Population Health Index -- CIHI Slides

Population Health Index -- CIHI Slides

On Measuring Outcomes and Productivity in Canadas Health Care Sector first principles and basic definitions the UK Atkinson Report, the System of National Accounts (SNA), and the standard approach to measuring (health sector) productivity empirical nuggets and awkward facts alternative and better approaches NB More detail can be seen in the notes view; still draft, please do not circulate without permission 1 02/23/20 01:14 LifePaths Michael Wolfson Statistics Canada First Principles - I Population health is the fundamental objective Health outcomes relate to / depend on health interventions i.e. social activities, whether deliberate or inadvertent Health care is one kind of intervention which often contributes to health but not always, and certainly not solely

2 02/23/20 01:14 LifePaths First Principles - II Doing more with less is a good thing i.e. being more efficient or more productive is beneficial People and care providers are heterogeneous so summing or averaging to produce overall indices can produce misleading results 3 02/23/20 01:14 LifePaths Definition (by Construction) Population Health I ask everyone (or a sample thereof) a structured set of questions (or do an exam) to assess each persons health status i.e. a profile for each person (n.b. gives micro detail) construct an index for each person, based on their health profile e.g. McMaster Health Utility Index, or QALY average over people (perhaps age-standardized)

4 02/23/20 01:14 LifePaths Definition - Population Health II or combine individual-level summary health indices with life table (mortality rates) to measure Health-Adjusted Life Expectancy (HALE) 5 02/23/20 01:14 LifePaths Cause Deleted Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE) LE 2.5 2 2.4 1.5 1 HALE

0.5 0 0.5 1 1.5 IHD 1.8 1 0 0.8 0.5 Breast cancer Colorectal cancer 0.3

0.3 0.4 0 Melanoma 0 0 Osteoarthritis Mental disorders 2.2 Men Women 0.7 0.7 0.5 0.5 0.4 0.3

Diabetes 0.1 0.5 0.4 0.2 0.1 1 0.9 2.4 1.1 Source: Manuel et al, ICES and Health Canada, NPHS 6 02/23/20 01:14 LifePaths 2.5 0.9 0.5 COPD 0.4 0.4

0.7 0.6 Stroke 0.4 0.3 Women 2 1.5 Lung cancer 0.7 0.6 Men 0 Definition - Health Outcome

health intervention health status before health status after other factors health outcome change in health status attributable to a health intervention (for an individual) 7 02/23/20 01:14 LifePaths Charles Wright on Vancouver Cataracts pre- and post-surgery patient self-completed questionnaires 31% of patients booked for cataract surgery report a visual function score of 91 points or more on a scale of 100. These data tend to confirm the observation that cataract surgery is now occurring in many patients with minor degrees of self-reported visual disability. The overall results are positive, but 27% of patients show either no change or deterioration of VFA (Visual Function

Assessment) score after the operation. 8 02/23/20 01:14 LifePaths Relative Risks of Preventive Tamoxifen 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

5.5 Breast Ca Fractures CHD Cataracts Stroke Deep Vein Thromb Endometrial Ca Pulmonary Emb (Fisher et. al., J National Cancer Institute, 1999) 9 02/23/20 01:14 LifePaths (9.27) Change in Life Expectancy Simulated Change in Life Expectancy for Canadian Women for Alternative Scenarios of Preventive Tamoxifen (95% CIs) 0.12 0.1 0.08 0.06

0.04 0.02 0 -0.02 -0.04 1.66 2.08 2.49 2.91 3.32 3.74 4.15 42.3% 24.6% 16.2% 9.0%

4.0% 2.2% 1.7% 5-yr Predicted Risk / Proportion of Women Affected (Will et. al., British J Cancer, 2001) 10 02/23/20 01:14 LifePaths Definition Health Care, per the Evans and Stoddart Plumbing Diagram thermostat bottom line 11 02/23/20 01:14 LifePaths (Tu et al on Coronary Surgery) e.g. almost n.b. virtually no differences in one year survival; but no data on differences in health-related QoL 17x, with no

benefits? 12 02/23/20 01:14 LifePaths Mortality Rate (%,18 age 65-70) (Career Earnings and Death) Career Earnings and Death for 500,000 Canadian Men 16 14 12 top quintile 10 8 6 4 2 0 0

