Transcript nsaho - GPI Atlantic

Genuine Progress Index for Atlantic Canada
Indice de progrès véritable - Atlantique
Measuring Population
Health to Enhance
Accountability
NSAHO, Dartmouth, 14 November, 2003
Pop. health context: Romanow and
the 3 burning health policy issues
1) How to treat the sick - supply side
2) How to improve the health of
Canadians = outcome measures
needed to enhance accountability
3) How to check spiralling health care
costs - demand side
The next Royal Commission......
What kind of Nova Scotia are
we leaving our children?
What kind of world are
we leaving our children?
• Canada’s premier quality of life
• More possessions, longer lives
• But, defining wellbeing more
broadly
• Some disturbing signs
Warning Signals:
Determinants of Wellbeing
•Higher stress rates, obesity, childhood
asthma
•Insecurity - safety, livelihood
•Greater inequality
•Decline of volunteerism
•Natural resource depletion, species loss
•Global warming
‘Healthy’ Economy =
Healthy Communities?
 More equals better (vs. health as
balance). Romanow = 1/3 of equation
 Resource depletion as economic gain
 Crime, sickness, pollution, make
economy grow —because money is
being spent.
Sending the Wrong
Messages
 GDP can grow as poverty, inequality
increase.
 More work hours, stress make economy
grow; free time has no value (Statcan.
study)
 GDP ignores work that contributes
directly to community health
(volunteers, work in home).
Why We Need New
Indicators: Policy reasons:
 Economic growth = ‘better off’ sends
misleading signals to policy-makers.
 Vital social, environmental assets
ignored.
 Preventive initiatives to conserve and
use resources sustainably, to reduce
poverty, sickness and greenhouse gas
emissions, are blunted and inadequately
funded.
Indicators are Powerful
What we measure:
 reflects what we value as a society;
 determines what makes it onto the
policy agenda;
 influences behaviour (eg students)
A good set of indicators
can help communities:
 foster common vision and purpose;
 identify strengths and weaknesses;
 change public behavior;
 hold leaders accountable at
election time - e.g. Teen smoking
as an election issue
 initiate actions to promote wellbeing
GPI Atlantic founded to address
need for better indicators
• Non-profit, fully independent research
group founded April, 1997
• Located Halifax. www.gpiatlantic.org
• Sole mandate is to create good, usable index
of wellbeing and progress
• Pilot GPI projects in Glace Bay, Kings
County as model for Canadian communities
Measuring Wellbeing
In the GPI:
 Health, free time, unpaid work (voluntary
and household), and education have value
 Sickness, crime, disasters, pollution = costs
 Natural resources = capital assets
 Reductions in sickness, GHGs, crime,
poverty, ecological footprint are progress
 Growing equity signals progress
Valuing a Healthy Population
GPI population health reports include:
• Costs of chronic disease in Canada and NS
• Women’s health in Canada + Atlantic Canada
• Income, Equity and Health in Canada / Atl. Can.
• Costs of tobacco, obesity, physical inactivity, HIV
• Economic Impact of Smoke-Free Workplaces
• Value of care-giving in two NS communities
• New Atlantic region health database
Chronic Disease as Cost
Prevention = Investment
• Costs of chronic disease are very high
• Indirect costs, particularly, are huge
• Large proportion of costs preventable
• Disease prevention (esp. dealing with
root causes) is cost-effective
5,800 Nova Scotians/yr die
from 4 chronic diseases
= 3/4 of all deaths in NS (cf 1900)
• Cardiovascular: 2,800
36%
• Cancer
30%
2,400
• COPD
370
5%
• Diabetes
230+
3%+
NS: High Rate Chronic
Disease
• NS - highest rate of deaths from cancer
and respiratory disease
• Highest rate arthritis, rheumatism
• 2nd highest circulatory deaths, diabetes
• 2nd highest psychiatric hospitalization
+ Gap with Canada is growing....
Chronic Disease Disability
• 1/4 Nova Scotians have long-term
activity limitation - highest in country
• NS has highest use of disability days
• 20% have arthritis or rheumatism
• 16% have high blood pressure
• 14% have chronic back problems
Costs of 7 types non-infectious
chronic disease, NS, 1998
• 60% medical costs = $1.2 billion / year
• 76% disability costs = $900 million
• 78% premature death costs = $900 mill.
