Population Health Index -

Transcript Population Health Index -

On Measuring Outcomes and Productivity in Canada’s Health Care Sector

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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 Michael Wolfson Statistics Canada 1 4/24/2020 22:35 LifePaths

First Principles - I

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Population health is the fundamental objective Health outcomes relate to / depend on health interventions

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i.e. social activities, whether deliberate or inadvertent

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Health care is one kind of intervention which often contributes to health

•

but not always, and certainly not solely 2 4/24/2020 22:35 LifePaths

First Principles - II

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Doing more with less is a good thing

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i.e. being more efficient or more productive is beneficial

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People and care providers are heterogeneous

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so summing or averaging to produce overall indices can produce misleading results 3 4/24/2020 22:35 LifePaths

Definition (by Construction) Population Health I

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ask everyone (or a sample thereof) a structured set of questions (or do an exam) to assess each person’s health status

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i.e. a profile for each person (n.b. gives micro detail)

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construct an index for each person, based on their health profile

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e.g. McMaster Health Utility Index, or QALY

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average over people (perhaps age-standardized) 4 4/24/2020 22:35 LifePaths

Definition - Population Health II

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or combine individual-level summary health indices with life table (mortality rates) to measure Health-Adjusted Life Expectancy (HALE) 5 4/24/2020 22:35 LifePaths

2.5

2.4

“Cause – Deleted” Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE)

Men Women 2 1.8

1.5

0.5

IHD

1 0.7

Lung cancer

0.8

0.6

0.5

0.4

0.3

0.4

0.3

0.7

0.4

Breast cancer Stroke COPD Colorectal cancer Diabetes

0.1

0 0 0

Melanoma Osteoarthritis Mental disorders

0 0.5

HALE

1 0.5

0.6

0.7

0.9

0.1

0.2

0.3

0.4

0.5

0.4

0.5

1 0.9

1.1

1.5

2 Men Women 2.2

2.5

2.4

Source: Manuel et al, ICES and Health Canada, NPHS

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Definition - Health Outcome

health intervention health status “before” health status “after” other factors health outcome

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change in health status attributable to a health intervention (for an individual) 7 4/24/2020 22:35 LifePaths

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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.”

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Relative Risks of “Preventive” Tamoxifen

Breast Ca 0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

Fractures CHD Cataracts Stroke Deep Vein Thromb Endometrial Ca Pulmonary Emb (9.27) (Fisher et. al., J National Cancer Institute, 1999) 9 4/24/2020 22:35 LifePaths

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

-0.02

-0.04

0 1.66

42.3% 2.08

24.6% 2.49

16.2% 2.91

9.0% 3.32

4.0% 3.74

2.2% 4.15

1.7% 5-yr Predicted Risk / Proportion of Women Affected (Will et. al., British J Cancer, 2001) 10 4/24/2020 22:35 LifePaths

Definition – Health Care, per the Evans and Stoddart “Plumbing Diagram” “thermostat” “bottom line” 11 4/24/2020 22:35 LifePaths

12 4/24/2020 22:35 LifePaths no data on differences in health-related QoL

Surgery)

e.g. almost 17x, with no benefits?

Mortality Rate (Career Earnings and Death) 16 14 12 10 8 6 4 2 0

Career Earnings and Death for 500,000 Canadian Men

top quintile

0 20 40 60 80 100 Average Earnings (age 45-64, 1988 $000s)

Source: Wolfson et al., Gerontology, 1993

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Definition – Productivity (General)

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productivity level

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“output” / “input” productivity growth

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growth in outputs growth in inputs

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i.e. getting more output for given inputs, or getting the same output from fewer inputs

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n.b. in common parlance

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no presumption that everything has to be measured in $$$

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indeed, usual thoughts are in physical units (e.g. patients seen or cataracts done per day) 14 4/24/2020 22:35 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

product lines for individual

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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 (p’s) change, and this is not “real” • and quantities (q’s) 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 

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productivity =  output – sum {  inputs }

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

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Public Sector Challenge to “Economists’ Productivity”

“Profits” Outputs Inputs ???

Commercial Sector Public Sector 18 4/24/2020 22:35 LifePaths

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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 OECD’s System of Health Accounts)

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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?

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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

% from 1997Q1 to 2003Q4 • nominal government spending up

% • ONS measure of real public sector output up

% (Huh?)  GDP as welfare measure • more $ on (e.g.) health care treatments increases welfare – certainly if appropriate and effective, but “asymmetric information”

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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)

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Atkinson Report – Selected

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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”

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tractors computers “Technology Adoption from Hybrid Corn to Beta Blockers”, Skinner and Staiger, NBER, 2005 (Skinner I) corn beta blockers 24 4/24/2020 22:35 LifePaths corn corn

adjusted 1 yr mortality rate adjusted 1 yr mortality rate beta blockers $$$ (Skinner II) adjusted 1 yr mortality rate beta blockers 25 4/24/2020 22:35 LifePaths (education and) social capital (education and) social capital

(Skinner III)

(Source: Skinner, Staiger, Fisher; Medical Technology, 2006) 26 4/24/2020 22:35 LifePaths

27 4/24/2020 22:35 LifePaths “Wall of Ignorance”

25 20 Ontario British Columbia Quebec 15 10 percent dead within one year 5 Alberta 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 4/24/2020 22:35 LifePaths 60

E. A. Codman and W.E. Deming

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Codman: early 1900s Boston surgeon famous for “End Results Cards” – to keep track of surgical patients and follow them up one year later to

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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 4/24/2020 22:35 LifePaths

Underlying Person-Oriented Information (POI) for Heart Attack / Revascularization Analysis one year observation window (excluded) one year follow-up window 30 4/24/2020 22:35 LifePaths Heart Attack (AMI) Treatment (revascularization = bypass or angioplasty) Death

25 Ontario British Columbia 20 Quebec 15 10 percent dead within one year Alberta 5 better (less intervention, & better survival) (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 4/24/2020 22:35 LifePaths 60

Hospital 65+ Patient Co-morbidity

CHF High BP CPD Diab's Ca RA etc.

Psych Deprn number (000's) pct of all 111 16.4

237 35.0

128 18.9

125 18.5

101 14.9

16 2.3

20 3.0

30 4.5

cond'n only (%) 23.7

cond'n +1 cond'n +2 cond'n +3 37.1

27.5

9.9

37.7

37.6

18.4

5.4

28.0

38.0

23.7

8.7

22.8

41.9

25.2

8.5

47.8

31.0

15.2

4.8

27.7

36.3

23.5

9.6

26.0

35.1

24.6

10.6

24.0

35.0

25.6

11.6

33 4/24/2020 22:35 LifePaths based on 676,508 hospital inpatient discharges across 10 provinces in 2001/2

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Health Care Outputs or Health Outcomes?

SNA approach: health care inputs  outputs (i.e. “treatments”) health care • 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

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Platitudes?

You can’t manage what you can’t measure You get what you measure

“Don’t ask how many (health care) events per pound; ask how much health per pound.” D. Berwick, BMJ 2005

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Ontario Health Scorecard access / waits (Ontario Framework) production and use of evidence continuity of care sensible allocation healthy living clinical results health status spending / resources sustainability / equity 36 4/24/2020 22:35 LifePaths

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 4/24/2020 22:35 LifePaths