8/23/2014 9:17 PM 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)

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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”

8/23/2014 9:17 PM OECD Istanbul June 2007 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)

8/23/2014 9:17 PM OECD Istanbul June 2007 UK LE and HALE (Simpler Method)

8/23/2014 9:17 PM OECD Istanbul June 2007 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”

8/23/2014 9:17 PM OECD Istanbul June 2007 Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE) by Cause, Canada (Source: Manuel et al, ICES and Health Canada, NPHS) HALELE

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE), Canada 2001 at birthat age 65malesfemales at birth income terciles (thirds)

8/23/2014 9:17 PM OECD Istanbul June 2007 An Almost Familiar World Map cartogram algorithm: Mark Newman

8/23/2014 9:17 PM OECD Istanbul June 2007 Area Proportional to Population cartogram algorithm: Mark Newman

8/23/2014 9:17 PM OECD Istanbul June 2007 Area Proportional to GDP cartogram algorithm: Mark Newman

8/23/2014 9:17 PM OECD Istanbul June 2007 Area Proportional to HIV (prevalence ages 15 – 49) cartogram algorithm: Mark Newman

8/23/2014 9:17 PM OECD Istanbul June 2007 Area Proportional to “Unhealthy Life” (LE – HALE, based on WHO estimates) cartogram algorithm: Mark Newman

8/23/2014 9:17 PM OECD Istanbul June 2007 HALE GDP per capita, US $ at PPPs, 2002 National Income and Health, Correlated ? (Sources: HALE – WHO; GDP – World Bank)

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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)

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 (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?

8/23/2014 9:17 PM OECD Istanbul June 2007 Heart Attack Patients in Large Health Regions – Treatment and 30 Day Mortality Rates (%) – 1995/96 to 2003/ / /04

8/23/2014 9:17 PM OECD Istanbul June 2007 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

8/23/2014 9:17 PM OECD Istanbul June 2007 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