• 70% total burden of illness = $3 billion
= $3,200 per person per yr = 13% GDP
Cost of Chronic Illness in
Nova Scotia 1998 (2001$ million)
Circulatory
Cancer
Respiratory
Musculoskeletal
Endocrine
Nervous system
Mental
TOTAL:
Hosp.
Doctor
Drugs
Other
Total
Direct
Premat.
Death
Disability
TOTAL
161.6
71.4
21.6
55.9
18.5
55.3
104.2
26.6
11.8
3.2
20.3
7.2
27.9
17.7
63.6
7.5
16.6
22.0
29.3
19.2
39.2
137.8
49.6
22.7
53.8
30.1
56.0
88.2
389.6
140.3
64.1
152.0
85.0
158.5
249.2
326.8
427.2
43.4
3.5
43.8
30.0
16.0
244.4
14.5
78.1
307.2
27.0
158.6
72.3
960.8
582.1
185.5
462.8
155.8
347.0
337.5
488.4
114.8
197.5
438.1
1,238.8
890.8
901.9
3,031.5
These are under-estimates
• Exclude diseases: Digestive, cirrhosis of
liver, congenital, perinatal/LBW, blood, skin,
genitourinary (chronic renal failure), etc.
• “Principal diagnosis”: e.g. injury/fall vs
osteoporosis; diabetes under-reported
(complications: blindness, kidney failure,
amputations, cardiovascular disease,
infections). Diabetes 2 afflicts 4% (38,000)
Nova Scotians, disables 3,300, kills 230 850
What portion is preventable?
Excess risk factors account for:
• 40% chronic disease incidence
• 50% chronic disease premature mortality
• Small number of risk factors account for
25% medical care costs = $500 mill./yr
• 38% total burden of disease = $1.8 bill.
(includes direct and indirect costs)
A few risk factors cause many
types of chronic disease
• Tobacco - heart disease, cancers,
respiratory disease
• Obesity - hypertension, diabetes 2,
heart disease, stroke, some cancers
• Physical inactivity - heart disease,
stroke, hypertension, colon and breast
cancer, diabetes 2, osteoporosis
• Diet/fat - heart disease, cancer, stroke,
diabetes
Costs of Key Risk Factors,
Nova Scotia (2001 $ millions)
Deaths
Direct
Indirect
Total
Tobacco
1,700
$188
$300
$488
Obesity
1,000
$120
$140
$260
700
$107
$247
$354
Physical
Inactivity
Socio-economic
Determinants of Health
• Education, income, employment,
stress, social networks are key health
determinants. These too are
modifiable
• Lifestyle interventions effective for
higher income/education groups, not
lower - can widen inequity, health gap
Health Costs of Poverty
• Most reliable predictor of poor health,
premature death, disability: 4x more
likely report fair or poor health = costly
• e.g. Increased hospitalization:
Men 15-39 = +46%; 40-64 = +57%
Women 15-39 = +62%; 40-64 = +92%
Heart Health Costs of
Poverty
• Low income groups have higher risk of
smoking, obesity, physical inactivity,
cardiovascular risk = costly
• NS could avoid 200 deaths, $124
million/year if all Nova Scotians were
as heart healthy as higher income
groups
…delayed child development
• 31 indicators - as family income falls,
children have more health problems,
(NLSCY, NPHS, Statistics Canada)
• Child poverty -> higher rates
respiratory illness, obesity, high
blood lead, iron deficiency, FAS,
LBW, SIDS, delayed vocabulary
development, injury+….
Highest Risk Groups
• Single mothers & their children
• Homeless: longer hospital stay cf low income
• Unemployed, Aboriginals, migrants,
minorities, disabled
= Clustered disadvantages (poverty, illiteracy,
unemployment, ill-health): “Social
exclusion”
……health of single mothers
• Worse health status than married
(NPHS); higher rates chronic illness,
disability days, activity restrictions
• 3x health care practitioner use for
mental, emotional reasons = costly
• Longer-term single mothers have
particularly bad health (Statcan)
Prevalence of low incomewomen and men -1997 & 2000
Income: Female lone-parent
families - 1997 & 2000
Trend:Low income rates of children:
Single mother families ---1994-2000
Employment of Female Lone
Parents 1976-2001
Low Incomes :
1991-2000
Single mothers w/out paying jobs
The Economics of
Single-Parenting
• Single mothers with pre-school children
spend 12% income on child care cf 4% in
2-parent families. In one pocket .........
