Wold Indicators July08

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Health Indicators A Review o Reports

Currently in Use

Conducted or Te State o the USABy

Cheryl Wold, MPH

Wold and Associates

July 2008



Acknowledgements: Te author would like to thank Nicole Lurie, MD, MSPH, or her guidance with this project. Additional

thanks go to Charlotte Kahn (Te Boston Foundation); Neal Halon, MD, MPH (UCLA); Marilyn Metzler, RN (U.S.

Centers or Disease Control and Prevention); Alonzo Plough, PhD, MPH (Te Caliornia Endowment), Paul Simon, MD,

MPH (Los Angeles County Public Health); Sandra Ciske, MN (Seattle/King County Health Department); Larry Cohen,

PhD (Te Prevention Institute); and John E. Wennberg, MD, MPH (Dartmouth Medical School) or their advice. Tanks also

to David Moriarty (U.S. Centers or Disease Control and Prevention) or resources on composite measures o health, and to

Mercedes Perez, MPH, and Roberto San Luis or their assistance with the preparation o this report.



Te State of the USA • Health Indicators—A Review o Reports Currently in Use 1

Contents

1.0 Background ............................................................................................................................................................ 4

2.0 Methods ................................................................................................................................................................. 5

3.0 Overview o Reports .............................................................................................................................................. 8

3.1 Approaches ................................................................................................................................................. 8

able 1: Reports Included in Review: Focus and Key Features ............................................................... 13

3.2 Health Indicators and Data Sources ......................................................................................................... 22

able 2: Selected Indicators Common to General Health Sets ............................................................... 25

able 3: Selected Indicators Common to General Health Sets ............................................................... 26

able 4: National Data Sources ................................................................................................................ 27

able 5: Selected Indicators or Health System Perormance: Access to Care ........................................ 32

able 6: Selected Indicators or Health System Perormance: Cost/Eciency o Care .......................... 33

able 7: Selected Indicators or Health System Perormance: Quality—Eective Care, Patient Saety . 34

able 8: Health System Perormance Data Sources ................................................................................ 35

3.3 Presentating and Framing o Health Indicators ....................................................................................... 37

3.4 Gaps in Indicators .................................................................................................................................... 41

able 9: Example Indicator Set—Merging Lie Course and Determinants Approaches ........................ 42

4.0 Summary o Each Indicator Report

4.1 General Health—National Reports ......................................................................................................... 43

4.1.1 America’s Health Rankings: A Call to Action or People and their Communities(United Health Foundation, American Public Health Association,Partnership or Prevention) ........................................................................................................ 43

4.1.2 Community Health Status Indicators—CHSI(U.S. Centers or Disease Control and Prevention)..................................................................... 45

4.1.3 Healthy People 2010—Leading Health Indicators (National Center or Health Statistics) ..... 474.1.4 Robert Wood Johnson Foundation—Commission to Build a Healthier America .................... 48

4.1.5 America’s Children (Interagency Forum and Child and Family Statistics) ............................... 50

4.1.6 Kids Count (Annie E. Casey Foundation) ................................................................................. 52

4.1.7 Older Americans 2008: Key Indicators o Well-Being(Interagency Forum on Aging-Related Statistics) ..................................................................... 54

(Contents continued on page 2)


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4.2 General Health—State and Local Health Reports .................................................................................. 56

4.2.1 Communities Count—Seattle/King County, Washington(Public Health—Seattle and King County) ............................................................................... 56

4.2.2 Georgia Health Disparities Report (State o Georgia Public Health) ....................................... 58

4.2.3 Key Health Indicators (Los Angeles County Public Health) .................................................... 60

4.2.4 New York City Community Health Proles(New York City Department o Health and Mental Hygiene) .................................................. 62

4.2.5 New York City Health Disparities Report(New York City Department o Health and Mental Hygiene) .................................................. 64

4.2.6 Health o Wisconsin Report Card 2007(University o Wisconsin Population Health Institute) ............................................................. 65

4.2.7 Te Boston Paradox: Lots o Health Care; Not Enough Health.Indicators o Health, Health Care and Competitiveness in Greater Boston

(New England Healthcare Institute or Te Boston Foundation) ............................................. 66

4.3 Quality o Lie—Comprehensive Indicator Systems ............................................................................... 68

4.3.1 Quality o Lie Factbook 2008(Te Organization or Economic Cooperation and Development) ........................................... 68

4.3.2 Boston Indicators Project (Te Boston Foundation) .................................................................. 68

4.3.3 Jacksonville Quality o Lie Report ( Jacksonville County Community Indicators) ................... 70

4.3.4 Australia’s Measures o Progress (Australian Bureau o Statistics) ............................................. 71

4.3.5 Canadian Index o Well-Being (Atkinson Foundation) ............................................................. 71

4.4 Health System Perormance .................................................................................................................... 72

4.4.1 State Scorecard on Health System Perormance (Te Commonwealth Fund) .......................... 72

4.4.2 Dartmouth Atlas o Health Care (Dartmouth Institute or Health Policy and Clinical Practice, Dartmouth Medical School) .................................................................... 74

4.4.3 National Healthcare Quality Report (Te Agency or Healthcare Quality and Research) ......... 76

4.4.4 National Healthcare Disparities Report (Te Agency or Healthcare Quality and Research).....77

4.4.5 Organization or Economic Cooperation and Development—Health Care Quality Index ...... 78

4.4.6 Five Million Lives (Te Institute or Healthcare Improvement) ............................................... 80

4.4.7 Patient Saety in American Hospitals Study (HealthGrades) .................................................... 81

4.4.8 Hospital Compare (Centers or Medicare and Medicaid Services) ........................................... 824.4.9 rends and Indicators in a Changing Health Care Marketplace Chartbook

(Kaiser Family Foundation) ....................................................................................................... 84

4.4.10 World Health Organization’s World Health Statistics (WHO Inormation Systems) ............. 85

4.4.11 Health Care Costs 101 (Caliornia Healthcare Foundation) ..................................................... 86

Contents




4.5 Other—Framing Approaches/Gaps/Frameworks ....................................................................................87

4.5.1 op 10 Priorities or Prevention (rust or America’s Health) .................................................. 87

4.5.2 Good Health Counts: A 21st Century Approach to Health and Community in Caliornia—Prototype Indicator Set (Te Prevention Institute) .................................................................... 90

4.5.3 Environmental Public Health Indicators (U.S. Centers or Disease Controland Prevention, National Center or Environmental Health, Environmental Hazardsand Health Eects Program) ..................................................................................................... 91

4.5.4 Early Childhood Indicators—Project Trive Prototype(National Center or Childhood Poverty) .................................................................................. 89

4.5.5 Big Cities Health Inventory—Te Health o Urban USA(National Association o City and County Health Ocers) ..................................................... 93

5.0 Figures ...................................................................................................................................................................94

Figure 1: Determinants o Health ..................................................................................................................... 94Figure 2: Social Determinants—Community Guide .........................................................................................94

Figure 3: Lie Course Health Development (IOM) ......................................................................................... 95

Figure 4: Early Experiences and Health (RWJ) ................................................................................................ 95

Figure 5: Six Key Dimensions o Health Care (IOM Committee on the Quality o Health Care) ................. 96

Figure 6: Health System Perormance—Health Care Quality Index (OECD) ................................................ 97

Figure 7: OECD Factbook: Quality o Lie ...................................................................................................... 98

Figure 8: Measures o Australia’s Progress ......................................................................................................... 99

Figure 9: Canadian Index o Well-Being .......................................................................................................... 99

Figure 10: Hospital Care Intensity Index (Te Dartmouth Atlas) .................................................................... 100Figure 11: Example o Standard Selection Criteria ........................................................................................... 101

Figure 12: Framing Example: rust or America’s Health ................................................................................ 101

Figure 13: Framing Example: Prevention Institute Prototype ...........................................................................101

Figure 14: Ranking Example: Big Cities Inventory .......................................................................................... 103

Figure 15: Grades Example: Wisconsin ............................................................................................................ 104

Figure 16: Grades Example: Georgia ................................................................................................................ 105

Figure 17: Use o GIS and Maps: U.S. Lie Expectancy by County ................................................................. 106

Figure 18: Health rajectories ........................................................................................................................... 106

6.0 Reerences .......................................................................................................................................................... 107

Appendix A: Links to echnical Data About Data Sources ....................................................................................... 109

Appendix B: Selected Indicators and Data Sources .................................................................................................... 110

Contents



1.0 Background

he State o the USA (SUSA) is a comprehensive key indicator system planned or launch early in 2009. It will

eature indicators rom all sectors o American lie, and provide a rich inormation environment that seeks to be

the “rst and nal word or inormation on progress.” Several o SUSA’s stated aims have implications or the selection

o indicators. SUSA requires indicators that are relevant, and those that resonate with users in order to build their

brand and interest. Te site must eature indicators that are supported by the highest quality data sources and statistics

to support SUSA’s aim to be the rst place many Americans go to both rame and answer serious questions.

A review o health indicator reports was prepared or SUSA to support the process o indicator selection, specically,

to provide background inormation to a committee o the Institute o Medicine charged with the task o selecting 20

health indicators or the launch o the SUSA web site. Although challenging, this committee’s work will benet rom

decades o collective experience in the development and use o health indicators in the U.S. and abroad. Indicators

are powerul tools or monitoring and communicating critical inormation about health. Tey have been used in thehealth arena in varied ways, in support o planning, community engagement, and health policy development. Tey have

been used successully to promote accountability among governmental and nongovernmental agencies and to engage

partners in civic eorts. Tis review will provide a broad range o working examples o such indicators as obtained rom

reports and systems primarily in the U.S. and also internationally.




