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Stefan Larsson 談醫生可從彼此身上學習到什麼

Stefan Larsson: What doctors can learn from each other

 

Photo of three lions hunting on the Serengeti.

講者:Stefan Larsson

2013年10月演講,2013年11月在TED@BCG Singapore上線

 

翻譯:洪曉慧

編輯:朱學恆

簡繁轉換:洪曉慧

後製:洪曉慧

字幕影片後制:謝旻均

 

影片請按此下載

MAC及手持裝置版本請按此下載

閱讀中文字幕純文字版本

 

關於這場演講

不同醫院採取不同醫療程序,因而產生不同成效。只是病人無法得知相關資訊,使選擇醫生相當於高風險賭注。Stefan Larsson以髖關節置換手術為例,檢視衡量醫療成效及分享手術資訊的影響,以觀察哪種技術能提供最佳醫療效果。如果醫生能不斷互相學習,是否能使健保擁有更佳品質、更低成本?(攝於TED@BCG)

 

關於Stefan Larsson

擁有醫生資格、任職於BCG(波士頓諮詢公司)的Stefan Larsson探討醫療成效及成本透明化如何從根本上改變健保產業。

 

為什麼要聽他演講

在已開發國家,健保預算佔國內生產總值(GDP)9%至18%-這些成本增加的速度快於經濟成長。Stefan Larsson自2010年加入BCG(波士頓諮詢公司),為BCG斯德哥爾摩辦公室資深合夥人兼執行董事,BCG健保付費者及提供者諮詢部門全球領導人,他認為解決之道不僅在於成本管理,也在於改善患者的治療成效。

 

這種方式的中心理念為:衡量醫療成效。藉由制定醫療品質衡量標準、分享程序及如何執行的資訊,且不斷互相學習,醫生和護士可成為改革的推手,同時提供更佳的醫療及較低的成本。

 

Larsson為國際健康成效衡量聯盟共同創辦者,這是一個非營利全球醫療成效衡量標準組織,其合作夥伴為Michael Porter、哈佛商學院及卡羅琳學院。

 

Stefan Larsson的英語網上資料

Bio: BCG

Q&A: BCG Global Health Trends

Non-profit: ICHOM

 

[TED科技‧娛樂‧設計]

已有中譯字幕的TED影片目錄(繁體)(簡體)。請注意繁簡目錄是不一樣的。

 

Stefan Larsson 談醫生可從彼此身上學習到什麼

 

五年前,公休假期間,我返回母校醫學院。我穿上白袍,真正為病人看診,這是17年來第一次,自從我成為管理顧問後。

 

那個月當中,有兩件事令我訝異。第一是,我們討論的主題往往和醫院預算及削減成本有關。第二件令我相當困惑的事是:我遇見的幾位同事,就讀醫學院時的朋友,他們是我遇過最聰明、最積極、最投入、最熱情的人,其中許多人變得悲觀、消極或不願和醫院管理扯上關係。因此將重點放在削減成本,我自問,這是否忽略了病人?

 

許多你們代表的國家和我的國家都因健保成本問題而焦頭爛額,它佔了國家預算大部分。許多不同的改革著重於控制成本增長,在某些國家中,病人得等待很長一段時間才能動手術;在某些國家中,新藥並未列入補助範圍,因此病人無法使用;在某些國家中,醫生和護士在某種程度上成了政府的標靶,畢竟健保重大花費決定權掌握在醫生和護士手中。你可選擇昂貴的檢測、你可選擇為年老力衰的病人動手術,因此限制醫生選擇的自由是壓低成本的一種方式。結果是,現今有些醫生表示,他們沒有完全的自由做出他們認為對病人最好的選擇,難怪我的一些老同事感到灰心。

 

