State of the USA Health Indicators Letter Report (2009) / Chapter Skim
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Hoenig: The Institute of Medicine established the Committee on the State of the USA Health Indicators to provide guidance to the State of the USA, Inc.
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The intent of SUSA is to make it possible for members of the public and policymakers, in a relatively short period of time spent on the website, to discover interesting facts that are valid and important. COMMITTEE CHARGE The Committee on the State of the USA Health Indicators was asked to provide guidance on topic areas and indicators that should be included in the health/health care domain of the SUSA website.
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The committee also examined current national surveys that collect health data. These include the National Health Interview Survey, the National Health and Nutrition Examination Survey, the National Vital Statistics System, the Behavioral Risk Factor Surveillance System, the Youth Behavioral Risk Factor Surveillance System, the National Immunization Survey, the Medical Expenditure Panel Survey, the Current Population Survey, the American Community Survey, the Health Care Utilization Program, and the National Survey on Drug Use and Health.
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In the early 1800s in the United States, Lemuel Shattuck spearheaded the effort to adopt and collect public health measures at local and state levels, advocating the use of statistical surveys to collect vital information. Then, as basic survival became less uncertain and more people lived longer, new health issues such as chronic disease emerged and measures of health expanded to include assessments of morbidity.
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This framework for indicator development should not be interpreted as a model of the determinants of health outcomes because a complete model would need to include other determinants such as biologic or genetic predispositions that influence the ways that social, environmental, behavioral, and health services shape health outcomes. Social and Physical Environment Health-Related Health Behavior Outcomes Health Systems FIGURE 1 Framework for health and health care indicator development.
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The committee examined potential indicators to make sure that there was a balance of indicators of health/health care across the life course, resulting in elimination of some. For example, life expectancy at age five was eliminated but life expectancy at birth and life expectancy at age 65 were retained.
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That is, a user should be able to take a single health/health care indicator (e.g., infant mortality rate) and select additional displays of the data that stratify that indicator by other factors.
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. The health outcome indicators chosen are: Mortality • ife expectancy at birth: Number of years that a newborn is L expected to live if current mortality rates continue to apply • nfant mortality: Deaths of infants aged under 1 year per 1,000 live I births
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, asthma, cancer, and arthritis) • erious psychological distress: Percentage of adults with serious S psychological distress, as indicated by a score of ≥ 13 on the K6 scale Life Expectancy at Birth Indicator: Number of years that a newborn is expected to live if current mortality rates continue to apply.
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Table 2 presents such comparisons for selected countries. The committee believes that the number of years that a newborn is expected to live if current mortality rates continue to apply is an important indicator both of the health of the nation overall and as a means of identifying disparities among populations within the United States.
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TABLE 2 Life Expectancy at Birth for Selected Countries and Selected Years Male Female Country 1995 2000 2003 Rank 1995 2000 2003 Rank Australia 75.0 76.6 77.8 5 80.8 82.0 82.8 6 Bulgaria 67.4 68.5 68.9 34 74.9 75.1 75.9 35 Canada 75.1 76.7 77.4 7 81.1 81.9 82.4 9 Cuba 75.4 74.7 75.4 24 77.7 79.0 79.8 28 England and Wales 74.3 75.6 76.5 13 79.5 80.3 80.9 20 Greece 75.0 75.6 76.5 13 80.3 80.6 81.3 17 Japan 76.4 77.7 78.4 2 82.9 84.6 85.3 1 Puerto Rico 69.6 71.1 71.8 31 78.9 80.1 80.6 23 Romania 65.5 67.8 67.7 36 73.5 74.8 75.1 36 Spain 74.3 75.7 76.9 11 81.5 82.5 83.6 3 Sweden 76.2 77.4 77.9 4 81.4 82.0 82.5 7 United States 72.5 74.1 74.8 26 78.9 79.5 80.1 26 SOURCE: NCHS, 2007.
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Whereas life expectancy at birth is largely influenced by causes of death that affect persons at younger ages, life expectancy at age 65 is an important general indicator of the prevalence, prevention, and management of chronic disease because older persons experience a much higher incidence of these conditions than those in younger age groups. The committee believes that the number of years of life remaining to a person at age 65 if current mortality rates continue to apply is an important indicator of the health of a growing segment of the U.S.
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The WHO Statistical Information System contains data that could be used for international comparisons. Self-Reported Health Status Indicator: Percentage of adults reporting fair or poor health.
