For the Public's Health The Role of Measurement in Action and Accountability (2011) / Chapter Skim
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3 Measuring Health for Improved Decisions and Performance
3 Measuring Health for Improved Decisions and Performance
Pages 67-110
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From page 67... ...
; and (3) enhancing responsiveness of the population health information system to the needs of end users.
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From page 68... ...
NCHS's current mission statement and the committee's understanding of the agency's scope of work suggest that its current role consists primarily of conducting several major surveys on population health, as well as managing the nation's vital statistics system and managing surveys of nursing homes, hospitals, outpatient facilities, and other clinical care providers (NRC, 2009)
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From page 69... ...
NCVHS also has a population health subcommittee.2 The committee recognizes that two provisions of the Affordable Care Act (ACA) 3 have potential pertinence to strengthening the nation's population health information system.
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From page 70... ...
In continually reviewing the nation's population health information system and its contributions to understanding health at the community and subpopulation level, NCHS could facilitate a move toward a more coherent system. In reviewing the major domains in which data are collected, the agency could call for new indicators to be added and for those of decreasing relevance to be culled.
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From page 71... ...
That suggests the need for coordination to establish systems that maximize efficiency, streamline bureaucratic procedures, and expand the new HHS data warehouse (through the Community Health Data Initiative [CHDI] effort)
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2. The National Prevention, Health Promotion, and Public Health Council include in its annual report to Congress on its national prevention and health-promotion strategy an update on the prog ress of the National Center for Health Statistics transformation.
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NCHS could · oordinate research on and support the development of -- within C HHS and in collaboration with relevant stakeholders -- several population health information tools and processes described in recommendations elsewhere in this chapter: o standardized set of measures of community health (see Recom A mendation 2)
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From page 74... ...
the NPHPPHC's guiding principle pertaining to public–private collaboration (National Prevention Health Promotion and Public Health Council, 2010) , and believes that a federal advisory committee like NCVHS (which includes private-sector representatives, whose numbers could be expanded)
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From page 75... ...
. The current usage of the term community health indicators differs somewhat from the committee's thinking about true measures of community health that convey information about characteristics of the community as opposed to aggregated data on its individual members.
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The presence of smoking restrictions, requirements of menu labeling (before the ACA provision that pre-empted such local and state laws) , pedistrian-friendly planning, and effective regulation of the clinical care system are all examples of regulatory and enforcement environments as good markers of aspects of community health (e.g., National Complete Streets Coalition, 2010)
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From page 77... ...
is of established relevance to overweight and obesity and thus points to potentially important indicators of community health that could be routinely collected and shared. In summary, although a number of national indicator sets include a few indicators of broad social determinants of health, the committee believes that unified guidance is needed to describe and build an evidence base for an actionable set of additional indicators that would support community decision-making with respect to local health-promoting initiatives.
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From page 78... ...
Summary Measures of Population Health Because a summary measure of population health, described in detail below, would serve as a marker of the progress of the nation and its communities in improving health, it is important that it be implemented in data-collection and public communication efforts at the federal, state, and local levels. The committee believes that public officials need to take steps to educate Americans about the meaning of summary measures of population health and their linkage to determinants that are amenable to action at individual and societal levels.
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From page 79... ...
Lessening of the burden of disease and attendant improvement in health-related quality of life are important objectives of population-based and clinical care delivery interventions. For example, use of life expectancy does not capture any information about the gains associated with the better dentition that accompanies fluoridated water or the better vision achieved with cataract surgery, and it only incompletely captures the effects of obesity and its sequelae (for example, arthritis and diabetes)
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. In the final step in creating summary measures of population health, the life expectancy of a population is combined with its HRQL to create "health-adjusted life expectancy" (HALE)
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. Over the last decade, use of the HALE and HALY summary measures has grown in both domestic and international clinical care and population
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. Although summary measures of population health like QALYs are prominent in discussions of rationing and the debate around the approach to curtailing clinical care costs, the uses of HALYs are far broader, permitting methods for monitoring health and for forecasting or directly studying the effects of different health and clinical interventions on communities and subpopulations.
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From page 83... ...
The international working groups have identified the need to develop a "principled" weighting system derived from an empirical foundation or other agreed-on theory-based analytic technique that will unite the individual concepts of function into a summary measure. A measure arising from those efforts, which has been vetted by international and US measurement experts and is used at the national level, offers a model for building a BOX 3-1 The Budapest Initiative and the Washington Group The Budapest Initiative (originally called the Task Force on Measuring Health Status)
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From page 84... ...
By embedding the building blocks with which to calculate HALE and HALYs in routine data-collection efforts at all geographic levels, the health system can gain a greater understanding of the effects of clinical care, population health interventions, and social policies on the health of the nation, its communities, and subpopulations that have been historically at higher risk for poorer health outcomes. As the most distal outcome measure (see Figure 3-2)
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From page 85... ...