我們在BCG(波士頓諮詢公司)探討了這一點。我們自問,這絕非正確的健保管理方式,因此我們退一步反思:「我們試圖達成的目標為何?」歸根究柢,在健保體系中,我們的目標是改善病人的健康。我們必須在有限或可負擔的成本下達成這個目標,我們稱之為「以價值為基礎的健保」。在後方螢幕上,你可以看見我們對價值的定義:病人注重的成效相對於花費的金錢,Michael Porter和Elizabeth Teisberg 2006年的著作對此有極佳的描述。

 

在照片中,你看見的是我的岳父,和圍繞在他身旁的三位美麗女兒。當我們在BCG開始進行研究時,我們決定不將重點放在成本,而放在品質。研究過程中,引起我們興趣的是其中的差異性。比較同一國家的醫院,你會發現有些相當棒,但也會發現許多極差的醫院,其中的差異十分顯著。我岳父Erik罹患攝護腺癌,或許需要動手術。現居歐洲的他可選擇前往德國就醫,他們擁有聲譽卓著的健保體系。如果他前往德國一家普通醫院,術後尿失禁的風險約50%,因此他得再度開始穿尿褲。就像擲硬幣,50%的風險,機率相當大。如果他前往漢堡一家名為Martini-Klinik的診所就醫,風險只有1/20。你可選擇如擲硬幣的機率,或1/20的風險,這是相當大的差異,七倍之差。當我們檢視許多醫院、觀察許多不同疾病後,發現這種極大的差異。

 

但你我都一無所知,我們沒有這項資料。通常這項資料根本不存在,無人知曉,因此選擇醫院相當於買樂透。

 

好,我們不一定得承擔這種風險,還有一線希望。1970年代末期,一群瑞典骨科醫生在醫學年會上相遇,他們探討髖關節置換手術的不同操作程序。你在投影片左側看見的各種金屬物件是人工髖關節,用於需要置換新髖關節的患者。醫生們都知道彼此採用的手術程序不盡相同,他們都聲稱:「我的技術最好」,但他們承認沒人能確定這一點。因此他們說:「或許我們需要對品質進行評估,這樣才能有所學習,向最佳醫生借鏡。」因此他們花了兩年時間討論:「何謂髖關節手術品質?喔,我們該評估這個;不,我們該評估那個。」最後他們達成共識。一旦達成共識,他們開始評估,並開始分享資訊。不久後,他們發現,如果先將骨水泥填入病人的骨骼,然後再置入金屬支架,確實可提高耐用度,大多數病人餘生不需再重做手術。他們發表這些資料,確實改變了該國的手術程序,大家都認為這十分明智。從此之後,他們每年發表相關資料,公佈排行榜:誰最棒、誰殿後?他們互相參訪學習,因此形成進步的循環。多年來,瑞典的髖關節醫生擁有世上最佳的手術成果,至少以參與評估的醫生而言,許多醫生並未參與。

 

我認為這個策略確實令人振奮。醫生齊聚一堂,對品質標準達成共識,開始評估、分享資訊,找出最佳醫生、向其借鏡、不斷改進。

 

好,這並非唯一令人振奮的部分。這本身已令人振奮不已,但如果將成本納入考量,事實證明,注重品質的醫生治療成本也是最低的,雖然這並非最初的目標,因此我們再次以髖關節手術為例。幾年前進行了一項研究,將美國和瑞典比較,檢視有多少病人首次手術後七年間須再次動手術。美國的數量是瑞典的三倍;太多不必要的手術、太多不必要的痛苦,對所有七年間必須再次動手術的病人來說。好,你可以想像這個策略將替社會省下多少錢。

 

在一項研究中,我們檢視OECD(經濟合作發展組織)的資料。OECD每隔一段時間會檢視健保品質,他們可從會員國獲取相關資料。以美國來說,許多疾病的醫療品質低於OECD平均值。好,如果美國健保體系能更加注重品質的衡量,將醫療品質提升至OECD平均水準,每年將替美國人省下5000億美元,這是該國健保預算的20%。

 

好,你或許會說,這些數字太驚人了,整個策略十分合理,但可行嗎?這必須大幅改變健保制度。我認為這不僅可行,也必須進行改革,推手是健保體系的醫生和護士。

 

