【作者】 张成琪；

【导师】 孟庆跃； 薛付忠；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 健康体检是面向社会绝大多数没有主观症状的受检者通过医学检查,尽可能的发现不易觉察的疾病或疾病隐患,从而达到有病早治,无病早防的目的。健康体检是健康管理的重要途径,是现代人对健康本质认识的不断深化,注重健康思维的充分体现。健康水平的提高和健康消费的发展也是社会发展、社会文明的重要标志。通过定期健康体检可以早期发现潜在的疾病,及时予以治疗;早期了解健康指标,监测身体各项功能状态的变化;早期改变不良生活、工作习惯,避免危险因子诱发健康问题。规范和有效的健康体检可以实现双重效益,即社会效益和经济效益。社会效益主要体现在健康体检可以促进个人健康,提高全民健康素质。经济效益主要体现在健康体检可以减轻个人医疗负担,节省医疗费用支出;盘活医院资源,增加医院效益;拉动健康内需,促进经济发展,推动健康产业。目前,国外对体检资料的研究较多的是如何做好健康管理,如何利用健康体检数据库构建健康风险评估(health risk appraisal HRA)体系预测疾病或死亡风险等,尚未见健康体检服务包研制的相关研究。我国健康体检的历史,虽然只有短短的20年,但已经形成了初具规模的“健康体检市场”。目前国内对体检资料的研究多是对个人健康状况调查结果的分析与评估,或对每年的健康体检结果的检出率、患病率的统计或相关因素的分析,也未见对健康体检服务包的系统研究。然而,在健康体检产业的发展过程中,无论是其市场运行机制还是其体检服务内容的科学性等方面,均存在许多问题。例如,卫生主管部门尚未把健康体检列入综合医院服务范围,体检中心定位不明确,缺乏相应的管理办法;各健康体检机构没有规范的运行模式,其规模、场所、设备、体检项目、服务水平等均没有相应的行业标准;许多健康体检中心服务单一、价格昂贵,辖区内一般居民无机会利用。更为突出的是许多健康体检机构推出的形式多样的“健康体检套餐”,这些套餐主要是以盈利为目的,根据自身开设的体检项目及服务价格并结合体检对象的需求和支付能力来制定,缺乏严格的科学依据,没有考虑到利用现有检查手段最大限度的检出疾病及阳性提示,也未针对不同性别不同年龄组和疾病谱的变化制定不同层次的健康体检服务包。本研究遵循体检服务提供方和体检服务需求方利益最大化原则,从实际出发,依据世界卫生组织健康体检项目选择建议,结合流行病学、临床医学、卫生经济学等学科理论,利用医学统计学方法,制定不同层次、不同需求的健康体检服务包。本研究以山东省某省级综合医院体检中心城镇职工健康体检数据为基础建立研究数据库,以城镇职工为目标人群,提出两个健康体检服务包的研制方案。第一个方案特需健康体检服务包:按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和人体解剖系统分类疾病谱研制的系统体检服务包,按人体解剖系统确定体检项目,研制系统健康体检服务包。第二个方案基本健康体检服务包:按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和系统聚类方法,研制分性别、年龄健康体检服务包。根据疾病或阳性提示在目标人群中的描述流行病学分析,进行分层设计:首先将样本按性别分为男性和女性两个亚群体,然后分别在男性和女性的两个群体中采用聚类分析,以疾病及阳性提示的年龄别检出率为聚类指标对年龄组进行聚类,划分体检服务包的层次。本研究的总目标为通过服务包的研制规范体检市场,提高体检质量和效率,保证体检结论的真实性和可靠性,使体检收费公开、透明、规范,进而为政府部门制定科学的健康体检产业法律、法规提供科学依据。研究结果:1、基于人体解剖系统的特需健康体检服务包按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和人体解剖系统分类疾病谱研制了9个特需健康体检服务包:呼吸系统、循环系统、消化系统(肝、胆、胰、脾服务包和胃、肠服务包)、泌尿系统、血液系统、内分泌代谢系统、神经骨骼系统、妇科、男科体检服务包。体检项目价格严格按照山东省物价局标准统一定价。2、基于性别、年龄、疾病谱的基本健康体检服务包按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和系统聚类方法,研制了10个性别、年龄分层基本体检服务包:(1)4个男性健康体检服务包:男性40岁以下健康体检服务包,男性40岁～49岁健康体检服务包,男性50岁～59岁健康体检服务包,男性60岁以上健康体检服务包。(2)6个女性健康体检服务包:女性30岁以下健康体检服务包,女性30岁～39岁健康体检服务包,女性40岁～49岁健康体检服务包,女性50岁～54岁健康体检服务包,女性55岁～64岁健康体检服务包,女性65岁以上健康体检服务包。每个年龄组健康体检服务包中,依据疾病或阳性提示在目标群体中的发生概率的高低又分为A、B、C三个层次。服务包A定义为基础体检服务包,对机体确实需要检查或经济实力允许的体检对象可自由组合服务包A、B、C。若选择服务包组合,组合中的项目不重复收费。研究结论:1、按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和人体解剖系统研制了9个特需健康体检服务包满足了不同体检对象的需求。2、按照国际疾病分类标准ICD-10,基于疾病、阳性提示概率分布和系统聚类方法研制的分层基本健康体检服务包以性别、年龄作为服务包分层的标准,增加了服务包的可操作性。3、本研究制定的城镇职工健康体检服务包具有一定的适用性和推广应用价值,既兼顾了体检服务提供方的利益也充分考虑了体检服务需求方利益。4、本研究通过城镇职工健康体检服务包的研制,为各类体检人群体检服务包的制定提供了基本思路和方法。建议:1、卫生主管部门应当重视体检服务包的研究工作,为规范健康体检市场创造条件。2、健康体检机构应总结和评价服务包的使用效果,能够从体检的成本和效率等角度选择适宜的服务包,提高健康体检的服务水平。3、健康体检机构应重视体检信息的收集、整理和分析工作。4、在规范健康体检服务包的基础上,宣传健康体检的重要性,加大政府投入,增强居民健康投资意识,提倡健康体检与健康保险结合,提高健康体检的利用率,充分发挥体检机构为大众健康服务的作用。5、进一步评价健康体检服务包的效益,开展支付意愿调查分析。更多还原

【Abstract】 Physical examination is referred as a tool packages to detect the unobservable disease or the latent period of disease among the people who objectively have no symptom. The aims are to treat the detected diseases as soon as possible on the one hand, and to prevent illness on the other hand. It is an important health care management method to understand the nature of health in peoples’ daily life and to pay attention to improve the healthy behavior. In addition, the improvement of health and health status are an important symbol to present social development and social civilization. The goal of physical examination is to find the potential disease earlier in order to treat and cure the disease as soon as possible; to screen various healthy indicators and then measure the change of various physical functions of a person; to intervene the life behavior to prevent the risk factors affecting health. The criterion and effective physical examination could achieve both social benefit and economic benefit. In other words, social benefit means the improvement of an individual’s health and then lead to the improvement of population health. In addition, economic benefit represents the reduced health expenditures of an individual; the effective reallocation of hospital resource. These could lead to improve the demand for health and then promote the health care industries.At present, the international literature shows that the research of physical examination are focused on how to well manage the physical examination, and the use of physical examination database to establish health risk appraisal system to forecast disease or the risk of mortality. However, there is no detailed research on the physical