2.0 Methods

Sample Selection

R eports at the national level, compiled by ederal agencies and private oundations, were supplemented with state,

local, and international reports in order to analyze and present a variety o examples o health indicator content,

topics, and conceptual and communication approaches. Reports were selected or review on the basis o the ollowing

eatures: Tey had to be created rom high-quality and currently available data, relevant to important health problems,

and created through the use o participatory processes and involving reputable individuals and organizations. An eort

was made in the selection process to represent dierent geographic regions and to avoid redundancy in approach

or content. All reports in the sample were designed or broad dissemination. A small group o project advisors—

individuals knowledgeable about health indicators and reports, data sources, and the use o health indicators—provided

input to address potential gaps in the report selection (see Acknowledgements).

Te review drew upon conceptual models in widespread use to allow the broadest sample o indicators to be captured

in a practical manner. Conceptual models o health are based upon the weight o peer-reviewed science about the major

contributing actors to health. Tose reerenced in this review were developed and/or promulgated in conjunction with

the Institute o Medicine, Healthy People and the Federal Interagency Forum, and other reputable processes. Te

primary models o interest to the review included the broad determinants o health (Section 5.0, Figure 1), those with

a special ocus on social determinants (Figure 2), lie course (Figure 3, Figure 4), and key dimensions o the health care

system (Figure 5 and Figure 6). Tese conceptual approaches were supplemented with other approaches, including

those used to monitor health equity, quality o lie (comprehensive key indicator systems) and aspects o health system

perormance to more ully represent the landscape o health indicator sets.

Many health indicator sets are developed using a broad health determinants approach, shown in Figure 1 (Evans and

Stoddart, 1990). Tis approach is based upon the understanding that patterns o health and disease are infuenced by

conditions in the social and physical environment as well as by personal behaviors, biology, and availability and use

o medical care. Tis model is also consistent with changing denitions o health over the past hal century, which

have shited toward concepts o well-being, quality o lie, and ability to unction ully and to adapt to changing

circumstances. Broad health determinants have been used to inorm public health interventions to improve individual

and population health (IOM, 2007). Te social determinants o health approach is related, and ocused on those

societal conditions (institutions, surroundings, and social relationships) that aect health, as shown conceptually in

Figure 2 (Anderson, et al, 2003).

Te Lie Course conceptual model emphasizes health optimization throughout the lie course, and is primarily ocused

on health and development early in lie. During the prenatal period through age ve, biology, social relationships and

environments interact “continuously and dynamically” to infuence health and well-being (Shonko 2000). Prenatal and

early lie exposures to toxins, economic and social stress, and interactions with one’s environment prooundly infuence

health during childhood. A large body o research has shown that brain, cognitive, and behavioral health during early

childhood are strongly linked to an array o important health outcomes later in lie, including many chronic diseases,



obesity, smoking, drug use, and depression—conditions that account or a major portion o preventable morbidity and

premature mortality in the United States (Braveman, 2008).

Te conceptual model or Lie Course Health Development (IOM, 2004a) eatures indicators related to amily,

institutional, and community social environments, characteristics o the care systems with which children and amilies

interact, as well as physical environmental exposures. Te time periods o exposure to these risk and protective actors

are considered critical in this approach, as there are specic biologic and developmental stages where interactions with

these actors have greater or lesser impact (Halon 2002). Lie course and social determinants indicators are oten

merged, because o the magnied infuence o these social actors on health development early in lie (Section 5.0,

Figure 4).

Te Committee on the Quality o Health Care in America (IOM, 2001) proposed six aims or a 21st century health care system that orm the conceptual approach or indicators related to health system perormance. Tese six

dimensions state that health care should be sae, eective, patient-centered, timely, ecient, and equitable (Section

5.0, Figure 5). Te conceptual model developed by the Health Care Quality Indicators Project o the Organization or

Economic Cooperation and Development (OECD) is consistent with these aims, however provides a more complete

conceptual model (Arah, 2006) or health that includes non-medical health determinants, access, cost, and equity

(Section 5.0, Figure 6).

Tese conceptual approaches were supplemented with three types o indicator sets to address gaps or enable a

broader sample. First were indicators that track health care costs and spending, a critical component o health system

perormance. Growth health care costs and spending (due to infation, intensity o resource use, public entitlements)has resulted in health care spending that will consume an estimated 20% o the entire U.S. GDP by 2015. Te U.S.

Comptroller has called or several dramatic measures to reign in costs and spending, not the least o which includes

calls or key national indicators to better track and monitor spending and perormance in the health sector (Walker,

2008).

Te other indicator sets included were those ocused on health equity, a conceptual lens that is applied to both medical

and non-medical determinants o health to examine disparities in these determinants and outcomes. Last, quality

o lie, is a general approach used requently by comprehensive indicator systems to provide a complete picture o

lie in communities and nations, including health. Such systems have played a role in the conceptual and practical

development o Te State o the USA (GAO 2003 and 2004).

2.0 Methods




Analysis and Organization o Findings

he sample o reports was reviewed or content (indicators, measures, and ocus areas) and context (conceptual

approaches, rameworks, and purposes o the indicators) with key themes rom this analysis summarized in

Section 3.1.

Next, an analysis at the individual indicator level examined the characteristics o the indicators based on representative

sets o health indicators rom sub-samples o the reports. Selected data sources and measures were also examined to

aid in the committee’s consideration o the analytical capabilities o the measures (e.g., ability to be disaggregated by

geography, race-ethnicity, age, income, or other characteristics), availability o data, strengths and limitations o selected

data sources, and ability to make international comparisons (see Section 3.2).

Communication aspects o health indicators were examined based on the reports and other inormative sources.

Presentation and raming approaches, measures used to translate complex statistics into meaningul inormation or

broad audiences, graphical and other eatures were examined, and are described in Section 3.3. Observed gaps in

indicators or data, and possible indicators to ll those gaps are presented in Section 3.4.

Te next section o the report (4.0) is a summary o each report in the sample, including the indicator sets and ocus

areas, and other observations. Figures, reerences and technical data are provided in Sections 5.0 and 6.0, and in the

Appendices.

2.0 Methods



3.1 Approaches

he sample, based on dierent conceptual approaches, resulted in a comprehensive set o associated indicators.

able 1 summarizes each indicator report including its compiling organization, ocus areas, and key eatures. able

1 is organized into our groups o reports.

National General Health Reports

he rst group includes general population health indicator reports produced at a national level. Tese include

Community Health Status Indicators (produced by the U.S. Centers or Disease Control and Prevention and

reviewed in its current drat orm), America’s Health Rankings (produced by United Health Foundation, AmericanPublic Health Association and the Partnership or Prevention), Healthy People 2010 Leading Indicators (produced by

the National Academy in conjunction with the U.S. Department o Health and Human Services), and the Commission

on a Healthier America (report titled What Drives Health? ), a joint public and private eort (sponsored by the Robert

Wood Johnson Foundation).

Although the ocus varies somewhat, these our reports eature indicators consistent with a broad health determinants

approach. Te Community Health Status Indicators include the most comprehensive set o health indicators, and has

been designed to provide data or local areas (counties) throughout the U.S. Tese reports share similar emphases on

major health outcomes infuenced by the major health determinants. Indicators include those or behaviors, such as

smoking, physical activity, and alcohol and drug abuse, chronic health conditions, such as obesity and diabetes, injuries,and other outcomes such as mortality, health related quality o lie, and health unction. All with one exception include

access to health care and appropriate use o clinically eective services, such as cancer screening, prenatal care. Te

degree that social determinants are emphasized in the health indicator reports varies. Te Robert Wood Johnson

Foundation’s Commission or a Healthier America has compiled a set o 13 indicators based upon 6 social actors and

three key health conditions (early childhood, obesity, and diabetes) impacted by these social actors, which include, or

example, income/poverty and educational attainment. In addition, indicators related physical environmental health

determinants are limited (examples o such indicators are provided later in this report). Specic indicators are shown in

detail in Section 3.2.

Te next three reports in this group ocus on the general well-being o specic population groups, namely children

and amilies and older Americans. America’s Childrenand Older Americans are both produced by Federal Interagency

Forums—one on Child and Family Statistics and the other on Aging-Related Statistics. Kid’s Count (produced by the

Annie E. Casey Foundation) ocuses on the well-being o children and youth.

3.0 Overview o Reports




Te child health indicators primarily refect a combination o broad determinants and lie course approaches. For

children, measures o health and development are intertwined with saety, economic security, social and emotional

well-being, and educational and developmental opportunities—all actors that optimize healthy development as well as

infuence short- and long-term health outcomes.

Te Older Americans report constructs a “broad picture o well-being” in the later lie stages—those starting at age 65

years and beyond. Indicators o health are refective o a wider dimension o health outcomes, as compared to general

health reports, refective o the health experience o older persons, including the maniestations o normal aging as well

as reduced health due to chronic conditions, physical and psychological impairments, and increased need or health

care and supportive services. Health problems, ability to unction independently, sensory impairments, and use o

prescription medication and equipment, out-o-pocket medical costs, long term care, and health literacy, are examples.

