Overview of Health Indicators Module 1 Cheryl Wold

Overview of Health Indicators Module 1 Cheryl Wold, MPH Wold and Associates for the National Library of Medicine

Looking Ahead… • Module 2 – Will explore Community Health Status Indicators (CHSI), an on-line health indicator resource. • Module 3 - Case study of librarian involvement in indicators. • Module 4 – Look in-depth at a few health indicator reports and on-line tools. Health Indicators, Part I

Goal for Today’s Presentation: Understand the variety of health indicators, their data sources, their key attributes, context and use. • Describe health indicators – Models of health • Common health indicators and data sources • How are health indicators used and compiled? - Examples of reports and on-line tools - Resources for further reading Health Indicators, Part I

Background • Presentation draws upon my experience with developing health indicators and data. • Review of health indicators conducted for Institute of Medicine Committee for The State of the USA (July 2008). http: //www. stateoftheusa. org • Showed the range of content and use associated with health indicators. Health Indicators, Part I

What is Health? By far, the most accepted definition is that of the World Health Organization: “[Health is] the state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1948) and the “extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities” (WHO, 1984). Health Indicators, Part I

What are Health Indicators? (1) With the goal of good health in mind, think of an indicator as “…a measure that helps quantify the achievement of a goal. ” -Mark Friedman Health Indicators, Part I

What are Health Indicators? (2) Power of indicators is comparisons - over time (trends) - geographic areas - groups of people and the focus on the most essential domains of health. Health Indicators, Part I

What makes a good indicator? • Data Power – high quality, available data • Proxy Power – central importance to health • Communication Power – that the meaning is transparent. Health Indicators, Part I

What are the bases for health indicators? Health indicators are based upon conceptual models for what influences health status, based upon scientific research. Models have evolved over time, as have definitions of health, but trace historical improvements in health, e. g. , increases in life expectancy, declines in mortality due to infectious diseases. Context is important: For example, in 1900 the leading causes of death were Pneumonia, Tuberculosis, and Diarrhea and Enteritis as compared to Heart Disease, Cancer, and Stroke in 2006. Source: MMWR. July 30, 1999 / 48(29); 621 -629 http: //www. cdc. gov/nchs/data/nvsr 57/nvsr 57_14. pdf Health Indicators, Part I

Current Conceptual Frameworks Today’s context: • Rate of healthcare spending is unsustainable, and, levels of spending not consistent with level of health. Ripe opportunities for increasing the return on investments in health through prevention. • Burden of chronic diseases (e. g. , premature mortality, costs) and • Complex public health problems (e. g. , violence, obesity, HIV), and health-related behaviors (e. g. , smoking, diet, substance use) • The influence of social and environmental conditions on determining health outcomes, either directly or indirectly • Deep, persistent disparities in health Health Indicators, Part I

Common Frameworks for Health Indicators 1. Broad “Determinants of Health” - emphasizes the physical environment, social environment, health behaviors, medical care. 2. “Life Course” - emphasizes conditions/experiences early in life (e. g. , 0 -5) and interactions at developmental stages throughout life in optimizing our health "trajectory". 3. “Social Determinants” emphasizes educational, economic, and social conditions and interactions in shaping health. Health Indicators, Part I

How are health indicators used? Indicators are powerful tools for monitoring and communicating critical information about population health. Indicators are used to support planning (identify priorities, develop and target resources, identify benchmarks) and track progress toward broad community objectives. Engagement of partners into civic and collaborative action (build awareness of problems and trends, generate interventions). Inform policy and policy makers, and can be used to promote accountability among governmental and non-governmental agencies. Health Indicators, Part I

Who compiles health indicators? • Reports are compiled at every jurisdictional level • State and local level - Health departments, foundations and philanthropic organizations, businesses, educational, law enforcement, human services providers, and other civic leaders, faith organizations, universities, media. • National – Federal government/private partnerships. • International – OECD, WHO

Common Health Indicators (1) The most common health indicators are those related to birth and death: – – – – Life expectancy, Premature mortality (e. g. , Years of Potential Life Lost or YPLLs) Age-specific death rates (e. g. , infants, teens) Cause specific deaths (e. g. , lung, cervical cancer) Births to teens Very/Low birth weight Adequacy of prenatal care Social characteristics of parents (e. g, maternal educational attainment). These are robust—high completeness of reporting, widely available through the National Vital Statistics System, and standardized so as to be are comparable across states and nations. But, also limited. Health Indicators, Part I

Common Health Indicators (2) Morbidity/Health Status • Health-related Quality of Life: –Poor health days –Self-rated health status • Obesity – Body Mass Index based on self-reported height and weight • Diabetes, asthma, and other chronic diseases.