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BRFSS data can be analyzed by age, county of residence, education level, employment status, ethnicity, income, marital status, race, and sex. Obtaining comparable data for international comparisons is likely to prove difficult.
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website at http://www.cdc.gov/hrqol/findings.htm. These findings include: • early a third of Americans say they suffer from some mental or N emotional problem every month -- including 10 percent who said their mental health was not good for 14 or more days a month • ounger American adults, aged 18–24 years, suffered the most Y mental health distress • lder adults suffered the most poor physical health and activity O limitation • ative Americans and Alaskan Natives have reported the highest N levels of unhealthy days among American race/ethnicity groups • dults with the lowest income or education reported more A unhealthy days than did those with higher income or education • mericans with chronic diseases or disabilities reported high levels A of unhealthy days (CDC, 2007a)
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While the World Health Survey asks some questions about health during the past 30 days, these questions are not comparable to unhealthy days. Chronic Disease Prevalence Indicator: Percentage of adults reporting one or more of six chronic diseases (diabetes, cardiovascular disease, chronic obstructive pulmonary disease [chronic bronchitis and emphysema]
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C • he medical care costs of people with chronic diseases account for more than T 75 percent of the nation's $2 trillion medical care costs. • hronic diseases account for one-third of the years of potential life lost before C age 65.
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The committee believes that the percentage of adults reporting one or more of six chronic diseases (diabetes, cardiovascular disease, chronic obstructive pulmonary disease [chronic bronchitis and emphysema] , asthma, cancer, and arthritis)
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Adults with serious psychological distress were significantly more likely to report more unhealthy days (mental and physical) and activity limitation days than were adults without serious psychological distress.
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The committee has identified under the domain of Health-Related Behaviors the following major areas for which indicators have been developed: smoking, physical activity, excessive drinking, nutrition, obesity, and condom use among youth. The indicators identified for the Health-Related Behaviors domain are: • moking: Percentage of adults who have smoked ≥ 100 cigarettes in S their lifetime and who currently smoke some days or every day • hysical activity: Percentage of adults meeting the recommenda P tion for moderate physical activity (at least 5 days a week for 30 minutes a day of moderate-intensity activity or at least 3 days a week for 20 minutes a day of vigorous-intensity activity)
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The BRFSS allows analysis by age, county of residence, education level, employment status, ethnicity, income, marital status, The specific variable is current smoking, SAS name "_RFSMOK3" where 1 = not a current smoker, 2 = current smoker, and 9 = missing/refused/don't know.
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, described numerous associations between physical activity and various health outcomes. For example, even moderate regular physical activity lowers mortality rates while higher levels are associated with lower mortality rates for both older and younger adults.
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. It is likely that this global initiative will result in data collection on levels of physical activity.
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The NHIS data can be analyzed by age, citizenship, education level, employment status, ethnicity, income, insurance status, place of birth, race, and sex. The BRFSS allows analysis by age, county of residence, education level, employment status, ethnicity, income, marital status, race, and sex.
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. The data collected by NHANES can be analyzed by age, education level, employment status, ethnicity, income, marital status, place of birth, race, and sex.
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eSaturated Fat and Sodium get a score of 8 for the intake levels that reflect the 2005 Dietary Guidelines, < 10% of calories from saturated fat and 1.1 grams of sodium/1,000 kcal, respectively. SOURCE: Adapted from USDA Center for Nutrition Policy and Promotion, 2008.
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Obesity has been shown to be associated with several poor health outcomes, including:
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The combination of interview and physical examination in the NHANES enables more valid measurement of health conditions such as obesity because NHANES directly measures the height and weight of participants. Drill-down analysis can be performed by age, education level, employment status, ethnicity, income, marital status, place of birth, race, and sex.
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have a 50 to 100 percent increased risk of premature death from all causes, compared to individuals with a healthy weight. HEART DISEASE • The incidence of heart disease (heart attack, congestive heart failure, sud den cardiac death, angina or chest pain, and abnormal heart rhythm)
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• Obesity can affect the quality of life through limited mobility and de creased physical endurance as well as through social, academic, and job discrimination. CHILDREN AND ADOLESCENTS • Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency in overweight children and ado lescents compared to those with a healthy weight.
