overall health. Although they have been generated for use in slightly different contexts, (for example, the QALY has been used primarily to study the cost-effectiveness of medical treatments, 4 the DALY to measure the burden of disease worldwide, 5 and the YHL to track the health of the U.S. population, 6 in measuring the aggregate health of defined populations, HALEs, QALYs, DALYs, and YHLs are all suited to making comparative assessments of the health needs of populations. In addition, they share the potential for evaluating the effects and performance of different types of health programs.
As we shall hear in more detail during this meeting, there is growing interest at international, federal, and state levels in using these measures to guide prioritization of health care investments. Within the U.S. health care policy arena, QALYs were used in the Oregon Medicaid Demonstration project to develop a list of priority services for which full coverage would be available to all Oregonians. 7 DALYs were initially applied in the context of developing priorities for resource investments in health within the developing world. 8 YHLs, HALEs, and a variation on DALYs have been used, respectively, at the federal level within the United States, in Canada, and in the Netherlands to describe the overall health of nations. The Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services (DHHS) is exploring the longitudinal use of one health status measure, the SF36, 9 to track outcomes at the clinical care level. Although the SF 36 is not designed to be combined with survival information, the intent of the tracking parallels other efforts being conducted using combined measures.
There are a number of arenas where summary measures are being used to assess the health of populations. In general, however, these metrics are not in wide use at the policy level. Despite a 25-year history of development and fine-tuning, summary measures are most frequently used and cited by the research community that has created them. Discussion of the merits and demerits of summary measures has been conducted primarily among philosophers and methodologists. Application at the delivery and program evaluation side of health care has lagged substantially behind the general public health tracking function.
The reasons for the disconnect between the measurement and the policy communities are many. Most obviously, busy policy makers often are not aware of these techniques. A wider effort to inform decision makers about the range of uses of summary measures is required and we hope that this meeting and the committee’s report will contribute to this effort and help familiarize different interests with the potential opportunities created by the measures. It is also true, however, that many decision makers are at least glancingly aware of the opportunities that summary measures create in informing policy, but are reluctant to use them because methodological and ethical concerns they feel have been inadequately addressed to date.
For example, on the methods side, summary measures capture a continuum of components of health which may not have credibility to all constituencies. Some measures harvest information directly from patients regarding their mental health, symptoms, and physical, social, and role function; they are designed to provide information at the clinical care level. Others capture the judgments of health experts about the health states associated with particular diseases or conditions with the goal of capturing snapshots of disease burden in large populations. This type of summary measure may not always capture what is most salient to decision makers and their constituencies as they consider priorities for resource allocation.
Other concerns may arise from the differential sensitivities that measures have in recording decrements in particular aspects of health. For example, a measure that includes information only on pain and physical function may paint a far harsher picture of arthritis than of some types