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    Report from the Third Consensus Conference on Health Indicators

    Health Indicators Consensus Conference report: Report from the Third Consensus Conference on Health Indicators

    Introduction
    The Health Indicators project
    The Health Indicator framework
    Current Health Indicators
    Health Indicators (as of March 2009)
    The Third Consensus Conference
    User consultation
    Results from the consultation
    The Conference
    Health Indicators: future directions
    Conclusion

    Acknowledgements

    The Canadian Institute for Health Information (CIHI) and Statistics Canada wish to thank the participants of the 'Third Health Indicators Consensus Conference', as well as representatives from Health Canada, the Public Health Agency of Canada and the regional and provincial representatives who provided the invaluable feedback that forms the basis of the report.

    This report could not have been completed without the generous support and assistance of many CIHI and Statistics Canada staff members who worked on the print, translation, communications, web design and distribution; and provided ongoing support to the core team.

    Special appreciation goes to Marie Patry, Brenda Wannell, Lawson Greenberg, Robin Landry, Tim Johnston and Linda Lefebvre at Statistics Canada and to Indra Pulcins, Eugene Wen, Zeerak Chaudhary and Carolyn Sandoval from CIHI for their contribution to this print report.

    Introduction

    Health indicators are measures of health and of the factors which influence health. As such they can be used to inform health policy, manage the health care system, enhance our understanding of the broader determinants of health, as well as to identify gaps in the health status and outcomes for specific populations. While there are countless indicators that could be calculated, the challenge is to identify which are the most important to measure and track; what types of indicators best reflect the needs of those who use them; which of the current indicators are no longer relevant and may therefore be dropped or replaced by more suitable measures; and finally, how can the cross-cutting dimension of equity be addressed in the evaluation of the indicator set. These and other questions were discussed at the Third Health Indicators Consensus Conference, held in March 2009. The results of the Conference are summarized in this report.

    The Health Indicators project

    The Health Indicators project, which is a collaboration between Statistics Canada and Canadian Institute for Health Information (CIHI), began ten years ago with the objective of providing health regions, health care providers and the public in general with reliable and comparable data on the health of Canadians, the health care system and the determinants of health. The First Consensus Conference on Population Health Indicators was held on May 4, 1999. During this Conference, participants agreed on a conceptual model for this project - the Health Indicator Framework along with the initial set of indicators and suggestions for future development. In March 2004, Statistics Canada and CIHI convened the Second Consensus Conference on Population Health Indicators, to guide the further development of health indicators and to introduce the equity dimension explicitly to the framework.

    In addition to these events, ongoing consultations with provincial and regional health authorities help to ensure data quality and consistent methods.

    In the last decade, over 80 indicators have been developed to measure the health of the Canadian population and the performance of the health care system. The goal of this collaborative project has been to compile indicator data and make the information widely available. The Health Indicators Internet publication, accessible from both CIHI and Statistics Canada websites, holds the entirety of regional indicator data produced by the Indicator project.

    What is a 'health indicator'?

    The term health indicator refers to a single summary measure, most often expressed in quantitative terms, that represents a key dimension of health status, the health care system or related factors. A health indicator must be informative, and also be sensitive to variations over time and across jurisdictions. Designed to provide comparable information at the health region and provincial/territorial levels, these health indicator data are produced from a wide range of the most recently available sources. The statistics produced support health authorities in their role of monitoring, improving, and maintaining the health of the population and the functioning of the health system.

    Indicator selection criteria

    • reliable and valid measure of an important health issue;
    • clear, interpretable, and actionable;
    • based on standard and therefore comparable definitions and methods;
    • use data that are available at the national, provincial, territorial, health region and sub-regional levels or which are feasible to develop.

    The Health Indicator framework

    The Health Indicator Framework has five dimensions, i.e. Health Status, Non-medical Determinants of Health, Health System Performance, Community and Health System characteristics, and Equity. Participants of past Conferences have agreed on an initial core set of indicators which populate the framework.

