Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015.
Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015.
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DOI：
10.1016/s0140-6736(17)30818-8
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发表时间：
2017-07-15
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影响因子：
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通讯作者：
GBD 2015 Healthcare Access and Quality Collaborators
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作者：
GBD 2015 Healthcare Access and Quality Collaborators. Electronic address: cjlm@uw.edu;GBD 2015 Healthcare Access and Quality Collaborators
通过衡量在有效医疗条件下不应致命的原因（即可调整的死亡率）所造成的死亡率，可以大致估算出个人保健服务的国家水平和质量。以前对适用于卫生保健的死亡率的分析只侧重于高收入国家，并面临一些方法上的挑战。在本分析中，我们使用通过全球疾病、伤害和风险因素负担研究（GBD）产生的高度标准化的死亡原因和风险因素估计，以改进和扩大1990年至2015年195个国家和地区的个人医疗保健可及性和质量的量化。我们将Nolte和McKee开发的最广泛使用的个人卫生保健原因列表映射到32种GBD原因。我们通过广泛的数据标准化过程和为GBD开发的再分配算法来解释死亡原因认证和错误分类的差异。为了隔离个人医疗保健获取和质量的影响，我们通过消除当地环境和行为风险的共同影响，并加上2015年GBD估计的全球风险暴露水平，对每个地理年份的特定原因死亡率进行了风险标准化。我们使用主成分分析来创建一个单一的、可解释的汇总度量——医疗质量和获取（HAQ）指数——在0到100的范围内。与人均卫生支出（r= 0.88）、11项全民健康覆盖干预措施指数（r= 0.83）和每千人卫生人力资源（r= 0.77）等卫生系统指标相比，HAQ指数具有较强的收敛效度。基于HAQ指数和社会人口指数（SDI）之间的关系，我们使用了带有bootstrapping的自由处置船体分析来产生一个边界。社会人口指数（SDI）是一个衡量整体发展的指标，包括人均收入、平均受教育年限和总生育率。这一前沿使我们能够更好地量化在整个发展范围内实现的个人保健机会和质量的最高水平，并查明观察到的水平与潜在水平之间的差距随着时间的推移而缩小或扩大的地理位置。1990年至2015年期间，几乎所有国家和地区的HAQ指数都有所提高；2015年最高和最低HAQ指数的差异大于1990年，为28.6 ~ 94.6。自1990年以来，在195个地区中，167个地区的HAQ指数有显著增长，其中韩国、土耳其、秘鲁、中国和马尔代夫是2015年增长最快的地区。在HAQ指数上的表现和个别原因在区域和发展水平上表现出不同的模式，但在一些原因上出现了很大的异质性，包括最高sdi国家的癌症；中sdi国家的慢性肾病、糖尿病、腹泻病和下呼吸道感染；麻疹和破伤风在sdi最低的国家。虽然全球HAQ指数平均值从1990年的40.7（95%不确定区间为39.0 ~ 42.8）上升到2015年的53.7(52.2 ~ 55.4)，但在缩小HAQ指数观测值与最高水平之间的差距方面进展甚微；在全球水平上，观测值与前沿HAQ指数的差异仅从1990年的21.2减小到2015年的20.1。如果每个国家和地区都以相应的SDI水平达到最高的HAQ指数，那么2015年全球平均HAQ指数为73.8。一些国家，特别是撒哈拉以南非洲东部和西部的国家，其HAQ指数达到了与其发展水平相似或超过其发展水平的水平，而其他国家，即撒哈拉以南非洲南部、中东和南亚，则落后于1990年至2015年间类似发展地区的水平。GBD研究的这一新颖延伸表明，在整个发展范围内，个人保健获得和质量改善的潜力尚未开发。在国家一级个人卫生保健取得实质性进展的同时，在特定国家或地区，个别原因的不同模式表明，很少有地方在卫生系统职能和治疗领域始终实现最佳的卫生保健可及性和质量。这在发展中国家尤其明显，其中许多国家最近经历了或目前正在经历流行病学转变。HAQ指数如果与卫生系统特征的其他措施（如干预覆盖率）相结合，可以提供一个强有力的途径，用于跟踪全民健康覆盖的进展情况，并确定在世界各地加强个人卫生保健质量和可及性的地方重点。比尔和梅林达·盖茨基金会。
National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.