6/1/2015 10:13 AM CMA Ottawa October 2007 On Improving Measures of Outputs and Outcomes in Health Care what do we want to know? outputs – why bother

04/18/23 19:52 CMA Ottawa October 2007

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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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


(total health spending as pct GDP)

“Health care costs 10% of GDP”


0 5 10 15 20 25 30 35 40 45

hospitals

other instn's

physicians

dental

vision care

other prof'nals

Rx - prescibed

non-prescribed

capital

pubilc health

admin

research

other

Private

Public

Health Spending, 2006(estimated, $ billions, Source: CIHI)


Example – Capital Health (Edmonton Alberta) Institutional Structure

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


Economics 101

input

output


Economics 101

input

output


Economics 101

input

output


Economics 101

input

output

inefficient


Economics 101

input

output“flat of the curve”

inefficient


Economics 101

input

output“flat of the curve”


(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?


(fisher 1)

Medicare Spending Varies Widely Across the U.S., both per capita, and using an “end of life” spending index

Fisher et al., 2003


(fisher 2)

Q1 to Q5: quintiles (fifths) of “hospital referral regions” with increasing levels of an index of Medicare spending (based on “end of life” expenditures)

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


Underlying Person-Oriented Information (POI) for Heart Attack / Revascularization Analysis

Heart Attack (AMI)Treatment (revascularization = bypass or angioplasty)Death

one year observation window

one year follow-up window(excluded)


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


SNA Approach: Treat Public Sector Activities the Same as the Private Sector

Define (i.e. make up) “Outputs”

???“Profits”

Inputs

(total $)

Commercial Sector

Public Sector

Outputs

(total $)

Industries


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


5 Day Forecast from Environment Canada Sunday Sunday night Monday

High 6°C Low -5°C High 9°C

POP 40%

Sunny with cloudy periods

A few clouds Chance of showers

Tuesday Wednesday Thursday

High 9°C Low 3°C

High 13°C Low -1°C

High 5°C Low 5°C POP 70%

A mix of sun and cloud A mix of sun and cloud Chance of showers

Simple Weather Forecast


Detailed Cloud Forecast


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)


Stat Can / CIHI Outcomes Analysis Framework


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


“Wall of Ignorance”


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

Claudia Sanmartin

Up to this point, we need to have made the case that there are two things we need:1. population level measures of outcomes - information that is useful when reported at this leveland 2. need more outcome information that can be provided by admin data - i.e. HRQL, patient satsifaction


Vision – Coherent, Integrated Statistical System

Broad Summary Indicators

Regional Indicators / Planning Info

Facility Management Information / Unit Costs

Basic Encounter Data / Health Surveys

Health Accounts / Simulation Models


(blank)


Hospital 65+ Patient Co-morbidity

CHFHigh 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


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


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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6/1/2015 10:13 AM CMA Ottawa October 2007 On Improving Measures of Outputs and Outcomes in Health Care what do we want to know? outputs – why bother