中医在美国发展的概况

从上世纪90年代开始,美国政府包括白宫、国会、公共卫生服务部和美国国家卫生研究院(Na-tional Institutes of Health,NIH)决定发展补充替代医学(Complementary&Alternative Medicine),在美国现代医学史翻开了崭新的一页。补充替代医学的范围涵盖除西医以外的各种医学和疗法,相当于世界卫生组织所规范的"传统医学"(Traditional Medi-cine),补充替代医学正在美国医疗保健系统中发挥     

The returns from cardiovascular research: the impact of the National Heart Foundation of Australia's investment

OBJECTIVE: To evaluate the outcomes of the research investment of the National Heart Foundation of Australia (NHF). DESIGN AND SETTING: The NHF Research Evaluation Working Group was established in 2002 to oversee evaluation of research funding and outcomes data collected over a 5-year period. The evaluation included a bibliometric analysis conducted by the Research Evaluation and Policy Project at the Australian National University. OUTCOME MEASURES: Level and leverage of research funding; funding levels across the disciplines of biomedical, clinical, and public health research; and visibility and knowledge impact of NHF-supported research in international cardiovascular journals. RESULTS: The NHF's investment in research increased by 27% from 2001 to 2005. This increase resulted from leveraged support for fellowships and scholarships of $1.5 million over this period, and $2.2 million from the pharmaceutical industry. There was an increase in fellowship and scholarship funding from 26% in 2001 to 46% in 2005. There was a 75% increase in the funding allocated to public health research from 2002 to 2004. NHF-funded research publications were found in high impact journals at levels above Australian and world averages, but received fewer citations than expected based on citation rates for all similar articles. CONCLUSIONS: The NHF has been successful in implementing a policy to allocate 50% of its research funding to people and 50% to projects. This strategy has led to an increase in funding support for public health research. NHF-funded research has performed very well in terms of knowledge impact. The NHF is now well placed to strategically fund relevant research in the future.     

Implementing the Institute of Medicine report on lesbian health

The Institute of Medicine (IOM) recently published the report of its committee on lesbian health research priorities, which concluded that there has been little emphasis on and funding for research on the health of lesbians, despite the increased emphasis on women's health research in the 1990s. The report recommended additional research to determine if lesbians are at higher (or lower) risk for certain health problems than other women. It noted significant barriers to conducting lesbian health research, including lack of funding and several methodological issues. The IOM anticipates that the research recommended will benefit other populations as well. Several federal agencies in the Department of Health and Human Services can provide technical expertise and support to implement the report's recommendations, and suggestions are given here. The IOM report legitimizes scientific investigation into lesbian health, which should increase public and private research funding and the number of researchers in this area. A paradigm shift for lesbian health research is on the horizon, and we are grateful to the dedicated cadre of researchers, both published and unpublished, who have pioneered and persisted in this research during the past 25 years.     

The other side of the coin: safety of complementary and alternative medicine

Most consumers consider complementary and alternative medicine (CAM) products inherently safe. The growing simultaneous use of CAM products and pharmaceutical drugs by Australian consumers increases the risk of CAM-drug interactions. The Therapeutic Goods Administration (TGA) has a two-tier, risk-based regulatory system for therapeutic goods - CAM products are regulated as low risk products and are assessed for quality and safety; and sponsors of products must hold the evidence for any claim of efficacy made about them. Adverse reactions to CAM products can be classified as intrinsic (innate to the product), or extrinsic (where the risk is not related to the product itself, but results from the failure of good manufacturing practice). Adverse reactions to CAM practices can be classified as risks of commission (which includes removal of medical therapy) and risks of omission (which includes failure to refer when appropriate). While few systematic studies of adverse events with CAM exist, and under-reporting is likely, most CAM products and practices do not appear to present a high risk; their safety needs to be put into the perspective of wider safety issues. A priority for research is to rigorously define the risks associated with both CAM products and practices so that their potential impact on public health can be assessed.     

