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EUROCHIP
Health Indicators for
Monitoring Cancer in Europe
Health Monitoring Program (HMP)
EUROPEAN COMMISSION
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
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EUROCHIP
GROUP OF SPECIALISTS on
MACRO
SOCIAL-ECONOMIC
VARIABLES
Paris, 5th-6th December 2002
Chairperson: Dr Juliette Bloch
EUROCHIP PROJECT:
PRESENTATION
Dr. Andrea Micheli
EUROCHIP INTRODUCTION
AIM: To produce a list of health indicators which describe
cancer in Europe, to help the development of the future
European Health Information System
STEP 1 (Jan 2002 – Jul 2002) : To discuss a preliminary list at national
level, in all members of the European Union. The result was a
list of more than 100 indicators subdivided by priority level
STEP 2 (Sep 2002 – Dec 2002) : To discuss the indicators (of the list
produced at STEP 1) by different domain (prevention, epidemiology and
cancer registration, screening, treatment and clinical aspects, and macro
social-economic variables). To discuss methodological problems for
the indicators at high priority.
STEP 3 (Jan 2003 – May 2003) : Definition of the final list of indicators
subdivided by domain and by priority level.
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EUROCHIP
Comprehensive range of health indicators for cancer:
EUROCARE/EUROPREVAL
CAMON
OCCURENCE
SURVIVAL
RISK FACTORS
LIST
OF
CANCER CARE/
PREVALENCE
CANCER
RECURRENCE
AND MORTALITY
CANCER
INDICATORS
PRE-CLINICAL
ACTIVITY/
SCREENING
DIAGNOSTIC AND
THERAPEUTIC
PROCEDURES
CLINICAL
FOLLOW-UP
Standardised methods for collecting, checking and validating the data
will be proposed for each indicator
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FRAMEWORK OF THE PROJECT
Steering Committee
GS: Groups of specialists
Discussion of indicators at
national and domain level
Working Team
Operational work
Panel of Experts
GS
Discussion &
organization at
national level
GS
GS
GS
GS
Methodological Group
GS
Methodological aspects
of the indicators
GS
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FIRST AND FUTURE STEPS
130
CANCER SPECIALISTS ARE INVOLVED IN EUROCHIP
17
INTERNATIONAL MEETINGS HELD
ALL COUNTRIES OF THE EUROPEAN UNION ARE
PARTICIPATING IN THE PROJECT
Next steps:
 Groups of Specialists in each of five domains (prevention,
screening, data registration and epidemiology, macro-health
variables, and clinical aspects and treatment) discuss the indicators
at the European level.
 Final meeting at which the final selection of indicators will be
drawn up
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RESULTS
For each indicator we compile a FORM subdivided in three sections:
 DESIRED INDICATOR: all indicator characteristics we wish to have
 METHODOLOGY: operational definition, possible sources and
methodological issues
 AVAILABILITY in different countries
LIST OF INDICATORS
PRELIMINARY LIST OF 158 INDICATORS
EUROCHIP MEETINGS
39 INDICATORS AT HIGH PRIORITY
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EUROCHIP FINAL RESULTS
(AT THE END OF STEP 3)
For each indicator at high priority EUROCHIP will produce:
1. A DESCRIPTIVE
•
•
•
FORM
including:
Desired indicators characteristics (definition, use, caveat …)
Operational definition and indications on sources
Indications on availability in all EU member countries
2. A METHODOLOGICAL FORM
•
•
•
including:
Methodological aspects (standardisation, validity, variability)
Bibliography on the indicator
Suggestions to the European Commission
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INTRODUCTION
TO THE
MEETING
Dr. Julietta Bloch
AIMS OF THE MEETING
• Discussion on the complete list of the indicators
• An updated list of indicators for “macro social-economic
variables” domain
• A consensual classification of these indicators by priority
• Information on sources for indicators at high priority
• Discussion on validity and standardization of indicator at
high priority
• Study of the realization of the indicator “Total
Expenditure on health for cancer”
CONSIDERATIONS
Participants have to consider that:
• indicators at high priority should be in a limited
number;
• indicators should be able to suggest actions to
reduce inequalities and to promote health;
• indicators should refer to the “macro socialeconomic” domain
• indicators have been developed considering 3 axes:
1) the natural disease’s history (prevention, screening,
diagnosis, treatment, surveillance, end results)
2) indicator groups as suggested by the ECHI
HMP project (demographic and social-economic factors,
health status, determinant of health, health system)
3) cancer sites
THOROUGHNESS
OF THE
INDICATOR LIST
Dr. Andrea Micheli
LIST OF EUROCHIP HIGH PRIORITY INDICATORS
PREVENTION
EPIDEMIOLOGY AND CANCER REG.