examination package in China. Although the history of physical examination is just about 20 years, it has growing to a relatively large market for physical examination. So far, the current research for the physical examination is just to the analysis and evaluation of an individual’s health status, or to the factor analysis such as prevalence and mobility rate. There is little research to systematically analyze the physical examination package. In addition, there are still some occurred problems as such the business plan and content of the package in the process of developing the physical examination industry. For example, the integration of physical examination into the boundary of hospital services was not permitted by health authorities. This leads to the objective of physical examination is not clear and then to relevant less managerial method; to nonindustrial standard in accordance with business module, location, equipment, physical examination items, and service level; to less service provided to the general population due to less service item provided and relative expensive prices. In particular, the "combination of physical examination items" provided by hospitals and/or institutions are for profit motivation. Furthermore, the items and service price were not designed in accordance the demand for physical examination and affordability. These are referred as lacking of restrict scientific evidence, of non considering of maximally detecting disease and positive rate, and of various service items to meet the different demand categorized by gender, income, and epidemiological pattern. Therefore, the selective suggestions be made, in accordance with WHO recommended physical examination items, to maximize the benefit of physical examination service providers and demander for the services. A combination theory from epidemiology, clinical medicine, and health economics, able to design various service package to meet different demand. The objective of the study is to design two physical examination item packages, by targeting the particular population, basing on the database obtained from urban employee physical examination results at a specialized hospital in Shandong province.The first package is to design a particularly required physical examination items in line with ICD-10. It is based on disease category, the probability distribution of the positive rate, and disease pattern of anthroponomy. In addition, it ensures the package in line with the disease category.The second is to design a basic physical examination item in line with ICD-10. The physical examination package, designed by income level and age, is based on disease category, the probability distribution of the positive rate, and the cluster analysis. It is stratified in accordance with disease category and positive rate identified. Firstly, the sample is categorized into both male and female sub-sample by gender. Secondly, the cluster analysis is undertaken in each male and female sub-sample. Finally, the disease category and positive rate are treated as the cluster factors to cluster the physical examination package among different age groups.The objective of designing the Physical examination packages are as follows; a) It should meet the need of an individual’s choice in accordance with her/his gender, age, health status, economic condition. This may lead to reduce the asymmetric information and then to increase the transparency of choosing appropriate "combination of physical examination items" for each individual. Therefore, it may more or less reduce the phenomena of supply-induced demand. In general, it could save the limited resource and reduce the financial burden for individual; b) The purpose of designing the stratified Physical examination packages are to well understand the common base disease for both male and female, age-specified mobility, and so on. In other words, it is useful for researchers to analyze the chronic disease management and its effective interventions, epidemiological survey, and molecule genetics; c) The importance of designing reasonable physical examination package is to guide the collection of individuals’ health information, risk evolution and forecast, health maintenance, and health promotion; d) It is also a value-added method to enrich and develop the theoretical research of physical examination industry. In conclusion, the general objective of the study is to criterion the