Rediscovering university teaching hospitals for Australia

Partnership between research and health services has a long history in other countries, but has been relatively recent in Australia, with several models arising in the 1960s and 1970s as research-based specialties developed. Since the implementation of Medibank, which became Medicare, Australian Health Care Agreements have been primarily crafted on the basis of transactional numbers, ignoring the need for links with teaching and research and the need to implement new developments. Education and research have been seen as the responsibility of the federal government, and hospitals are progressively less recognised or funded for these functions by the states. Australia's teaching hospitals are in danger of falling seriously behind those in other countries and losing their capacity to monitor quality, to innovate and to branch into new strategies in partnership with primary care services. We should look at initiatives in other countries such as the United Kingdom and Canada, which are making big strides in tackling similar issues. University hospitals hold the key, if appropriately linked with other services. The current Australian Health Care Agreements are on hold. A new agency is needed to support clinical and service-related research, with a new structure and track for federal government funding, and providing oversight of research and development, of clinical governance and quality of outcomes in health care, linked with new strategies for prevention and treatment. A component of the foreshadowed additional federal government funding for health should be sequestered to set up such an agency.     

Academic medicine as a public trust

Academic medicine is entrusted by society with the responsibility to undertake several important social missions toward improving the health of the public, including education, patient care, and research. This trust is given implicit authority by generous public funding and considerable autonomy. Medical academia can take pride in its successes, manifested by a premier scientific establishment, the development and use of sophisticated medical technologies and drugs, and the recent dramatic declines in death rates from heart disease and stroke. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indexes of population health, uneven quality of care, an unfavorable geographic and specialty mix of physicians, and widespread disability from long-term medical and psychiatric problems. Although there are many cogent reasons why academic medicine has chosen to define its task relatively narrowly (the nature of its funding successes, the intractability of the social problems, and the attractiveness of the biomedical model), the central issue is how well academic medicine is fulfilling its responsibilities to the public. To the degree that academic medicine defines its central mission narrowly, it may violate its implicit social contract and jeopardize its primary source of financial support. Alternatively, in recognition of its public responsibilities, academic medicine can choose to expand its current activities to be more responsive to the health concerns of the general population.     

基于文献挖掘的国际补充替代医学研究现状与趋势分析

目的：把握目前国际补充替代医学（complementary and alternative medicine, CAM）研究的发展态势,为我国中医药相关工作的开展提供参考依据和科学的量化信息支持。 方法：以PubMed数据库为检索源,国际CAM科技论文为研究对象,采用普赖斯指数增长定律、布拉德福定律等信息计量学经典方法和关联规则等文本挖掘技术,对目前国际CAM研究的文献增长规律,高生产力国家、机构,核心期刊,以及研究的热点、前沿领域进行系统、全面的分析。 结果：1998~2010年,国际CAM科技论文量呈上升趋势,且增长规律符合普赖斯指数增长定律;开展CAM研究的国家和地区范围广泛;期刊分布核心趋势明显;高等院校是研究的主体;植物药、针灸、心身疗法、整体疗法等是研究的热点疗法;肿瘤（乳腺癌）、慢性疾病（中风、糖尿病、高血压）、心身疾病（心理应激、焦虑、抑郁、精神障碍）、疼痛（下腰背痛、颈痛）等则是采用CAM疗法进行干预的主要病症。 结论：CAM研究将继续增加;肿瘤的CAM防治研究仍是世界范围内的关注重点;主要疗法的临床疗效、安全性与生物学基础是CAM研究的重要任务;心身疗法研究不断增多,临床疗效与生物机制研究是关键;CAM干预症状受到重视,研究前景广阔;CAM符合并有助于促进现代医学模式的发展与完善;中医药是CAM研究的重要领域,中国的优势地位面临挑战。     

Use of complementary and alternative medicines by patients with chronic obstructive pulmonary disease