State and Local Health Reports

General health reports rom state and local health departments complement the rst group o national reports with

other approaches. Seattle-King County’s Communities Count and Los Angeles County’s Key Health Indicators

each provide examples o the use o social indicators in health reports. Specically, Seattle tracks societal resources or

health (e.g., living wage, aordable housing and homelessness, social cohesion), and both include health indicators

o amily and community environments during in early childhood (e.g., child care needs and experience, parenting

practices). Both o these indicator sets benet rom local surveys or their breadth.

Reports rom the State o Georgia and New York City provide examples o indicators ocused on health inequities or

disparities. Variations in health determinants and health outcomes by income or geographic jurisdiction (i.e., counties,

neighborhoods), and race or ethnic background are shown. Te Health o Wisconsin grades health and disparities using

ew indicators per age group. Te report is organized by lie stage and uses grades to communicate how the state is

doing as compared to selected states and among its own demographic sub-groups.

A local health report, Te Boston Paradox: Lots o health care; not enough health, provides some contextual data that is

unique to local health reports, and describes the health care economy and the juxtaposition o quality o lie and better

and more equitably distributed health, relative to costs and spending on health care.

3.1 Approaches



Quality o Lie—Comprehensive Indicator Systems

Several examples o comprehensive indicator systems, rom around the world and within the U.S. are based upon

a quality o lie approach. Tese were important to include as they directly relate to the evolution o the State o

the USA model, which was inormed by many comprehensive indictor systems that were the subject o a national

indicators orum (GAO 2004). Health is usually one o a dozen or so components o overall societal well-being. For

example, the Organization or Economic Cooperation and Development in its Factbook: 2008 Economic, Environmental

and Social Statistics includes eleven categories (as shown in Section 5.0, Figure 7). Health is included under “Quality

o Lie” and includes just three indicators: lie expectancy, inant mortality, and obesity. Another system, Measures o

Australia’s Progress (MAP), outlines several dimensions o progress that are ramed or “individuals” (includes health,

education and training, work), “the economy and economic resources”, “the environment”, and “living together” (see

Section 5.0, Figure 8). Te MAP areas are similar to OECD’s cross-cutting categories (economic, environmental,social). In the Australian example, the indicator or health is lie expectancy. Te Canadian Index o Well-being is

currently developing a similar comprehensive indicator system or the nation which includes eight categories (shown in

Section 5.0, Figure 9), although constructs o each are not available.

Te comprehensive systems vary greatly, but are generally used to promote civic engagement and problem solving on

the part o communities, and responsiveness and accountability on the part o agencies and public leaders. Similar

to the national indicator systems, health is one among several components contributing to the overall quality o lie

in these regions. Several o these systems were the subject o a orum and subsequent GAO review (GAO 2003;

GAO 2004) and contributed to the evolution o the State o the USA. Examples o such systems include the Boston

Indicators Project and the Jacksonville County Community Indicators.

Health System Perormance Reports

his next section o reports includes indicators or the ollowing broad dimensions o health system perormance:

access, cost o health care, and quality.

Tere are two transitional points worth noting here. First, is that access to health care is both a eature o general health

reports as well as a key dimension o health system perormance. Nearly all o the general health reports include

indicators regarding health insurance coverage, and several include measures o related to having a usual source o care

or “medical home”. Many include indicators related to barriers to getting needed care (e.g., cost o care or other barriers

such as waiting times). However, they rarely include measures related to scal and economic, structural, quality, and

saety aspects o the health care system.

3.1 Approaches




Te State Scorecard on Health System Perormance produced by Te Commonwealth Fund uses indicators that are similar

to those just described, and also creates a bridge between general health and health system perormance reports. Tis

report is ocused on equity in access, quality, avoidable use o hospitals and costs o care, and mortality amenable to

health care.

Another report plays a bridging role. Te Older Americans, although included above with general health reports,

links to the health system perormance indicator reports or at least two reasons. Te rst is because the majority

o those receiving health care services in the U.S. are older adults, and the majority o health care use by individuals

occurs during the last two years o lie. Tis report diverges rom some o the standard health reports used in general

to include indicators o long term care, sensory impairments, depressive symptoms, out-o-pocket health care

expenditures, veterans’ health care, personal assistance and equipment, and need or/use o residential services.

Indicator sets that track costs and opportunities to reduce health care spending include those rom the Kaiser Family

Foundation (KKF), Te Dartmouth Atlas o Health Care , the Organization or Economic Cooperation and

Development’s (OECD) Health Care Quality Indicators, and Health Care Costs 101 rom the Caliornia HealthCare

Foundation. Tese reports provide examples o indicators that quantiy key measures and variations in health care

expenditures, costs, intensity o health care resource use, and identiy where spending could easibly be reduced and

greater eciencies realized. Te most recent release o Te Dartmouth Atlas o Health Care is ocused on the treatment o

chronic conditions in the last two years o lie, and includes indicators that refect the intensity o health care resources

use and explore unwarranted variations and costs between hospitals and types o services.

It is also important to consider indicators o cost rom the perspective o consumers and businesses, as refective o public concern. For example, among KFF’s many indicators are those that speak to the increasing burden o health care

costs on individuals and amilies due to increasing out-o-pocket costs, rising insurance premiums—also a burden or

employers—and avoidance o needed care by millions due to cost, and among those without health care coverage.

Te last broad dimension or indicators o health system perormance is quality. One o the most extensive bodies

o indicators work regarding health system quality comes rom the Agency or Healthcare Research and Quality

(AHRQ). wo reports produced by AHRQ are the National Healthcare Quality Report and the National Healthcare

Disparities Report . ogether, these reports provide one o the most comprehensive set o health systems measures related

to quality. Both ollow the six conceptual areas outlined by the IOM (Figure 4; IOM, 2001), although also acknowledge

that indicators are not uniormly available or all o these dimensions. Te rst o these reports provides a set o 41 core

measures o health care quality: use and delivery o eective care (screening, treatment, disease management), timely

care, and patient centeredness. Te National Healthcare Disparities Report adds indicators o access because disparities

in quality are driven, in part, by dierential access by race/ethnicity and income. Te OECD also developed indicators

based upon extensive review by participating countries or the purpose o acilitating international comparisons in

health care quality. While ewer in number, these indicators are similar to AHRQ’s.

3.1 Approaches



Te Dartmouth Atlas uses domestic comparisons and benchmarking to show unwarranted variations—variation in

clinical practice or spending that cannot be explained on the basis o illness, strong scientic evidence, or well-inormed

patient preerences—in spending and resource use. Tese variations contribute to poorer outcomes and quality (e.g., use

o clinically eective care, patient experience) as well as ineciency in health care.

Te Institute or Healthcare Improvement (IHI), also a private sector leader in health care quality, is monitoring eorts

to improve patient saety and reduce incidents o harm, in the context o its quality work. Te “Five Million Lives”

Campaign is a comprehensive health system reorm initiative with goals to involve over 4,000 hospitals and prevent ve

million people rom incidents o medical harm. Indicators are aligned with those rom all o the major national health

care improvement initiatives (see Exhibit 4.4.6; Five Million Campaign, 2007). Another example o a patient saety

indicator set is provided by HealthGrades, which has produced a report card based on a composite index using the

Agency or Healthcare Research and Quality’s Patient Saety Indicators (PSIs). Individual hospitals are ranked along with state on measures o patient saety.

Indicators addressing health system quality in terms o patient-centered care rom the patient’s perspective are

included in consumer-oriented sites such as Hospital Compare and Nursing Home compare, compiled by the Centers

or Medicare and Medicaid Services. Many o these same indicators are drawn rom surveys, such as the Consumer

Assessments o Healthcare Providers and Systems (CAHPS), which also used by the Agency or Healthcare Research

and Quality (AHRQ) in quality monitoring eorts.

3.1 Approaches




Table 1: RepoRTs included in Review: Focus and Key FeaTuRes

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus

(NumBeR OF iNDiCaTORs)

KeY

FeaTuRes

3. Hthy

Pop 2010

ldn (x.

t)

NCHs wth

dr, prvt

prtnr.

Ovr oc o objctv to

ncr th qty o nd

onvty, nd rdc hth

dprt.

ldn ndctor corrpondn

to 26 objctv + cro cttn

objctv.

• Objectives for health

provnt n th u.s. (ovr

400).

• Well regarded and broadly used.

• Developed using consensus.

• Indicators are suggested

r nd r not wy

trckd nory.

2. Conty

Hth stt

indctor (drt

or)

CDC, NCHs, nd

othr pbc

prtnr.

sry r o hth,

nton dn c o dth,

r o brth nd dth,

rtv hth portnc,

vnrb popton,

nvronnt hth,

prvntb ncto d,

prvntv rvc ,

cc to cr, rk ctor or

prtr dth

(~ 60 ndctor nd ~200

r)

• Indicators for 3,140 U.S.

cont.

• Comparative data (peer

cont, Hthy Pop 2010)

• Interpretive tools to facilitate

brod (.., rnkn or

rtv hth portnc)

nd downodb p nd

brochr.

1. arc’

Hth Rnkn

untd Hth

Fondton,

arcn

Pbc Hth

aocton, nd

th Prtnrhp

or Prvnton

Dtrnnt o hth nd

otco: pron bhvor,

conty nvronnt, pbc

hth nd hth poc, nd

cnc cr.

(20 ndctor)

• Collaborative private effort –

pportd by pronnt hth

ornzton.

• State rankings and state data.

• Statistical and contextual data

o hh-qty (.., vdtd

throh pr rvw.)

