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

2. 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

3. 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!

4. 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

5. 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’)

7. 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)

8. 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

9. 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

10. 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

11. Community Asset Use

12. 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

13. 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?

14. 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%)

15. 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 (p<0.001; 95% CI 0.03 to 0.05)
Can compare this to the effect of having certain limiting conditions:
Back Pain: (about 4-times the size of our effect)
Osteoarthritis: (about 4-times the size of our effect)
Diabetes: (about the same size as our effect)

16. 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?

17. 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: £ (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)

18. 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

19. 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

20. 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?

21. 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

22. Thank You