8/23/2014 9:17 PM OECD Istanbul June 2007 Making Progress in Health and Health Care how do we know...

04/11/23 00:30 OECD Istanbul June 2007

Making Progress in Health and Health Care

how do we know we are making progress? need to distinguish two broad domains:

progress in population health progress in health care services

Michael Wolfson, Statistics Canada

Denise Lievesley, UK NHS and ISI

(please use “normal view” or “notes page” to see speaking text)


World’s Two Most Widely Used “Health” Indicators

Life Expectancy ( + other indicators based on mortality rates, e.g. infant mortality) good as far as it goes; clearly fundamental but leaves out how healthy people are while alive

Health Care Spending as % of GDP very poor indicator is more spending better or worse? focuses on inputs to health care, rather than results

We can and should do better for our most basic measures of progress in health and health care


How do we know we are making progress in population health?

currently, a plethora of indicators often a failure to distinguish “health” from

antecedents, e.g. risk factors like smoking, correlates, e.g. bio-medical parameters like blood pressure, and sequalae, e.g. social participation like work, mortality

simple idea: HALE = health-adjusted life expectancy builds on already very widely use measure, life expectancy progress ≡ “adding years to life” and/or “adding life to years”


Basic Definitions LE = area under survival curve HALE = “weighted” area under survival curve

where “weights” are levels of individual health status, ranging between zero (dead) and one (fully healthy)


UK LE and HALE (Simpler Method)


Measuring Functional Health Status in a Population

examples: McMaster Health Utility Index, Euroqol EQ-5D, WHO World Health Survey

define a set of health domains develop a parsimonious set of survey questions

to elicit levels of functioning for each domain, and collect data for a representative sample Budapest Initiative

apply a systematic method for eliciting values for various health states for another, typically smaller, sample

estimate a “valuation function”


2.2

0.9

0.7

0.5

0.4

0.5

0.2

1

0.9

1.5

0.6

0.5

0.7

0.5

0.3

0.4

0.1

2.4

1.1

0 0.5 1 1.5 2 2.5

Men

Women

Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE)

by Cause, Canada

2.4

1

0

0.5

0.4

0.4

0.3

0.1

0

0.7

1.8

0.7

0.6

0.8

0.3

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0.3

0

0

0.4

00.511.522.5

IHD

Lung cancer

Breast cancer

Stroke

COPD

Colorectal cancer

Diabetes

Melanoma

Osteoarthritis

Mental disorders

Men

Women

(Source: Manuel et al, ICES and Health Canada, NPHS)

HALELE


Progress in Levels and in Differences – Health Inequality

old (statistical) adage: “beware of the mean” HALE is fundamental for measuring overall

progress in population health – analogous to “size of the pie” in income analysis

but HALE itself says nothing about “how the pie is divided” – about the distribution of health within a population


The Concept of Health Inequality concept of health inequality is different income inequality is “univariate”

e.g. what share of income goes to the top 1%; how many individuals are living on less than $1 per day?

health inequality is “bivariate”, i.e. about correlations, especially systematic associations with socio-economic status e.g. how does health (HALE) vary from one region

in a country to another; how steep is the gradient – i.e. how much does

health status improve as we move up the social ladder within a country


Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE), Canada 2001

50

55

60

65

70

75

80

85

90

bottom middle top bottom middle top

HALE LE

male female male female

at birth at age 65 males femalesat birth at birth

income terciles (thirds)


An Almost Familiar World Map

www.worldmapper.org; cartogram algorithm: Mark Newman

http://www.worldmapper.org/


Area Proportional to Population




Area Proportional to GDP 2002




Area Proportional to HIV(prevalence ages 15 – 49)




Area Proportional to “Unhealthy Life”(LE – HALE, based on WHO estimates)




0

10

20

30

40

50

60

70

80

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

HALE

GDP per capita, US $ at PPPs, 2002

National Income and Health, Correlated ?(Sources: HALE – WHO; GDP – World Bank)


How do we know we are making progress in health care?

this is a far more popular question than progress in population health, but also not nearly so fundamental simple reason: there is far more to the

determinants of health than health care – e.g. poverty, lifestyle, hierarchy

progress in health care ≡ { health care interventions improved health of individuals treated } n.b. most interventions are not well evaluated


Definition - Health Outcome

health status “before”

health status “after”

health intervention

other factors

health outcome change in health status attributable to a health intervention

(for an individual)


How NOT to Know Whether We are Making Progress in Health Care

try to use SNA (System of National Accounts) concepts to measure health care “outputs”

try to apply macro-economic concepts of aggregate productivity to the health care sector


SNA Approach: Treat Public Sector Activities the Same as the Private Sector

Define (i.e. make up) “Outputs”

???“Profits”

Inputs

Commercial Sector

Public Sector

Outputs

Industries


Why the SNA Approach is Problematic

“outputs” do not exist naturally in publicly provided health care we certainly can count “activities”, like numbers of

vaccinations (probably all useful) and numbers of coronary procedures (see later slide!)

but outcomes of interventions should clearly be the objective of systematic and routine measurement

productivity is obviously important but high “productivity” in doing useless or iatrogenic

activities is bad remember the three “E’s”: efficacy, effectiveness,

and efficiency; no point measuring efficiency unless we know efficacy and effectiveness


(Tu et al on Coronary Surgery)n.b. virtually no differences in one year survival; but

no data on differences in health-related QoL

e.g. almost 17x, with no

benefits?


Heart Attack Patients in Large Health Regions – Treatment and 30 Day Mortality Rates (%) – 1995/96 to 2003/04

0

5

10

15

20

0 10 20 30 40 50 60 70Percent Revascularized within 30 Days

30 D

ay M

orta

lity

Rat

e

1995/96

2003/04


What Does this Graph Tell Us? we may be missing important data

treatments – e.g. nothing on thrombolysis, post AMI medication and rehabilitation

Framingham risk factors – smoking, obesity, physical activity

other risk factors – income, chronic stress (n.b. age, sex and comorbidity included)

health care is driven by opinions clinical judgment is not well-informed by rigorous

and systematic evaluation health system managers have no empirical bases

for judging the effectiveness of their activities

aggregate SNA style measures of “productivity” miss the real issues


Concluding Comments need to measure both progress in population

health and in health care for population health: HALE is fundamental for health care: outcomes are fundamental for both: a common metric for measuring individual

health status is essential – propose Budapest Initiative short form questions (along with items covering many other facets of health)

using basic health information principles incentive compatibility – providers of crucial health

information should have a stake… empowerment – information should enable both general

public and providers (as well as health system managers) to improve outcomes / quality

8/23/2014 9:17 PM OECD Istanbul June 2007 Making Progress in Health and Health Care how do we know...

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