GeneRal HealTH RepoRTs—naTional

4. Coon

to Bd

Hthr

arc—

What Drives

Hth?

Robert Wood

Johnon

Fondton

Foc on ht oc ctor:

ry xprnc, dcton,

nco, work, hon,

conty, rc nd thncty,

nd th conoy. Thr hth

condton: obty, chronc

d, nd ry chdhood.

• Emphasizes underlying causes of

poor hth nd dprt.

• Emphasizes social factors and

conty nvronnt.

3.1 Approaches



Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

5. arc’

Chdrn

intrncy

For on Chd

nd Fy

stttc (ovr

40 dr

dprtnt,

nc nd

ofc).

svn cton tht covr y

nd oc nvronnt (8),

conoc crctnc (3), hth

cr (4), phyc nvronnt nd

ty (7), bhvor (5), dcton

(6), nd hth (6).

• Collaborative federal effort –

brod ncy pport.

• Broad approach – health and

w bn o chdrn nd yoth

n u.s.

• Identies data gaps

6. Kd Cont ann e. Cy

Fondton

Foc: Condton o brth

throh yon dthood. Brod

dtrnnt.

• Data center that links with state

nd conty-bd dt, whr

vb.

• User-friendly query system.

7. Odr

arcn 2008:

Ky indctor

of Well-Being

intrncy

For on

an-Rtd

stttc

Fv oc r (38 ndctor

tot) ncdn popton (6),

conoc (7), hth tt (7),

hth rk nd bhvor (8),

hth cr (10).

Th rport o contn two

ddton oc r on trcy

nd hth trcy, nd dntf

dt p.

GeneRal HealTH—naTional wiTH Focus on speciFic aGe GRoups (cHildRen and eldeRs)

8. Cont

Cont (stt

Kn Conty,

Washington)

stt/Kn

Conty Pbc

Hth wth

pbc nd

prvt prtnr

a t o 38 oc, hth,

nvronnt nd rt ndctor:

Basic Needs and Social Well-being

(7), Potv Dvopnt throh

l st (8), sty nd Hth

(19), Conty strnth (4),

Ntr nd Bt envronnt (5),

nd art nd Ctr (4).

• Indicators are framed by “valued

condton” xprd by

conty rdnt throh

prodc rvy.

• Breadth of social and health

dtrnnt.

• Linked to community process/

cvc nd.

GeneRal HealTH—local and sTaTe

9. gorHth

Dprt

Rport

stt ogor Pbc

Hth

soc nd conoc w-bn;Hth tt (d, prtr

dth); Qty nd cc to cr;

Hth proon workorc.

• County proles with grades (andcrtr) nd rnkn/copron

to othr cont n th tt.

Table 1: RepoRTs included in Review: Focus and Key FeaTuRes (t)

3.1 Approaches




11. Nw York

Cty Conty

Hth Prof

NYC

Dprtnt

o Hth nd

mnt Hyn

Coprhnv hth rport

crd or Nw York’ 42

nhborhood. On n h

qck p nd tttc or 42

boroh on tn ndctor.

• Indicators supported by large

oc rvy.

• On-line query system.

• Related static reports.

• Interesting organization of large

amount (Ten “Take Care New York

go”)

10. lo an

Conty

Ky Hth

indctor

lo an

Conty Pbc

Hth

Brod dtrnnt o hth:

oc nd nvronnt

dtrnnt, bhvor, hth

tt nd otco.

• Rich local data on social and

nvronnt dtrnnt

pcy rtd to ry

chdhood, chronc d

prvnton.

• Indicators supported by large

oc rvy.

• Static report and limited on-line

qry yt.

GeneRal HealTH—local and sTaTe (t)

12. Nw York

Cty

Hth

DprtRport

NYC

Dprtnt

o Hth nd

mnt Hyn

Hth dprt bd on oc

nqt. Ftr ropd

nhborhood copron o

hth otco (.., prtrortty, orbdty).

• Poor/afuent neighborhood

copron.

• Geographic, racial/ethnic

(ncdn o rntrop), ndr dprt

13.Hth o

Wisconsin

Rport Crd

2007

unvrty

of Wisconsin

Popton

Hth inttt

Foc ortty nd hth-

rtd qty o n drnt

t: innt (<1 yr);

chdrn nd yon dt (

1-24 yr); workn d dt

(25-64 yr); nd, odr dt

( 65 +).

• Grades are assigned for each

rop by ndr, dcton

ttnnt, typ o conty, nd

rc/thncty, nd or dprt.

• Clear criteria for grading.

14. Th Boton

Prdox: lot o

hthcr; not

noh hth

Nw ennd

Rrch

inttt

Foc on brod hth

dtrnnt

• Includes indicators related to

th hth cr conoy nd

nvtnt n pbc hth nd

rrch.

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes


3.1 Approaches



QualiTy oF liFe (compReHensive indicaToR sysTems)

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

16. Boton

indctor

Projct

Th Boton

Fondton;

Th JohnLaWare

ldrhp

For; Th

Cty o Boton;

Boton

Rdvopnt

athorty;

mtropotn

ar Pnnn

Conc

Qty o (10 ctor): cvc

vtty, ctr nd th rt,

th conoy, dcton, thnvronnt, hth, hon,

pbc ty, tchnooy, nd

trnportton.

Hth rwork: ndctor

ornzd rond ht

o (20 ndctor r, nd

pproxty 40 ndvd

r).

• Comprehensive indicator system.

• Public-private effort that

pport cvc nd.• Data paired with information

bot poc nd othr

ovrnnt nd prvt

nttv.

15. OeCD

Fctbook 2008:

econoc,

envronnt

nd soc

stttc

Ornzton

or econoc

Cooprton

nd

Dvopnt

Qty o rwork ncd

hth, r, octy, trnport.

• Indicators suitable for

ntrnton copron on

23 contr crrnty.

17. Jckonv

indctor or

Pror—JCCi

2007 Qty o

l Rport

Jckonv

Conty

Conty

indctor

Qty o , pror (9 r):

dcton, conoy, ntr

nvronnt, oc nvronnt,

rt nd ctr, hth,

ovrnnt, trnportton, nd

pbc ty. (100+ ndctor)

• Well regarded comprehensive

oc ndctor rport.

• Broad participation (i.e.,

bn, conty br,

non-proft nd ovrnnt

nc).

• Community perceptions survey.


3.1 Approaches




QualiTy oF liFe (compReHensive indicaToR sysTems) (t)

HealTH sysTem peRFoRmance

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

18. atr’

mr o

Pror

atr

Br o

stttc

Frwork: ndvd, conoy

nd conoc rorc, th

nvronnt, nd vn tothr.

“Headline” dimensions of

pror: Hth, dcton,

trnn, nton nco,

conoc hrdhp, nton

wth, hon, prodctvty,

th ntr ndcp, th r

nd tophr, ocn nd

tr, y, conty, nd

oc cohon, cr, docrcy,

ovrnnc nd ctznhp.

sppntry dnon:ctr nd r,

copttvn nd opnn,

ination, communication, and

trnport.

19. Cndn

Index of Well-

bn

(Prototyp)

atknon

Fondton

(brod

cobortv

ort)

Foc r: hthy popton,

conty vtty, t ,

dctd popc, coyt

hth, rt nd ctr, cvc

nnt, vn tndrd.

• National comprehensive

ndctor yt wth pr to

susa.

• Composite index will be created

ro oc r.

20. Coon-

wth

Fnd stt

scorcrd on

Hth syt

Prornc

Prvt

rrchr

Coond

by Coon-

wth Fnd n

coborton

wth Co-

on or

Hth syt

Prornciprovnt.

Foc r (nbr o

ndctor): cc (4), qty

(14), potnty vodb

o hopt nd cot o cr (9),

qty, hthy v (5)

• Improvement and equity focus.

• Several measures comparable to

dvopd contr (.., OeCD)


3.1 Approaches



Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

21. Drtoth

at o Hth

Cr

Drtoth

inttt or

Hth Pocy

nd Cnc

Prctc,

Drtoth

mdc schoo

Foc: mdcr pndn,

rorc octon nd ,

nd ptnt otco t tt,

ron nd hopt v.

• Interactive data tools providing

coprhnv tttc on hth

yt prornc.

• Comparative statistics and

bnchrk by hopt, hopt

rrr r, conty, tt, nd

nton.

• Emphasis on Medicare

bnfcr wth ro chronc

n nd ptnt wth vr

chronc n n thr t two

yr o .

22. Nton

Hthcr

Qty Rport

ancy or

Hthcr

Qty nd

Rrch

wth th u.s.

Dprtnt

o Hth nd

Hn srvc

(HHs)

Foc ctvn, ptnt

ty, tn, ptnt-

cntrdn, nd fcncy o

hth cr rvc.

Dnon o fcncy

xpord n th 2007 rport.

• Uses highest quality data

vb, whch not yt

nory vb cro

dnon or rvc ctor.

• 42 core measures

• Effectiveness of prevention,

dno, trtnt,

nnt or nn cnc

condton/cr ttn.• State snapshots (online)

copr qty trnd or

ctd copot r.

23. Nton

Hthcr

Dprt

Rport

ancy or

Hthcr

Qty nd

Rrch

( bov)

Foc dprt n

ctvn, ptnt ty,

tn, nd ptnt-

cntrdn o hth cr

rvc.

• Disparities by race/ethnicity,

oco-conoc tt, nd

wthn/btwn othr prorty

popton.