Tobacco consumption
Exposure to asbestos
Coverage of cancer registration
Stage at diagnosis
Person-years life lost due to cancer
Completeness of the registration
SCREENING
Breast cancer screening coverage
Cervical cancer screening coverage
Colo-rectal cancer screening coverage
Organised screening process indicators
MACRO SOCIALECONOMIC VARIABLES
Total National Expenditure
on Health for cancer
Total Public Expenditure
on Health for cancer
TREATMENT AND CLINICAL ASP.
Interval between diagnosis
and first treatment
Patients treated by surgery /
chemotherapy / radiotherapy
Radiation equipment
% of centres with at least
2 radiation equipments
CAT equipment
Compliance with guidelines
Palliative care teams
INDICATORS AT HIGH PRIORITY (1)
PREVENTION
1) Tobacco consumption
2) Consumption of fruit and vegetable *
3) Consumption of alcohol *
4) Body Mass Index *
5) Exposure to asbestos
6) AIDS incidence *
7) Prevalence of hepatitis B/C *
EPIDEMIOLOGY AND CANCER REGISTRATION
8) Coverage of cancer registration
9) Incidence rates *
10) Survival rates *
11) Prevalence proportion *
12) Mortality rates *
13) Stage at diagnosis
* Connected with other HMP projects
14) Person-years life lost due to cancer
15) Completeness of the registration (DCO and Incidence / mortality)
16) % of microscopically cases *
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INDICATORS AT HIGH PRIORITY (2)
SCREENING
17) Breast cancer screening coverage
18) Cervical cancer screening coverage
19) Colorectal cancer screening coverage
20) Organized screening process indicators
TREATMENT AND CLINICAL ASPECTS
21)
22)
23)
24)
25)
26)
27)
Interval between diagnosis and first treatment
Radiation equipment
% of centres with at least 2 radiation equipments
CAT Equipments
Compliance with guidelines
Patients treated by surgery / chemotherapy / radiotherapy
Palliative care teams
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INDICATORS AT HIGH PRIORITY (3)
MACRO SOCIAL-ECONOMIC VARIABLES
28)
29)
30)
31)
32)
33)
34)
35)
36)
37)
37)
38)
Education level attained *
Average Income *
Gini level *
Gross Domestic Product *
Total Social Expenditure *
Total National Expenditure on Health *
Total National Expenditure on Health for cancer
Total Public Expenditure on Health *
Total Public Expenditure on Health for cancer
Expenditure on primary cancer prevention
% elderly in 2010-2020-2030 *
Age distribution of population *
* Connected with other HMP projects
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PRIORITY
LEVELS
Dr. Juliette Bloch
PRIORITY LEVELS
A
Direct indicator – Important – With or without any problem
B
Indirect indicator – Important – With or without any problem
C
Potentially useful but with presenting a great deal of problems
D
Very low priority – Irrelevant
DO YOU WANT SOMETHING ELSE
AT HIGH PRIORITY?