• CPI for child care, restaurant good rises
faster than wages
• Robin Douthitt: “time poverty”. Fulltime single mothers = 75 hour week
Health Cost of Inequality
• British Medical Journal: “What matters
in determining mortality and health
is less the overall wealth of the
society and more how evenly wealth
is distributed. The more equally
wealth is distributed, the better the
health of that society.”
• e.g. Sweden, Japan vs USA
Costs of Inequality in NS
• Excess physician use (Kephart)
(Small fraction of total costs):
– No high school
Lower income
= +49% than degree
= +43% than higher
– Educational inequality = $42.2 million
Income inequality
= $27.5 million
= costs avoided if all Nova Scotians
were as healthy as higher income / BA
If Equality->Health, What are Trends?
Average Disposable H’hold Income Ratios, 1980-98
Canada
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Richest 20% : Poorest 20%
1980
1990
1998
8.2
7.1
8.5
7.6
5.8
7.3
7.4
6.2
6.7
7.1
6.2
8.5
6.7
6.1
7.0
7.6
6.9
7.9
7.8
7.1
8.3
8.8
6.7
7.6
8.1
7.3
7.4
9.1
7.4
10.4
9.3
7.6
8.0
Regional inequality = CB
requires special attention
• High unemployment and low-income
rates,
• Much higher incidence of chronic illness,
disability, and premature death than
Halifax
• Highest age-standardized mortality rate in
Maritimes
• Highest death rate from circulatory
disease, heart disease in Maritimes – 30%
above nat.av.
Of 21 Atlantic health districts,
Cape Breton has highest rates
of:
• Cancer death (231.8 per 100,000) – 25%
higher than the national average, lung
cancer
• Deaths due to bronchitis, emphysema, and
asthma (9.2 per 100,000) –50%+ higher
than the national average
• High blood pressure– 21.7%, (24.3%
women 19% men = 72% higher than the
Canadian rate. The next highest rates are
in south-southwest Nova Scotia
Cape Breton = highest:
• Arthritis and rheumatism: 31% of women,
23% of men
• Activity limitation (34%), followed by
Colchester, Cumberland, and East Hants
counties (30.1%)
Life expectancy: 72.8 years for men, and 79.4
for women. (Canada: 75.4 years - men and
81.2 years -women
Disability-free life
expectancy
• Cape Bretoners have an average
disability-free life expectancy of only
61.8 years, seven fewer than the
national average, and the lowest of all
the 139 health regions in Canada.
• This means that Cape Bretoners can
expect to live considerably more years
with a disability than other Canadians.
Potential years of life lost
• highest number of potential years of life lost
due to both cancer and circulatory diseases.
• Cape Bretoners lose 2,261.9 potential years of
life per 100,000 population due to cancer –
41% higher than the national average of
1,603.7,
• and they lose 1,684 potential years of life per
100,000 population due to circulatory diseases
– 65% higher than the national average of
1,020.7.
Social Supports
• Health Canada: “...as important as
established risk factors” in contributing
to health and medical outcomes, and
reducing premature death, depression,
mental illness, stress, chronic disability,
aiding recovery from illness
• Family, friends, communities, volunteers
Aging - Delay vs Cure
Saves $
• NS 65+: 2001 = 14%;
2036 = 28%
2011 = 16%;
• 5-year delay in onset cardiovascular
disease could save NS $200 million / yr
• Physically active - lower lifetime illness
• Nutritional intervention - reduce
hospital use 25-45% among elderly
“Compression of
Morbidity”
• Fries: “The amount of disability can
decrease as morbidity is compressed
into the shorter span between the
increasing age at onset of disability
and the fixed occurrence of death.”
(= about 85: analysis of 1900s data)
• “Successful aging” can preserve
independence into old age
Disease Prevention is
Cost-Effective Investment
• E.g. Workplace = 2:1
WIC = 3:1
• “Smoke-Free for Life”
= 15:1
• Pre-natal counselling
= 10:1
• Next Steps....A Chronic Disease
Prevention Strategy for Nova Scotia - the responsibility of all sectors
Can it be
done?...1900s/1980s...