Participation in Community Assets and Health-Related Quality of Life and Health Care Utilisation Amongst Older People Luke Munford

Acknowledgements This presentation represents independent research funded by the National Institute for Health Research (NIHR), project 12/130/33. Luke Munford was supported by the Medical Research Council, through a Skills Development Fellowship (grant number MR/N015126/1). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health, or the Medical Research Council. Great co-authors: Mark Sidaway, Amy Blakemore, Matt Sutton, Pete Bower, Andrew Jones

Community Assets and Health Widely held consensus that community assets do improve health and well-being of participants However, this evidence based is usually based on qualitative interviews and focus groups “tell us how your health changed as a result of xyz” Hard to quantify magnitudes, and generalisability So what we want to do: Use an existing study of integrated care to explore the role of community assets in improving health in older people Get some numbers!

Evaluation Framework: Data We used data collected as part of the Comprehensive Longitudinal Assessment of Salford Integrated Care (CLASSIC) Sample of around 4,000 older people (aged 65+) with a recorded long-term condition Questionnaires are sent out roughly every 6 months Asks information on age, gender, etc. Collects information on health and use of healthcare services Use of community assets More information on relevant questions next

Health Measures 1 The first health indicator we use is the EQ5D – a standardised measure of health outcomes recommended by the National Institute of Health and Care Excellence (NICE) Has information of 5 ‘domains’ Each is answered on a 1 – 5 scale These scores are then fed into an algorithm which produces a value of health related quality of life Values range from 0 – 1 0 is equivalent to ‘death’ 1 is equivalent to ‘full health’ NB: it is possible to have negative values (‘worse than death’)

Health Measures 2 We also have information on use of healthcare services Individuals are asked to report how many times in the last 6 months they’ve Visited their GP Attended hospital (as an outpatient) Attended casualty/A&E Called an ambulance out (dialled 999)

Health Measures 2 Each healthcare use has a monetary cost attached to it GP visits (£65 for a c. 17 minute consultation; PSSRU Unit Costs) Hospital (outpatient) visits (£134.22; NHS Reference Costs) Casualty/A&E (£131.92; NHS Reference Costs) Ambulance call outs (£96.35; NHS Reference Costs) We use the above to calculate the total value of NHS resources used by an individual Both in a six month period, but also in a year

Health Measures 3 We can combine (health) benefits and costs into one measure – called the ‘net-benefit’ NB=(EQ5D Score*Value of a QALY) – Total Healthcare cost Note this uses annual cost data Example: A person has an EQ5D score of 0.75 NICE are prepared to pay £20,000 for a QALY This person uses healthcare to the value of £9,000 per year Net-benefit = (0.75*20000) – 9000 = £6,000 We do this for all individuals

Health Measures 4 Individuals are also asked to self-report whether they have any one of 23 long-term conditions Also asked to indicate on a 1-5 scale how much these conditions limit their daily activity We consider 2 definitions: Whether or not an individual has a condition Whether that condition limits daily activity (defined as a score of 4 or 5) We use this information to hold underlying health status as constant as possible

Community Asset Use

How big is our data? 4,377 (33.6%) Usable questionnaires 12,989 Questionnaires mailed 4,447 (34.2%) Questionnaires returned 4,377 (33.6%) Usable questionnaires 3,686 (28.4%) Estimation Sample 70 (0.5%) Excluded as duplicates/not uniquely identifiable 691 (5%) Excluded as information missing on either EQ5D, age, or qualifications

Research Questions What is the use of CAs, and does it change over time? Changes in participation How does CA use relate to health and healthcare use? Are participants healthier? And do they use fewer services? What benefits are associated with CAs? What is the net-benefit? How much should we be willing to pay? Does CA use impact on future health? What happens to people how start to use CAs, compared to those who don’t?

Use of CAs over time 50% of individuals reported participating in a CA Average number for whole sample is 1, but 2 for individuals who do participate Few differences in characteristics between participants and non-participants – including long-term conditions One exception: 9% of participants have university qualifications, compared to 4% of non-participants Change in use:   Follow-up 1 Participate Don’t Baseline 1168 (37%) 455 (14%) 302 (9%) 1263 (40%)

Use of CAs and Health Raw average difference in EQ5D scores between participants and non-participants is 0.09 (p<0.001; 95% CI 0.08 to 0.11) When we control for characteristics, including having limiting health conditions, the difference is 0.04 (p<0.001; 95% CI 0.03 to 0.05) Can compare this to the effect of having certain limiting conditions: Back Pain: -0.17 (about 4-times the size of our effect) Osteoarthritis: -0.16 (about 4-times the size of our effect) Diabetes: -0.05 (about the same size as our effect)

CAs and Use of Healthcare Raw average difference in use between participants and non-participants: is -0.3 GP visits (95% CI -0.5 to -0.1) [3 compared to 3.3] is -0.3 hospital outpatient visits (95% CI -0.5 to -0.1) [2.2 compared to 2.5] Also make fewer visits to casualty and have fewer ambulance callouts Total cost difference is -£97 (95% CI -161 to -33) [£448 compared to £545] When we control for characteristics, including having limiting health conditions, the differences remain negative, but not statistically significant However, if we do not condition on limiting conditions, the effects are significant Perhaps health conditions dominate?

The Net-Benefit NICE have an upper and lower threshold on how much a quality adjusted life year (QALY) is worth: £20,000 - £30,000 Using these value, we get a net-benefit of: Lower limit: £763 (95% CI 478 to 1048) Upper limit: £1,142 (95% CI 725 to 1558) Recent work by University of York has stated that these values are too high, and proposed a value of £12,936. This value of a QALY gives us a net-benefit of: £496 (95% CI 302 to 689)

Causal evidence? What happens to people how start to use CAs, compared to those who don’t? This longitudinal work should help us overcome some problems of using a single point in time We observe 302 people who started using CAs between baseline and follow-up 1 We can match these to ‘similar’ people who don’t use CAs in either wave Similar in terms of age, sex, living arrangements, and health at baseline Only observable difference between two groups in the uptake of CAs

Causal evidence? The difference between the ‘treated’ (those who join in CAs) and the ‘control’ (those who never use CAs) outcomes at follow up 1 can be thought of as the ‘treatment effect’ EQ5D: increases by 0.06 (95% CI 0.3 to 0.8) Total costs: increase by £33 (95% CI -65 to 131) Net-benefit: increases by £980 (95% CI 346 to 1614) The results for longer time frames are consistent People with the biggest gains in terms of wave 4 health are those who start and then continue to go

Discussion Possible limitations Response rate to CLASSIC survey Restricted list of CA resources Crude measure of use Some costs are missing (physio, dietician, etc.) How generalisable is Salford?

Next Steps Linkage to integrated care intervention Geographical data on CAs Effects of new interventions (e.g. community champions, neighbourhood funds, etc.) Link to administrative healthcare utilisation data

Thank You luke.munford@manchester.ac.uk