MACRO SOCIAL-ECONOMIC VARIABLES
Education level attained *
Deprivation index *
Income *
Gross Domestic Product *
Total Social Expenditure *
Total National Expenditure on Health *
Total National Expenditure on Health for cancer
Total Public Expenditure on Health *
Total Public Expenditure on Health for cancer
% elderly in 2010-2020-2030 *
Age distribution of population *
INDICATORS AT
HIGH PRIORITY
SOURCES:
OECD Health Data 2000, Health for All
INDICATORS AT HIGH PRIORITY
For each indicator we have to discuss on
• Availability
• Validity
• Standardization
INDICATOR 1: Education level attained
FROM: OECD Health Data 2000
Educational attainment is expressed as the percentage
of the adult population (25 to 64 years old) that has
completed a certain highest level of education defined
according to the ISCED system. Data on years before
1998 refer to the old ISCED classification.
ISCED-97
(in parenthesis the eventual differences with old ISCED)
- ISCED 0 = Education preceding the first level (pre-primary)
- ISCED 1 = Education at the first level (primary)
- ISCED 2 = Education at the lower secondary level
- ISCED 3 = Education at the upper secondary level
- ISCED 4 = post secondary, non-tertiary level. (before 1998
included in ISCED 3 or 5)
- ISCED 5b = Programmes at the tertiary level that focus on
practical, technical or occupational skills for direct entry into
the labour market. (ISCED-76: level 5)
- ISCED 5a = Programmes at the tertiary level equivalent to
university programmes. (ISCED-76: level 6)
- ISCED 6 = Advanced research programmes at the tertiary
level, equivalent to PhD programmes. (ISCED-76: level 7)
INDICATOR 2: Income by decile
FROM: OECD Health Data 2000
This indicator of inequality is based on a division of
households in ten groups (or deciles), where the 1st decile
represents households with the lowest total disposable
incomes. The data provides the percentage of total income
obtained by each decile.
Note: a household is defined as a collection of individuals,
who are sharing the same housing unit. Each household is
weighted by the number of individuals who belong to this
household. The total household income is defined as the
total disposable income (including all incomes, taxes, and
benefits). Individuals are ranked according to their
household total disposable income per equivalent household
INDICATOR 3: Gini levels
FROM: OECD Health Data 2000
'Gini levels' is a commonly-used summary indicator of
income inequality in a population. It can either be
presented as a 'coefficient' ranging from 0 to 1 or (if
multiplied by 100, as done in this database) as a 'level'
ranging from 0 to 100.
Note: a Gini level which is increasing towards 100
means that the distribution of income is becoming more
unequal, while a gini coefficient that is declining
towards 0 means a more equal income distribution.
INDICATOR 4: Gross domestic product
FROM: OECD Health Data 2000
Gross Domestic Product (GDP) is defined as total
domestic expenditure plus exports and less imports
of goods and services.
A statistical discrepancy factor is included too.
INDICATOR 4: Gross domestic product
FROM: Health for All
INDICATOR 5: Total social expenditure
FROM: OECD Health Data 2000
Social expenditure is the provision by public (and private)
institutions of benefits to, and financial contributions
targeted at, households and individuals in order to provide
support during circumstances which adversely affect their
welfare, provided that the provision of the benefits and
financial contributions constitutes neither a direct payment
for a particular good or service nor an individual contract or
transfer. Such benefits can be cash transfers, or can be the
direct ('in-kind') provision of goods and services.
Note: The collection of social expenditure and of health
accounts are at present only partially harmonised.
INDICATOR 6: Total expenditure on health
FROM: OECD Health Data 2000
Total (or national) expenditure on health is based on the
following identity and functional boundaries of medical
care :
TPHE = Total personal expenditure on health =
Personal health care services +
Medical goods dispensed to out-patients
TCHE = Total current expenditure on health =
TPHE +
Services of prevention and public health +
Health administration and health insurance
TEH = Total expenditure on health =
TCHE + Investment into medical facilities
Source: ICHA-proposal (OECD International Classification for Health Accounts)
Total expenditure on health: Sources & Methods
FROM: OECD Health Data 2000
Sources and methodological remarks listed below for total
expenditure on health in general apply to sub aggregates (e.g.
public expenditure, total/public investment on medical
facilities) as well.