• 42 measures of quality and 8

r o cc

24. OeCD

Hth Cr

Qty indx

Ornzton

or econoc

Cooprton

nd

Dvopnt +

Hth cr qty provnt

(13 r).

• Indicators suitable for

ntrnton copron.

• Health care system performance

r—coprb tttc

on cnc qty o cr nd

otco or 23 contr.

3.1 Approaches





27. Hopt

Copr

Cntr or

mdcr

nd mdcd

srvc

Foc n or r: proc o

cr, otco o cr, ptnt

xprnc wth cr, nd

mdcr pynt nd vo.

Copron to vr o u.s.

hopt nd hopt n tt or

ron.

26. Ptnt

sty narc

Hopt stdy

Hthgrd Ptnt sty Rport crd or

u.s. hopt bd pon aHRQthodooy (16 ptnt ty

ndctor).

• Composite safety score and

rnkn o tt.• Analysis of best performing

hopt/yt.

• Trends in medical error and costs.

25. Fv mon

lv

inttt or

HthCr

iprovnt

12 ntrvnton n 4,000 u.s.

hopt to rdc ncdnt o

ptnt hr by 5 on ovr

two yr prod.

• Large private campaign to

trnor hth cr yt.

• Possible indicators cut across to

dcrb prtcpton (dopton

o cton by hopt) nd

nbr o ncdnt o hr

prvntd.

HealTH sysTem peRFoRmance (t)

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

28. Trnd nd

indctor n

th ChnnHth Cr

mrktpc

Chrtbook

Kr Fy

Fondton

Foc on trnd n hth cr

pndn nd cot, ncdn

prcrpton dr, hthnrnc nront, hth

nrnc pr, hth

nrnc bnft, trctr o

th hth cr rktpc,

hth pn nd provdr

rtonhp, nd pcton

o hth rkt, nd trnd or

conr nd th ty nt.

• Approximately 80 indicators.

• Describes increasing costs

nd dprt n on thnnrd nd by pyr typ.

• On-line chart book; regularly

pdtd.

29. World

Hth

Ornzton

World Health

Ornzton

inortonsyt

Foc o Tn stttc Hhht:

Rk Fctor, Nton Hth

accont, Hth syt

Foc o rport: hth tt

(ortty, orbdty), hth

rvc covr, rk ctor,

hth yt, nqt

n hth, dorphc nd

ococonoc tttc.

• Comparative statistics for 193

contr.

• “Ten statistical highlights”

3.1 Approaches




oTHeR—FRaminG appRoacHes and Gaps

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

30. Hth Cr

Cot 101

Corn

HthCr

Fondton

Trnd n hth cr pndn

(dor ont, rowth,

pndn ctor nd pynt

orc, drvr o ) n th u.s.

(ctd dt or Corn).

ur-rndy nphot o hth

cr pndn.

31. Trt or

arc’

Hth:Top 10 prort

or prvnton

(Frwork

xp)

Trt or

arc’

Health – Acoton

o 130+

ornzton.

Tn prort: Prootn d

prvnton; cobtn th

obty pdc; prvntntobcco nd xpor;

prvntn nd contron

ncto d; prprn or

potnt hth rnc nd

botrror ttck; rconzn

th rtonhp btwn

hth nd u.s. conoc

copttvn; rdn

th nton’ ood ppy;

pnnn or chnn hth

cr nd o nor; provn

th hth o ow-nco nd

norty cont; rdcnnvronnt thrt; p

cro-cttn rcondton or

hodn ovrnnt ccontb

or protctn th hth o

arcn.

• Ten components of an

ctv nton prvnton

trty provd rwork orcondrton.

32. Prvnton

inttt—good

Hth Cont

(Prototyp)

Th Prvnton

inttt

(Coond

nd pbhd

by thCorn

endownt)

Frwork: envronnt (oc

nd phyc) tht proot hth

nd prvnt hth prob.

• Potential use for addressing

p n ndctor or hthy

conty condton--phyc

nd oc nvronnt tht

optz hth.

3.1 Approaches





oTHeR—FRaminG appRoacHes and Gaps (t)

Name

OF RePORT

COmPiliNg

ORgaNiZaTiON

FOCus


KeY

FeaTuRes

35. BCt Hth

invntory

Ntonaocton o

Cty nd Conty

Hth Ofc

Foc o r: trnd nd ctyrnkn n hth otco by

ndr, rc/thncty.

• 54 largest cities in the U.S.• Health outcomes and status

(ortty, brth dt, nd

rportb d).

• City socio-demographic data.

34. ery

Chdhood

indctor—

Projct Thrv

(Prototyp)

Nton

Cntr on

Chdhood

Povrty

Foc o r: ovrrchn

otco, popton-bd

rk, hth nd dc ho,

pc nd, oc-oton

dvopnt nd nt hth,

ry cr nd dcton, y

pport nd prntn.

• Comparisons of data available in

jor nton ndctor t.


p n ndctor or ry

chdhood —oc dtrnnt

nd pocy/yt ntrvnton.

• Uses results-based accountability

pproch.

33.Environ–

nt

Pbc Hth

indctor

Projct

u.s. Cntr or

D Contro

nd Prvnton,

Nton

Cntr or

envronnt

Hth,

envronnt

Hzrd nd

Hth ect

Pror

Phyc nvronnt

dtrnnt o hth.

• Topics: Based upon Healthy

Pop 2010 nd pthwy or

orc, nt, nd vnt.

• Type of indicators (hazard,

xpor, hth ct, nd

ntrvnton)

• Tiers of indicators (core,

opton, nd dvopnt).


p n phyc nvronnt

dtrnnt.

3.1 Approaches




3.2 Health Indicators and Data Sources

his section describes indicators rom selected reports, and highlights key data sources or those indicators. ables

2 and 3 compare indicators rom a sample o national general health indicator reports, and able 4 shows several

data sources used to create those indicators. ables 5, 6 and 7 compare indicators o health system perormance (access,

cost, and quality, respectively) and able 8 is the companion data source summary. Tis summary is illustrative, and

points out some general similarities and dierences among the various indicators as well as some o the data source

capabilities. Indicators rom each o the individual reports are provided in Section 4.1–4.5 o this report. echnical

inormation rom a sample o reports is provided in Appendix B.

General Health Indicators and Data Sources

able 2 shows the areas o greatest similarity between the indicators used in general health indicator reports. Most

use comparable measures related to birth and death. Indicators or lie expectancy, premature mortality (measured

in Years o Potential Lie Lost or YPLLs), and health early in lie (low birth weight, or adequacy o prenatal care, social

characteristics o the amily or mother such as age o educational attainment) are very robust, and are available rom

the National Vital Statistics System. Tese data benet rom completeness o reporting and support demographic sub-

group and small geographic level analysis (e.g., to the county level).

Another commonly-used type o indicator measures health-related quality o lie. Sel-assessments o overall health

status by individuals or their proxies (e.g., health-related quality o lie assessed using a measure o poor health days orsel-rated health status) are very reliable measures and have an extensive literature about their useulness in capturing

morbidity, early mortality, and use o health care services. Composite measures that capture multiple dimensions o

health, such as healthy lie expectancy, quality-adjusted lie years, and disability-adjusted lie years, are used in studies

but less oten in indicator reports at the present time. (See Agwunobi, 2006, and reerences provided in Appendix A.)

ypical indicators or health risks/behaviors include obesity, smoking, physical inactivity, and alcohol and drug abuse,

lack o insurance coverage.

Social indicators and risks that are standard to most (i not all) reports include educational attainment or completion o

high school, crime, violence, and poverty as important determinants o health. All reports include indicators or race/

ethnicity or emphasize disparities, although how this is presented varies depending on the ocus o the report.

able 3 illustrates how indicators used in various reports diverge in emphasis. For example, CHSI emphasizes

outcomes—specic health conditions and disease, including health risks and protective actors. Tese indicators largely

mirror the availability o national data at local (county) levels or health. Other reports, such as the Robert Wood

Johnson Foundation report, emphasize social indicators, a number o which are available to support state and county-





level analyses. Indicator reports that are ocused on child and amily well-being also emphasize social indicators and a

range o experiences and exposures to children (e.g., parental educational attainment).

Examples o data sources or Social and Environmental Determinants are shown in able 4. Tere are several high

quality data sources that provide data or social, economic, educational and social indicators (e.g., household income,

educational attainment, household and amily size and composition, languages spoken, including English prociency,

and employment) rom Census products. For example, in addition to the decennial Census, the American Community

Survey now provides annual estimates or populations o 65,000 or greater. Estimates or smaller areas or sub-groups

within regions may be obtained by combining years. Te survey was designed to provide annual data to local areas and

replaces the “long orm” that was ormerly conducted every ten years. Design and sampling eatures, or example, a 15%

sample o the U.S. households and very high response rates, make this a very robust data source.

Another Census product, the Current Population Survey, also provides high-quality annual household data but reliable

disaggregation is limited to the state level (and selected large sub-state areas). Te CPS is an important source o data

regarding children’s health insurance coverage, income, and ood security.

Examples o data sources or Health Outcomes are also shown in able 4. Data or birth and death are available in any

jurisdiction in the U.S. rom the Vital Statistics Reporting System. Te data are considered to be high-quality and

accompanying demographic data support sub-group analysis.

Data sources or health outcomes throughout the lie course (health behaviors, risks, status) are primarily rom surveys

and disease reporting systems, which vary in analytical potential. While all are respected data sources at the nationallevel, each will have limitations or producing local estimates or conducting geographical and/or sub-group analyses.