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By addressing the use of condoms among sexually active youth the committee does not intend to endorse sexual activity among youth, nor does it intend to imply sexual activity in and of itself is an indicator of health. However, recognizing that such activity does take place and that unprotected sex can result in serious health problems, the committee believes an important indicator of health-related behavior is the proportion of youth in grades 9–12 who are sexually active and do not use condoms, placing them at risk for sexually transmitted infections is an important indicator of health-related behavior.
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Health Systems The health system is broadly defined as the set of institutions and actors whose purpose is to maintain or improve people's health. The health system includes the health care system, those directly involved in care delivery, as well as the public health system that attempts to improve or maintain health by affecting health-related behaviors and environmental factors or by other population-oriented activities such as surveillance, food service inspections, water quality testing, and mosquito abatement.
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. Because the number of indicators for the SUSA Health Indicators study was sharply constrained, the committee chose to focus on domains for which there are measures of fairly broad generality and not on disease-specific measures.
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From the patient perspective, there are numerous measures of particular processes of acute care or particular care settings, but generalized measures are less evident; measures of end-of-life care are even less available. Therefore, the committee focused on the staying healthy and chronic care domains, motivated as well by the high burden of chronic disease on both quality of life and costs of care.
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Since the committee has recommended a number of health outcome indicators for the SUSA website for which cross-national comparisons are available, including the per capita health care expenditures measure will allow users to make these comparisons and form judgments about the relative efficiency of the U.S. health care system relative to other developed nations.
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International comparisons are available from the OECD website (http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_ 1_1_1,00.html)
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. The uninsured are also less likely than those with insurance to obtain preventive services and care for major health conditions such as traumatic injuries, heart attacks, and chronic diseases, thus leading to serious consequences (Dorn, 2008; Kaiser Commission on Medicaid and the Uninsured, 2008)
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Moreover, all federal and nonfederal surveys that ask about insurance coverage obtain very consistent patterns with respect to disparities across socio-demographic groups. The committee suggests that SUSA provide drill-down analysis capabilities that allow users to look at the percentage of people with various types of insurance coverage including Medicare, Medicaid, employer sponsored, and private non-group.
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ACS data can be analyzed by age, citizenship, education level, employment status, English proficiency, ethnicity, income, marital status, race, and sex. In the short run however, SAHIE numbers might be included in the SUSA website.
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MEPS data can be analyzed by age, citizenship, education level, employment status, ethnicity, income, insurance status, place of birth, race, and sex. The committee suggests that in addition to the composite unmet/ delayed needs measure, SUSA should provide users with the capability to drill down to look at unmet medical, dental, and prescription drug needs individually.
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For example, HIV screening in pregnant women greatly decreases mother-to-child transmission rates (Chou et al., 2005) and mammography has reduced mortality rates from breast cancer in women 40–75 years of age (Humphrey et al., 2002)
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that can compro mise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration; • Residents of nursing homes and other chronic-care facilities; • Health-care personnel; • Household contacts and caregivers of children aged < 5 years and adults aged > 50 years, with particular emphasis on vaccinating contacts of children aged < 6 months; and • Household contacts and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza.
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The structure of the MEPS survey allows for analysis by age, citizenship, education level, employment status, ethnicity, income, insurance status, place of birth, race, and sex.
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causing concern about potential outbreaks of disease in urban areas with large underserved populations. Childhood immunization rates also vary by geographic region (NIS, 2007b)
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The committee believes the percentage of children aged 19–35 months who are up to date with recommended immunizations is an important indicator of the health of the United States. The data source for this indicator is the National Immunization Survey (http://www.cdc.gov/nis/)
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to track hospital admission rates for 14 ACSCs: • Diabetes, short-term complications • Diabetes, long-term complications • Uncontrolled diabetes • Lower extremity amputations among patients with diabetes • Perforated appendicitis • Chronic obstructive pulmonary disease • Congestive heart failure • Angina without procedure • Hypertension • Low birth weight • Dehydration • Bacterial pneumonia • Urinary infections • Adult asthma Although hospitalization for these conditions can often be avoided with high quality ambulatory care, any particular individual's hospitalization may also reflect other factors including inadequate monitoring, lack of the patient education needed for appropriate self-management, or patient preference not to follow treatment recommendations (AHRQ, 2004)
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Social and physical determinants include SES, race/ethnicity, social support, health literacy and limited English proficiency, and the social and physical environment in which people live, learn, work, and play. Socioeconomic status is one of the most important determinants of health.
