英文文献及翻译

Improving the Health and Health Care of Older Americans

Arlene Bireman, William Spector

Introduction

As we enter the new millennium, the Nation is confronted with the enormous challenge of preparing to meet the demands of an aging society. In the face of current demographic trends, increasing health care costs, and concerns about the quality of health care, the financing and delivery of care for older people is a critical health care policy challenge.

Figure 1 The Conceptual Framework of a Patient-centered Health Policy Early in the related discussions, we decided to focus our efforts on cost-effective interventions that enhance functioning and health-related quality of life (HRQOL) or prevent functional decline. With this decision, we focused on gaps in knowledge that influence the ability of health care services to improve functioning and HRQOL including costs, financing, barriers to access, organization and delivery of care, and clinical practice, as well as the interaction of these factors with individual patient characteristics and preferences, family, and community. Figure 1 describes the conceptual framework we used. It includes a patient-centered rather than

disease-specific focus. This framework also recognizes the role of health policy in influencing patient outcomes. All of the arrows on our framework are bidirectional, recognizing the multiple, complex interrelationships that influence health and function in older people. A focused research effort to determine how the health care system can most cost-effectively prevent disability, reduce functional decline, and extend active life expectancy in older people can provide decisionmakers with the

information needed to accelerate the decline in age-specific disability rates and to allocate limited resources efficiently.

Delivering Health Care to an Aging Population An aging population, together with rising health care costs and rapid health system Change, presents a major challenge in the delivery of health care to older Americans.

The changing composition of the population is already putting increasing pressure on the health care system. In 2011, 77 million baby boomers will begin to turn 65, and by 2025, the number of Medicare beneficiaries is expected to reach 69.3 million, representing 20.6 percent of the U.S. population, with the "old old"—those over age 80—comprising the fastest growing segment of the population. Along with the increased numbers of older Americans, the elder population is becoming increasingly diverse; it is expected that by the year 2030, one in four people over the age of 65 will be from a racial or ethnic minority. Moreover, there is also concern that changes in fertility, women's labor force participation, and increases in the divorce rate may reduce the ability of families to take care of older family members who have disabilities, placing even greater demands on public and social programs.

Because of these demographic trends, there is concern that health care costs for the elderly population will continue to grow dramatically. Per capita expenditures for elderly living in the community were more than three times those of the nonelderly in 1996—$5,644 vs. $1,865—and are projected to increase to $7,674 (in 1996 dollars) by 2005. Medicare and Medicaid long-term care expenditures are also projected to double by 2005.These projected increases in taxpayer-funded costs will place great pressure on these programs to reduce costs. Consequently, there is apprehension that continuing and rising pressures to contain costs will adversely affect health care quality and access.

Furthermore, the rapid changes in the health care system that have already occurred have had significant effects on the care provided to elderly people. For example, previous efforts to control costs have resulted in an increase in Medicare managed care, market instability, and shifting of care to ambulatory settings. There have also been significant changes in the provision and financing of long-term care, with growing use of community-based long-term care such as home care and assisted living communities. The role of institutions has also changed, with nursing homes being used more extensively for subacute care. Nursing homes are confronting many other changes, such as capitation and prospective payment for skilled nursing home care and quality measurement and reporting. There are many unanswered questions about the effect of these changes on quality and cost

Providing and Financing Health Care Services for Older People The unique challenges in providing and financing health care services for older people require a targeted research focus.

Caring for older people involves clinical complexities that are difficult to coordinate at the health system level and because of fragmented financing, are also difficult to manage financially. Aging results in both pathophysiologic and pharmacokinetic changes that must be addressed in clinical practice. Comorbidity is common, presenting a challenge to clinical management. End-of-life decisionmaking grows in importance, focusing attention on quality of life. Family members often play an important role in providing and managing care, and require education, support, and assistance in these tasks.

Nevertheless, the majority of older people remain active and independent and the prevention of disability among this group of elders is critical. Effective and efficient care for older people therefore requires new models of coordination among preventive, acute, chronic, rehabilitative, and long-term care services. Furthermore, financing of care to older people is fragmented and improved models of care will depend on appropriate payment models.