By conducting a "what if" analysis (for example, modeling with HALYs) , a community might find that a particular type of investment in population-based initiatives could generate a particular number of HALYs at a particular cost and thus save money in the clinical care delivery system.
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From page 86... ...
A summary measure of population health that can be used to estimate and track health-adjusted life expectancy for the United States. Ideally, these activities will be conducted with advice from a fully resourced and strengthened NCHS (see Recommendation 1)
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, and clinical care all contribute to the total health of a community, a state, or a nation. The aggregated experience of individual people in health-related quality of life and longevity was viewed by the committee as the common distal health outcome that the health system works to maximize.
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From page 88... ...
It would afford clinical care the weight it merits as well as heighten understanding of the myriad other loci available for action. Other wealthy nations brief their populations on the social and environmental determinants of health, and such efforts are intended to heighten awareness and promote action that leads to improved health and health equity.
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From page 89... ...
The report listed the multiple determinants of the health of Canadians (housing, physical environment, early childhood environment, education, income and social status, employment and working conditions, and culture and sex) and showed that clinical care -- on which Canada, like the United States, outspends many peer nations -- alone cannot improve health outcomes.
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From page 90... ...
One of the challenges facing the population health information system is intersectoral information exchange, coordination, and collaboration, including the interface between public health agencies and the clinical care delivery system but extending to education, transportation, and other fields in which public-sector and private-sector decisions can affect population health. The interface between the clinical care system and public health agencies is a major potential source of valuable information on population health, but, as discussed below, various concerns must first be addressed.
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From page 91... ...
Some state and local public health agencies also perform the role of health-information stewards, analysts, and technical advisers, collecting population health–relevant data from providers in a community and conducting supporting activities to help providers to improve their performance and patient outcomes. It should be noted that some public health agencies are combined with or include departments that oversee clinical services, whereas others are separate from departments charged with clinical care assurance.
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From page 92... ...
For example, although it is financially daunting to mount a health-examination survey in every community, some key information already present in the clinical care system in many communities can be used to assess the prevalence and control of diabetes, hypertension, and hyperlipidemia and the use of clinical preventive services. The current state of data-sharing between public health agencies and medical care organizations varies greatly from one jurisdiction to another, and data-sharing is poorly standardized.
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From page 93... ...
Clinical care data can contribute substantially to public health agencies' knowledge of population health and enhance their ability to identify and solve community health problems. This is also Essential Public Health Service #1 -- "monitor health status to identify and solve community health problems" -- as described in Ten Essential Public Health Services developed by the Core Public Health Functions Steering Committee in 1994.
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Great care will be needed to change the current state with legislation, funding, logistics, and technology and to define the attributes of the mechanisms for maximizing the use and usefulness of clinical care data to health-system stakeholders. For data-sharing to be successful, it is critical that benefit flow from government public health agencies to clinical care stakeholders.
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and measures of preventive-service delivery and chronic-disease control. Other indicators that help in assessing the readiness of the community to interact with the clinical care delivery system in an informed manner might be added to the clinical data collected.
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Monitoring Outcomes of the Clinical Care System Monitoring of the outcomes of the clinical care system by public health agencies can provide critical information about appropriate use, overuse, underuse, and misuse of medical technologies and can make the clinical care delivery system more efficient. However, different jurisdictions might make different decisions regarding whether this function is best housed in government public health agencies.
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From page 97... ...
Also, the collaborative convening of public health agencies and clinical care entities would likely include activities such as the joint development of evidence-based indicators and the development of a process to use data for system improvements, and will require a strong assurance of the privacy and confidentiality of clinical data to facilitate openness and collaboration. In settings where the public health agency is the quality assurer or regulator, establishing collaborative
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. Statistical and simulation models are increasingly used in clinical care and in the study of population health.
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that influence health-related quality of life, life expectancy, and, ultimately, HALYs. Models can consider health behaviors, social characteristics, and systems variables and suggest what can happen if variables change.
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. Health impact assessments (HIAs)
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(2006) , Health Impact Assessment Gateway (APHO, 2007)
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that influence health, productivity, and the volume of patients flowing into the clinical care system requires increased use of analytic approaches that elucidate interactions and interdependences among differ
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. "Bending the curve" of effects of chronic diseases and injury on functioning, productivity, clinical care use, and cost will require better information to support systemic improvements.
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2007. Health impact assessment: A tool to help policy makers understand health beyond health care.
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ii-4. Community Health Status Indicators.
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2010. Immunization registries can be building blocks for national health information systems.
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2006. Using local health information to promote public health.
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2004. Using linked data to calculate summary measures of population health: Health-adjusted life expectancy of people with diabetes mellitus.
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. National Prevention Health Promotion and Public Health Council.
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2010. A healthy bottom line: Healthy life expectancy as an outcome measure for health improvement efforts.
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