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Although these social and physical characteristics are fundamental determinants of health, the committee did not include them in the list of 20 health/health care indicators because it anticipates that, with the exception of social support and health literacy and limited English proficiency, they will be covered in other SUSA domains.10 For example, the committee believes it is highly likely that the economy domain will include indicators for employment and income, that the environmental domain will include indicators of air and water quality and toxic hazards, and that the education domain will have indicators related to educational attainment. Therefore, the committee determined that it was best not to include items such as individual indicators within the health/health care Health literacy levels in the NAAL are below basic (able to perform tasks such as signing a form or adding the amounts on a bank deposit slip)
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In the case of social support and health literacy and limited English proficiency, the committee would have liked to have included these as indicators but was unable to identify an appropriate measure. To a degree, drill-down capabilities in SUSA will allow users to make connections between some aspects of the social environment and health outcomes, particularly to the extent that data can be displayed when stratified by income and education.
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One example is to report for Mexican-Americans and Cuban-Americans as well as subsuming both into a single heterogeneous Hispanic category, or distinguishing different Asian-American national origins. The committee believes that where possible disparities should also be reported by socioeconomic status (SES)
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Rural residents are more likely to be elderly, poor, in worse health, and to have chronic conditions than are their urban counterparts (AHRQ, 2006)
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, it should be noted that other types of differences that are not always regarded as disparities might be analyzed and presented in a similar manner when data are available that make this possible, such as differences by limited English proficiency, date of immigration, or gender. Indicators to Be Included in Disparities Reporting Any indicator that is measured at the individual level can also be analyzed for disparities, as long as the data source can be linked to data on race/ethnicity and/or a measure of SES.
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For example, life-table estimates of life expectancy automatically adjust for age distribution. Measures of quality of health care typically are designed to apply only to the relevant clinical population.
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The National Healthcare Disparities Report (AHRQ, 2006) uses comparisons of each group to the most-advantaged group to describe disparities.
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levels. Use of area-based measures is widespread in epidemiology and health services research; methodological findings from this research are summarized on the website of the Public Health Disparities Geocoding Project at the Harvard School of Public Health (http://www.hsph.harvard.
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health systems. The committee recommends that the State of the USA website include the following indicators for the health/health care domain: Health Outcomes • ife expectancy at birth: Number of years that a newborn is L expected to live if current mortality rates continue to apply • nfant mortality: Deaths of infants aged under 1 year per 1,000 I live births • ife expectancy at age 65: Number of years of life remaining to a L person at age 65 if current mortality rates continue to apply • njury related mortality: Age-adjusted mortality rates due to I intentional and unintentional injuries • elf-reported health status: Percentage of adults reporting fair or S poor health • nhealthy days physical and mental: Mean number of physically U or mentally unhealthy days in past 30 days • hronic disease prevalence: Percentage of adults reporting one C or more of six chronic diseases (diabetes, cardiovascular disease,
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• erious psychological distress: Percentage of adults with serious S psychological distress as indicated by a score of ≥ 13 on the K6 scale Health-Related Behaviors • moking: Percentage of adults who have smoked ≥ 100 cigarettes S in their lifetime and who currently smoke some days or every day • hysical Activity: Percentage of adults meeting the recommenda P tion for moderate physical activity (at least 5 days a week for 30 minutes a day of moderate-intensity activity or at least 3 days a week for 20 minutes a day of vigorous-intensity activity) • xcessive Drinking: Percentage of adults consuming four E (women)
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, race/ethnicity, social support, health literacy and limited English proficiency, and the social environment in which people live, learn, work, and play. Furthermore, many health outcomes are linked to features of the physical environment such as air and water quality, temperature, and characteristics of the built environment.
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Atlanta, GA: HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion.
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2008g. Chronic disease prevention and health promotion: Chronic disease overview.
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http://www.health.gov/dietary guidelines/dga2005/report/default.htm (accessed September 28, 2008)
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2008. Tobacco use among those with serious psychological distress: Results from the National Survey of Drug Use and Health, 2002.
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2008. Psychological distress and occupational injury: Findings from the national health interview survey 2000–2003.
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2008. The gap gets bigger: Changes in mortality and life expectancy, by education, 1981–2000.
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1993. Self-rated health, mortality, and chronic diseases in elderly men.
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2006b. Serious psychological distress and substance use among young adult males.
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1991. Delayed access to health care: Risk factors, reasons, and consequences.
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