擔任管理顧問期間,我每年大概會遇見上百位醫生和護士,和其他醫院職員或健保體系成員,他們有一項共同點:他們十分在意本身的醫療品質成效。醫生-如同在座大部分聽眾-十分好勝,他們一向是班上的佼佼者,我們一向是班上的佼佼者。如果有人能證明他們的醫療成效不如其他人,他們會竭盡所能地改進,但大多數醫生不知道這一點。但醫生還有另一項特質:同儕的認可會使他們更上一層樓。如果心臟科醫生打電話給另一家競爭醫院的同行,討論對方醫院的醫療成效為何好得多,他們會彼此分享,他們會分享如何改善的資訊。因此藉由衡量品質及資訊透明化,將形成進步的循環,如投影片所示。

 

好,你或許會說這是個好想法。但這不僅是想法,也將成為現實。我們正著手創立一個全球社群,大型全球社群,我們可在其中衡量及比較各種醫療成效。在兩家學術機構的合作下-哈佛商學院的Michael Porter和瑞典的卡羅琳學院-BCG成立了所謂的ICHOM。你或許認為我在打噴嚏(ICHOM的發音類似打噴嚏),但這並非打噴嚏,而是一個縮寫,代表「國際健康成效衡量聯盟」。我們聚集了頂尖醫生,和病人逐一討論各種疾病,定義何謂品質、應如何衡量,並制定全球標準。他們進行了-四個工作小組去年進行了以下討論:白內障、背痛、冠狀動脈疾病-也就是心臟相關疾病,和攝護腺癌。四個小組將於今年11月發表研究結果。這是我們首次以同一個標準進行比較,不僅侷限於單一國家,而是各國間的比較。明年我們計劃研究8種疾病,後年則是16種,未來三年,我們計劃涵蓋40%疾病,以相同標準比較,何者較佳?為何較佳?

 

五個月前,我在北歐最大的教學醫院主持一場研討會,新任院長表示她的願景是:「對於這所大型機構的管理,我希望更加注重病人關心的品質和成效。」那天,我們在研討會中,和醫生、護士及其他工作人員討論兒童白血病。我們討論現今該如何衡量品質、我們能改進衡量方法嗎?我們討論該如何治療這些孩童、需進行重大改革的部分為何?我們討論這些病人的醫療支出、我們是否能進行更有效率的治療?全場充滿能量、充滿想法、充滿熱情。會議結束時,該部門的主任站起身來。他審視與會成員,開口說-我忘了提,他先舉起手來-他舉起手,握緊拳頭,然後對大家說:「謝謝、謝謝,今天我們終於對醫院的角色進行了正確的討論。」

 

藉由衡量健保價值,不僅考量費用,也包括病人注重的成效,我們將使醫院職員及健保體系成員不再是問題所在,而是解決方案的重點。我相信關於健保價值的衡量將引發變革,我相信現代醫學之父,希臘的希波克拉提斯-他總是以病人為中心-將含笑九泉。

 

謝謝。

 

(掌聲)

 

以下為系統擷取之英文原文

About this talk
Different hospitals produce different results on different procedures. Only, patients don’t know that data, making choosing a surgeon a high-stakes guessing game. Stefan Larsson looks at what happens when doctors measure and share their outcomes on hip replacement surgery, for example, to see which techniques are proving the most effective. Could health care get better -- and cheaper -- if doctors learn from each other in a continuous feedback loop?
 
About Stefan Larsson
A doctor by training, Stefan Larsson of BCG researches how transparency of medical outcomes and costs could radically transform the healthcare industry.
 
About the transcript
Five years ago, I was on a sabbatical, and I returned to the medical university where I studied. I saw real patients and I wore the white coat for the first time in 17 years, in fact since I became a management consultant.
 