Improving the quality of care for older people is likely to have a substantial impact on their functional status and therefore their quality of life. The underuse of effective interventions, the overuse of interventions shown to be ineffective, and the misuse of others (especially polypharmacy) have all been well documented in the elderly. Many doctors do not routinely assess the functional status of their older patients, nor do they have the knowledge and skills requisite for geriatric practice. Quality measures are needed to assess the effectiveness of interventions to improve care in these areas.

While the unique constellation of issues confronting the elderly described here necessitates a targeted focus on older people, aging-related research shares common issues with research on improving care for the chronically ill and disabled; so there is a need to coordinate and collaborate across research in all three of these areas

Using Aging-Related Health Services Research to Answer Key

Questions

Aging-related health services research can provide answers to key questions about outcomes and effectiveness; cost, use, and access; and quality measurement and improvement for older people.

The issues addressed in general health services research (e.g., optimal treatment, access to care, and the organization of care) need to be addressed specifically with respect to the health needs of older people. Health services research is uniquely able to address the multiple factors that impact upon health outcomes in the elderly such as comorbidity, patient beliefs, values and preferences, social support, and multiple sites and settings of care, as well as finance and policy factors. Health services research is multidisciplinary and conducted collaboratively by clinicians, nurses, and social scientists. Distinctive features of this research are its patient-centered focus and emphasis on studies related to maximizing function and health-related quality of life. The "basic sciences" of health services research are essential to this endeavor:

outcomes and effectiveness research, cost-effectiveness analysis, decision analysis, health status measurement, quality measurement and improvement, and health economics.

改进美国老年人的健康和医疗卫生

Arlene Bireman, William Spector

引言

当我们进入新世纪时，美国这个国家正面临着一个巨大的挑战，这就是如何应对一个老龄化社会的需求。面对当前的人口趋势、日益增加的医疗成本以及对于医疗卫生质量的关注，为老年人口提供财政援助和医疗照顾就成了关键的医疗卫生政策的挑战。

图1 以病人为中心的卫生政策的概念框架

在先前有关的讨论中，我们决定将我们的努力重点放在成本—效益干预上。这种干预可以强化功能以及与健康相关的生活质量，或可以防止功能的下降。基于这样的决定，我们集中关注一些知识上的鸿沟，这些鸿沟会影响旨在改善功能和与健康相关的生活质量（包括成本、融资、进入壁垒、医疗照顾的组织与提供、临床实践）的医疗服务能力，同时也会影响这些要素与单个病人的特征、偏好、家庭和社区的互动。图1描述了我们所采用的概念框架。它包括了以病人为核心而非以疾病为核心的关注重点。这样的框架也承认卫生政策在影响病人效果方面的作用。这样一项具有侧重点的研究为的是确定医疗制度如何才最符合成本—效益要求的防止能力丧失、减少功能下降，延长老年人积极生活的预期寿命。这些研究可以为决策者提供所需的信息，以加快因年龄原因而丧失能力的比例的下降，并能够高效地对有限

的资源进行配置。

为老龄人口提供健康照顾

人口的不断老化，再加上不断提升的医疗卫生成本，以及快速变化的医疗体制，向如何为美国的老年人口提供医疗卫生提出了重要的挑战。

人口年龄结构的改变已经给美国医疗制度造成了越来越大的压力。进入2011年，7700万婴儿潮时期出生的人口将进入65岁的年龄段。到2025年，美国需要医疗福利的人口将达到6930万，占美国总人口的20.6%。“老老龄人口”（年龄超过80岁的人口）将构成美国人口增长最快的部分。随着美国老龄人口的增加，老龄人口也变得更加分化了。据估计，到2030年，超过65岁的人口中每四人中就会有一个来自少数族裔。另外，人们还关注到，随着出生率的改变、妇女劳动力的参与以及离婚率的上升，都会降低家庭照顾老年家庭成员的能力。当这些老龄人口丧失自理能力时，将对公共的和社会的项目提出更多的要求。

