Chronic diseases as tracer
conditions in international
benchmarking of health systems:
the example of diabetes
Ellen Nolte1, Chris Bain2, Martin McKee1
1
2
European Centre on Health of Societies in Transition
London School of Hygiene and Tropical Medicine, UK
School of Population Health, University of Queensland, Australia
How do countries compare?
¾ Optimal management requires
¾ Approach: ‘probe disorders’ or ‘tracer
conditions’ that capture certain elements of
the health care system
Discrete and identifiable health problem
Evidence of effective, well-defined health care
intervention
Natural history of condition varies with utilisation
and effectiveness of health care
Sufficiently common
Diabetes mortality (SDR0-39) and
incidence (SIR0-14)
40
1.4
35
1.2
0.6
15
0.2
0
0.0
De UK
nm
Au ark
st
ra
Po lia
rt u
ga
Sp l
a
E s in
to
ni
Au a
st
ri
Fr a
an
Bu ce
lg
a
Li
t h r ia
un
an
ia
Is
ra
el
La
tv
ia
Ja
pa
n
5
¾ Can provide important insights into primary
and specialist care, and into systems for
communicating among them
¾ Deaths (<45) considered ‘avoidable’ by
timely and effective health care
Study design
commonly used in cancer epidemiology as a crude
indicator of cancer survival or “case fatality”
may be interpreted as an indicator of the overall quality
of health care
0.4
10
Fi
nl
an
Ca d
na
da
SIR 0-14
0.8
20
co-ordinated inputs from range of health
professionals incl. primary care & specialists
access to essential medicines & monitoring
equipment
active participation of informed patients
¾ Outcome measure: Mortality-to-incidence ratio
SDR 0-39
1.0
25
¾ Health systems are complex with multiple
functions
¾ They must respond to varied health needs of
the population with limited resources
¾ They involve trade-offs, e.g. between
prevention & treatment or primary &
specialised care
¾ It is unlikely that any system will perform well
on all possible measures
Diabetes as tracer condition
¾ Different models of health care provision
¾ Differences at different levels
30
Assessing health system
performance
SDR0-39
¾ Age-standardized incidence rates for ages 0-14
years (WHO DiaMond study, 1990-1994)
¾ Age-standardised death rates from diabetes for
ages 0-39 (WHO mortality database, 19941998)
¾ Study population: 29 industrialised countries
SIR0-14
1
Diabetes: MortalityMortality-incidence ratio
Russia
Latvia
Lithuania
Japan
Romania
Bulgaria
Estonia
Poland
Hungary
USA
Denmark
Slovakia
Israel
Portugal
Finland
Slovenia
Norway
Germany
Austria
Australia
Netherlands
New Zeal
France
Canada
Sweden
UK
Spain
Italy
Greece
Ratio of national SDR
(1994-98)
Scenario
Finland
30-39
Israel
20-29
United Kingdom
500 1000 1500 2000 2500
0.15
0.2
0.25
SDR-SIR ratio
Next steps
M/I ratio only an indicator of potential differences in
health system performance & should stimulate detailed
assessments to confirm whether the apparent
variations are real and identify the reasons
Scrutinise data
Understand immediate causes of death
¾
vs. UK
vs.
Canada
2.0
3.3
3.2
Excess: 10%
2.4
1.8
3.0
2.9
Excess: 20%
2.1
1.6
2.7
2.6
Excess: 50%
1.3
1.0
1.7
1.6
(iii) Increase US incidence rate to
0
Death rate (100,000 person yrs)
0.1
US vs.
Canada
2.6
(ii) US death rate
United States
0.05
Ratio of M/I ratios
US vs.
UK
(i) as reported
(US incidence: 14.8/100,000)
Japan
0
¾
Sensitivity analysis
e.g. ~50% of deaths in Estonia & Latvia due to acute
complications of diabetes compared to only 22% in Finland
(Podar et al. 2000)
Understand processes of care
a. highest regional rate
(17.8/100,000)
-
-
2.8
2.7
b. upper 95 CI of highest
regional rate (20.3/100,000)
-
-
2.4
2.4
(iv) (iii a) + 20% mortality excess
-
-
1.9
1.9
Conclusions (1)
¾ M/I ratio for diabetes provides means of
differentiating countries that appear to provide
differing quality of care to people with diabetes and
by extension to other chronic diseases
¾ Further work is required to develop
a battery of performance indicators that capture other
aspects of health system performance
instruments that can be used for detailed health system
diagnosis once indicators suggest the presence of a
problem
Conclusions (2)
¾ International comparisons of health (care) systems have
focused on what can most readily be measured, not
what is necessarily important
¾ While indicating the existence of a possible problem
they provide few insights in how to respond
¾ Tracer conditions offer approach to overcome some of
these limitations
¾ This study is an attempt to show how to shift the
agenda on performance assessment to disorders such
as chronic disease that are critically important
2