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State of the USA Health Indicators: Letter Report December 3, 2008 Christopher Hoenig President and Chief Executive Officer State of the USA, Inc. 1146 19th Street, NW Suite 300 Washington, DC 20036 Dear Mr. 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. (SUSA) on 20 potential indicators that could be used to track progress in the areas of health and health care. The body of this letter report provides the committee’s findings and recommendations regarding that task. SUSA is a newly formed, nonprofit corporation established in 2007 to provide Americans with high-quality information about changing societal, economic, and environmental conditions via a website now under development. Financial support for SUSA is currently provided by the William and Flora Hewlett Foundation, the Rockefeller Foundation, the John D. and Catherine T. MacArthur Foundation, the Carnegie Corporation of New York, the Peter G. Peterson Foundation, and the F.B. Heron Foundation. The SUSA website is intended to provide the most reliable and objective facts about the state of the USA and to serve as a tool for Americans to track the progress made on a broad range of issues, such as education, health, and the environment. Additionally, the website will allow users to make comparisons at the local and state level as well as nation-to-nation comparisons. The ultimate goal of the website is to help Americans become more informed and, thus, active participants in focusing public debate on important issues. Data collected in public opinion polls over the past 20 years show that the American public has identified health as a key issue. In fact, while economic issues are of primary importance, “health care issues compete for the second priority” in terms of most important problems (Westat and AmericaSpeaks, 2008). Furthermore, there is widespread discussion about health care quality (IOM, 2000c, 2001), about disparities in health and access to health care (IOM, 2003b), and about the factors that contribute to the health of individuals and populations (IOM, 2000b, 2003a). Health and health care became major points of debate in the 2008 Presidential
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State of the USA Health Indicators: Letter Report campaign with both parties advancing their solutions to the health care problems facing the United States. SUSA is now poised to begin populating its website with data and, with advice from The National Academies, is assembling a set of key indicators that measure specific conditions or trends. An early domain in which data will be made available is the health/health care domain. It is important to note that the SUSA website is not intended for researchers interested in pursuing in-depth analysis of various issues and relationships among variables. 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. In conducting its task, the committee was asked to give consideration to the following: Availability of high-quality data at the national level to accurately reflect the indicator construct, including the availability of data that can be broken down by important population subgroups (e.g., age, gender, socioeconomic status [SES], race/ethnicity), and geographic region (states, cities, communities); Reliability and quality of data and data sources; Issues that are most salient for intended audiences and users of SUSA; Indicators that are sensitive to changes in other societal domains (socioeconomic or environmental conditions or public policies); and Indicators that permit cross-country comparisons. SUSA also asked that, to the degree possible, the indicators selected should be those that best reflect: (1) the overall health of the nation and the factors that are important in determining the current and future health of the nation and (2) the effectiveness and efficiency of the U.S. health care and public health systems. During the presentation by SUSA at the first committee meeting, SUSA President Christopher Hoenig stated that no more than 20 indicators should be developed for the health/health care domain. Additionally, because SUSA intends that official federal statistics will be the initial source of data (http://stateoftheusa.org/faqs/index.asp#5), the committee was charged with selecting only those indicators
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State of the USA Health Indicators: Letter Report that could be measured with federally collected data. This letter report includes the committee’s recommendations to SUSA about the topic areas and 20 indicators that should be included in the health/health care domain of the SUSA website. COMMITTEE PROCESS Developing a set of 20 indicators that can be used to track the progress of health and health care in the United States was a challenging task. During this 6-month study, the committee met three times. The first meeting was held in conjunction with an information gathering session with SUSA staff and consultants, and experts from organizations engaged in developing health indicators (see Appendix A for agenda). In addition, the committee reviewed existing health indicator sets and the data used to measure them. Because the study time frame was short, and to facilitate the committee’s work, SUSA provided a review of health indicator reports for the committee to use as background information (Wold, 2008). A list of the reports addressed in that review may be found in Appendix B. 