    While the framework has been widely used in guiding indicator development and related discussions, some people may have difficulty distinguishing between the framework itself and the indicators listed within each "cell" of the framework. It might be helpful to clarify that the framework is a conceptual "shelf" that can be used to categorize indicators and to inform indicator selection. It does not refer to a mere indicator list; rather, the listed indicators were developed under the guidance of the framework. They may change frequently to meet the needs from the field, while the framework remains relatively stable. In fact, the International Organization for Standardization (ISO) is in the process of adopting the Health Indicator Framework as a formal international standard.

    Health Indicator framework

    Health Status
    How healthy are Canadians? Health status can be measured in a variety of ways, including well-being, health conditions, disability or death.

    Well-being

    Health conditions

    Human function

    Death

     

    Broad measures of the physical, mental, and social well-being of individuals.

    Alterations or attributes of the health status of an individual which may lead to distress, interference with daily activities, or contact with health services; it may be a disease (acute or chronic), disorder, injury or trauma, or reflect other health related states such as pregnancy, aging, stress, congenital anomaly, or genetic predisposition.

    Levels of human function are associated with the consequences of disease, disorder, injury and other health conditions. They include body function/structure (impairments), activities (activity limitations), and participation (restrictions in participation).

    A range of age-specific and condition specific mortality rates as well as derived indicators.

     

    Non-medical determinants of health
    Non-medical determinants of health are known to affect our health and, in some cases, when and how we use health care.

    Health behaviours

    Living and working conditions

    Personal resources

    Environmental factors

     

    Aspects of personal behaviour and risk factors that epidemiological studies have shown to influence health status.

    Indicators related to the socio-economic characteristics and working conditions of the population, that epidemiological studies have shown to be related to health.

    Measures the prevalence of factors, such as social support that epidemiological studies have shown to be related to health.

    Environmental factors with the potential to influence human health.

     

    Health system performance
    How healthy is the health system? These indicators measure various aspects of the quality of health care.

    Acceptability

    Accessibility

    Appropriateness

    Competence

    All care/service provided meets the expectations of the client, community, providers and paying organizations, recognizing that there may be conflicting or competing interests between stakeholders, and that the needs of the clients/patients are paramount.

    The ability of clients/patients to obtain care/service at the right place and right time, based on respective needs.

    Care/service provided is relevant to the clients'/patients' needs and based on established standards.

    An individual's knowledge and skills are appropriate to the care/service being provided.

     

    Continuity

    Effectiveness

    Efficiency

    Safety

     

    The ability to provide uninterrupted, coordinated care/service across programs, practitioners, organizations, and levels of care/service, over time.

    The care/service, intervention or action achieves the desired results.

    Achieving the desired results with the most cost-effective use of resources.

    Potential risks of an intervention or the environment are avoided or minimized.

     

    Community and health system characteristics
    These measures provide useful contextual information, but are not direct measures of health status or the quality of health care.

    Community

    Health System

    Resources

    Characteristics of the community or the health system that, while not indicators of health status or health system performance in themselves, provide useful contextual information.

     

    Current Health Indicators

    Priorities and directions for health indicators work are regularly reviewed to ensure that the indicator data meet the changing needs of users across Canada. As a result of ongoing research and consultations, certain indicators have been added and changed; others have been dropped.

    There is potential for an ever-expanding list of indicators which is not ideal. Not only are there limited resources to maintain the latest data, but there is a risk that the set of indicators may be multiple measures for the same issue. Therefore, the exercise of evaluating current indicators goes hand in hand with adding indicators.

    In recent years, due to data quality concerns, limited data availability or geographic coverage, the following indicators have been removed from the framework:

    • Self-esteem
    • Depression
    • Smoking Initiation
    • Decision Latitude at Work
    • Social Support
    • May not Require Hospitalization
    • Expected Compared to Actual Stay
    • Hip Fracture Hospitalization

    Several indicators have been added to the framework, some of which are the result of new questions added to the Canadian Community Health Survey (CCHS) while others represent expanded use of administrative data. Many of these indicators are intended to replace, expand, or more accurately measure an aspect of health formerly represented by an indicator which has been dropped from the framework. These changes have been reinforced by consultation feedback. The following indicators have been added to the framework:

    • Perceived Mental Health
    • Mood Disorders
    • Small for Gestational Age
    • Pre-term Births
    • Hospitalized Stroke Event Rate
    • Hospitalized Acute Myocardial Infarction (AMI) Event Rate
    • Sedentary Activity
    • Food Security
    • Sense of Community Belonging
    • Life Satisfaction
    • Colorectal Cancer Screening
    • Regular Medical Doctor
    • Wait Time for Hip Fracture Surgery
    • Percutaneous Coronary Intervention (PCI)
    • Hospitalized Hip Fracture Event Rate
    • Cardiac Revascularization

    Refer to the current Health Indicators table which has been updated to reflect these changes to the indicator set:

    Health Indicators(as of March 2009)

    Health status

    Well-being

    Health conditions

    Human function

    Death

     
    • Perceived health
    • Perceived mental health
    • Perceived life stress
    • Adult body mass index
    • Youth body mass index
    • Arthritis
    • Diabetes
    • Asthma
    • High blood pressure
    • Pain or discomfort that prevents activities
    • Pain or discomfort by severity
    • Mood disorders
    • Low birth weight
    • Cancer incidence
    • Injury hospitalization
    • Injuries
    • Hospitalized stroke event rate
    • Hospitalized Acute Myocardial Infarction (AMI) event rate
    • Functional health
    • Two–week disability days
    • Participation and activity limitation
    • Life expectancy
    • Disability–free life expectancy
    • Disability–adjusted life expectancy
    • Health–adjusted life expectancy
    • Infant mortality
    • Perinatal mortality
    • Life expectancy
    • Total mortality and selected causes
    • Potential years of life lost (PYLL) by selected causes
     

    Non-medical determinants of health

    Health behaviours

    Living and working conditions

    Personal resources

    Environmental factors

     
    • Smoking
    • Heavy drinking
    • Physical activity during leisure-time
    • Breastfeeding practices
    • Fruit and vegetable consumption
    • High school graduates
    • Post–secondary graduates
    • Unemployment rate
    • Long–term unemployment rate
    • Low income rate
    • Children in low income families
    • Average personal income
    • Median share of income
    • Government transfer income
    • Housing affordability
    • Crime incidents
    • Adults and youth charged
    • Food security
    • Sense of community belonging
    • Life satisfaction
    • Exposure to second–hand smoke at home
    • Exposure to second–hand smoke in vehicles and public places
     

    Health system performance

    Acceptability

    Accessibility

    Appropriateness

    Competence

     

    • Influenza immunization
    • Mammography
    • Pap smear
    • Regular medical doctor
    • Wait time for hip fracture surgery
    • Colorectal cancer screening
    • Caesarean section

     

     

    Continuity

    Effectiveness

    Efficiency

    Safety

     

     

    • Pertussis (PHAC)
    • Measles (PHAC)
    • Tuberculosis (PHAC)
    • HIV (PHAC)
    • Chlamydia (PHAC)
    • Pneumonia and influenza hospitalization
    • Causes amenable to medical intervention
    • Ambulatory care sensitive conditions
    • 30-day acute myocardial infarction (AMI) in–hospital mortality
    • 30-day stroke in-hospital mortality
    • Acute myocardial infarction (AMI) readmission rate
    • Asthma readmission rate
    • Hysterectomy readmission rate
    • Prostatectomy readmission rate
    • Pneumonia readmission rate

     

    • In-hospital hip fracture
    • Hospitalized hip fracture event rate
     

    Community and health system characteristics

    Community

    Health System

    Resources

    • Population estimates
    • Population density
    • Dependency ratio
    • Urban and rural population
    • Aboriginal population
    • Immigrant population
    • Internal migrant mobility
    • Metropolitan influenced zones (MIZ)
    • Lone–parent families
    • Visible minority population
    • Teen pregnancy
    • Inflow/outflow ratio
    • Coronary artery bypass graft (CABG)
    • Percutaneous coronary intervention (PCI)
    • Cardiac revascularization
    • Hip replacement
    • Knee replacement
    • Hysterectomy
    • Contact with alternative health care providers
    • Contact with a medical doctor
    • Contact with health professionals about mental health
    • Contact with dental professionals
    • Physicians
    • Nurses
    • Allied professional
    • Health expenditures
     

