root cause analysis of health care demand: how determinants of health impact health and health...

Victoria Lee – CMHO Fraser Health

Paul Hasselback - MHO Island Health

Both speakers are employed by Health Authorities.

Both speakers are Order-in-Council appointments as Medical Health Officers by the Government of BC.

Neither speaker have financial interests associated with the content of the presentation.

Co-chairs of the Population Health working group of Health Officers Council of BC.

Lay a solid foundation of understanding about the “Determinants of Health”.

Explore how determinants should be relevant to health planning and health service delivery.

Develop concrete roles for the health sector in addressing determinants.

PHAC, What Makes Canadians Healthy or Unhealthy, 2003

Meet Bob, who is a Metis older

adult living in a dilapidated house

in a rural part of Mission with

multiple chronic diseases. In

2015, he visited various EDs in the

area, was hospitalized and

readmitted multiples times.

Determinants of Health

Income and Social Status Physical Environments

Social Support Networks Personal Health Care Practices & Coping Skills

Education Healthy Child Development

Employment/Working Conditions

Biological and Genetic Endowment

Social Environments Health Services

Gender Culture

Heart

Cancer

Lung

Stroke

Arthritis

Depression

Diseases Risk factors Determinants

Tobacco

Alcohol

Diet

Physical Fitness

Social Fitness

Economic status

Education

Work life

Environments

Social support

Genetics

Gender

Child life

Culture

Lifestyles and coping

Health Services

Health field concept – Lalonde 1976.

Ottawa Charter – prerequisites for health 1987.

Determinants of Health – What makes us healthy? – 1994.

“Social” Determinants of Health - 2003.

WHO – Commission on Social

Determinants of Health 2008.

“A health care system – even the best health care system in the world – will be only one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment, or empty with despair.”

Roy Romanow

Those in the lowest SES quintile often

50-100% more likely to develop

illness.

Those in the lowest SES quintile: 30-

300% more likely to be admitted given a

specific ACS condition .

Data scarcer for other conditions

Those in the lowest SES quintile 10-25% less likely to

recover

Develop illness When sick, utilization of services

Recovery/response to care

“Our common values and responsibilities towards humanity move us to fulfill our pledge to act on social determinants of health. We firmly believe that doing so is not only a moral and a human rights imperative but also indispensable to promote human well-being, peace, prosperity and sustainable development.”

~Rio Declaration, 2011

The most disadvantaged* groups experience: ◦ More risk factors

◦ Higher burden of illness

◦ More difficulties accessing services and resources

◦ Require more intense health care services ($)

Thus the burden on our health care system is also not equal.

5.7

years

6.9

years

6.3

years

70

72

74

76

78

80

82

84

86

88

LHA 85 -VI North

LHA 70 -Alberni

LHA 72 -Campbell

River

LHA 67 -Ladysmith

LHA 66 -Lake

Cowichan

LHA 68 -Nanaimo

LHA 65 -Cowichan

LHA 71 -Courtenay

LHA 62 -Sooke

LHA 61 -GreaterVictoria

LHA 69 -Qualicum

LHA 64 -Gulf

Islands

LHA 63 -Saanich

Life Expectancy of Island Health Residents Compared to Island Health and BC 2009-2013

Female Male BC Female BC Male Island Health Female Island Health Male

-0.8-0.6-0.4-0.200.20.40.60.81

LHA 70 - Alberni

LHA 85 - VI North

LHA 66 - Lake Cowichan

LHA 68 - Nanaimo

LHA 72 - Campbell River

LHA 65 - Cowichan

LHA 67 - Ladysmith

LHA 61 - Greater Victoria

LHA 69 - Qualicum

LHA 71 - Courtenay

LHA 62 - Sooke

LHA 64 - Gulf Islands

LHA 63 - Saanich

Correlation with life expectancy p<0.001

Male 0.93 Female 0.83

Average Potential Years of Life Lost (PYLL) for Highest and Lowest SES for Major Causes of Death in BC.

0.00

0.50

1.00

1.50

2.00

2.50

Highest SES

Lowest SES

Communities in Fraser East have the highest ED visit rates and have experienced the greatest increase in ED visit rates over the past decade.

Source: Fraser Health Emergency Department Data

Hospitalization rates 22% higher from poorer communities (50% higher in 45-64 year olds).

Much more likely to be admitted for preventable (ACS) conditions. ◦ Wier et al. Healthcare Cost and Utilization Project Statistical Brief 73 http://www.hcup-

us.ahrq.gov/reports/statbriefs/sb73.pdf (33-100%).