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. Information on the public’s perception of issues of importance in health and health care were also analyzed by the committee. These included reports of public opinion polls, focus groups, and the proceedings of a SUSA-convened working session for the policy analysis community. A recently released report by The Commonwealth Fund (2008) was also reviewed, along with other published literature related to determinants of health and performance of the health care and public health systems. TRACKING PROGESS IN HEALTH AND HEALTH CARE Measuring and tracking the health of populations has a long history. The London “Bills of Mortality” were published annually beginning in 1629. They contained information that allowed authorities and residents to track the number of deaths associated with the plague and other causes (Last, 2001). Mortality rates were also used in early efforts to compare the health status of populations; those with lower mortality rates were
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State of the USA Health Indicators: Letter Report considered to be healthier than those with higher rates. Mortality rates are still used to compare the health of populations. 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. The U.S. government began, in the mid-1950s, to collect indirect measures of morbidity (e.g., symptom rates and use of health care services) through major surveys. These surveys produced population-based data that included information about specific illnesses, injuries, and levels of activity in the population (IOM, 1999). Additionally, surveys included measures of health system performance in terms of cost, efficiency, and quality. Today, measures include not only mortality and morbidity statistics but also data on health status and wellness, health systems, health expenditures and financing, and other information (IOM, 2003a). As measures for assessing health have changed over time, so too have the frameworks for thinking about the determinants of health. In the early 1970s, Lalonde (1974) proposed a framework for thinking about health and its determinants that includes environment, lifestyle, human biology, and health care organization. The report, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, identified three categories of determinants of disease and disability in the United States—preventive health services, health protection, and health promotion (DHEW, 1979). Additionally, the report included areas where improvement could be achieved given concerted effort. Evans and Stoddart (1990) proposed a complex framework of health determinants that takes into account distinctions among disease, health, functioning, and well-being. Furthermore, that framework includes “both behavioral and biological responses to social and physical environments.” Kaplan and colleagues (2000) emphasized that there are multiple levels of determinants and that bridges should be built connecting these levels in order to understand their effects on health. They proposed that the major factors affecting health include pathophysiological pathways, genetic/constitutional factors, individual risk factors, social relationships, living conditions, neighborhoods and communities, institutions, and social and economic policies. Kindig and colleagues (2008) proposed a population health framework for setting national and state health goals that included health outcomes, health determinants (health care, health behaviors, socioeconomic factors, and physical environment), and health policies and interventions. Other models that involve a multilevel understanding of health and its determinants include the works of Dahlgren and
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State of the USA Health Indicators: Letter Report Whitehead (1991) and Grzywacz and Fuqua (2000). Several IOM reports (IOM, 2003a,c, 2006) have emphasized the need to understand that multiple determinants of health are linked and related in many ways. FRAMEWORK FOR INDICATOR DEVELOPMENT No single measure can capture the health of the nation. Indicators are needed that reflect a broad range of factors such as health, risk for illness, and health system performance. As described earlier, SUSA intends that official federal statistics will be the initial sources of indicator data. Over time, as new information becomes available and the source of indicator data expands, important indicators may change. Therefore, the set of indicators presented in this report should not be viewed as perfect or permanent, rather the committee identified potential indicators that met the data constraints and then applied the framework described below to determine the final selection of indicators. The committee considered the previously discussed frameworks of determinants of health and developed a simplified framework (see Figure 1) to guide the selection of the 20 indicators for the SUSA website. 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. FIGURE 1 Framework for health and health care indicator development.