There were two things that surprised me during the month I spent. The first one was that the common theme of the discussions we had were hospital budgets and cost-cutting, and the second thing, which really bothered me, actually, was that several of the colleagues I met, former friends from medical school, who I knew to be some of the smartest, most motivated, engaged and passionate people I'd ever met, many of them had turned cynical, disengaged, or had distanced themselves from hospital management. So with this focus on cost-cutting, I asked myself, are we forgetting the patient?
 
Many countries that you represent and where I come from struggle with the cost of healthcare. It's a big part of the national budgets. And many different reforms aim at holding back this growth. In some countries, we have long waiting times for patients for surgery. In other countries, new drugs are not being reimbursed, and therefore don't reach patients. In several countries, doctors and nurses are the targets, to some extent, for the governments. After all, the costly decisions in health care are taken by doctors and nurses. You choose an expensive lab test, you choose to operate on an old and frail patient. So, by limiting the degrees of freedom of physicians, this is a way to hold costs down. And ultimately, some physicians will say today that they don't have the full liberty to make the choices they think are right for their patients. So no wonder that some of my old colleagues are frustrated.
 
At BCG, we looked at this, and we asked ourselves, this can't be the right way of managing healthcare. And so we took a step back and we said, "What is it that we are trying to achieve?" Ultimately, in the healthcare system, we're aiming at improving health for the patients, and we need to do so at a limited, or affordable, cost. We call this value-based healthcare. On the screen behind me, you see what we mean by value: outcomes that matter to patients relative to the money we spend. This was described beautifully in a book in 2006 by Michael Porter and Elizabeth Teisberg.
 
On this picture, you have my father-in-law surrounded by his three beautiful daughters. When we started doing our research at BCG, we decided not to look so much at the costs, but to look at the quality instead, and in the research, one of the things that fascinated us was the variation we saw. You compare hospitals in a country, you'll find some that are extremely good, but you'll find a large number that are vastly much worse. The differences were dramatic. Erik, my father-in-law, he suffers from prostate cancer, and he probably needs surgery. Now living in Europe, he can choose to go to Germany that has a well-reputed healthcare system. If he goes there and goes to the average hospital, he will have the risk of becoming incontinent by about 50 percent, so he would have to start wearing diapers again. You flip a coin. Fifty percent risk. That's quite a lot. If he instead would go to Hamburg, and to a clinic called the Martini-Klinik, the risk would be only one in 20. Either you a flip a coin, or you have a one in 20 risk. That's a huge difference, a seven-fold difference. When we look at many hospitals for many different diseases, we see these huge differences.
 
But you and I don't know. We don't have the data. And often, the data actually doesn't exist. Nobody knows. So going the hospital is a lottery.
 
Now, it doesn't have to be that way. There is hope. In the late '70s, there were a group of Swedish orthopedic surgeons who met at their annual meeting, and they were discussing the different procedures they used to operate hip surgery. To the left of this slide, you see a variety of metal pieces, artificial hips that you would use for somebody who needs a new hip. They all realized they had their individual way of operating. They all argued that, "My technique is the best," but none of them actually knew, and they admitted that. So they said, "We probably need to measure quality so we know and can learn from what's best." So they in fact spent two years debating, "So what is quality in hip surgery?" "Oh, we should measure this." "No, we should measure that." And they finally agreed. And once they had agreed, they started measuring, and started sharing the data. Very quickly, they found that if you put cement in the bone of the patient before you put the metal shaft in, it actually lasted a lot longer, and most patients would never have to be re-operated on in their lifetime. They published the data, and it actually transformed clinical practice in the country. Everybody saw this makes a lot of sense. Since then, they publish every year. Once a year, they publish the league table: who's best, who's at the bottom? And they visit each other to try to learn, so a continuous cycle of improvement. For many years, Swedish hip surgeons had the best results in the world, at least for those who actually were measuring, and many were not.
 
Now I found this principle really exciting. So the physicians get together, they agree on what quality is, they start measuring, they share the data, they find who's best, and they learn from it. Continuous improvement.
 