    The Third Consensus Conference

    User consultation

    In preparation for the Third Consensus Conference, extensive consultations were conducted with the purpose of

    • Learning more about data users;
    • Ensuring the relevance of current indicators;
    • Identifying priority health issues and potential indicators for development; and
    • Identifying ways to improve data access/dissemination.

    The consultation was initiated as a Web survey inviting input from key stakeholders from across the country. The survey was directed towards individuals who work with health indicators or are involved in health services and/or population health research. The questions in the survey were designed to get feedback on the current set of indicators (including any suggestions for new indicators) and ways to improve access to the data. The Web survey was launched for three weeks in January 2009 during which approximately 200 responses were received.

    Separate consultations, covering the same questions, were organized with the Public Health Agency of Canada and Health Canada. Their input was provided in reports and later incorporated into materials developed for the Consensus Conference discussions.

    Results from the consultation

    The first section in the online survey addressed the usage and relevance of the current set of indicators. Overall, it appeared that indicators are used fairly equally as information for the public and the health sector, for policy and planning and for performance management, monitoring and quality improvement. Respondents also noted that indicator data are used for research and teaching purposes as well as for community based health assessments/comparisons (at the regional and provincial levels).

    Over half of the respondents revealed that the existing set of health indicators met their data needs, but over 40% felt that additional indicators would be useful. Respondents were asked to provide suggestions for new indicators along with the rationales behind them, resulting in an extensive list. These suggestions were then grouped together into related 'health issues'. These issues and the indicator ideas within them would be used as a part of discussion materials for the Consensus Conference.

    A question discussing a reduction of the current indicator set resulted in only twenty percent of respondents identifying indicators that could be dropped or replaced within the framework.

    To better understand priority aspects of the equity dimension across indicators—going beyond the regularly produced breakdowns by age group, sex, health regions—respondents were asked to rank equity-related breakdowns for health indicators. It was found that breakdowns by income, rural/urban, education, Aboriginal population, and census metropolitan area (listed in order of importance) need further development.

    Questions in the second section of the survey were designed to identify difficulties accessing health indicator data. Overall, it was found that the Statistics Canada and CIHI websites are used equally to access indicator data with a lesser percentage relying on the print publication. While the majority of respondents reported experiencing no difficulty finding health information released by the Health Indicators Project, one third of respondents experienced problems with navigating the web-sites and finding the most recent or appropriate data.

    However, for both websites only 1 in 5 users experienced difficulty in using Statistics Canada data tables and/or the CIHI data interface.

    Many activities are currently underway to improve access to health indicators, some of which have been implemented within the Health Indicators release in June 2009.

    The Conference

    On March 26, 2009, Statistics Canada and the Canadian Institute for Health Information (CIHI) convened the Third Consensus Conference on Health Indicators. This event marked the 10th anniversary of the Statistics Canada and CIHI Health Indicator Project. The purpose of the meeting was to present the current set of indicators designed to support health regions in monitoring the health of the population and the healthcare system as well as to outline priority areas for indicator development.

    Various stakeholders were invited to participate from across the health field, including individuals from public health, the healthcare system, and government organizations invested in health (See Appendix 4 – Conference participants). Participants were presented with an overview of results from the consultation process as well as the latest set of indicators. Using a summary of the health issues identified through these consultations (See Appendix 1 – Consultation results: health issues and indicators), participants collaborated on the identification of priority health areas and discussed potential indicators that could be developed within these fields. Information about the work underway developing indicators on health inequality was also presented (See Appendix 3 - Agenda of the Third Health Indicator Consensus Conference)

    Health Indicators: future directions

    During the Conference, group discussions helped to prioritize health areas highlighted by the consultation process, to address current gaps in the Health Indicators Framework, and to communicate indicator development preferences. The groups referred to a summary of the indicator areas suggested during the consultations, and a consensus building process was used to attain a set of health areas deemed most important for future indicator development work.

