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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.

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on improving measures of outputs and outcomes in health care
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

CMA Ottawa October 2007

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(blank)

CMA Ottawa October 2007

what do we want to know in the context of outputs and outcomes
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

CMA Ottawa October 2007

total health spending as pct gdp
(total health spending as pct GDP)

“Health care costs 10% of GDP”

CMA Ottawa October 2007

example capital health edmonton alberta institutional structure
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

CMA Ottawa October 2007

economics 101
Economics 101

output

input

CMA Ottawa October 2007

economics 1011
Economics 101

output

input

CMA Ottawa October 2007

economics 1012
Economics 101

output

input

CMA Ottawa October 2007

economics 1013
Economics 101

output

inefficient

input

CMA Ottawa October 2007

economics 1014
Economics 101

output

“flat of the curve”

inefficient

input

CMA Ottawa October 2007

economics 1015
Economics 101

output

“flat of the curve”

input

CMA Ottawa October 2007

tu et al on coronary surgery
(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?

CMA Ottawa October 2007

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 1)

CMA Ottawa October 2007

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

(fisher 2)

CMA Ottawa October 2007

underlying person oriented information poi for heart attack revascularization analysis
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

CMA Ottawa October 2007

slide17
1995/96

2003/04

Heart Attack Patients in Large Health Regions – Treatment and 30 Day Mortality Rates (%) – 1995/96 to 2003/04

CMA Ottawa October 2007

slide18
SNA Approach: Treat Public Sector Activities the Same as the Private Sector  Define (i.e. make up) “Outputs”

“Profits”

???

Outputs

(total $)

Inputs

(total $)

Public Sector

Commercial Sector

Industries

CMA Ottawa October 2007

why the sna approach is problematic
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

CMA Ottawa October 2007

simple weather forecast
Simple Weather Forecast

CMA Ottawa October 2007

detailed cloud forecast
Detailed Cloud Forecast

CMA Ottawa October 2007

definition health outcome
health status “before”

health status “after”

health intervention

other factors

Definition - Health Outcome

health outcome  change in health status attributable to a health intervention (for an individual)

CMA Ottawa October 2007

e a codman and w e deming
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

CMA Ottawa October 2007

wall of ignorance
“Wall of Ignorance”

CMA Ottawa October 2007

platitudes
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

CMA Ottawa October 2007

vision coherent integrated statistical system
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

CMA Ottawa October 2007

blank1
(blank)

CMA Ottawa October 2007

hospital 65 patient co morbidity
Hospital 65+ Patient Co-morbidity

based on 676,508 hospital inpatient discharges across 10 provinces in 2001/2

CMA Ottawa October 2007

the sna approach es or let us assume economics
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

CMA Ottawa October 2007

definition productivity standard economics and sna
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 }

CMA Ottawa October 2007

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