Transcript Population Health Index -

On Improving Measures of Outputs
and Outcomes in Health Care
 what do we want to know?
 outputs – why bother ?
 outcomes – absolutely !
 context (“awkward facts” ?)
 the SNA / productivity approach
 alternative approaches – person-level
health and health care trajectories
Michael Wolfson, Statistics Canada
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(blank)
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What Do We Want to Know?
(in the context of “outputs” and “outcomes”)
 are our health care (or health more
generally) dollars being spent efficiently
and effectively
 what changes in the way we allocate
health dollars would improve the health
status of the Canadian population
 what kinds of institutional structures are
most likely to lead to cost-effective use of
scarce health dollars
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(total health spending as pct
GDP)
“Health care costs 10% of GDP”
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other
research
admin
pubilc health
Private
Public
capital
non-prescribed
Rx - prescibed
other prof'nals
vision care
dental
physicians
other instn's
hospitals
0
5
10
15
20
25
30
Health Spending, 2006
(estimated, $ billions, Source: CIHI)
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35
40
45
Example – Capital Health (Edmonton
Alberta) Institutional Structure
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



11 hospitals
6 community health / primary care centres
1 rehab centre
1 specialized heart institute
10 community mental health clinics
36 continuing care facilities
29 public health establishments (including
specialized units for birth control, immunization,
STDs, TB, and travellers)
 37 patient labs
 69 physiotherapy clinics
 17 x-ray clinics
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Economics 101
output
input
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Economics 101
output
input
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Economics 101
output
input
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Economics 101
output
inefficient
input
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Economics 101
output
“flat of the curve”
inefficient
input
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Economics 101
output
“flat of the curve”
input
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n.b. virtually no differences in one year survival; but
no data on differences in health-related QoL
(Tu et al on Coronary Surgery)
e.g. almost
17x, with no
benefits?
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Medicare Spending Varies Widely Across the U.S.,
both per capita, and using an “end of life” spending index
Fisher et al., 2003
(fisher 1)
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Q1 to Q5: quintiles (fifths) of
“hospital referral regions”
with increasing levels of an
index of Medicare spending
(based on “end of life”
expenditures)
(fisher 2)
Cohorts: subsets of the
Medicare population with
selected conditions (MCBS
= Medicare Beneficiary
Survey)
Conclusion: if anything,
more spending increases
mortality
Source: Fisher et al, 2003
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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
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Heart Attack Patients in Large Health Regions – Treatment
and 30 Day Mortality Rates (%) – 1995/96 to 2003/04
20
30 Day Mortality Rate
1995/96
2003/04
15
10
5
0
0
10
20
30
40
50
Percent Revascularized within 30 Days
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60
70
SNA Approach: Treat Public Sector
Activities the Same as the Private Sector
 Define (i.e. make up) “Outputs”
“Profits”
???
Outputs
(total $)
Inputs
(total $)
Commercial
Sector
Industries
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Public
Sector
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 (recall earlier 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
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5 Day Forecast from
Environment Canada
Sunday

High 6°C
Sunday night

Sunny with cloudy
periods
Tuesday


High 9°C
Low 3°C


A mix of sun and cloud
Monday
Low -5°C


A few clouds
Chance of showers
Wednesday
Thursday
High 13°C
Low -1°C
A mix of sun and cloud



High 9°C
POP 40%
High 5°C
Low 5°C
POP 70%
Chance of showers
Simple Weather Forecast
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Detailed Cloud
Forecast
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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)
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Stat Can / CIHI Outcomes Analysis Framework
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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 the field of statistical process
quality control
 50 years later: not yet implemented in
health care
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“Wall of Ignorance”
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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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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
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(blank)
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Hospital 65+ Patient Co-morbidity
CHF
number (000's)
High
BP
CPD
Diab's
Ca
RA etc.
Psych
Deprn
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
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The SNA Approach(es), or
“Let us Assume…” Economics
 “Measures of productivity growth constitute core
indicators for the analysis of economic growth.”
 “desirable characteristics of productivity measures
(are defined) by reference to a coherent framework
that links economic theory and index number theory
… much of the underlying methodology relies on the
theory of production and on the assumption that
there are similar production activities across units of
observation (firms or establishments).”
from “Measuring Productivity, OECD Manual”, 2001
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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  productivity =  output – sum { inputs }
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