Data for recent years are partially Secretariat estimates (see
sources by country). The OECD Secretariat retains the
overall responsibility for these estimates. Although, there
are various sources in many countries for estimating public
expenditure on health, it is usually more difficult to assess
growth rates of private expenditure on health. This can be
critical in years of major changes in the public/private mix of
health care financing, e.g due to significant increases of copayments.
INDICATOR 6: Total expenditure on health
FROM: Health for All
INDICATOR 7: Public expenditure on health
FROM: OECD Health Data 2000
Publicly funded health care by both publicly and
privately owned providers. Public funds are state,
regional and local Government bodies and social
security schemes. Public capital formation on health
includes publicly-financed investment in health
facilities plus capital transfers to the private sector for
hospital construction and equipment and subsidies
from government to health care service providers. It
includes funds for state employees.
INDICATOR 7: Public expenditure on health
FROM: Health for All
INDICATORS 4-5-6-7
Also other Databases are used OECD Definition
DISCUSSION ON
• Validity
• Standardization
CONCLUSION
• Use OECD Indicators
TOTAL EXPENDITURE
ON HEALTH FOR CANCER
PROPOSAL OF ESTIMATION
INTRODUCTION
• Example based on the Italian situation
• First attempt to face the estimation of the indicator
• Information derived from Internet
ITALY: WHAT IS “SDO”?
• SDO: Hospital discharge record
• One SDO for each admission or day hospital into
public or private care hospitals
• SDO includes:
• Demographic data of the patient
• Information on the care institution
• Motivation of the admission
• Principal diagnosis
• Other eventual 5 Secondary diagnosis
• Principal surgery
• Other 5 eventual surgeries or diagnostic procedures
• No information on drugs and medicines
ITALY: WHO FILL “SDO”?
• The compilation of the principal diagnosis is a
task for the specialist
• The list of all diagnostic and therapeutic
procedures is a task for both the doctors and the
nurses
• Every 3 months the Institutes have to send all
SDOs to their Region (or Province)
• Every 6 months the Regions (or Provinces)
sent the SDOs to the Italian Health Ministry
ITALY: “SDO” and CANCER
• The principal diagnosis is the principal condition
treated or studied during the admission or the
condition that needed the most quantity of resources
• For the diagnosis ICD 9 and ICD 9 CM are used
• If the admission is intended to treat a cancer, this
tumor is to be defined as principal diagnosis unless
the admission is intended essentially to radiotherapy
or chemotherapy.
• If radiotherapy/chemotherapy follows a surgical
operation or are used to define the cancer stage the
principal diagnosis is the cancer.
ALTERNATIVE 1
• We should use the SDO registration
• We should define a “database of expenses” for each
cancer diagnosis, surgery operations and other
procedures
• This way we could link the SDO database (limited
to cancer patients) with this expenses database to
have the total expenditure for cancer hospitalisation
• This procedure is applicable only for those
countries with a similar SDO system
• We should define a method to define cancer drug
and prevention expenditures
DRG: Diagnosis Related Groups
• The DRG is a classification system of the
patients dismissed by the hospital
• Each patient is allocated to a specific DRG by a
program called DRG-Grouper
• Using the “principal diagnosis” each patient is
assigned to one of 25 MDCs (Major Diagnostic
Category) that classify the diseases principally by
organ. After this, there are other classifications
inside each MDC.
• In total we have 489 different DRGs
• Each ICD 9 CM diagnosis is contained in a DRG
DRG characteristics
• The DRG are exhaustive and mutually exclusive
• Each admission has only one DRG
• The DRGs are homogeneous groups composed
by non-identical patients
• Each DRG has one specific tariff that represents
the average cost of the admission
• These tariffs are decided by Health Ministry
considering personal costs, material use, machine
depreciation and general costs.
