1. Chronic diseases as tracer conditions in international benchmarking of health systems: the example of diabetes 1 European Centre on Health of Societies in Transition London School of Hygiene and Tropical Medicine, UK 2 School of Population Health, University of Queensland, Australia Ellen Nolte 1, Chris Bain 2, Martin McKee 1

2. Assessing health system performance  Health systems are complex with multiple functions  They must respond to varied health needs of the population with limited resources  They involve trade-offs, e.g. between prevention & treatment or primary & specialised care  It is unlikely that any system will perform well on all possible measures

3.  Different models of health care provision  Differences at different levels How do countries compare?  Approach: ‘probe disorders’ or ‘tracer conditions’ that capture certain elements of the health care system Discrete and identifiable health problem Evidence of effective, well-defined health care intervention Natural history of condition varies with utilisation and effectiveness of health care Sufficiently common

4.  Optimal management requires co-ordinated inputs from range of health professionals incl. primary care & specialists access to essential medicines & monitoring equipment active participation of informed patients  Can provide important insights into primary and specialist care, and into systems for communicating among them  Deaths (<45) considered ‘avoidable’ by timely and effective health care Diabetes as tracer condition

5. Diabetes mortality (SDR 0-39 ) and incidence (SIR 0-14 ) SIR 0-14 SDR 0-39 SIR 0-14

6.  Outcome measure: Mortality-to-incidence ratio commonly used in cancer epidemiology as a crude indicator of cancer survival or “case fatality” may be interpreted as an indicator of the overall quality of health care  Age-standardized incidence rates for ages 0-14 years (WHO DiaMond study, 1990-1994)  Age-standardised death rates from diabetes for ages 0-39 (WHO mortality database, 1994- 1998)  Study population: 29 industrialised countries Study design

7. Diabetes: Mortality-incidence ratio

8. Sensitivity analysis Ratio of national SDR (1994-98) Ratio of M/I ratios ScenarioUS vs. UK US vs. Canada vs. UKvs. Canada (i) as reported (US incidence: 14.8/100,000) 2.62.03.33.2 (ii) US death rate Excess: 10%2.41.83.02.9 Excess: 20%2.11.62.72.6 Excess: 50%1.31.01.71.6 (iii) Increase US incidence rate to a. highest regional rate (17.8/100,000) --2.82.7 b. upper 95 CI of highest regional rate (20.3/100,000) --2.4 (iv) (iii a) + 20% mortality excess--1.9

9. Next steps  M/I ratio only an indicator of potential differences in health system performance & should stimulate detailed assessments to confirm whether the apparent variations are real and identify the reasons Scrutinise data Understand immediate causes of death  e.g. ~50% of deaths in Estonia & Latvia due to acute complications of diabetes compared to only 22% in Finland (Podar et al. 2000) Understand processes of care

10. Conclusions (1)  M/I ratio for diabetes provides means of differentiating countries that appear to provide differing quality of care to people with diabetes and by extension to other chronic diseases  Further work is required to develop a battery of performance indicators that capture other aspects of health system performance instruments that can be used for detailed health system diagnosis once indicators suggest the presence of a problem

11. Conclusions (2)  International comparisons of health (care) systems have focused on what can most readily be measured, not what is necessarily important  While indicating the existence of a possible problem they provide few insights in how to respond  Tracer conditions offer approach to overcome some of these limitations  This study is an attempt to show how to shift the agenda on performance assessment to disorders such as chronic disease that are critically important