Making Progress in Health and Health Care

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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
2
Worlds 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

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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

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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)

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UK LE and HALE (Simpler Method)
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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

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Changes in Life Expectancy (LE) and
Health-Adjusted Life Expectancy (HALE) by Cause,
Canada
HALE
LE
(Source Manuel et al, ICES and Health Canada,
NPHS)
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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

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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

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Life Expectancy (LE) and Health-Adjusted Life
Expectancy (HALE), Canada 2001
at birth
at age 65
males
females
at birth
at birth
income terciles (thirds)
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An Almost Familiar World Map
www.worldmapper.org cartogram algorithm Mark
Newman
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Area Proportional to Population
www.worldmapper.org cartogram algorithm Mark
Newman
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Area Proportional to GDP 2002
www.worldmapper.org cartogram algorithm Mark
Newman
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Area Proportional to HIV(prevalence ages 15 49)
www.worldmapper.org cartogram algorithm Mark
Newman
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Area Proportional to Unhealthy Life(LE HALE,
based on WHO estimates)
www.worldmapper.org cartogram algorithm Mark
Newman
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National Income and Health, Correlated
?(Sources HALE WHO GDP World Bank)
HALE
GDP per capita, US at PPPs, 2002
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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

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Definition - Health Outcome
health outcome ? change in health status
attributable to a health intervention (for
an individual)
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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

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SNA Approach Treat Public Sector Activities the
Same as the Private Sector ? Define (i.e. make
up) Outputs
???
Profits
Outputs
Inputs
Public Sector
Commercial Sector
Industries
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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 Es efficacy,
  effectiveness, and efficiency no point
  measuring efficiency unless we know efficacy and
  effectiveness

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

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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