For example, the Behavioral Risk Factor Survey System (BRFSS; sample size approximately 350,000) is comprehensive

and representative, and is able to support state and large MMSA analyses. Reliable estimates at the county level depend

on population size, sample (denominator) and prevalence estimate (numerator). o illustrate this point, estimates o the

number o counties reportable rom aggregation o BRFSS surveys were tabulated or the CHSI project (available in

methods documents or this source). Te number o reportable U.S. counties ranges rom 2,719 counties or diabetes, as

compared to 687 counties or Pneumonia vaccine or persons ages 65 years and older. (See Community Health Status

Indicators). National Health Interview Survey (NHIS) produces excellent national-level data. Its sampling rame is

also used by other studies, such as the Medical Care Expenditure Panel’s Household component. It also provides child-

related health data through its substantial sample o children.

Several issues apply to the quality and representativeness o dierent surveys, which are beyond the scope o this review.

Tere are many helpul resources or assessing the strengths and limitations o dierent survey methods and quality

o data. For example, Fahimi, et al (2008) compares estimates rom the BRFSS, NHIS and NHANES in light o

declining telephone survey response rates. Additional reerences or reviewing data sources are provided in Appendix A

or the committee’s reerence and consideration, depending on the indicators selected.




Tere are many instances where an indicator may be considered important, but not be able to produce reliable state

or local estimates. For example, i the committee selects childhood overweight as an indicator, it will be currently be

limited to sel-reported data (by a parent/legal guardian) rom the National Survey o Children’s Health (NSCH) or

National Health Interview Survey (NHIS). Height/weight measures, provide more accurate data, but are available

only rom the National Health and Nutrition Examination Survey (NHANES), which pairs interview data with

clinical exams. While a valid national sample, NHANES is limited to national estimates (although state estimates can

be obtained by combining multiple years). Te problem o indicators or childhood overweight may improve as other

data sources become available, however. For example, the use o school-based testing has become a valuable source o

surveillance or child overweight, and is becoming more common. In Caliornia, or example, height/weight measures

or 5th, 7th, and 9th grade students who attend public schools are available rom the Caliornia Department o

Education as part o its tness testing program (Simon and Lee 2005).

A dierent but related issue is in the many possible cases where multiple data sources are available or the similar

indicators. Such a case would be with health insurance coverage, which is most oten obtained rom the Current

Population Survey, the National Health Interview Survey, and the Medical Expenditures Panel Survey. However, in all

these examples, health insurance coverage is asked and can be quantied in multiple ways, with dierent implications

or the indicator. For example, asking whether anyone in the household was without health insurance at some point

during the past year will yield a higher proportion than asking whether the respondent is currently (or recently)

uninsured. While the ormer may quantiy the extent o the problem more ully, the latter may provide more accurate

point-in-time estimates. (See Understanding Estimates o Uninsured.) Appendix A includes a table with examples o

health insurance indicators and data sources.





C H s i

a H R

H P 2 0 1 0 ( l d )

R W J

a r c ’ C h d r n

O d r a r

c n

T a b l e 2 : s e l e c T e d

i n d i c a T o R s c o m m o n T o

G e n e R a l H e a l T H s e T s

l x p c t n c y

m o r t t y b y g

i n n t o r t t y

l d n g c

o d t h n d

p r v n t b d t h

( n j r y , v o n c ) .

m r o B r t h

( B r t h t o

w o n < 1 8

y r , n r r d

w o n , o w / v r y

o w b r t h w g h t

n d p r t r

b r t h ) .

R k c t o r

( o k n g ,

d r n k n g , p h y c

n c t v t y , r t n d

v g t b t n g ) .

H t h c r

( h t h n r n c ,

p r v n t v r v c

— c n c r

c r n n g ,

n z t o n ) .

H R Q l ( p o o r h t h

d y , - r t d

h t h t t ) .

N o H s d p o ,

r c n t d r g .

R c / t h n c t y

P r t r d t h

( Y P l l )

i n n t o r t t y

B n g d r n k n g ,

o b t y ,

o k n g

l c k o h t h

n r n c ,

n z t o n

P o o r p h y c /

n t h t h

d y

H s g r d t o n ,

v o n t c r ,

c h d r n n p o v r t y

R c / t h n c t y

P r v n t b

d t h ( c o d

b p c f d

w t h Y P l l o

r

j o r c

o

p r t r d t h )

l o w b r t h w

g h t

s b t n c

b ,

p h y c c t v t y ,

w g h t , t o b

c c o

.

H t h c r

c c ,

H t h n r n c ,

i n z t o n

V o n c ,

p o v r t y

D p r t

l x p c t n c y

i n n t o r t t y ,

o w b r t h w g h t

P h y c n c t v t y ,

o k n g

s - r p o r t d

h t h t t ,

c t v t y t t o n

R c / t h n c t y

P r v n t b

d t h ( n j r y ,

v o n c )

m o r t t y ( n n t ,

c h d r n , y o t h )

o w b r t h w g h t ,

d o c n t b r t h

s o k n g , c o h o

, c t d r g

i n z t o n ,

h t h n r n c

P o v r t y

R c / t h n c t y

l x p c t

n c y ,

o r t t y

s o k n g , p h y c

c t v t y , o b

t y

V c c n t o n

s - r t d h

t h

t t




C H s i

a H R

H P 2 0 1 0 ( l d )

R W J

a r c ’ C h d r n

O d r a r

c n

T a b l e 3 : s e l e c T e d

i n d i c a T o R s c o m m o n T o

G e n e R a l H e a l T H s e T s

m j o r c h r o n c

c o n d t o n

( o b t y , d b t ,

h y p r t n o n )

s v r w o r k

d b t y

m j o r d p r o n

P h y c n / h t h

c r p r o v d r

p p y

D n t t p p y

T o x c c h c / r

q t y t n d r d

u n p o y d

n d v d .

C H D n d c n c r

d t h

O c c p t o n

t t

P r v n t b

h o p t z t o n

a d q c y o

p r n t c r

P r c p t p b c

h t h p n d n g

P r v n t b

d t h ( c o d

b p c f d

w t h Y P l l o

r

j o r c

o

p r t r d t h )

D b t y

H y p r t n o

n

c r n n g ,

d b t c y

x ,

c n c r c r

n n g /

d t c t o n

O r h t h .

P h y c

n v r o n n

t

C o g n t v

d v o p n t

a d t c h r o n c

c o n d t o n

( o b t y , d b t ,

C H D )

a c t v t y t t o n

d t o c h r o n c

c o n d t o n

u o r c o

c r

s o c c t o r ,

h o n g ,

c o n t y , w o r k ,

t h c o n o y ,

n c o

H t h c r

x p n d t r

( O e C D c o n t r )

P r v n t b l d t h

( n j u r y , v o l n c )

a t h m

e m o t o n l /

b h v o r l

d f c u l t

C h l d m l t r t m n t

F m l y n d o c l :

P r n t d u c t o n l

t t n m n t , l n -

g u g p o k n t

h o m , d f c u l t y

p k n g e n g l h ,

c h l d l v n g r r n g -

m n t .

e d u c t o n : F m l y

r d n g t o y o u n g

c h l d r n , m t h n d

r d n g c h v -

m n t , H s c d m c

c o u n l n g , y o u t h

n o t n c h o o l o r

w o r k n g , c o l l g

n r o l l m n t )

e c o n o m c c r c u m -

t n c : s t b l p r -

n t m p l o y m n t ,

o o d n c u r t y n d

d t q u l t y - H l t h y

e t n g i n d x ( H e i ) .

P h y s i c a l E n v i r o n –

m n t n d s t y :

D r n k n g w t r

q u l t y , h o u n g

p r o b l m , y o u t h

v c t m o r o u

c r m .

C h l d n d

d o l c n t n j u r y

C h r o n c h

t h

c o n d t o n

s n o r y

p r n t

,

o r h t h ,

d p r v

y p t o ,

F n c t o n

t t o n

D t q t y

— H e i

u o h t h c r

r v c ,

o g r

p h y ,

p r c r p t o n

d r g

H t h c r

x p n d t r ,

s o r c o

p y n t o

r

h t h c r

r v c .

C o t o c r

( o t o p o c k t

x p n d t r ) ,

v t r n ’ h

t h

c r , n r n

g

h o c r

l t r c y , h t h

t r c y





Table 4: naTional daTa souRces

Toxc Rinvntory, ePa

NHaNes

ar Qtysyt, ePa

Toxc chc r ntonvronnt

indoor r qty

Otdoor r qty (potntconcntrton, tot pnddprtct)

X

X

X

X

X

some

some

( bow)

Dt coctd by tt ndron r qty ontornnc

arcn Honsrvy

Hon X X lr tro r

Ntonant oedctonProrus Dpt. o edcton

edcton chvnt(.., th, rdn, cncprofcncy)

X X lr rbn dtrct

CrrntPopton srvyus Cn Br

Chdrn’ hth nrnccovr, nco, ood crty,poynt, bor orcchrctrtc

X X approxt p 60,000hohod (ro yr 2001orwrd); tt-bd pdn

arcnContysrvyus Cn Br

Popton nd dorphcchrctrtc (.., ,x, rc/thncty, nco,povrty, chdrn vnn povrty, dcton

ttnnt, hohod z ndcopoton)

X X X X aCs p provd nntt to popton o65,000 or rtr

NaTiONalDaTa sOuRCes

eXamPles OFiNDiCaTORs/measuRes

geOgRaPHiCDRILL DOWN

aPPROXimaTe samPle siZe;geOgRaPHiC aND suB-gROuPaNalYses; OTHeR CaPaBiliTies

i NT ’ l

NaT i ON

s T aT e

C O uNT Y

s ert Hth dtrt

ph ert




Nton Vtstttc syt—mortty ndmtp C oDth FNCHs

C-pcfc ortty,Prtr ortty (.., YPll),l xpctncy

X X X X Dt or ot jrdcton.art r nddn c nryvb or b-rop nynd n yr rportn.