OBJECTIVES: To investigate complementary and alternative medicine (CAM) use by patients with chronic obstructive pulmonary disease (COPD) and to explore their beliefs about CAM. DESIGN AND PARTICIPANTS: Cross-sectional study of 173 patients with moderate to severe COPD, and in depth interviews with a purposive sample of 28 patients. SETTING: Ambulatory care. MAIN OUTCOME MEASURES: Use of CAM; beliefs about the value of CAM. RESULTS: 71 patients (41%) claimed to be using some form of CAM. Most commonly used were multivitamins and minerals, and garlic was the most commonly used herbal preparation. Patients reported that advertisements and people with prior experience of using CAM were their major sources of information. Extent of knowledge about CAM, degree of faith in CAM and personal attitudes influenced decisions to try CAM. Patients used CAM to promote general wellbeing, to counteract drug side effects, to compensate for dietary deficiencies and to ameliorate their disease. Efficacy appeared less important to users than safety. CAM practitioners were regarded as more convincing, informative, considerate and available compared with mainstream health professionals. CONCLUSIONS: Communication between patients and mainstream health professionals about CAM use could be improved by health professionals being more accepting of CAM use and having some basic knowledge about commonly used CAM preparations.     

Whither the World Health Organization?

The outgoing Director-General of the World Health Organization, Gro Harlem Brundtland, has successfully returned health issues to the international arena. The new Director-General will have to cope with reduced control over funding, debate over WHO's mandate, and the relationships between WHO and other organisations. Despite the broad role described in WHO's constitution, many groups see WHO's mandate as narrowly directed at disease eradication. The method of choice for funding health programs has become public-private partnerships. These have the advantages of bringing private money, management expertise and research knowledge to bear on health problems, but rarely consider the health system as a whole, focusing instead on specific diseases. This has the potential to distort resource allocation and priorities. The international community needs to work to strengthen WHO and maintain its broad mandate to achieve the highest possible level of health for all people.     

Teaching integrated care: CAM familiarisation courses

As the use of CAM grows, CAM familiarisation offers educational opportunities for undergraduates to understand CAM, their attitudes to medical change and the process of evidence-based medicine. Such courses also offer the opportunity to integrate patient care and improve the relationship between medical and CAM practitioners. CAM familiarisation courses are available in many medical schools in the United States and the United Kingdom. The multiprofessional model which we have developed at the University of Southampton (UK) offers valuable experience to those thinking of establishing such courses.     

Three Decades of Research on Computer Applications in Health Care: Medical Informatics Support at the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality and its predecessor organizations—collectively referred to here as AHRQ—have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives.This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives.Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.Three decades ago, when the federal government''s National Center for Health Services Research and Development began to support research on computer applications in health care, few imagined the impact that information systems and sciences would have on medical care today. For most, the idea of a national clearinghouse of guidelines, available through a computer that sits on a home office desktop, seemed like science fiction. For a few researchers and those supporting their work, however, visions of what could become possible in the management of health care information called for development of computerized systems and the evaluation of their effects on quality, cost, and access to care.The Agency for Healthcare Research and Quality (AHRQ, from 1999) and its predecessor agencies—the National Center for Health Services Research and Development (beginning in 1968) and the Agency for Health Care Policy and Research (from 1989 to 1999)—have a rich history of funding research, development, and evaluation in medical informatics. Although the grant investments since 1968 total only $107 million ($246 million in 2000 dollars), they supported initiatives that have established a research framework for many of the computer applications now being used today.The focus of AHRQ''s early research funding in medical informatics was on acquiring patient care data and communicating patient care management information. The goal was not only to improve the quality of care, but also to achieve reductions in costs and medical personnel resource use by processing data more efficiently. Research aimed at improving communication of information was targeted at what we would call today “getting the right information to the right place at the right time.” The promise of this research was its ability to provide findings that would guide reorganization of care delivery, take advantage of the more rapid communication of necessary information, and reduce manpower needs.¹ Over time, AHRQ''s funding has emphasized the application of health services research methods to evaluations of information technology used in community health settings. This article highlights key accomplishments emerging from AHRQ''s funding that have improved the quality of patient care in studied sites and have the potential to improve health care in all settings.Other federal agencies (such as the National Library of Medicine, the Veterans Health Administration, and the Department of Defense) and private organizations (such as The John A. Hartford Foundation, The Robert Wood Johnson Foundation, and the American Hospital Association) have supported developments in medical informatics, with some having greater research expenditures and earlier histories than AHRQ. Nevertheless, it is the Agency''s contributions to medical informatics that are the focus of this study. The purpose of this article is to provide a historical perspective for understanding the benefits of past research funded by AHRQ that supports health care applications of information technology today and that foreshadows AHRQ''s medical informatics initiatives for the future.     

