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04/11/23 00:30 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)
04/11/23 00:30 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
04/11/23 00:30 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”
04/11/23 00:30 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)
04/11/23 00:30 OECD Istanbul June 2007
UK LE and HALE (Simpler Method)
04/11/23 00:30 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”
04/11/23 00:30 OECD Istanbul June 2007
2.2
0.9
0.7
0.5
0.4
0.5
0.2
1
0.9
1.5
0.6
0.5
0.7
0.5
0.3
0.4
0.1
2.4
1.1
0 0.5 1 1.5 2 2.5
Men
Women
Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE)
by Cause, Canada
2.4
1
0
0.5
0.4
0.4
0.3
0.1
0
0.7
1.8
0.7
0.6
0.8
0.3
0.4
0.3
0
0
0.4
00.511.522.5
IHD
Lung cancer
Breast cancer
Stroke
COPD
Colorectal cancer
Diabetes
Melanoma
Osteoarthritis
Mental disorders
Men
Women
(Source: Manuel et al, ICES and Health Canada, NPHS)
HALELE
04/11/23 00:30 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
04/11/23 00:30 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
04/11/23 00:30 OECD Istanbul June 2007
Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE), Canada 2001
50
55
60
65
70
75
80
85
90
bottom middle top bottom middle top
HALE LE
male female male female
at birth at age 65 males femalesat birth at birth
income terciles (thirds)
04/11/23 00:30 OECD Istanbul June 2007
An Almost Familiar World Map
www.worldmapper.org; cartogram algorithm: Mark Newman
04/11/23 00:30 OECD Istanbul June 2007
Area Proportional to Population
www.worldmapper.org; cartogram algorithm: Mark Newman
04/11/23 00:30 OECD Istanbul June 2007
Area Proportional to GDP 2002
www.worldmapper.org; cartogram algorithm: Mark Newman
04/11/23 00:30 OECD Istanbul June 2007
Area Proportional to HIV(prevalence ages 15 – 49)
www.worldmapper.org; cartogram algorithm: Mark Newman
04/11/23 00:30 OECD Istanbul June 2007
Area Proportional to “Unhealthy Life”(LE – HALE, based on WHO estimates)
www.worldmapper.org; cartogram algorithm: Mark Newman
04/11/23 00:30 OECD Istanbul June 2007
0
10
20
30
40
50
60
70
80
0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000
HALE
GDP per capita, US $ at PPPs, 2002
National Income and Health, Correlated ?(Sources: HALE – WHO; GDP – World Bank)
04/11/23 00:30 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
04/11/23 00:30 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)
04/11/23 00:30 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
04/11/23 00:30 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
04/11/23 00:30 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
04/11/23 00:30 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?
04/11/23 00:30 OECD Istanbul June 2007
Heart Attack Patients in Large Health Regions – Treatment and 30 Day Mortality Rates (%) – 1995/96 to 2003/04
0
5
10
15
20
0 10 20 30 40 50 60 70Percent Revascularized within 30 Days
30 D
ay M
orta
lity
Rat
e
1995/96
2003/04
04/11/23 00:30 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
04/11/23 00:30 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