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State of the USA Health Indicators: Letter Report The indicator framework chosen shows health outcomes influenced by three types of determinants: the social and physical environment, health-related behaviors, and health systems. Health outcomes were chosen because these reflect both the well-being of the population as well as the burden of illness. Social and physical environmental determinants were selected because they play a particularly important role in health since they impact health outcomes both directly and indirectly by influencing the other determinants. Health-related behaviors were chosen because behavioral patterns account for 40 percent of the deaths in the United States (McGinnis and Foege, 1993). Finally, health systems determinants were selected because access to available services is crucial to the treatment and prevention of some illnesses. In Figure 1 the committee recognizes, but does not show for reasons of simplicity, that sometimes health outcomes also have impact on determinants and that interactions among determinants are many and complex. The entire framework is embedded in the understanding that a broad concept of health requires equity across subpopulations in both outcomes and determinants. Once the framework was developed (see Figure 1), each committee member was asked to identify the top 20 indicators he or she would choose for health/health care that fit within that framework. The number was limited to 20 because of the limit set by SUSA. The resulting list included almost 200 separate indicators. The next step was to place each of the indicators in one of the boxes of the framework—outcomes, health-related behaviors, health systems, or social and physical environment. Then, the committee proceeded to discuss the various indicators, what they conveyed about health or health care, and how they might be measured. 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. Others were eliminated because they were indicators of very similar things. For example, insurance coverage, unmet needs, and having a regular source of care were all highly related. The committee determined that, given the restriction on the number of indicators, it was necessary to eliminate one of these and decided to exclude having a regular source of care from the indicator list. Some indicators were eliminated from consideration because adequate data are not available. For example, many quality of care indicators have been identified for particular subsets of the health care system (e.g., members of managed care plans or individual hospitals) but national data that cross health systems are not available. Indicators of state and
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State of the USA Health Indicators: Letter Report local public health expenditures were eliminated for a variety of reasons including lack of comparability across jurisdictions, failure to capture a substantial portion of public health services and programs, or the fact that the data used reflects budgets rather than expenditures. Other potential indicators were eliminated from consideration because the committee believes that they will be captured in other domains of the SUSA website, for example, employment and income as indicators in the economy domain; air and water quality and pollution as indicators in the environmental domain; and educational attainment in the education domain. Indicators were selected for each of the components of the framework illustrated in Figure 1. Overall, each indicator was chosen because of its importance to health or health care; because reliable, high-quality data are available to measure change in the indicator over time; and because the data can be viewed by population subgroups or geographic region. While the committee believes that the chosen indicators reflect the overall health of the nation and the effectiveness and efficiency of U.S. health systems, it is important to note that these indicators do not fully reflect all the factors that are important to health status, health care, and public health. To include all factors would require many more indicators than 20. Indicators are only as good as the data on which they are based. All of the indicators recommended in this report are based on data provided by the federal statistical system. The functioning of that system is often taken for granted and assumptions are made that budgets are sufficient to provide the high-quality data needed. Continuing and sufficient support for the federal statistical system is crucial to populating the SUSA website with high-quality data. For the various indicators, the committee has identified variables such as race/ethnicity, income, and education as “drill-down” variables. 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. These factors may include demographics (e.g., age, gender, race/ethnicity), socioeconomics (e.g., income, education, employment status, insurance status), and geographic region (e.g., state, county, or urban/rural). The variables available for drill-down analysis will vary by indicator because they must be available from the original source data set used for each indicator. Another form of drill-down analysis may involve taking a single indicator (e.g., infant mortality) and allowing a more fine-grained breakdown of that indicator into one or more component indicators (e.g., neonatal mortality, postneonatal mortality, etc.). Again, the ability to do this sort of analysis will vary by indicator, depending on the level of detail available in the underlying source data.
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State of the USA Health Indicators: Letter Report It is important to note that as one drills down into smaller units, such as counties or for small populations, the number of events, such as infant deaths, may become so small that they are statistically unreliable. The committee believes that SUSA should develop and apply a set of standards so that unreliable estimates are not included. (See Appendix C for further discussion of statistical reliability of drill-downs and methods for improving small-area estimates.) Moreover, the committee encourages SUSA to consider several statistical techniques to reduce the instability of estimates as described in Appendix C. The set of indicators identified by the committee is described below. For each indicator, information is provided about its importance as a measure of health/health care, the data available to measure the indicator, and the kinds of drill down analyses that can be conducted. INDICATORS Health Outcomes The committee embraces a broad definition of health for the SUSA website, such as that proposed by the World Health Organization: “the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948) and the “extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities” (WHO, 1984). Health outcome measures are used to quantify and track the health of nations, states, communities, and individuals. In light of the small number of indicators sought by SUSA, the committee recommends eight indicators in three general outcome categories: mortality, health related quality of life (or morbidity), and major health conditions. Particular attention was given to including major causes of morbidity and mortality in different age groups, as well as important health outcomes that were not captured in the determinant categories (e.g., injury mortality). The health outcome indicators chosen are: Mortality Life expectancy at birth: Number of years that a newborn is expected to live if current mortality rates continue to apply Infant mortality: Deaths of infants aged under 1 year per 1,000 live births
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State of the USA Health Indicators: Letter Report Life expectancy at age 65: Number of years of life remaining to a person at age 65 if current mortality rates continue to apply Injury-related mortality: Age-adjusted mortality rates due to intentional and unintentional injuries Health-Related Quality of Life (Morbidity) Self-reported health status: Percentage of adults1 reporting fair or poor health Unhealthy days, physical and mental: Mean number of physically or mentally unhealthy days in the past 30 days Condition-Specific Outcomes Chronic disease prevalence: 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) Serious psychological distress: Percentage of adults with serious 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. Life expectancy at birth is a standard for comparing populations both within countries and internationally. It reflects the overall mortality pattern of a population across all age groups (WHO, 2008d) and is often used as an overall measure of the state of a population’s general health (Human Resources and Social Development Canada, 2008). In 2005 in the United States, overall life expectancy at birth was 77.8 years. Table 1 provides data on life expectancy at birth for selected years broken down by race and sex. Life expectancy at birth is commonly used to identify disparities among populations. For example, Harper and colleagues (2007) used U.S. vital statistics data to assess the gap in life expectancy between blacks and whites. Meara and colleagues (2008) used life expectancy at birth to examine educational disparities in life expectancy among non-Hispanic blacks and whites. 1 Adults are defined as 18 years and older for all surveys except for National Health Interview Survey which considers adults to be those 17 years and older.