20 40 60 80 100 Average Earnings (age 45-64, 1988 $000s) 13 02/23/20 01:14 LifePaths Source: Wolfson et al., Gerontology, 1993 120 Definition Productivity (General) productivity level output / input productivity growth growth in outputs - growth in inputs i.e. getting more output for given inputs, or getting the same output from fewer inputs n.b. in common parlance

no presumption that everything has to be measured in $$$ indeed, usual thoughts are in physical units (e.g. patients seen or cataracts done per day) 14 02/23/20 01:14 LifePaths Definition Productivity (business school) let me compare myself to another firm, typically a competitor is she producing her widgets at lower unit costs than me? i.e. benchmarking for individual product lines 15 02/23/20 01:14 LifePaths Definition Productivity (standard economics and SNA) the economy has myriad productive agents (firms) each of whom uses inputs = total capital services + total labour services (factors of production) to produce outputs (goods and services) summing to GDP everything is measured in $ -- with the total being (conceptually) the sum of unit prices x quantities

but over time, prices (ps) change, and this is not real and quantities (qs) change e.g. in terms of quality to measure productivity, time series of outputs and inputs are constructed taking out pure price changes, and adjusting for improvements in quality so that productivity = output sum { inputs } 16 02/23/20 01:14 LifePaths Definition Health Sector Productivity (standard economics and SNA) standard economists and National Accountants want to treat health care as an industry, with health care services its outputs, analogous to private sector industries firms in the health sector are divided (mainly) into hospitals, nursing homes, and providers of ambulatory care (OECD SHA) n.b. no concept of regional health authority or local health integration network ideal concept for outputs is care for episodes of illness, though DRGs in practice (OECD SHA) n.b. no concept of continuum of care, nor chronic illness, nor

recognition of co-morbidities 17 02/23/20 01:14 LifePaths Public Sector Challenge to Economists Productivity Profits ??? Outputs Inputs Commercial Sector 18 02/23/20 01:14 LifePaths Public Sector UK Office of National Statistics (ONS) and their Productivity Paradox UK Labour Government massively increased spending in health care (and education) starting in the late 1990s the ONS had been dutifully measuring public sector productivity, using SNA / economists concepts

productivity declined (unfortunately) ONS (2004) asked Sir Tony Atkinson what to do (and many jurisdictions are considering the Atkinson report recommendations, as well as gradually adopting the OECDs System of Health Accounts) 19 02/23/20 01:14 LifePaths ONS, Atkinson, and Productivity mandate from ONS National Statistician: To advance methodologies for the measurement of government output, productivity and associated price indices (OK) in the context of the National Accounts (Oh oh!) question: why not first pose issue in general and then only secondarily ask whether SNA is an appropriate framework, and if not what would be? 20 02/23/20 01:14 LifePaths Atkinson Report Analysis I SNA data are the essential foundation for macroeconomic management and as an indicator of social welfare UK context per Bank of England (May 04) CPI up 10% from 1997Q1 to 2003Q4

nominal government spending up 62% ONS measure of real public sector output up 14% (Huh?) GDP as welfare measure more $ on (e.g.) health care treatments increases welfare certainly if appropriate and effective, but asymmetric information 21 02/23/20 01:14 LifePaths Atkinson Report Analysis II National Accounts are not a substitute for performance indicators (para 1.27) It is not necessarily the case that even a crude measure of government output is preferable to an index based on total cost. (para 2.25) i.e. the conventional way of doing the SNA measurement of quality change (e.g. improvements in methods and technology) is a major challenge the UK, as part of the EU, is bound to measure SNA according to international standards (but the US and Canada, so far, have ignored these) 22 02/23/20 01:14 LifePaths Atkinson Report Selected Recommendations

the SNA should measure government non-market output (e.g. health care services) using a procedure parallel to that of the market sector (para 4.7) use the treatment or GP visit as the canonical output of the health care sector weight different kinds of treatment by their costs try to adjust for quality change ideally by moving from treatments to care pathways, and connecting care to health outcomes n.b. sounds good, but feasibility? also treat shorter waits as improved quality n.b. nothing on appropriateness, or watchful waiting 23 02/23/20 01:14 LifePaths tractors Technology Adoption from Hybrid Corn to Beta Blockers, Skinner and Staiger, NBER, 2005 (Skinner I)