◦ Disano et al. Can Nurse 2010 106(1) 24 (250-300%).

Childhood respiratory rates nearly double (e.g.Hawker Resp Med 2003 97(11) 1219) injury and poisoning

Risk of developing cancer.

Rates of participation in screening programs.

Waiting times to receive care.

“Stage” at time of diagnosis.

Access to types of treatment.

Access to participation in clinical trials.

Longer for lower income and rural.

Lower radiation utilization for rural residents.

Mastectomy rates higher in lower income and rural residents.

Colostomy rates higher in rural communities.

However, treatment is equitable in terms of radiation wait times, radiation utilization by income and colostomy by income.

6-25% lower cancer survival among better educated.

Diabetes mortality 50-60% higher in lowest income groups (CMAJ 2010 182 http://www.cmaj.ca/content/182/1/E1.abstract)

Social supports, including pets improved coronary survival at one year.

Cancer and income: Diagnosed later, higher stages, and survival poorer even when adjusted for stage and delay in diagnosis.

Rural disparity in BC on cancer, cardiac, birth outcomes.

Poverty

Developing illness

Requiring health care

Poorer outcome

More disability

Less employment

Lower income

Poverty

Discussion point

Improve Health Outcomes and Promote Healthy Communities.

Decrease burden on the health care system. ◦ High quality and safe care

◦ Improved outcomes

◦ Increase appropriate access to care

◦ Decrease length of stay (appropriate)

◦ Decrease health care costs

Fairness and justice benefits the health of all.

Health Impact Pyramid (Frieden AJPH, 2010 100(4) 590)

Counselling

and health

education

Direct Clinical Care

Clinical interventions with

limited contact that confer

long term protection

(immunization, screening,

chronic disease management

Change context to make default decisions healthy

Addressing Determinants of Health

Counselling and health education

Direct Clinical Care

Where do we currently direct our resources?

Addressing Determinants of Health

The Spinning Top Model of Resource Expenditure

Population Health Approach ◦ Look at the health of the community vs the

individual.

◦ Focus on a broad range of factors (determinants) both in and out of the healthcare system that can influence health.

◦ Differences in health exist across communities, some may be due to unavoidable factors (genetic pre-conditions) but others are unfair and avoidable...

http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf

Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.

Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

Early years investments ◦ Are children in your health organization a priority?

Healthy Places, Healthy People ◦ What philosophy is taken to supporting

communities in deriving their own priorities?

Fair Employment and Decent Work ◦ Can Health Authorities commit to living wage?

Social Protection across the lifecourse

Universal Health Care ◦ How close are we? Home care, pharmacy.

Health equity in all Policies, Systems and Programmes. ◦ Does HA embrace and demonstrate equity?

Fair financing ◦ Do resource allocation models include equity

Market Responsibility

Gender equity ◦ Has a formal assessment of HA on gender equity been

undertaken?

Political Empowerment – Inclusion and Voice. ◦ Does workforce reflect the population served?

Good Global Governance.

Are Measures of Determinants of Health routinely incorporated into reporting?

Are staff trained on impact of DOH?

Is priority given to reducing disparities? ◦ Is this reflected in goals, vision, mission?

Divisions of Family Practice Poverty Intervention Tool. ◦ https://www.divisionsbc.ca/kb/povertyintervention

Fraser Health Equity Assessment Tool.

Screening for economic risk in prevention settings. ◦ https://www.divisionsbc.ca/CMSMedia/WebPageRevisions/PageRev-

3526/BC-Poverty-2015-Final.pdf

Step 1: Inquire about poverty – integrate it into your screening. Screen everyone – regardless of age, ethnicity or medical status – by asking:

Do you ever have difficulty making ends meet at the end of the

month? (Sensitivity, 98%. Specificity, 64% for those living below the poverty line).

Step 3: Intervene: 8 simple questions to ask your patients living in poverty.

Why use HEAT? ◦ Fraser Health identifies health equity as a priority.

◦ The HEAT Handbook and Workbook can help you prioritize health equity in your work.

◦ Develop strategies to reduce health inequities in the populations you serve.

How is HEAT used? ◦ The HEAT Handbook and Workbook should be used

together and are intended to be used collaboratively with your team.

Defines Health Equity ◦ Equity vs. Equality

Provides information about Health Equity ◦ Determinants of Health

Describes using Health Equity lens in your work ◦ Health Equity Lens

◦ Population Health Approach

Equitable Health System = Patient and Population Centred Health System.

What tools do you think you need?

How would you leave today and apply determinants to your work?

What one thing will you do

in the next month?

Clinical Associate Professors – UBC PH – U Victoria VL - SFU