• Regions could change these tariffs following
particular needs
ESTIMATION OF THE INDICATOR
USING DRG
• During the linkage between SDO and DRG the
information on diseases is lost but the DRG Grouper,
probably, attaches the patient code in its record
• This way we can link the two databases to estimate
the expenditure for cancer relatively to hospital
expenses
PROBLEMS
• The DRG tariffs are average expenses and we
should control if they are real
• This way we do not consider the expenses in
cancer prevention and drugs
• Not all countries use DRG System
• How many countries have a registration system
similar to Italian SDO?
ALTERNATIVE 2: PATIENT COURSE
• There are some quality control programmes (ABC and
ABM: Activity Based Costing and Management) that
study the course of a patient from the admission to the
discharge
• We could study a sample of cancer patients, in each
country, considering all phases of the patient admission
and their corresponding expenses
• The survey will give the average expenditures for
standard patient courses to multiply with the number of
cancer patients with these courses (information derived
from SDO)
EUROPEAN COMMISSION
PUBLIC HEALTH
PROGRAMS
Dr. Andrea Micheli
PUBLIC HEALTH
IN EUROPE
• the European past and next strategy
FOCUS ON CANCER
• past/present in HMP: EUROCHIP and CAMON
• next: Working Party
Priority areas of
the public health programme
General health policy
Health
information
Health determinants
Health threats
By Dr. Tapani Piha
Bringing programmes together
-2002
Health monitoring
Injury
Health
Cancer
Pollution
Aids
information
Rare diseases
2003By Dr. Tapani Piha
Bringing programmes together
-2002
Health monitoring
Injury
Health
Cancer
Pollution
Aids
information
Rare diseases
2003By Dr. Tapani Piha
Public health programme
Implementation focus
• European added value
• Large scale (in content and geographical
coverage) multi-annual and multidisciplinary
• Leads to sustainable results and outputs
• Relevant and contributes to policy development
• Attention to the evaluation of the process and
results
By Dr. Tapani Piha
Stages in data processing
Stage 3
Data collection,
processing and storage
at EU level
Stage 4
Analysis, advice,
reporting, informing
and consulting
Stage 5
Mechanisms for
exchanging, promoting
and disseminating
results
Stage 2
Support to
data collection
at national level
Stage 1
Data definition
and
quality development
By Dr. Tapani Piha
DECISIONS
OF THE
MEETING
TOTAL EXPENDITURE FOR CANCER
It is very difficult to study all the
expenditures on cancer together.
We decide to study proxy indicators for
• prevention,
• screening,
• care
• registration
• research
EXPENDITURE FOR CANCER
PREVENTION
Public Expenditure against tobacco:
this indicator is a good proxy for the public
actions for cancer prevention
EXPENDITURE FOR CANCER
SCREENING
Public Expenditure for organized
screening programmes:
It is quite easy to collect. This could be an
extra information over the other screening
indicators
EXPENDITURE FOR CANCER CARE
Good proxies for the cancer care expenditure
could be:
• the pharmaceutical expenditure on
chemotherapy specific to cancer drugs, on
some adjuvant therapies specific to cancer (to
list) and pain relief drugs
• the number of fractions delivered for
radiotherapy (if it is possible by machine type)
• number of blood marrow transplants
EXPENDITURE FOR CANCER
REGISTRATION
expenditure on population-based cancer
registration
EXPENDITURE FOR CANCER
RESEARCH
Good proxies for the cancer research could
be:
• Public expenditure on cancer clinical trials
not supported by pharmaceutical companies
• Fundamental research
• Contributions to International
Organizations
EXPENDITURE OF PRIVATE/NON
PROFIT INSTITUTIONS
Expenditure subdivided by
• prevention (including screening),
• research and treatment (for example
surgical facilities),
• registration