Nton Vtstttc syt—Brth F ndlnkd Brth-Dth FNCHs

Brth (nnt ortty, ow brthwht, dqcy o prntcr, dcton ttnnt oprnt)

X X X X Dt or ot jrdcton. lowprvnc vnt td orb-rop ny nd nyr rportn





i NT ’ l

NaT i ON

s T aT e

C

O uNT Y

Hth ot: brth dth

Hth ot: Hth stt, Rk, bhr

montorn thFtr

Dr, coho, crtt ,tttd, nd prcptonon yoth (n 8th, 10th, nd12th rd)

X approxty 48,500 tdntn 410 choo wr rvyd n2006

DsrvncsytCDC

incto d (HiV/ aiDs, TB, Hptt, sxyTrnttd D)

some X X X a jrdcton; vrbcoptn o rportn ontrnton copron

Bhvor RkFctor srvy

syt (BRFss)CDC

Hth-rtd qty o (poor hth dy, tc.), hth

condton (th, dbt),obty/ovrwht, orcondd hth crrvc, hth bhvor (..,okn, phyc ctvty), ndcc to cr

X X some Vrb by popton znd prvnc tt* (

not); ann p zpprox. 350,000. Ovrpvb. 170 tropotn ndcropotn tttc r(mmsa)

Table 4: naTional daTa souRces (t)


*Hhy vrb dpndn on popton z, p (dnontor) nd prvnc tt (nrtor). ett o th nbr

o cont rportb ro rton o BRFss rvy wr tbtd or th CHsi projct. For xp, th nbr o rportb

cont rnd ro 2719 cont or dbt to 687 cont or Pnon vccn or pron 65 yr nd odr.








i NT ’ l

NaT i ON

s T aT e

C

O uNT Y

Hth ot: Hth stt, Rk, bhr (t)

Yoth RkBhvor srvyCDC

Ovrwht, phyc ctvty,dt, choo ood nvronnt.

X some Dt or ctd r (..,prvnc o ovrwht or29 tt nd 14 r trodtrct)

Nton

inztonsrvyNCHs, CDC, NiP

inzton drn chdhood

or vccn-prvntb d

X X sp z pproxty

27,000 chdrn 19-35onth. Dt vb by ttnd pprox. 30 rbn r bypovrty, rc/thncty.

Nton srvyo Chdrn’Hth (NsCH)(anyzd by CaHmi)

NCHs

Hth nd ncton tt(oton, bhvor, hth,dvopnt prob onchdrn; chdhood ovrwht,th); ery chdhood(prntn prctc), ddchdhood nd docnc(p, xrc, rdn,oc/oton dfct,

choo nnt); Fynctonn (y ctvt,tr); Prnt hth,Nhborhood condton.

X X HRsa ron.Rbty o ndn?

Nton Hthnd Ntrtonexntonsrvy (NHaNes)

CDC nd NHCs

Chronc d (ncdnndnod condton) ndcondton, obty, rchotro, bood prr,phyc ftn, dt ndntrton, okn, xpor totobcco ok, nztontt, nt hth, orhth

X Ntony rprnttvp; ann contnopn (ro 1999 orwrd).approx. p z 9,000-10,000 or 2003-04. Ovrpo o b-rop; tdrc/thnc b-rop ny.

Nton Hthintrvw srvyCDC

in, njr, ctvtytton, hth nrnccovr, o hth rvc,hth condton, okn,coho , vccnton, cncrcrnn, nd othr nrhth topc

X adt nd chd dt; Rcntrvy hv ovrpd Bcknd Hpnc pron. Dtddorphc dt nbb-rop ny. spz (coptd ntrvw) pproxty 35,000hohod contnn bot

87,500 pron. No rbtt-v tt.


Table 4: naTional daTa souRces (t)



Indicators and Data Sources or Health System Perormance

able 5, able 6, and able 7 provide examples o indicators o health system perormance, organized by access,

cost, and quality.

Indicators o access to health care primarily relate to insurance coverage, usual (or regular) source o care, diculties/

delays in the receipt o needed care due to cost, physician supply, and physician/dental visits (able 5). Reports ocused

on disparities diverge slightly, with Georgia emphasizing provider supply and diversity, linguistic isolation, and the

availability o ederally qualied health centers. Kaiser Family Foundation also provides measures related to the health

care saety net. Te National Healthcare Disparities Report, unlike its companion report also rom AHRQ, includes

indicators o access to health care as a contributor to poor quality.

able 6 shows examples o indicators related to health care costs and eciency. Health care costs are measured in several

reports using comparable measures or the nation as a whole and or governmental spending (e.g., per capita health

care spending, annual growth in spending, percentage o GDP, spending by category, etc.); several o these measures

are comparable to those in OECD countries, and are appropriate or international comparisons. In addition to national

spending, costs are measured rom other perspectives such as employer costs (e.g., insurance premiums) and costs to

consumers (out-o-pocket spending on prescription medication, co-payments) in both the Kaiser and the Caliornia

HealthCare Foundation reports.

Another category related to cost is unnecessary spending and avoidable care. Indicators like avoidable hospitalizations

(e.g., ambulatory care sensitive conditions, readmission rates) are shown in the State Scorecard as well as AHRQ reports. Tese measures are oten linked to poor access to outpatient care or variation in hospital capacity. Other

indicators measure variations in expenditures (use and cost o health care) among Medicare recipients during the

last two years o lie relative to national or regional benchmarks, as shown in the Dartmouth Atlas. Tese indicators

represent huge costs in terms o Medicare reimbursements. Te Atlas uses several measures to identiy patterns o care

that, i changed, would generate savings and improve quality and the receipt o eective care.

Eciency measures are important, but not widely available. However, two reports use composite indexes to quantiy

relative eciencies o hospitals. Te rst, published by the Dartmouth Atlas’s is the “hospital care intensity index” or

HCI (Section 5.0, Figure 10). Te HCI index can be generated to show or compare any hospital reerral region, county,

or state using an interactive eature on the web site or other query tools. Te second is AHRQ’s “relative index o

hospital cost eciency”, which is considered developmental at this point.

able 7 shows indicators related to quality, including the use o clinically eective care, patient saety, receipt o timely

and patient-centered care, and patient perspectives on experience with receipt o health care services. One o the main

sources o quality indicators is the National Healthcare Quality Report rom AHRQ, the result o a broad consensus

and technical process involving agencies throughout HHS. Te majority o measures are or use o eective care in





the detection, treatment, and management o chronic conditions as well as acute health events. Fewer measures are

available or receipt o timely and patient-centered care.

In terms o patient saety, indicators rom HealthGrades employ patient saety indicators (PSIs) developed by the

AHRQ in a composite measure that can be used to compare perormance in dierent hospitals and states, as done

in their report card. Te PSI’s, however, may represent a limited spectrum o patient saety indicators. By contrast,

IHI’s Five Million Lives campaign sets a broader quality ramework or improvements in patient saety, and may oer

indicators to monitor the impact o the system improvements that result in decreased incidents o medical error and

patient harm. (See Five Million Lives, 2007).

Examples o data sources or Health System Perormance indicators are shown in able 8. Many data sources come rom

individual reports rom hospitals and providers, or example, hospital discharge and billing data, and represent datathat are voluntarily reported as well as mandated. In some cases, the data are designed or other purposes and may

be incomplete (e.g., data on medical error and patient saety as derived rom discharge codes) but still represent the

most valid data available. Indicator reports that provide summary measures o U.S. health care costs are based on data

rom several sources, including the Centers or Medicare and Medicaid Services (CMS) Oce o the Actuary, which

publishes data on total national health expenditures.

While the ocus o this review is largely on available data collected at a national level and disaggregated to state and

local level, many indicators worthy o consideration may be limited in their ability to be disaggregated geographically

or by population groups (age, racial/ethnic groupings). Te review attempts to be suciently broad as to be useul or

inorming uture data development or collection eorts.

In addition, local jurisdictions oten analyze state and local inormation or their indicator eorts, and many

such examples are noted in the individual report summaries. Such sources include local surveys or assessments,

administrative data rom state or local service systems, or geographic level data about community conditions. While

this review is limited to national data sources that can be disaggregated to local levels, it is acknowledged that part o

the challenge to the committee and to SUSA will be sorting out what state/local data may be standardized enough to

roll up (or scale) to the national level.

Selection criteria

Last, selection criteria are related to all aspects o indicator reports. Selection criteria are critical or evaluating

whether the indicators themselves represent a vital health issue, and multiple dimensions o an important

health problem. Selection criteria are relevant to the data sources and ability to measure the condition o importance,

and whether the data can be analyzed in a way as to be meaningul (e.g., geographic, racial/ethnic, or other sub-

groups). And selection criteria apply to communication and whether people intrinsically understand the indicator as

communicated. An example o standard selection criteria or health indicators is provided in Section 5.0, Figure 11.




