了在医疗服务生产的复杂系统中，由于多种原因，医疗服务的使用不足和过度使用是如何发生的。由于不良医疗护理普遍存在，并对全球数十亿人的健康和福祉产生重大影响，因此，纠正这一问题在道德和政治上都是紧迫的任务。全民健康覆盖是实现适当医疗的关键步骤。因此，充分考虑潜在的变革杠杆必须包括一个上游视角，即理解导致过度使用和使用不足的系统层面因素，以及在临床接触中起作用的各种激励因素。系统层面因素的一个例子是分配资源（例如，医院床位和临床医生）以满足当地人口的需求，从而最大限度地减少过度使用或使用不足。另一个例子是使用卫生技术评估等工具进行优先排序，以指导安全、有效和具有成本效益的医疗服务的最佳扩散。在本系列论文中，我们研究了消除医疗服务使用不足和过度使用的一系列杠杆。一些杠杆可以在许多不同的卫生和政治系统中有效运作（例如，通过决策支持增加患者的积极性），而其他杠杆则必须针对当地情况进行调整（例如，根据特定的成本效益比做出覆盖决策）。理想情况下，政策必须超越纯粹的增量；也就是说，政策仅仅在出现使用不足或过度使用之后才在政策边缘进行调整。在这方面，提高公众意识、动员和赋权的努力作为普遍方法具有很大的希望，可以重置所有其他背景，并由此增强促进适当医疗的所有其他努力。