Common Health Indicators (3) Health Behaviors: – Not smoking – Regular physical activity – Diet and nutrition – Moderate or no drinking, not using drugs. Access to Health Care – Insurance coverage – Regular source of care – Avoidable hospitalizations – Receipt of preventive services Health Indicators, Part I

Data Sources for Common Indicators • National Vital Statistics System (Birth, Mortality) • Surveys (Behavioral Risk Factor Survey--Adults and Youth, National Health Interview Survey, National Health and Nutrition Examination Survey, National Survey of Children's Health, National Immunization Survey) • Disease Surveillance Systems • Health services administrative data (Medicare/Medicaid Claims, hospital billing data or other required/voluntary reporting) Health Indicators, Part I

Social Indicators (1) Physical environment: • Area-based measures, e. g. , income/poverty, population density • Access to public transportation, housing • Environmental pollution, e. g. , air and water quality. Social environment: • Income (individual/family) • Education (e. g. , high-school graduation rates, students reading/doing math at grade level) • Social support and connectedness. Health Indicators, Part I

Social Indicators (2) Child and family focused: • Parental educational attainment • Parent practices (e. g. , breastfeeding, reading to child, regular meal/bedtimes) • Access to services such as early developmental screening • Family social environment (e. g. parent stress, depression) Health Indicators, Part I

Data Sources – Social/Environmental Social and Environmental: • Census (American Community Survey, Current Population Survey) • National Survey of Child Health • Education Dept. (National Assessment of Educational Progress) • Environmental Protection Agency (Air Quality Monitoring data, Toxics Release Inventory) Federal sources are supplemented on the state and local level with administrative data from e. g. , human services, educational, and justice systems Health Indicators, Part I

Gaps in Data Sources or Measures Examples of indicators that lack of systematically collected and standardized data: • Early life - developmental outcomes at the time of kindergarten entry and conditions throughout childhood and youth, e. g. , obesity. • Later life – community care and support, long term care, quality and availability of services. • Social environments, e. g. , neighborhood characteristics, quality of social interactions. Health Indicators, Part I

Health System Performance Indicators • Access (additional) – Trends in health insurance enrollment, range of benefits, exclusions, premiums – Rural health provider supply, linguistic or cultural barriers to getting care • Cost – – – Total health expenditures Health as share of Gross Domestic Product (GDP) Prescription drug costs Payments to hospitals, facilities Comparisons of resources used per patient between hospitals/areas • Quality of care – Effective care – receipt of recommended screenings, treatment, readmission rates. – Patient Safety – medical error Health Indicators, Part I

Data Sources for Indicators (Health System Performance) • Surveys (Consumer Assessment of Health Providers and Systems, Medical Expenditure Panel Survey) • Hospital billing records (reported to state oversight bodies) • Medicare/Medicaid Claims (Centers for Medicare and Medicaid Services) • Voluntary reporting to Federal government (Agency for Healthcare Research and Quality) • Required reporting (Healthcare Effectiveness Data and Information Set – HEDIS) • Studies (Public/Private) Health Indicators, Part I

Using the Indicators: Criteria for Report Selection in SUSA Review Criteria for report selection: • • Created from high-quality and currently available data Used expert input and broad participatory processes Designed for dissemination to diverse audiences Represented a variety of geographic regions Health Indicators, Part I

Using the Indicators: Results of Review The Review Identified: • Types of health indicator reports • • – General Health Indicator (national, state, local, international) – Quality of Life--Comprehensive Indicator Systems – Health System Performance Universe of health indicators and their attributes Data sources and disaggregation potential Range of practices related to accessing and presenting the indicators. Gaps in data Health Indicators, Part I

Using the Indicators: Overview of Features/Focus Areas • Disparities • Social indicators • Ranked comparisons, benchmarks, composite measures • Children and families • Local health planning • Comprehensive indicator systems • Health system performance Health Indicators, Part I

Using the Indicators: Focus on Disparities and Social Indicators • Disparities – Georgia Health Disparities Report (State of Georgia Public Health) http: //dch. georgia. gov/vgn/images/portal/cit_1210/5/49/111684019 Georgia_Health _Equity_Initiative_Health_Disparities_Report_2008. pdf – Health of Wisconsin Report Card (Univ. of Wisconsin Population Health Institute) http: //uwphi. pophealth. wisc. edu/pha/healthiest. State/report. Card/2007. htm • Social indicators – Commission on a Healthier U. S. , (Robert Wood Johnson Foundation) http: //www. commissiononhealth. org/What. Drives. Health. aspx Health Indicators, Part I

Source: Wisconsin County Health Rankings (2007), University of Wisconsin, Population Health Institute.

Using the Indicators: Focus on Rankings, Benchmarks, Trends • Rankings / Benchmark comparisons – America’s Health Rankings (United Health Foundation, American Public Health Association, Partnership for Prevention) http: //www. americashealthrankings. org/ – Big Cities (National Association of City and County Health Officials) http: //eweb. naccho. org~ – State Scorecard on Health System Performance (Commonwealth Fund) http: //www. commonwealthfund. org/Content/Publicatio ns/Fund-Reports/2009/Oct/2009 -State-Scorecard. aspx Health Indicators, Part I

America’s Health Rankings Source: http: //www. americashealthrankings. org/glance. aspx Health Indicators Part 1