physical examination market, improve the quality of physical examination service and its efficiency, ensure the reliable and testable results, improve the equity and transparency of the price of physical examination service. It is expected that the results obtained from the study could be recommended to policy makers for making appropriate policy and documents.Results:1、The specified physical examination package by the disease pattern of anthroponomy It is designed by ICD-10. Nine specified physical examination packages, including Respiratory System、Circulatory System、Alimentary System (Liver、Gallbladder、Pancreas、spleen service package and stomach、intestine service package)、urinary system、hematological system、Endocrine and metabolic system、nervous and skeletal system、gynecologic and anthology exam service package, are designed in accordance with disease category, the probability distribution of positive rate, and the disease pattern of anthroponomy. The price of medical examination projects is in strict accordance with the standards of uniform pricing regulated by Shandong bureau of price.2、The basic physical examination package in terms of gender, age, and disease patternIt is designed in accordance with ICD-10. Ten basic physical examination packages are designed, stratified by gender and age group, basing on disease category, probability distribution of positive rate, and the cluster analysis.a) Four packages are designed with specification for male. They are 40 years old below, 40-49 age group, 50-59 age group, and 60 years old and above respectively.b) Six packages are designed for female including 30 years old below, 30-39, 40-49,50-54,55-64, and 65 years old and above age group respectively.In terms of age group in each physical examination package, it is ranked as A, B, and C according to the probability of disease category and positive rate identified in the target population. Hence, Package A represents the basic physical examination package. The combination of choosing package A, B, and C are decided by the needs for physical examination or each individual financial affordability. However, the repeated items in the package are not double charged if they are overlapped among different packages.Conclusions:1. Nine specified physical examination packages are designed, in accordance with ICD-10, to satisfy the various demand for physical examination. The packages are scientifically designed basing on disease category, the probability distribution ofpositive rate identified, and the disease pattern of anthroponomy.2. Basing on disease category, the probability distribution of the positive rate identified, and systematic cluster analysis, the packages are designed in line with ICD-10. In addition, it is further stratified in terms of gender and age group to increase the flexible operation.3. The applicability and penalization of the urban residents’ physical examination packages are reasonable. It not only gives attention to the benefit of the providers, but represents the benefit of demand side for the physical examination services.4. It provides a theoretical method and idea for each target population of the physical examination items through studying the urban residents’ physical examination packages.Recommendations:1. The health authorities should pay attention to the research of physical examination. Basing on the research results, it could rationally regulate the physical examination market.2. The physical examination service providers should evaluate and summary the effectiveness of using the different packages. This is required the providers choosing appropriate packages in terms of effectiveness, cost and efficiency of the physical examination service. Thus, the quality of service could be improved.3. The service provider should pay attention to collect information of each physical examination. This further helps to trim and analysis the results.4. In addition, to criterion the Physical examination packages, it is required the emphasis of educating the importance of Physical examination, the increasing financial inputs from the government, the improvement of utilization rate of the Physical examination services. Then, these measures could exert the objective of servicing the general population for the service providers.5. The further study should pay attention to evaluate the benefit of each physical examination package and undertake the willingness to pay analysis.更多还原