    The priority health areas identified by the group were:

    • Health care outcomes
    • Child and youth health
    • Mental health
    • Social determinants of health
    • Healthy environments
    • Aboriginal health

    The Conference participants then gathered into new discussion groups in order to identify potential indicators which could best characterize each health issue (again working with summarized feedback from the pre-conference consultations). Participants identified data gaps within each area and suggested indicators that could be developed in the next five years. It was acknowledged that these discussions were only the beginning of the challenging process of developing new indicators. Additional consultation and collaborations with expert groups and with other relevant indicator initiatives will be essential to move forward in the coming years.

    In addition to the extensive list of indicators suggested during the discussion sessions, some participants noted that changes to the framework structure may be necessary in the future. This observation included the potential need for removal of blank category cells and/or renaming of some category headings.

    The following is a brief summary of the discussion themes surrounding each priority health area. Please refer to Appendix 2 - The Third Consensus Conference – discussion notes for a more detailed list of suggested indicators and discussion topics within these priority areas, identified both during the 2009 Consensus Conference and through the consultation process.

    1. Health care outcomes

    As part of the Health Care Outcomes discussion, the group planned to focus on all health care system performance issues, including patient safety, access to care, efficiency of care, appropriateness as well as outcomes. All of the framework categories under Health System Performance were brought into the discussion as areas that could potentially be measured to fully represent the 'outcome' of any one indicator. An important aspect of the discussion focused on 'value for money' associated with these outcome indicators and the importance of adding a standardized cost component to aid in the areas health research and policy.

    2. Child and youth health

    There are clear challenges in terms of sample size and resources for the collection of health indicators for this specific population. Many of the indicator suggestions put forth were under the categories of health conditions, health behaviours, and environmental factors.

    3. Mental health

    The area of mental health is particularly challenging for indicator development, as the data available are limited. The group discussed issues and potential indicators related to utilization of services, suicide, prevalence of disorders, dependency behaviours, and the importance of measuring aspects such as stigma and discrimination as well as positive mental health measures.

    4. Social determinants of health

    Discussion covered measures of equity including outcomes of inequality such as reliance on social systems, education, income, housing affordability, nutrition, food security, social capital, homelessness, and numerous other factors related to living and working conditions, and social supports known to have an influence on health.

    5. Environmental health

    Indicator areas measuring the built environment (e.g., neighbourhood walkability) and environmental factors (e.g., air and water quality, exposure to contaminants, pesticide use) were explored in the discussion as well as potential data sources and the general problems associated with collecting national level comparable data in these areas.

    6. Aboriginal health

    The area of Aboriginal health was identified as being crucial in the expansion of health indicators work. It was noted that in many ways Aboriginal health indicators cut across the entire framework. Furthermore, work to identify indicator data needs should involve collaboration with existing indicator initiatives on Aboriginal Health. As a result, there was no discussion group set up for this topic in particular.

    Conclusion

    In the ten years since Statistics Canada and CIHI released the first series of health indicator data, indicators have been evolving and expanding to serve a wide range of purposes. Conference participants from diverse health backgrounds have described the many ways in which indicators are used at different health jurisdiction levels. In addition to setting priorities for future development, the Third Consensus Conference provided an opportunity to celebrate 10 years of indicator work between Statistics Canada and the Canadian Institute for Health Information and to reflect on the project's evolution and the challenges that lie ahead.

    Each of the indicators identified through the consultations and Conference discussions holds importance for some type of research or for a certain organization. The challenge in responding to such a range of suggestions is to pinpoint which indicators are the most relevant given the current health culture and also which indicators can realistically be produced given the existing or potential data sources. Now that priority health areas have been clearly identified by our data users, the next step is to collaborate with other indicator initiatives and use potential data sources for further indicator development. Though not all indicators can be cultivated through this process, we are hopeful that progress will be made in several of these health areas through research, additional consultations and collaboration in the coming years.

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