2009 State Scorecard Summary of Health System Performance

State Variation: Ambulatory Care Quality Indicators

Health System Performance • Focus on access to health care, costs, quality and effectiveness, including patient safety. – State Scorecard on Health System Performance (Commonwealth Fund) – Dartmouth Atlas (Dartmouth Medical School) http: //www. dartmouthatlas. org/interactive_map. shtm – Hospital Compare (Centers for Medicare & Medicaid Services (CMS)) http: //www. hospitalcompare. hhs. gov/ Health Indicators, Part I

Using the Indicators – Focus on Age Groups Age Group focus – Kids Count (Annie E. Casey Foundation) http: //datacenter. kidscount. org/databook/2009/Default. aspx – America’s Children (Federal Interagency Forum on Child and Family Statistics) http: //www. childstats. gov/americaschildren/index. asp – Older Americans 2008: Key Indicators of Well. Being (Interagency Forum on Aging-related Statistics) http: //www. agingstats. gov/agingstatsdotnet/main_site/default. aspx Health Indicators, Part I

Using the Indicators: Focus on Local Health Reports • Planning and policy at the local level – Communities Count (Public Health - Seattle-King County) http: //www. communitiescount. org/ – New York City (New York City Department of Health and Mental Hygiene) http: //www. nyc. gov/html/doh/html/data. shtml#3 Health Indicators, Part I

Comprehensive Indicator Systems • Focus on overall Quality of Life with health being one of many components (e. g. , economy, health, education) – Boston Indicator Project (The Boston Foundation) http: //www. bostonindicators. org/Indicators 2008/ – Jacksonville Quality of Life Report (JCCI) http: //www. jcci. org/jcciwebsite/pages/indicators. html – Organization of Economic Cooperation and Development (OECD) http: //www. oecd. org/document/~ Health Indicators, Part I

Boston Indicators Project “Hub of Innovation” • • • Civic Vitality Cultural Life and the Arts Economy Education Environment & Energy • • • Health Housing Public Safety Technology Transportation Health Indicators, Part I

Comprehensive Indicator Systems: Use of the Index • Index simplifies complex measures, but caution is advised: – Canadian Index http: //www. ciw. ca/en/Home. aspx – Child Well-being Index (Duke University and Foundation for Child Development) http: //www. fcd-us. org/initiatives/~ – Well-being Index (Gallup-Healthways) http: //www. wellbeingindex. com/ Health Indicators, Part I

[sic] An illustration of trends in the CIW with two domains (Living Average CIW Standards and Healthy Populations) compared with the Median CIW GDP, 1994 -2008. [sic] http: //www. ciw. ca/en/The. Canadian. Index. Of. Wellbeing/Composite. Index. aspx

Conclusion: IOM Framework for Health Indicators Recommended to The State of the USA http: //books. nap. edu/openbook. php? record_id=12534&page=5 Health Indicators, Part 1

Further Resources and Reading— Health Indicators Publications: • Health Indicators: A Review of Reports Currently in Use (July 2008) www. cherylwold. com~ • Institute of Medicine Committee Report http: //www. iom. edu/Reports/2008/State-of-the-USA-Health. Indicators-Letter-Report. aspx Health Indicators, Part 1

Further Resources and Reading – Health Indicators • HSRR (Health Services and Sciences Research Resources) [Internet]. Bethesda (MD): National Library of Medicine (US), National Information Center on Health Services Research and Health Care Technology (NICHSR). [cited 2010 Jan 1] http: //wwwcf. nlm. nih. gov/hsrr_search/index. cfm • Melnick, Daniel. Finding and Using Health Statistics [Internet]. Bethesda (MD): National Library of Medicine (US), National Information Center on Health Services Research and Health Care Technology (NICHSR); 2007. [updated 2007; cited 2010 Jan 1]. http: //www. nlm. nih. gov/nichsr/usestats/index. htm Health Indicators, Part I

Further Resources and Reading – Health Indicators • • Braveman P and Egerter S (2008). Overcoming Obstacles to Health: Report for the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. http: //www. rwjf. org/files/research/obstaclestohealth. pdf Chrvala CA and Bulger RJ , eds. (1999). Institute of Medicine. Leading Indicators for Healthy People 2010: Final Report. National Academy of Sciences. Washington DC. http: //www. nap. edu/catalog. php? record_id=9436 Evans RG and Stoddart GL. Consuming research, producing policy? Am J Public Health. 2003; 93: 371 -379. Friedman, Mark (2005). Trying Hard is Not Good Enough. Trafford Publishing. Vancouver, Canada. Government Accountability Office (2003; GAO-03 -672 SP). Forum on Key National Indicators: Assessing the Nation’s Position and Progress. http: //www. gao. gov/review/d 03672 sp. pdf Institute of Medicine (1997). Improving Health in the Community: A Role for Performance Monitoring. http: //www. nap. edu/catalog. php? record_id=5298 Robert Wood Johnson Foundation (2008). What Drives Health? http: //www. commissiononhealth. org/What. Drives. Health. aspx. Health Indicators, Part I

THANK YOU! for more information contact cheryl@cherylwold. com Ione_auston@nlm. nih. gov Health Indicators, Part I