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