Chronic diseases as tracer conditions in international benchmarking of health systems: the example o...
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Chronic diseases as tracer conditions in international benchmarking of health systems: the example of diabetes. Ellen Nolte 1 , Chris Bain 2 , Martin McKee 1. 1 European Centre on Health of Societies in Transition London School of Hygiene and Tropical Medicine, UK

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Ellen nolte 1 chris bain 2 martin mckee 1

Chronic diseases as tracer conditions in international benchmarking of health systems: the example of diabetes

Ellen Nolte1, Chris Bain2, Martin McKee1

1 European Centre on Health of Societies in Transition

London School of Hygiene and Tropical Medicine, UK

2 School of Population Health, University of Queensland, Australia


Assessing health system performance

Assessing health system performance

  • Health systems are complex with multiple functions

  • They must respond to varied health needs of the population with limited resources

  • They involve trade-offs, e.g. between prevention & treatment or primary & specialised care

  • It is unlikely that any system will perform well on all possible measures


Ellen nolte 1 chris bain 2 martin mckee 1

How do countries compare?

  • Different models of health care provision

  • Differences at different levels

  • Approach: ‘probe disorders’ or ‘tracer conditions’ that capture certain elements of the health care system

    • Discrete and identifiable health problem

    • Evidence of effective, well-defined health care intervention

    • Natural history of condition varies with utilisation and effectiveness of health care

    • Sufficiently common


Ellen nolte 1 chris bain 2 martin mckee 1

Diabetes as tracer condition

  • Optimal management requires

    • co-ordinated inputs from range of health professionals incl. primary care & specialists

    • access to essential medicines & monitoring equipment

    • active participation of informed patients

  • Can provide important insights into primary and specialist care, and into systems for communicating among them

  • Deaths (<45) considered ‘avoidable’ by timely and effective health care


Ellen nolte 1 chris bain 2 martin mckee 1

SDR0-39

SIR0-14

Diabetes mortality (SDR0-39) and incidence (SIR0-14)

SDR 0-39

SIR 0-14


Ellen nolte 1 chris bain 2 martin mckee 1

Study design

  • Outcome measure: Mortality-to-incidence ratio

    • commonly used in cancer epidemiology as a crude indicator of cancer survival or “case fatality”

    • may be interpreted as an indicator of the overall quality of health care

  • Age-standardized incidence rates for ages 0-14 years (WHO DiaMond study, 1990-1994)

  • Age-standardised death rates from diabetes for ages 0-39 (WHO mortality database, 1994-1998)

  • Study population: 29 industrialised countries


Ellen nolte 1 chris bain 2 martin mckee 1

Diabetes: Mortality-incidence ratio


Ellen nolte 1 chris bain 2 martin mckee 1

Sensitivity analysis


Next steps

Next steps

  • M/I ratio only an indicator of potential differences in health system performance & should stimulate detailed assessments to confirm whether the apparent variations are real and identify the reasons

    • Scrutinise data

    • Understand immediate causes of death

      • e.g. ~50% of deaths in Estonia & Latvia due to acute complications of diabetes compared to only 22% in Finland (Podar et al. 2000)

    • Understand processes of care


Conclusions 1

Conclusions (1)

  • M/I ratio for diabetes provides means of differentiating countries that appear to provide differing quality of care to people with diabetes and by extension to other chronic diseases

  • Further work is required to develop

    • a battery of performance indicators that capture other aspects of health system performance

    • instruments that can be used for detailed health system diagnosis once indicators suggest the presence of a problem


Conclusions 2

Conclusions (2)

  • International comparisons of health (care) systems have focused on what can most readily be measured, not what is necessarily important

  • While indicating the existence of a possible problem they provide few insights in how to respond

  • Tracer conditions offer approach to overcome some of these limitations

  • This study is an attempt to show how to shift the agenda on performance assessment to disorders such as chronic disease that are critically important


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