corn computers beta blockers corn 24 02/23/20 01:14 LifePaths corn adjusted 1 yr mortality rate adjusted 1 yr mortality rate $$$ beta blockers (education and) social capital 25 02/23/20 01:14 LifePaths (Skinner II)

beta blockers adjusted 1 yr mortality rate (education and) social capital (Skinner III) (Source: Skinner, Staiger, Fisher; Medical Technology, 2006) 26 02/23/20 01:14 LifePaths Wall of Ignorance 27 02/23/20 01:14 LifePaths 25 British Columbia Ontario 20 Quebec

15 10 percent dead within one year Alberta 5 percent revascularized within 30 days 0 0 10 20 30 40

50 Heart Attack Patients, 2000: Treatment and One Year Mortality Rates for Large Canadian Health Regions 28 02/23/20 01:14 LifePaths 60 E. A. Codman and W.E. Deming Codman: early 1900s Boston surgeon famous for End Results Cards to keep track of surgical patients and follow them up one year later to observe outcomes systematically learn from experience 100 years later: not yet implemented in health care Deming: post WW II concern with product quality in manufacturing father of field of statistical process quality control 50 years later: not yet implemented in health care

29 02/23/20 01:14 LifePaths Underlying Person-Oriented Information (POI) for Heart Attack / Revascularization Analysis one year observation window (excluded) one year follow-up window Heart Attack (AMI) Treatment (revascularization = bypass or angioplasty) Death 30 02/23/20 01:14 LifePaths 25 British Columbia Ontario 20 Quebec 15

10 percent dead within one year Alberta 5 percent revascularized within 30 days 0 0 10 20 30 40 50

Heart Attack Patients, 2000: Treatment and One Year Mortality Rates for Large Canadian Health Regions 31 02/23/20 01:14 LifePaths 60 25 British Columbia Ontario 20 Quebec 15 10 percent dead within one year

Alberta better (less intervention, & better survival) 5 (more output ???) percent revascularized within 30 days 0 0 10 20 30 40 50 Heart Attack Patients, 2000: Treatment and One Year

Mortality Rates for Large Canadian Health Regions 32 02/23/20 01:14 LifePaths 60 Hospital 65+ Patient Co-morbidity CHF High BP CPD Diab's Ca RA etc. Psych Deprn number (000's) 111

237 128 125 101 16 20 30 pct of all 16.4 35.0 18.9 18.5 14.9

2.3 3.0 4.5 cond'n only (%) 23.7 37.7 28.0 22.8 47.8 27.7 26.0 24.0 cond'n +1

37.1 37.6 38.0 41.9 31.0 36.3 35.1 35.0 cond'n +2 27.5 18.4 23.7 25.2

15.2 23.5 24.6 25.6 cond'n +3 9.9 5.4 8.7 8.5 4.8 9.6 10.6 11.6

based on 676,508 hospital inpatient discharges across 10 provinces in 2001/2 33 02/23/20 01:14 LifePaths Health Care Outputs or Health Outcomes? SNA approach: health care inputs health care outputs (i.e. treatments) leave for others to figure out connections from health care outputs health outcomes (para 7.27, OECD SHA) public policy priority: what (broad) allocation of resources produces the most health gain (i.e. increase in population health) inputs outcomes SNA approach is helpful on inputs and costs though focus on aggregation distracts from benchmarking, i.e. firm level analyses and SNA compulsion to create an artificial concept of output is useless for this purpose 34 02/23/20 01:14 LifePaths Platitudes? You cant manage what you cant measure

You get what you measure Dont ask how many (health care) events per pound; ask how much health per pound. D. Berwick, BMJ 2005 35 02/23/20 01:14 LifePaths access / waits Ontario Health Scorecard (Ontario Framework) continuity of care production and use of evidence sensible allocation healthy living spending /

resources 36 02/23/20 01:14 LifePaths clinical results health status sustainability / equity Vision Coherent, Integrated Statistical System Broad Summary Indicators Health Accounts / Simulation Models Regional Indicators / Planning Info Facility Management Information / Unit Costs Basic Encounter Data / Health Surveys 37 02/23/20 01:14 LifePaths

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