19 February 2010

Healthcare corner #7 - Quality of life and primary healthcare

dalhousie actually gave a snow day(!) on wednesday, so class was canceled...and rescheduled for today, the friday afternoon before "spring" break. imagine how many people showed up...

(from no snow the night before, this is what we saw outside our building in the morning. and it was still snowing. although, compared to the recent east coast slams, i realize this is nothing.)

**i warn in advance that this one is a bit denser than others. i tried to cut it down, but then there wouldnt be a point to writing it in the first place. i dont blame you if you are dulled to sleep, but at least skip to the interesting websites at the end**

the wrap-up to the "effectiveness" topic was a discussion on quality of life measures. so, traditionally, measuring life expectancy or mortality rates or reporting on the number and types of diseases present in a population are the preferred statistics to see how healthy your citizens are. the task of counting deaths for the year (to produce mortality rates or life expectancy) is something that even the most poor nations can usually do. the statistics you get from this action are considered to be very accurate and can easily be used by everyone in the world to get a number that can be directly compared. but, how much of the picture of health do we get?

in the developed nations with more money for research, newer measures have been created. the thought is, its great to try to understand the picture of when people are dying and from what diseases, but shouldnt we also care about the quality of the years of life they are living? what is the point of living longer if you are in a wheelchair, laying in the hospital, taking 40 pills a day, etc.?

in north america and europe, there has been development of measures to better understand the quality of the years people are living. the "health-adjusted life year" (HALY) combines information on both the length of life and quality of life. this type of measuring has been going on, solidly, since the late 1980s or early 1990s. its not as "strong" as a mortality rate (its more "touchy feely"), so it requires much more thought, debate, tweaking, etc over time to make sure you are measuring what you want to measure. europe has developed a measure for this that works for them, the u.s. has a couple they use, and canada uses the "health utility index" (HUI).

the HUI compiles information from 8 health areas: vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. the standardized/tested responses in these health areas are given weight/value and are condensed into a scale of 0 to 1 (0 = dead, 1 = perfect health). i will stop with further details, but i will say that canada uses this HUI to measure quality of life in some of its large, routinely performed, national surveys (the canadian community health survey and the national population health survey).

measuring HUI provides plentiful research fuel for scientists, but its also useful for cost-effectiveness analysis. for example, you can look at how much an intervention will cost to extend one additional year of life (is it worth it to fund something that costs $5 billion and will only increase the populations life by 1 year?) or extend one additional health-adjusted life year (is it worth it to fund something that costs $5 billion and will only increase the length of the populations period of "ideal health" by 1 year?). note: these quality of life measures (HALYs) are utilitarian in nature; the goal is to find the most efficient use of money that will maximize the total "good" for a population (so, no extra weight or consideration is given to "sicker" or "vulnerable" groups).

for the other part of the class we talked about primary healthcare and chronic disease management. due to canadas healthcare history, they have been covering hospital care for many, many decades. they have a strong system for that. but, as technology and trends have moved things out of hospitals, canada has had to learn to adapt. chronic disease and non-emergent care is in much higher demand than anything else now. however, the economic slow down in the 1990s didnt help canada move quickly in this area and its been lagging behind its european counterparts.

canadian general practitioners have lower marks (compared to western europe) in areas like: having patients records stored electronically, monitoring diseases and experiences of the patient pool served (monitoring the patient population of your entire practice. ie. how many patients do i serve with diabetes? how many get regular eye exams?), participating in quality control efforts, providing continuity of care for patients, and ease of patient access to doctors (by email, etc) or medical records.

efforts are underway to attack this problem and realign canada with its goals and vision of healthcare. researchers and policy makers would like to see the problem tackled like the wait time issue. when wait times were deemed to be inappropriate and in need of action, a government mandate provided funds and resource recommendations to make the situation better (not that its fixed completely, but it was shown to have made an impact). for primary care and chronic disease management, there are already provinces (ontario and quebec) doing well in these areas that can serve as models for the rest of canada if a new mandate were to come.

lastly, if you are still with me, a few different people have brought some interesting health-related sites to my attention:

1. my boss showed me this website that maps some health indicators by state and county in the u.s. its easy to use and might be fun to check out how your state or county is doing.

2. dave showed me this website that charts different countries of the world against many different statistics (i.e. life expectancy, deaths from earthquakes, number of computers per citizen). you can look within the u.s. (and other countries) or you can compare countries to each other. its kind of similar to that "equal societies" talk i went to.

3. my friend meg brought this website to my attention. its a new endeavor by an innovative u.s. physician who hopes to present and promote the idea that healthcare can be like any other consumer-driven market. with emerging technologies, we can put an individuals health more at their fingertips. by showing them what innovations are out there or coming (blogged about on the site) they can start driving the supply and demand chain and modifying the healthcare system. an interesting idea. i have yet to buy in completely, but i love the post about happiness and vacation planning.

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