預防醫學導論 季瑋珠 預防醫學研究所

Public Health Public health is the science and art of 1) preventing disease； 2) prolonging life； 3) promoting health and efficiency through organized community efforts

什麼是預防醫學 John M. Last的定義： Preventive medicine is the branch of medicine that is primarily concerned with preventing physical, mental, and emotional disease and injury, in contrast to treating the sick and injured. It may be thought of as more person oriented than population oriented. It comprises many of the same sciences, skills, and attitudes as public health, with an added clinical dimension. Of course, prevention is often inseparable from treatment and cure, ...

Individual vs. population This could be seen as an individual-level preventive medicine. To make it work, we need population or policy approach as well.

疾病自然史 易感受期 (susceptible stage) 臨床前期 (pre-clinical or pre-symptomatic stage) 臨床期 (clinical stage) 殘障期 (disable stage) 死亡 (death)

初段預防 (Primary prevention) preventing the occurrence of disease or injury. 針對易感受期。藉由改變個人的易感受性，或是降低暴露於病原的機會，以達到避免危險因子發生作用的目的。 健康促進 (health promotion) ：如營養、運動、個人衛生、健康社區及城市 特殊保護 (specific protection)：如預防接種、安全防護設施 實例：社區健康營造、預防接種卡、安全帽、安全帶等。

次段預防 (Secondary prevention) screening people with early, often pre-clinical, manifestations of diseases, to prevent its progression. 針對疾病初期，藉由早期診斷和適當 (迅速) 治療以防患或阻滯臨床前期和臨床初期的變化，以避免發生因治療過遲而導致的併發症、後遺症、殘障或死亡。包含疾病的篩檢 (screening) 及隨後的轉介治療。 實例：六分鐘護一生（子宮頸抹片）、三合一篩檢（高血壓、糖尿病、高血脂）、基隆市闔家歡篩檢服務（高血壓、糖尿病、高血脂、子宮頸癌、乳癌、大腸癌、結核病）、健保預防保健服務（成人、兒童、孕婦、子宮頸抹片）等。

末段預防 (Tertiary prevention) minimizing the effects of disease and disability by surveillance and maintenance aimed at preventing complications and premature deterioration. 藉各種臨床治療的方法，使患者早日康復，或使發生殘障者能恢復部份正長的機能。 限制殘障 (disability limitation)；殘障的壓縮（compression of disability） 復健 (rehabilitation) 實例：糖尿病共同照護、結核病短程直接觀察治療法、中風等疾病的復健。

Some myths: Is it always better prevention than cure? Are preventive medicine and clinical (curative) medicine against each other?

預防醫學的基本知識技能及方法 診斷與評估面 生物統計 流行病學 生物醫學知識 醫療資訊 社會行為：醫療社會、經濟、政治、心理、人類學 環境與職業醫學等

預防醫學的基本知識技能及方法 決策面 決策分析 (decision analysis)：個人層面 經濟評估：計畫層面，成本效益 (cost-benefit)、效果 (cost-effectiveness)、效用 (cost-utility) 分析 統合分析 (meta-analysis)：前人研究資料的綜合運用

預防醫學的基本知識技能及方法 治療或執行面 實證醫學 evidence-based medicine 衛生政策 衛生教育與行為科學 管理學 其他相關專業知識

History of Preventive Medicine in Taiwan Review: 人與醫學 History of Public Health and Preventive Medicine The role of physicians/dentists How they work together with other health professionals? How can we maintain their results and enhance our contributions?

Research methods in PM 實驗方法預防治療結果評估 非實驗性流行病學方法 成本效益分析；統合分析 政策分析

Evidence-based Preventive Medicine Rational-comprehensive model「理性綜合決策模型」。 Cost-benefit analysis（成本效益分析）：social perspective社會的觀點。 Whatever model of policy making：elite菁英決定、interest groups利益團體遊說、progressive/incremental漸進式的修訂、institution機構產物等。 Large-scaled community trials Observational epidemiologic studies

您的生活符合健康原則嗎？ 預防醫學醫師要為大家之表率！ 維持正常體重或努力減重 每週至少三次，每次至少20分鐘的有氧運動 每天吃質量均佳的早餐 飲食均衡，不過多攝取熱量、脂肪、鹽份 攝食足夠的纖維 不抽菸 適量飲酒或不飲酒 不用非必要的藥物但須服藥時遵行醫囑

您的生活符合健康原則嗎？ 騎機車戴安全帽；開車繫安全帶 遵守工作場所安全規範 酒後不開車，開車不喝酒 境內或出國旅遊時注意疫情並作好防範措施 保持愉快的心情及良好的人際關係 依照個人危險性定期定項接受身體檢查 注意寵物健康、人畜共通感染，為寵物結紮、植入識別證 熱心參與社區或機關團體的健康或環保活動：資源回收、用再生紙、無鉛汽油或搭公車、環保消費，

實例與作業 Colon cancer prevention Evidence-based preventive medicine Primary: diet, exercise, chemoprophylaxis Secondary: screening

美國預防醫學特別委員會 判斷標準 Review of Evidence: literature retrieval and exclusion criteria evaluating the quality of the evidence (Appendix A) grade I: RCT (randomized controlled trials) grade II-1: CT without R grade II-2: well-designed cohort or case-control studies, multi-center preferable

美國預防醫學特別委員會 判斷標準 cost-benefit, utility and effectiveness analysis grade II-3: multiple time-series with or without intervention, dramatic results of uncontrolled experiments grade III: opinion of respected authorities, based on clinical experiences; descriptive studies and case reports; case reports of expert committees cost-benefit, utility and effectiveness analysis meta-analysis and synthesis of research results updating evidence

美國預防醫學特別委員會 判斷標準 Translating science into clinical practice (Recommendation in Appendix A) level A: good evidence to support the recommendation that the condition be specifically considered in a periodic health examination level B: fair … level C: insufficient … but recommendations may be made on other grounds level D: fair evidence … be excluded level E: good evidence … be excluded External review from other organizations

USPSTF 2000-2 version A-B-C-D-I A: strongly recommends / improves important health outcomes and benefits substantially outweigh harms B: recommends / at least fair evidence … C: makes no recommends / at least fair evidence … but the balance of benefits and harms is too close to justify a general recommendation

USPSTF 2000-2 version D: recommends against routinely providing to asymptomatic patients / at least fair evidence that the service is ineffective or that harms outweigh benefits I: insufficient to recommend for or against routinely providing / lacking evidence …

Grade definition Good: evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes

Grade definition Fair: evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies

Grade definition Poor: evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes