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Health Care Systems, Access, and Quality
BUILDING THE EVIDENCE BASE FOR HEALTH REFORM
Rafael Lozano, Mexico National Academy of Medicine and Institute for Health Metrics and Evaluation, spoke of his experience over many years of attempting to build an evidence base for health care reform in Mexico. The main focus of any system reform, he said, should be to improve system performance, which entails an assessment of its performance in terms of efficiency, access, and quality (understanding the causes of unsatisfactory outcomes). At the same time, he said, one should not focus only on technical aspects but also take into account political and ethical dimensions of reform.
In the context of an aging population, Lozano noted several forces that may be at work. Providing health is becoming increasingly expensive, largely as a result of more technology. Populations are increasingly well educated, and people expect more for the taxes that they pay. However, a government’s payment capability for the technology that it uses often is limited. And, he commented, there is skepticism having to do with the fact that people want change but also wish to continue doing things in the same way (see Roberts et al., 2008). He mentioned that for health system planners to address efficiency, quality, and access, they need a “command center” with five buttons that may be pushed at different times and in different combinations in order to have an effect on society. He identified these five buttons as funding, payment, organization, regulation, and behavior.
A major question facing any national health system and potential reform is how to respond to current population health needs with the health system that now exists. Drawing on work done in the context of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD), a comprehensive and ongoing effort to measure epidemiological levels and trends worldwide,1 Lozano mentioned several health trends seen in many countries, and the reasons why current health systems have difficulty addressing these trends. One is the demographic transition that is shifting the disease burden from children to adults. This leads to a larger fraction of disease burden stemming from chronic health conditions. The corresponding disability transition is shifting the burden of disease to conditions that cause disability. And a risk transition is shifting the major risk factors from those of poverty to those associated with lifestyle. Health systems, however, may not be well equipped to deal with these trends, Lozano stated. Systems often have been designed to respond to acute episodes or acute diseases. They have been successful in treating infectious but not chronic conditions. Systems are organized to provide care but are not well organized to retain staff who provide the care. There is little incentive in public systems to provide follow-up care, he said, and the dominant focus is on curing diagnostics rather than being patient-centered.
Lozano presented preliminary results from a recent update of the GBD study that demonstrate how the disease burden is shifting in Latin America and the Caribbean (LAC). Disease burden is measured in disability adjusted life years (DALY), which is the sum of the number of years lost due to early death. Because of the success of prevention and treatment at younger ages, the share of overall disease burden at ages 0–14 changed from 42 percent in 1990 to 18 percent in 2013. At the other end of the spectrum, the share increased from 25 to 42 percent for people aged 50 and older. He showed the enormous global heterogeneity in the share of disease burden at age 60 and older; in Japan, 70 percent of the total disease burden is found in this age group, compared with 5–10 percent in many other countries.
In addition to looking at cause-of-death and DALY rankings, Lozano considered a method of analysis that attributes DALY to risk factors. He posed a question about the burden of disease attributed to factors such as poor diet or a high prevalence of hypertension. He said his analysis suggests that when all dietary problems are considered, they represent the largest
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1For more detailed information about the data sources and methods of GBD, see http://www.healthdata.org/gbd [August 2015].
share of the disease burden for the population aged 70 and older in the LAC region. High blood pressure and high-fasting blood glucose also are major problems in the region.
These various measures of health care needs are important for building the health evidence base, but Lozano stressed that another important focus is to determine how those needs translate into equivalents in human resources. For example, he posed, does a system have enough cardiologists, and are they properly distributed? He concluded by stating that Mexico (and other countries) needs to emphasize three notions in a vision of the health system: chronicity, continuity, and comorbidity. First is the notion of chronicity, in that disease burdens are increasingly chronic and treatment should be as well. More people need life-long treatment. The second notion is that of continuity. This does not just mean referral and counter-referral, he said, but continuity of information throughout the health information system, especially to address the third and perhaps most challenging notion, that of comorbidity. The set of conditions that a patient has must be addressed, as opposed to treating problems one by one. Being able to manage comorbid conditions requires team work, which means that health systems must work to strengthen their managerial and incentive components.
DEPRESSION AND HEALTH CARE SERVICES
The workshop focus then shifted to a consideration of late-life depression and health care utilization. Carmen Garcia-Peña, Mexican National Institute of Geriatrics, stated that depression is one of the most prevalent mental disorders in older adults, and one with different pathways: etiological, neurobiological, behavioral, and psychological. It is a complex phenomenon characterized by frequent relapses and a chronic clinical course. It can occur in a wide spectrum that ranges from subclinical depression to severe forms of major depression, and may be accompanied by multiple affective and somatic symptoms. She highlighted various consequences of depression, including increased physical symptoms of other conditions; decreased adherence to pharmacological treatment; an association with adverse behaviors; high direct costs in terms of treatment, health service utilization, disability, and loss of function; increased mortality; and an association with cognitive impairment.
She discussed a conceptual framework of stress vulnerability, depression, and health outcomes based on work by Kinser and Lyon (2014), noting that stress vulnerability may stem from chronic or acute burdens
(e.g., life events, current or past illnesses), the biological environment (e.g., inherited, epigenetic vulnerability, temperament), and the psychosocial environment (e.g., socioeconomic status, childhood events, lifestyle, intellect). Resulting depression may be related to both physiological factors (e.g., hypothalamic-pituitary axis dysfunction, neurobiological and immune alterations, inflammation, telomerase activity) and psychobehavioral factors (e.g., sense of control, connectedness, victimization, and coping behaviors). Health outcomes often include recurrent psychiatric symptoms (stress, anxiety, depressive symptoms, dysthymia), morbidity in the form of chronic disease, frailty, sarcopenia, and mortality.
Garcia-Peña then discussed a meta-analysis (Luppa et al., 2012) of the prevalence of depression in older people, using the dimension of diagnosis, which is the one typically used in surveys. All the reference studies were done in European countries, Canada, or the United States. There were widely varying prevalence rates, from 10 percent up to 40 percent. Garcia-Peña does not believe that these reported levels necessarily reflect if a country has more or less depression; rather, they speak about methodological problems with the measurement of depression (as mentioned by Carlos Cano in a previous workshop session). She then showed a compilation of studies in LAC that have, at least in part, addressed depression, with a similar wide range in estimates.
In addition to cross-national and cross-study issues with measuring depression, Garcia-Peña also noted that depression can differ qualitatively by age, especially between adolescents and older adults. For example, a study in Mexico City (Sanchez-Garcia et al., 2014) showed that issues relating to suicidal ideation are more salient for teenagers and young adults, while symptoms having to with anhedonia (loss of the capacity to experience pleasure) and psychomotor agitation have a greater weight or greater impact on the elderly. Data from another study (Perez-Zepeda et al., 2013) indicate that depression in adulthood has to do with beliefs about depression; for example, considering that depression is normal, it is part of aging, that depression is not a disease, that depression lasts forever, there is nothing the person can do about it, and she or he just has to get used to being depressed. In this study of 2,322 adults (mean age of 73) with depressive symptoms, only 25 percent sought medical help. Of that 25 percent, only 80 percent received some kind of help, and fewer than one-third of the help-seekers received effective care.
Garcia-Peña presented data from the 2012 Mexico National Survey of Health and Nutrition showing an increase with age in the number of
survey respondents with undiagnosed health problems (more than 20 percent aged 60 and older). Having symptoms without a diagnosis is almost certainly a sign of depression, she said. An important point, she added, is how to relate depression to health service use. Garcia-Peña presented data that compared patients with and without significant depressive symptoms, adjusted by severe recent morbidity. For both depressive-symptom categories, rates of health care usage were higher in the presence of recent severe morbidity. Health care utilization was seen to be 15–35 percent higher among depressed patients compared to the nondepressed, even with similar morbidity levels.
She concluded with a discussion of the major challenges regarding depression and health system use. There are help-seeking barriers imposed by doctors related to limited training for pharmacological or nonpharmacological treatment, as well as stigma and prejudice on the part of health personnel workers who often tell patients that it is normal to be depressed in older age. There is considerable inertia, particularly in public health systems, with regard to dispelling false beliefs about preventing depression. She stressed the importance of having pharmacological and nonpharmacological treatments for depression available at the level of primary care, which is the first point of contact for many patients, and not just in specialized care. She also mentioned the need to assess interventions at different levels within health systems, and to better consider the links between morbidity and depression.
Maria Teresa Calzada, University del Valle, Colombia, highlighted the importance of recognizing the topic of oral health, noting that nondental health care professionals are sometimes the first ones that older people visit for something that is happening in the mouth. Oral health is not only related to things that happen in the mouth structure but also affects different areas of older people’s lives, such as nutrition, socialization, performing different functions, and expressing affection, she said.
She described some previous work on oral health in Colombia, highlighting the circa-2000 SABE survey conducted in seven Latin American and Caribbean nations.2 The oral health component of SABE included questions on the presence or absence of teeth, the use of a dental prosthe
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2See http://www.icpsr.umich.edu/icpsrweb/RCMD/studies/3546 [August 2015].
sis, and the self-perception of oral health-related quality of life based on a Geriatric Oral Health Assessment Index.3 The latter involves three dimensions: physical function (eating, speaking, swallowing); social function (concerns about appearance, effects on social interaction); and pain and discomfort involving the capacity to eat.
She then described the most recent efforts in Colombia, one of which is the Fourth National Oral Health Study (En SABE 4), which was completed in 2014 but for which data are not yet available. This study of more than 20,000 individuals includes 3,490 people aged 45–79. En SABE 4 includes a clinical exam (by a dentist), a questionnaire, and a qualitative component. A second effort is the oral health component of a larger study called the Survey of Health and Wellbeing in Colombia 2015, which is part of the National System for Health Population Studies and Surveys. This system comprises 11 different surveys with common and complementary goals, using a master sample that provides national representativeness. The oral health component intends to collect data on the presence or absence of teeth, reconstructed teeth, oral hygiene and care, salivation, medications, dental-related spending, and information on the nexus of oral health and quality of life. The latter involves a new translation, cultural adaptation, and validation of the Geriatric Oral Health Assessment Index.
ADAPTING HEALTH CARE SYSTEMS TO SERVE THE NEEDS OF THE FRAIL ELDERLY
Luis Miguel Gutiérrez, Mexico National Institute of Geriatrics, spoke about health care systems and frailty. He stated the reality of aging populations means that one of the great challenges facing health care and system reform is trying to maintain people outside the hospital system without neglecting or undermining their health care. People are living longer, many with one or more long-term medical conditions, and for a significant number, advancing age brings frailty. The complexity of this problem has been recognized, he said, and while policies and guidance for the care of older people are now being developed, the challenge is to turn the rhetoric of personalized geriatric care into the reality of everyday care. Actions can be taken at different levels of the system to deal with this issue, but the
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3See http://www.adelaide.edu.au/arcpoh/downloads/publications/reports/miscellaneous/measuring-oral-health-and-quality-of-life.pdf [August 2015].
responsibility for quality of care and outcomes is located at the operational level of health provider teams.
Gutiérrez cited a report from the United Kingdom (Oliver et al., 2014) and noted that the UK issues in primary care and preventive measures currently are in many ways similar to those of the Mexican context. The report underscores the need for whole-system changes in order to deliver the right care at the right time, and in the right place, to meet older people’s health needs, care preferences, and goals. This entails a simultaneous shift toward prevention and proactive care, and a consideration of older people’s preferences and values that enables them to be active participants in, and not only beneficiaries of, the actions of the system.
He presented data showing that frailty among elders is common in Mexico (>25 percent), that more than 1 in 3 people (35 percent) aged 60 and older fall each year, and that there is considerable underdiagnosis of dementia (with an estimated annual incidence rate of 25/1000 among elders). Although increasing attention is now being paid to sarcopenia, osteoporosis, and cognitive impairment, he said that older people affected by these conditions receive suboptimal care compared to younger people with the same conditions. Two other conditions that are underrecognized and deserving of greater care, he said, are false incontinence and dementia (for information on dementia, see Mejia-Arango and Gutiérrez, 2011).
An important step for the health care system, according to Gutiérrez, is the development of a catalog of observed conditions in older age and a corresponding risk stratification system. The discussion should not be about general health programs for older people, he said, but rather, about programs relevant to the functional categories of the older population. A risk-stratification approach can better suggest actions geared toward the solution of specific problems, he stated. With regard to frailty and hospitalization, he mentioned a number of measures that can be taken to avoid readmissions in the short term and to enhance people’s possibilities for staying at home. These include targeted comprehensive geriatric assessments, liaison and in-reach services involving multiple hospitals wards, minimization of common adverse effects of hospitalization (e.g., infections and falls), immediate discharge planning from the time of admission, inclusion of caregivers in discharge plans, focusing on person-centered dignified care, developing post-discharge remote assessment and support, and ensuring communication for the continuity of care.
With regard to long-term care, Gutiérrez stated that long-term institutions cannot be developed in Mexico as fast as desired. Long-term care
services must be developed at the community level, including the capacity for systematic global geriatric assessments in long-term care settings and training and support for care staff. And, he asserted, the therapeutic approach has to change. It cannot have the same face of intervention used in the conventional hospital setting. Another needed change, he said, involves issues surrounding end-of-life choices and care. He noted that older people receive poor-quality care toward the end of life, and are often discharged from hospitals without support because they have obtained what is deemed to be the “maximal benefit attained” from hospital care. They are rarely involved in discussions about their options and hence are unlikely to die where they choose. He said there is a clear need for advance care planning, dissemination of information about advance directives, better development of palliative care services, and programs that support end-of-life homecare rather than hospital care.
Gutiérrez concluded that, for all these things to happen, a formula must be developed that will integrate medical services with social services at the community level. He pointed to a report of the Mexico National Institute of Geriatrics (2013) that summarized an evidence-based action proposal to reform the health system from the perspective of the needs of older people.