Now, that's not the only exciting part. That's exciting in itself. But if you bring back the cost side of the equation, and look at that, it turns out, those who have focused on quality, they actually also have the lowest costs, although that's not been the purpose in the first place. So if you look at the hip surgery story again, there was a study done a couple years ago where they compared the U.S. and Sweden. They looked at how many patients have needed to be re-operated on seven years after the first surgery. In the United States, the number was three times higher than in Sweden. So many unnecessary surgeries, and so much unnecessary suffering for all the patients who were operated on in that seven year period. Now, you can imagine how much savings there would be for society.
 
We did a study where we looked at OECD data. OECD does, every so often, look at quality of care where they can find the data across the member countries. The United States has, for many diseases, actually a quality which is below the average in OECD. Now, if the American healthcare system would focus a lot more on measuring quality, and raise quality just to the level of average OECD, it would save the American people 500 billion U.S. dollars a year. That's 20 percent of the budget, of the healthcare budget of the country.
 
Now you may say that these numbers are fantastic, and it's all logical, but is it possible? This would be a paradigm shift in healthcare, and I would argue that not only can it be done, but it has to be done. The agents of change are the doctors and nurses in the healthcare system.
 
In my practice as a consultant, I meet probably a hundred or more than a hundred doctors and nurses and other hospital or healthcare staff every year. The one thing they have in common is they really care about what they achieve in terms of quality for their patients. Physicians are, like most of you in the audience, very competitive. They were always best in class. We were always best in class. And if somebody can show them that the result they perform for their patients is no better than what others do, they will do whatever it takes to improve. But most of them don't know. But physicians have another characteristic. They actually thrive from peer recognition. If a cardiologist calls another cardiologist in a competing hospital and discusses why that other hospital has so much better results, they will share. They will share the information on how to improve. So it is, by measuring and creating transparency, you get a cycle of continuous improvement, which is what this slide shows.
 
Now, you may say this is a nice idea, but this isn't only an idea. This is happening in reality. We're creating a global community, and a large global community, where we'll be able to measure and compare what we achieve. Together with two academic institutions, Michael Porter at Harvard Business School, and the Karolinska Institute in Sweden, BCG has formed something we call ICHOM. You may think that's a sneeze, but it's not a sneeze, it's an acronym. It stands for the International Consortium for Health Outcome Measurement. We're bringing together leading physicians and patients to discuss, disease by disease, what is really quality, what should we measure, and to make those standards global. They've worked -- four working groups have worked during the past year: cataracts, back pain, coronary artery disease, which is, for instance, heart attack, and prostate cancer. The four groups will publish their data in November of this year. That's the first time we'll be comparing apples to apples, not only within a country, but between countries. Next year, we're planning to do eight diseases, the year after, 16. In three years' time, we plan to have covered 40 percent of the disease burden. Compare apples to apples. Who's better? Why is that?
 
Five months ago, I led a workshop at the largest university hospital in Northern Europe. They have a new CEO, and she has a vision: I want to manage my big institution much more on quality, outcomes that matter to patients. This particular day, we sat in a workshop together with physicians, nurses and other staff, discussing leukemia in children. The group discussed, how do we measure quality today? Can we measure it better than we do? We discussed, how do we treat these kids, what are important improvements? And we discussed what are the costs for these patients, can we do treatment more efficiently? There was an enormous energy in the room. There were so many ideas, so much enthusiasm. At the end of the meeting, the chairman of the department, he stood up. He looked over the group and he said -- first he raised his hand, I forgot that -- he raised his hand, clenched his fist, and then he said to the group, "Thank you. Thank you. Today, we're finally discussing what this hospital does the right way."
 
By measuring value in healthcare, that is not only costs but outcomes that matter to patients, we will make staff in hospitals and elsewhere in the healthcare system not a problem but an important part of the solution. I believe measuring value in healthcare will bring about a revolution, and I'm convinced that the founder of modern medicine, the Greek Hippocrates, who always put the patient at the center, he would smile in his grave.
 
Thank you.
 
(Applause)

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