Cancer complementary and alternative medicine research at the US national cancer institute

The United States National Cancer Institute(NCI) supports complementary and alternative medicine(CAM) research which includes different methods and practices (such as nutrition therapies) and other medical systems(such as Chinese medicine). In recent years,NCI has spent around $120 million each year on various CAM-related research projects on cancer prevention,treatment,symptom/side effect management and epidemiology.The categories of CAM research involved include nutritional therapeutics, pharmacological and biological treatments,mind-body interventions,manipulative and body based methods,alternative medical systems,exercise therapies,spiritual therapies and energy therapies on a range of types of cancer.The NCI Office of Cancer Complementary and Alternative Medicine(OCCAM) supports various intramural and extramural cancer CAM research projects.Examples of these cancer CAM projects are presented and discussed.In addition,OCCAM also supports international research projects.     

The importance of "throwing money at" the problem of global health

More funding from wealthy countries is required to improve health care and the infectious disease situation in developing countries. Although progress has been made, funds for fighting AIDS, tuberculosis, and malaria remain inadequate. These treatable and preventable diseases together kill over 6 million people every year. Funds are needed to improve access to existing medicines as well as to increase research and development of drugs. The idea that "throwing money at the problem is not going to solve it" rightly holds that increased funding is not sufficient for solving the health care problems of developing countries. In order to work, funds must be spent wisely. This does not mean that increased funding is unnecessary.     

Medical Savings Accounts in publicly funded health care systems: enthusiasm versus evidence

MEDICAL SAVINGS ACCOUNTS (MSAS) HAVE BEEN SUGGESTED as a possible solution to Canada's health care funding woes. This approach is intended to reduce demand for health services by making individuals financially responsible for their pattern of consumption. MSAs may have appeal in the private insurance industry. A review of the scant literature on the experience in the public systems of Singapore and China, where such plans have been implemented, and on a simulation using United States Medicare data, suggests that the approach alone has not controlled costs and may increase inequalities in publicly funded systems. The conclusion is that current knowledge of MSAs is too limited to recommend their incorporation into the Canadian health care system.     

中医药教育在美国发展现状及挑战

Over the past 4 decades Chinese medicine （CM） has comeincreasingly into the spotlight in the United States as the clinical effectiveness ofCM has been not only empirically well-tested over a long period of time but alsoproven by recent scientific research. It has proven cost effectiveness, safety, andis authorized for natural and holistic approaches. In consideration, CM is one of theunderutilized health care professions in the United States with a promising future.However, CM faces many challenges in its education and system, its niche in thehealth care system as an independent profession, legal and ethical issues. This paperdiscusses the confronting issues in the United States： present education, standardsof CM education with shifting first professional degree level, new delivery systemsof CM education. Development of new research models, training of evidence-basedpractice, and implementation of integrative medicine into CM education also are the key issues in the currentCM profession. This paper also discusses opportunities for the CM profession going beyond the current status,especially with a focus on fusion medicine.     

Primary health care research--essential but disadvantaged

Primary health care is the foundation of effective, sustainable population health and is associated with higher patient satisfaction and reduced aggregate health spending. Although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research. The pace of research activity in general practice and the rate and quality of publications do not match the pace of structural change or the level of funding provided. Recruitment difficulties are a major impediment, fuelled by general practitioners' time constraints, lack of remuneration, non-recognition, and workforce shortages. Radical reform is required to redress imbalances in funding allocation, including: funding of GP Research Network infrastructure costs; formalising relationships between primary care researchers and academic departments of general practice and rural health; and mandating that research funding bodies consider only proposals that include in the budget nominal payments for GP participation and salaries for dedicated research nurses.     