由于这些人口趋势，人们越来越关注到，老龄人口的医疗卫生成本将会继续快速增加。生活在社区中的老龄人口人均开支是1996年人口没有老龄化的三倍。这一比例是5644美元比18651美元。这一数字到2005年增加到7674美元（按照1996年美元价格计算）。到2005年，医疗保险和医疗补助计划方面的开支也将翻一番。这些由纳税人负担的计划的增加必然会对要求削减开支计划施加巨大的压力。最后人们产生了一种忧虑，这就是，对于控制成本的不断增加的压力将会对医疗卫生的质量和获得带来负面的影响。

另外，早已发生的医疗制度的快速变革将对向老年人提供照顾带来重要影响。比方说，先前的控制成本努力已经导致医疗保险制度中管理式医疗的增加，医疗市场的不稳定性，并将会把医疗卫生转移到那些非住院的护理机构。随着越来越多地采取以社区为基础的长期护理办法，比如家庭护理和社区生活援助等等，在长期护理的提供和财政支持方面也发生了重要的变化，比如有经验的护理院的资本化运作和采取预先支付的方式等，当然也要求相应的质量评估和报告。在质量和成本方面的这些变革的效果如何，还存在着许多需要解答的问题。

为老年人提供医疗卫生服务和融资

在为老龄人口提供医疗服务方面的特有挑战要求围绕具体目标进行专门研究。

对老龄人口的护理包括临床医疗方面的一些复杂问题。这些问题在医疗系统的层面上是很难予以协调的。由于财政划分方面的原因，对此在经济管理方面也同样存在着困难。老龄

化导致病理生理学和药物动力学方面的变化，这些必须要由临床实践来予以解决。综合病态成了一种常态，显示出对临床管理的挑战。生命终极决策变得越来越重要，这里关注的是对生命质量的关注。家庭成员在提供和管理医疗护理方面起着重要的作用。在实现这些任务方面需要有教育、支持和援助方面的努力。

无论如何，老年人口中的人多数仍然是积极和独立的。因此，防止老龄人口生活能力的丧失具有关键的意义。所以，对老龄人口的有效能和有效率的医疗护理要求有一种新的协调模式，也就是在防御性的、急症态、长症状态、康复的和长期照顾的服务之间进行协调。另外，为老龄人口提供健康服务的融资渠道是片段话的，这方面模式的改良有赖于适当的支付模式。

改善老龄人口护理质量有可能对其功能状态从而给他们的生活质量带来重大的影响。不采用有效的干预措施，过度使用被证明为无效的干预措施，以及误用其他方法（尤其是符合配方），这些都可能对老龄人口带来严重的影响。许多医生并不对他们的老年病人功能状况给出常规的评估，他们也不具备老年医疗所需的知识和技能。对于在这些领域中通过干预的有效性来改进照顾，需要一些质量方面的尺度。

尽管我们在这里所描述的老龄现象面对这一系列独有的问题，但与老龄化相关的研究其实与有关改进对常见病人和残疾人照顾的研究有很多共同之处，所以需要对所有这三个领域的研究加以协调与合作。

利用老龄化相关的医疗服务研究来回答一些关键的问题与老龄化相关的健康服务研究可以为有关成果和效能的关键问题提供答案。这些问题包括：成本、利用与进入途径；改进老龄状况的质量评估。

对一般健康服务研究方面提出的方面（即良好的医疗、获得护理的途径以及医疗护理组织等）需要在关于老年人健康需求的研究中特别予以关注。健康服务研究特别能够提出一些多重的因素，这些因素对老龄人口的健康结果会产生重要影响。这些因素包括：综合病症、病人信念、价值观与偏好、社会支持以及政策因素等。健康服务研究是一种多学科的研究，需要由临床医生、护理人员和社会科学工作者合作进行。这项研究与众不同的特征在于以病人为中心，强调的是最大限度地提高身体功能和提高健康生活的质量。健康服务研究的“基础科学”对于这方面的努力具有根本意义，包括：成果和有效性研究，成本—效益分析，决策分析，健康状态评估，质量评估和改进以及健康经济学。