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State of the USA Health Indicators: Letter Report TABLE 1 Life Expectancy at Birth by Race and Sex for Selected Years Year All races White Black or African American Male Female Male Female Male Female 1995 72.5 78.9 73.4 79.6 65.2 73.9 2000 74.3 79.7 74.9 80.1 68.3 75.2 2005 75.2 80.4 75.7 80.8 69.5 76.5 SOURCE: Adapted from NCHS, 2007. Life expectancy at birth is also used in international comparisons. 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. Data for this indicator can be found in the National Center for Health Statistics (NCHS) Vital Statistics reports (http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf). Data can be analyzed by age, education level, ethnicity, marital status, national origin, place of residence, race, and sex. International data can be obtained through the World Health Organization (WHO) Statistical Information System. Infant Mortality Rate Indicator: Deaths of infants aged under 1 year per 1,000 live births. The infant mortality rate is a leading indicator that is used to compare populations both within and across countries. Between 2002 to 2004, the infant mortality rate in the United States for all races was 6.9 but it is important to note that infant mortality varies by geographic region and race. For example, infant mortality for whites in New England was 4.3 but for blacks it was 11.0; in the West South Central Region, white infant mortality was 6.5 but black infant mortality was 13 (NCHS, 2007). Infant mortality is used as an indicator of the level of child health and overall development and is often used to identify disparities among populations within a specific country. Although infant mortality is sometimes criticized as focusing attention on a small part of the population, Reidpath and Allotey (2003) found that the infant mortality rate reflects the structural factors that affect population health. The committee believes that deaths of infants aged under 1 year per 1,000 live births is an important indicator of the health of the population.
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State of the USA Health Indicators: Letter Report TABLE 2 Life Expectancy at Birth for Selected Countries and Selected Years Country Male Female 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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State of the USA Health Indicators: Letter Report Social determinants play a particularly important role in health in that they impact health outcomes directly as well as indirectly by influencing other determinants. Social determinants include socioeconomic status (income, education, and employment status), 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. Because of the relationship of health to factors in the other domains that SUSA will be developing, the committee recommends that as the other domains in SUSA are developed and indicators become available which describe the important social and physical determinants of health, SUSA should make an effort to create appropriate, dynamic linkages to describe health more fully. The committee believes that it is important for the SUSA website to include an explanation of the framework used to develop the indicators for health/health care as introductory material to that domain. Therefore, the committee recommends that the following description of the framework be included on the website: The indicators in the health domain fall into two categories. The first is health outcomes, which track the health of nations, states, and communities. The second is determinants of health outcomes, in other words, factors that influence health outcomes. In addition to an individual’s own biology, there are three main types of health determinants which all interact to influence health outcomes. These determinants are characteristics of the social and physical environment, health-related behaviors, and health systems performance. Although the social and physical environments play a particularly important role in that they influence other determinants, this part of the website presents indicators relating to health outcomes, health-related behaviors, and health systems. Indicators of the social and physical environments can be found in other SUSA domains and can be linked to health. As discussed earlier, the charge to the committee explicitly mentions disparities as one of the areas to be included in the report. Because disparities are important in the examination of a variety of indicators across many of the domains that SUSA intends to include in its website, the committee believes that disparity indicators are best derived from a subset of the national indicators. Therefore, the committee recommends that for each indicator in the various SUSA domains, SUSA should include the ability to explore disparities by socioeconomic status, race/ethnicity, and geographic region.
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