As part of the Canadian Centre for Health Economics (CCHE) Friday Health Economics Series, we welcome Dr. Richard Cookson this Friday May 8th, 10am – 12pm in HS618 (Health Sciences Building 155 College Street). Please note the room change: the Seminar will take place in room 618 this week (6th floor of the Health Sciences Building). Dr. Cookson will explore “Incorporating Equity Into Health Care Performance Measurement: A Framework And Application”.
Richard’s research focuses on equity in health and health care, and he is conducting a five-year fellowship research programme on health equity impacts. Richard is a member of the NHS Outcomes Framework Technical Advisory Group (OFTAG). He served on the National Institute for Health and Clinical Excellence (NICE) Technology Appraisal Committee from 2002-7 and the Public Health Interventions Advisory Committee from 2007-9, and was seconded to the Prime Minister’s Delivery Unit in the Treasury in 2010. He helped set up the UK Health Equity Network in 1999, and co-chaired the economics sub-group for the Marmot review of health inequality in Europe from 2010-12. He edited the public health section of the Elsevier On-Line Encyclopedia of Health Economics from 2012-14, and from 2011-13 edited the collected works of Tony Culyer and Jonathan Bradshaw and published them in free e-book editions. He also writes the occasional blog about health economic issues.
Background: Equity is an important policy objective, yet remains isolated from mainstream health care performance measurement. National and local health care policy makers lack routine data to help them monitor the impact of their decisions on health inequalities.
Objectives: This study develops a population health framework for incorporating equity into health care performance measurement, and applies it to England from 2001 to 2011 during a period of accelerated health care expenditure growth and health system reform.
Methods: The framework integrates the measurement of average and equity performance across all main stages of the patient pathway, aligning health care objectives with the two population health objectives of improving average health and reducing health inequality. It also facilitates detailed local performance monitoring of sub-national administrative areas on a comparable basis. The application is based on nine performance indicators constructed using a data infrastructure combining primary care, hospital, mortality, population and area deprivation data for the whole of England at small area level (32,482 neighbourhoods of about 1,500 people) from 2001 to 2011. Average performance was measured using population means, and equity performance using regression-based slope and relative indices of inequality that can be interpreted as absolute and proportional gaps between the most and least deprived neighbourhoods in England. National and local “dashboards” were developed to communicate findings to decision makers in a one-page format, along with standardised “chartpacks” and flexible “google graphs” to provide in-depth data visualisation.
Preliminary Findings: Average performance improved on almost all indicators between 2001 and 2011. There were also significant reductions in inequality in full time equivalent primary care physicians per 100,000 need-weighted population and in primary care quality as measured by clinical process indicators in the UK pay for performance programme. However, after adjustment for age and sex (but not yet morbidity) inequality widened in preventable hospitalization, 12-month post-hospital mortality and mortality amenable to health care. Inequality in overall mortality and morbidity also widened. Sub-national equity performance is not closely correlated with sub-national area deprivation.
Discussion: By linking national administrative datasets at small area level, it is possible to integrate equity into health care performance measurement at both national and sub-national levels within a population health framework. Our application to England suggests that average performance improved during the 2000s, along with equity in primary care supply and clinical process quality, while equity in health care outcomes may have deteriorated. However, we have not yet controlled for morbidity and so it is not yet clear how far widening inequality in health care outcomes is due to social determinants of health beyond health care.
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