Symposium - The role of medical care in contributing to health improvements within societies
Symposium - The role of medical care in contributing to health improvements within societies
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DOI：
10.1093/ije/30.6.1260
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发表时间：
2001-12-01
影响因子：
7.7
通讯作者：
Bunker, JP
中科院分区：
文献类型：
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作者：
Bunker, JP
估计因治疗特定疾病而增加的预期寿命的月数或年数涉及三个步骤：计算因诊断特异性死亡率下降而增加的预期寿命，估计在最佳条件下提供治疗时预期寿命的增加，并估计在日常实践中提供的医疗护理可以在多大程度上降低疾病特有的死亡率。为了估计可归因于特定疾病的预期寿命的增加，使用了几种方法。预期寿命的变化可以直接从寿命表中计算出来，对于那些有死亡率的情况，可以按十年计算。根据马里兰州国家卫生统计中心公布的数据，这对心脏病、脑血管病和肺炎是可能的。13对于许多其他疾病，国家中心报告的死亡率变化是单一的年龄调整率，排除了完整的生命表估计。举例来说，按年龄调整的肺炎及流行性感冒死亡率，由一九五○年的每10万人26.2人下降至一九八九年的13.7人，即每10万人减少12.5人。在同一时期，所有原因的年龄调整死亡率从每10万人840.5人下降到每10万人523.0人，相差317.5人，预期寿命增加了7.1岁。作为第一近似值，肺炎和流感死亡率的下降估计贡献了12.5/317.5× 7.1= 0.28年，或约3个月。这种“信封背面”的近似值，当应用于心脏病和脑血管病以及肺炎和流感的年龄调整死亡率时，得到的答案与基于完整标准寿命表的结果相差10%或20%。对治疗条件下预期寿命增加的估计尽可能基于临床试验和荟萃分析，或者基于观察性或病例对照研究。根据公布的治疗率和接受治疗者的风险和获益率，估计了因药物治疗而改善的比例。例如，从1950年到1996年，脑血管疾病（主要是中风）的死亡率下降了三倍多，这意味着每年死亡人数减少了大约13万人，预期寿命增加了一年多一点。在此期间，美国对高血压的药物控制显著增加，从10%中度或重度血压升高的个体增加到约50%，14并且据报道，在抗高血压药物的随机临床试验中，中风死亡率下降了35-40%。15这可以解释中风死亡率降低15-20%的原因，预期寿命增加21⁄ 2-3个月。1950年至1995年间，美国心脏病死亡率下降了一半以上，预期寿命增加了约31⁄ 2年，其中一半至三分之二归功于冠心病护理单位，高血压的治疗，冠状动脉疾病的内科和外科治疗。16，17据估计，阑尾炎、糖尿病和终末期肾病的治疗分别对预期寿命的三分之一或更多做出了贡献，而其他许多疾病的治疗贡献较小。总而言之，临床服务，包括预防服务和治疗干预，我们认为5年或5.5年的时间里，
Estimation of months or years of increased life expectancy attributable to the treatment of a particular condition involved a three-step procedure: calculation of increases in life expectancy resulting from a decline in diagnosis-specific death rates, estimation of increases in life expectancy when therapy is provided under optimal conditions, and estimation of how much of the decline in disease-specific death rates could be attributed to medical care when provided in routine practice. To estimate gains in life expectancy attributable to a specific disease, several approaches were used. Changes in life expectancy could be calculated directly from life-tables for those conditions for which mortality rates are available decade by decade. This was possible for heart disease, cerebrovascular disease and pneumonia using data published by the National Center for Health Statistics in Maryland. 13 For many other diseases changes in mortality are reported by the National Center as a single age-adjusted rate, precluding a full life-table estimate. For example, the age-adjusted death rate for pneumonia and influenza fell from 26.2 per 100 000 in 1950 to 13.7 in 1989, a reduction of 12.5 per 100 000. During the same period the ageadjusted death rate for all causes fell from 840.5 per 100 000 to 523.0 per 100 000, a difference of 317.5, and life expectancy rose by 7.1 years. As a first approximation, the fall in death rate for pneumonia and influenza was estimated to have contributed 12.5/317.5× 7.1= 0.28 years, or about 3 months. Such a ‘back of the envelope’approximation when applied to age-adjusted death rates for heart and cerebrovascular disease, as well as for pneumonia and influenza, gave answers within 10% or 20% of those based on a full standard life-table. Estimation of increase in life expectancy under therapeutic conditions was based, whenever possible, on clinical trials and meta-analyses, or alternatively on observational or case-control studies. The proportion of improvement attributable to medical treatment was estimated from published treatment rates and rates of risks and benefits of those receiving treatment. For example, the death rate for cerebrovascular diseases, primarily stroke, fell more than three-fold from 1950 to 1996, representing approximately 130000 fewer deaths annually and an increase in life expectancy of a little more than one year. Medical control of hypertension in the US increased markedly during this period, from 10% of individuals with moderate or severe elevations of blood pressure to approximately 50%, 14 and stroke mortality was reported to fall by 35–40% in randomized clinical trials of anti-hypertensive drugs. 15 This would explain as much as 15–20% of the reduction in stroke mortality, with an increase in life expectancy of 21⁄ 2–3 months.Mortality from heart disease in the US fell by more than half between 1950 and 1995, with a resultant increase in life expectancy of approximately 31⁄ 2 years, half to two-thirds of which has been attributed to coronary care units, treatment of hypertension, and medical and surgical treatment of coronary artery disease. 16, 17 The treatment of appendicitis, diabetes, and endstage kidney disease were estimated each to have contributed a third of a year or more to life expectancy, with lesser contributions from the treatment of many other conditions. All told, clinical services, composed of preventive services as well as therapeutic intervention, we credited with 5 or 51⁄ 2 years of the