1-Author: Leo Nunnink
Health system performance can be measured at the level of outputs or outcomes. Outputs (such as doctor visits and hospital separations) are a reflection of health sector activity and are poorly correlated with outcomes. (Joumard & OECD., 2010, p. 26) Outcomes are patient focused. They quantify the health status of a population, as well as the sense of personal satisfaction from the health effect (Jacobs, Smith, & Street, 2006, p. 22) and the building of ‘social capital.’ (Duckett & Willcox, 2011, p. 4)
The health status of a population is the product of multiple factors. It incorporates economic status, environmental factors and lifestyle factors (Or, 2000) as well as population genetics and disease prevalence, in addition to health system performance. The measure of health system outcome has been described as the value added to health as a result of contact with the health system. (Jacobs, et al., 2006, p. 23) Teasing out this contribution can be complex. It is difficult to observe a baseline ie the health status that would have been secured in the absence of health system intervention. (ibid)
Mortality and longevity estimates have the longest history of use as health indicators, given their ease of recording. (Duckett & Willcox, 2011, p. 21) Thus these comparators are available over long time periods. (Joumard & OECD., 2010, p. 22)
Life expectancy at birth is a widely used summary measure. Separation along the gender dimension is advocated, as health systems may contribute more to improvement in female health status than male health status. (Or, 2000) Life expectancy may also be separated along an age dimension, with life expectancy at 65 providing additional information to other measures for several reasons. Many indicators (eg infant mortality, maternal mortality) miss the elderly population. Also life expectancy at 65 has a wider dispersion between countries than life expectancy at birth, and increments in health expenditure generally favour the elderly. (Joumard & OECD., 2010, p. 22)
One measure of preventable mortality reporting is the Potential Years of Life Lost by age 70. This overcomes some of the bias associated with raw mortalitystatistics – that is an infant death is weighted proportionally more highly than a death at age 65. (Or, 2000) Infant mortality itself is a measure that is less likely to be influenced by lifestyle factors (eg smoking) and therefore may be more reflective of health system performance. (Joumard & OECD., 2010, p. 22) However economic status is a significant confounder.
A measure that is proposed as a more pure measure of health system performance is the amenable mortality. This is defined as those deaths that are potentially preventable by timely and effective medical care. It is measured by age-specific mortality rates for selected causes of death. Disappointingly there is no universal definition, as causes of death and age limits vary between studies. (Joumard & OECD., 2010, p. 22)
Amenable mortality has a number of limitations. Data are incomplete, even for OECD countries. Differences in death certification and coding will impact on the results. Finally, amenable mortality, like longevity indicators, does not account for health care interventions aimed at improving the quality of life of the population that suffers non life-threatening illness.
2-Author: Susan Bathersby
Measuring Quality with Outcome Measures
The evaluation of health care systems is critical to ensuring a productive, client focused organisation that can respond to change. As part of this evaluation four components need to be investigated, these include equity, acceptability, efficiency and quality (Duckett and Willcox, 2o11). Of these, quality stands as an important measure as it ensures that the outcomes of health provision are safe and effective (Al-Assaf, 1996). Quality healthcare is often determined by patient outcomes, thus the use of clinical evaluation tools are a must to analyse this.
Quality is difficult to define and thus makes it challenging to monitor. Outcome measures allow clinicians, managers and organisations to determine their success. The Australian Commission for Safety and Quality in Health Care have adopted the following definition “the extent to which health care service or product produces a desired outcome/s” (2007). The key to this statement is the production of outcomes so hence the need to measure them.
At the coalface are clinicians who, on a daily basis measure clinical outcomes using a variety of what is thought as reliable and valid tools. Outcome measures are used to assess patients, determine treatment, evaluate progress, benchmark against other organisations and provide the raw data for research (Johnson, 2008). Without this information the ability of health care systems to analyse the quality of care they provide is limited.
All standardised and commonly used outcome measures undergo rigorous reliability and validity testing which allow clinicians, researchers and organisations to feel confident in their results. However this does not preclude the misuse of the resource. There are a number of key components that must be addressed when choosing the use of an outcome measure. Some of these include reliability, validity and responsiveness in a given population (Haywood, 2007). Take responsiveness as an example, if an outcome measure is unable to detect change even when there is a variation then an over or under estimate of results will occur. This does not allow for accurate measurement and thus little inference can be made about quality.
As with all measurements and more specifically outcome measures used clinically there are often a number of considerations that need to be addressed. This may include clinician experience, patient group and individual bias. The Functional Independence Measure (FIM) is a commonly used measure of patient function however it is open to rater bias (Wolfson et al., 2000). Despite the potential for bias the FIM is used extensively throughout the world and is considered an excellent tool for the measurement of function. What is important is that all measures will have flaws and thus when examining results thought needs to be given to ensure accurate analysis.