Increased expenditure on Australian health and medical research and changes in numbers of publications determined using PubMed

OBJECTIVE: To determine temporal trends in PubMed publications for Australian authors compared with changes in funding for health and medical research (HMR). DESIGN: Retrospective observational study. SETTING: Internet-based bibliometric study that collated Australian HMR expenditure from the Australian Institute of Health and Welfare and Australian (and other) research publications from PubMed. MAIN OUTCOME MEASURES: Australian expenditure on HMR and numbers of PubMed-cited publications from 1980 to 2004, with subgroup analyses for universities, clinical trials, and genetic and biotechnology research, and comparison with similar results from the United Kingdom and New Zealand. RESULTS: From 1980-81 to 2003-04, Australian HMR expenditure increased from $66 million to $1503 million and total Australian PubMed publications increased from 844 to 13 836. From 1995-96 to 2003-04, Australian publications for university-derived research and for clinical trials increased at a fairly constant rate. Genetic and biotechnology publications increased about fivefold (49 to 277) between 1990-91 and 2003-04. Between 1990 and 2004, total publications increased from 1754 to 3288 for New Zealand and from 12 401 to 19 600 for the UK. CONCLUSIONS: There is an association between increased funding for HMR and increased publications, as determined using PubMed, in the past 10 years. Using PubMed may be a simple way to track output from HMR expenditure.     

Ethical issues concerning research in complementary and alternative medicine

Franklin G. Miller, PhD; Ezekiel J. Emanuel, MD; Donald L. Rosenstein, MD; Stephen E. Straus, MD

JAMA. 2004;291:599-604.

The use of complementary and alternative medicine (CAM) has grown dramatically in recent years, as has research on the safety and efficacy of CAM treatments. Minimal attention, however, has been devoted to the ethical issues relating to research on CAM. We argue that public health and safety demand rigorous research evaluating CAM therapies, research on CAM should adhere to the same ethical requirements for all clinical research, and randomized, placebo-controlled clinical trials should be used for assessing the efficacy of CAM treatments whenever feasible and ethically justifiable. In addition, we explore the legitimacy of providing CAM and conventional therapies that have been demonstrated to be effective only by virtue of the placebo effect.

     

Translational Bioinformatics: Coming of Age

The American Medical Informatics Association (AMIA) recently augmented the scope of its activities to encompass translational bioinformatics as a third major domain of informatics. The AMIA has defined translational bioinformatics as “… the development of storage, analytic, and interpretive methods to optimize the transformation of increasingly voluminous biomedical data into proactive, predictive, preventative, and participatory health.” In this perspective, I will list eight reasons why this is an excellent time to be studying translational bioinformatics, including the significant increase in funding opportunities available for informatics from the United States National Institutes of Health, and the explosion of publicly-available data sets of molecular measurements. I end with the significant challenges we face in building a community of future investigators in Translational Bioinformatics.     

Evidence-based health policy-making, hospital funding and health insurance

An important goal of health services research is to improve the efficiency and effectiveness of health services through a quantitative and evidence-based approach. There are many limitations to the use of evidence in health policy-making, such as differences in what counts as evidence between the various disciplines involved, and a heavy reliance on theory in social science disciplines. Community and interest group values, ideological positions and political assessments inevitably intrude into government health policy-making. The importance of these factors is accentuated by the current absence of evidence on the impact of policy options for improving the health status of the community, and ensuring that efficiency and equity objectives for health services are also met. Analysis of recent hospital funding and private health insurance initiatives shows the limited role of evidence in the making of these decisions. Decision-making about health policy might be improved in the future by initiatives such as greater exposure of health professionals to educational inputs with a policy focus; increased contribution of doctors to health services research via special postgraduate programs; and establishing a national, multidisciplinary centre for health policy research and evaluation.