The assessment of quality is an essential component to ensure that health care systems meet the purpose they were designed for. Outcome measures are common in determining the success and quality of a service or organisation. There is no doubt that outcome measures permit improved patient care and enhance evidence-based practice. However when selecting and analyzing outcomes measures care must be taken to ensure that their interpretation is appropriate and enhances quality.
B- HEALTH ECONOMICS
1-Author: Fiona Finnegan
Gross domestic product (GDP) is a common way of expressing national income and can be used for international comparisons of spending in different sectors such as defence, education or health. The purpose of this post is to compare Britain and Australia’s health care spending as a percentage of GDP and suggest reasons for the differences that can occur in these figures.
GDP is defined as the “total market value of goods and services produced within a given period after deducting the costs of goods and services used up in the process of production but before deducting allowances for the consumption of fixed capital” (AIHW, 2011). In the most recent data provided by the OECD and AIHW, Australia in fact spent a smaller proportion of their gross domestic income on health care than the United Kingdom. Australia spent 9.1% of GDP on health in 2009 and 9.4% of GDP on health in 2010 (AIHW, 2011). The United Kingdom in comparison spent 9.8% of GDP on health in 2009 (OECD, 2011). The current economic situation has seen the proportion of GDP spent on health increase significantly in the United Kingdom over the past few years with a substantial increase of 1% of GDP from 2008 to 2009 (OECD, 2011). This increase has been attributed to the recent recession which has seen a decrease in the United Kingdom’s GDP over the 2008-2009 period while their health spending continuing to increase during this time (OECD, 2011).
Despite now spending very similar percentages of GDP on health, there are significant differences between Australia and the United Kingdom in who actually spends the money on health care.
In Australia, government share of expenditure during 2009-2010 accounted for 69.9% of total health expenditure with the remaining 30.1% of coming from private expenditure (AIHW, 2011). This is vastly different to the United Kingdom which in 2009 had a public expenditure of health of 84.1% (OECD, 2011). It has been suggested that greater public expenditure can lower total proportion of GDP spent on health as a stronger public funder is more likely to use of methods to restrict health care costs such as provider incomes and medical fees (Duckett, 2007). It has also been suggested that differences in percentages of GDP on health spending are principally explained by the differences in the private spending, i.e. private expenditure does not substitute for public expenditure but is additive (Duckett, 2007).
In conclusion, while Britain and Australia spend similar proportions of GDP on health, there are clear differences in who actually spends that money between the two countries. This split between public and private spending can also explain why some countries spend more on health per GDP than other countries.
2-Author: Erin Jackson
Gross Domestic Income (GDI) is a measure of the total and final income received by all areas of an economy within a year. Since all income is the result of production, the GDI should equal its Gross Domestic Product (GDP), a commonly cited statistic referring to the economic activity of a country (Phelps, 2003).
Percentage of GDP provides a meaningful unit of measure to analyse changes in past, present and future healthcare costs and thus whether a country is meeting healthcare requirements with current service expenditure (Getzen, 2007). According to 2007 statistics on spending across Organisation for Economic Co-operation and Development (OECD) countries, Australia and the United Kingdom (UK) were comparative with Australia only slightly further above OECD country average for healthcare expenditure than the UK (OECD, 2010).
There are a number of explanations as to why Britain spends a smaller proportion of their GDP on healthcare than Australia relating to healthcare system demand and supply and/or efficiency, effectiveness and equity.
Healthcare demand in economic terms refers to the relationship between price and quantity where the law of demand states that as product price falls demand of that product increases (Getzen, 2007). Within a healthcare setting demand varies in relation to disease prevalence and population demographics and thus a difference in proportion of GDP spent within the UK and Australia on healthcare may be suggestive of a differing demand (OECD, 2010). Healthcare supply refers to the total amount of a good or service available for purchase (Getzen, 2007). Thus a smaller proportion of GDP spent on healthcare in the UK may indicate a difference in healthcare resources available.
Healthcare efficiency, equity and effectiveness also play a key role in the amount of healthcare expenditure of a particular country. Efficiency refers to the relationship between use of resources, practices and results (Henderson, 2009). Equity refers to the quality of healthcare delivery across populations (Fiscella et al., 2000).Effectiveness in healthcare refers to the extent to which policy objectives are achieved through planned intervention strategies (Getzen, 2007). Health service efficiency, equity and effectiveness can be measured via healthcare outcomes as indicated by mortality, morbidity and life expectancy data (OECD, 2010). Referring to current statistics on health outcome measures the UK has a lower average life expectancy and higher rates of morbidity and mortality than Australia suggesting that although there is slightly less expenditure of GDP in that nation the efficiency, equity and effectiveness of their healthcare system is poorer than that in Australia.
In conclusion, it is evident that Britain does spend less in proportion of their GDP on healthcare than Australia, however further comparison of health outcomes between the two countries suggest Australia’s healthcare system is more efficient, effective and equitable (OECD, 2010). There is also potential for differences relating to the demand and supply of healthcare resources between the two countries and thus differences in healthcare expenditure (Getzen, 2007).
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