Table 5: selecTed indicaToRs FoR HealTH sysTem peRFoRmance: access To caRe

Trnd nd indctorn Chnn Hth

Cr mrktpc

Chrtbook (Kr Fy

Fondton)

Nton HthcrDprt Rport

(aHRQ)

stt scorcrdon Hth syt

Prornc (Th

Coonwth Fnd)

gor HthDprt Rport

Trnd n hth

nrnc nront

Trnd n hth

nrnc pr

Trnd n hth

nrnc bnft

Trnd n th trctr

o th hth cr

rktpc

Trnd n hth pn nd

provdr rtonhp

ipcton o hth

rkt trnd or

conr

Pop ndr 65 wth

hth nrnc

Pop nnrd yr

Pop who hv

pcfc orc o

onon cr

Pop who hv

prry cr provdr

Pop who xprnc

dfct or dy n

obtnn hth cr or

do not rcv ndd

cr

Pop who xprnc

dfct or dy

n obtnn hth

cr d to fnnc or

nrnc ron

Dnt vt n pt yr

Potnty vodb

hopt don

mnt hth nd

coho/dr trtnt

nd conn

adt ndr 65

nrd

Chdrn nrd

adt vt to doctor n

pt two yr

adt wthot t

whn thy ndd to

doctor bt cod not

bc o cot

acc to provdr—

Fdr Hth

Proon short

ar or prry cr,

nt hth nd

dnt hth

Hth proon

dvrty (phycn)

Hth nrnc

covr

Pron vn n

ntcy otd

hohod

Hth cr vb

or nnrd pop

(prry cr ty nt)





Table 6: selecTed indicaToRs FoR HealTH sysTem peRFoRmance:

cosT and eFFiciency oF caRe

Ornzton

or econoc

Cooprton nd

Dvopnt

Hth Cr Cot

101

(Corn

HthCr

Fondton

Drtoth at

(Drtoth

inttt or Hth

Pocy nd Cnc

Rrch)

stt scorcrd

on Hth syt

Prornc (Th

Coonwth

Fnd)

Nton

Hthcr Qty

Rport (aHRQ)

Hth crxpndtr:

Tot xpndtron hth, % gDPTot xpndtron hth, Prcpt us dor

Pbc xpndtron hth, % totxpndtr onhth

Phrctcxpndtr, % otot xpndtr

on hth

Hth crrorc:Prctcnphycn, nr:dnty pr 1,000popton

mdc rdt,nrn rdt:dnty pr1,000 prctcnphycn/nr.

act cr bd,dnty pr 1,000popton.

mRi nt pron poptonCT scnnr pron popton

Tot Hth crpndn

Hth cr hr o gDP

Pr cptpndn

growth npndn (totnd pr cpt)

Contrbtor topndnPynt orc

spndnctorgrowth npndn byjor pndnctor

ann ot-o-pockt pndnpr cpt

mdcr pndnon ptnt wth

chronc n nth t 2 yr o:

Copotr ontnty ohthcrrorc nt 2 yr o (HCi) rtv tobnchrk.

- Tot pndn

- Rorc nptpr 1,000 ptnt- Cr intnty- Trn cr- Copron tobnchrk

Rbrntpr dcdnt;hopt dy prdcdnt; ndrbrntpr dy; doront nd rto

o pndn tobnchrk.

avodb

Hoptzton

(abtoryCr sntv

Condton -

aCsC):

adon or

pdtrc th

athtc wth n

rncy roo

or rnt cr vt

mdcr hopt

dt or aCsC’

mdcr

30-dy hopt

rdon rt

Nrn Ho

rdnt wth

hopt don

or rdon

wthn 90 dy.

Tot n

pr pr

nrod poyt prvt ctor

tbhnt.

Tot mdcr

(a&B)

rbrnt pr

poy.

Cot o potnty

vodb hopt

don

Rtv ndx

o hopt cot

fcncy




Table 7: selecTed indicaToRs FoR HealTH sysTem peRFoRmance:

QualiTy—eFFecTive caRe, paTienT saFeTy

Hth Cr QtyRport (aHRQ)

Hth Cr Qtyindx (OeCD)

Ptnt sty:Hthgrd

Fv mon lvCpn—intrvnton

Brt Cncr: erycrnn nd trtnt,ortty

Dbt: mnnt odbt nd nd-trn d

Hrt D: Connon rk ctor, trtnto ami nd ct hrtr, dth pr 1,000

hopt don wthami.

HiV/aiDs: prvnton onw c.

mtrnty cr: Typrnt cr (n frttrtr), innt brthwht

Chd hth: rcpt ovccnton by 35 onth,trtnt o trontr-t, rcpt o prvntvhth cr, dnt vt.

mnt Hth ndsbtnc ab: trt-nt or dpron, b-tnc b.

Rprtory d:Pnon inztonnd trtnt, nnc-ry ntbotc (orcod).

ath nntTbrco trtnt

Nrn Ho, Ho

Hth nd Hopc Cr:Hr drn ty n nr-n ct, otco oho hth cr.

Tn: gttn p-pontnt or cr.

Ptnt Cntrdn:Ptnt xprnc o cr.

Cncr:Brt cncr rvvmorphy crnnCrvc cncr rvvCrvc cncr crnnCoorct cncr rvv

act myocrdinrcton (ami) 30-dyortty rt

strok 30-dy c ttyrtsokn rt

Vccn prvntb d-:Covr or bc vc-cnton

ath ortty rtInuenza vaccination fordt ovr 65

Waiting time for femurrctr rry

Copot cor bdpon 16 Ptnt styindctor ro aHRQ:proporton o hh/owprorn hopt;

Dth d tomd rror

Nbr o tt dopt-n NQF’ ptnt tydn.

Conr QtyindctorCms/CaHPs/HoptCopr

Copot qty cor( mdcr/mdcdnro)

Ptnt rtn o xpr-nc drn t hoptty.

Dpoy rpd rpont to ptnt t rko crdc or rprtoryrrt.

Dvr rb, vdnc-bd cr or ct yo-crd nrcton

Prvnt dvr drvnt throh dr rc-oncton (rb doc-

ntton o chn ndr ordr)

Prvnt cntr n nc-ton

Prvnt rc t nc-ton

Prvnt vnttor-oc-td pnon

Prvnt prr cr

Rdc thcn-rtnt stphyococc

r

(mRsa) ncton

Prvnt hr ro hh-rt dcton

Rdc rc copc-ton

Dvr rb, vdnc-bd cr or contvhrt r.

gt bord on bord.





Table 8: HealTH sysTem peRFoRmance daTa souRces

mdcr C—Cms enront, , cot, pynt,dtd rvc, dno,

procdr, cc to nd

qty o cr. Dt vb

or ot provdr nd typ

o hth cr rvc (..,

hopt, otptnt, nrn

ho, ho hth cr,

hopc).

CostQua

lity

X X X Dt or nro. Conty,cty, hopt nd hopt

rrr r v Drtoth

at.**

Hthcr Cot

nd utzton

Projct

(HCuP)

Pbc/Prvt

Hopt dchr dt ncd

dno nd procdr,

dchr tt, ptnt

dorphc, nd chr

or ptnt, rrd o

pyr (.., pron covrd

by mdcr, mdcd, prvt

nrnc, nd th nnrd)

X X Th norton trntd

nto nor ort to

ctt both ttt nd

nton-stt copron nd

ny. so (~20) tt o

contrbt rncy roo

don dt nd btory

rry dt, nd pdtrc

nptnt dt.

Hth Cr

Qty indctor

(HCQi)

OeCD

mr o ctvn,

ty, nd ptnt cntrdn

X stb or ntrnton

copron wth 23 OeCD

contr

Hthcr

ectvn Dt

nd inorton

st (HeDis)

NCQa

mr o o ctv

cr, cc to cr, ptnt

tcton n otptnt cr

ttn

X X other ud by Hth pn tht

r ccrdtd or crtfd

(rqrd or pn tht ccpt

mdcd nd mdcr). Dt

covr prtcptn hth cr

yt ony. Rport crd on

ndvd pn.

Conr

ant o

Hth Provdr

nd syt

(CaHPs)

aHRQ

Ptnt xprnc wh n th

hopt or n btory cr

ttn

X X spport tndrdzd rvy

o conr nd ptnt

xprnc wth hth cr.

avb on Hopt Copr

(Cms)

DaTa sOuRCe



NOTes

i NT ’ l

NaT i ON

s T aT e

C O uNT Y




Nton Hopt

Dchr srvy

HCuP

Prvntb hoptzton

(.., arc’ Hth

Rnkn), ldn c

o hopt don ( ..,

gor Hth Dprt).

Ptnt sty indctor

X X X By hopt. Rportd by

hopt to tt ovrht

nc. stt dt coctd

v HCuP ( dr-tt-

prvt prtnrhp tht

prodc ny dtb

rtd to hopt cr).

mdc

expndtr Pn

srvy (mePs)

aHRQ

Hth cr , xpndtr,

orc o pynt, nrnc

covr, nd qty o cr

X Hohod, dc provdr,

nd nrnc coponnt.

13–15,000 families annually.

DaTa sOuRCe



NOTes

i NT ’ l

NaT i ON

s T aT e

C

O uNT Y

** Not whr condry ny w crtc to ndctor dvopnt


Table 8: HealTH sysTem peRFoRmance daTa souRces (t)




3.3 Communication—Presenting and Framing o Health Indicators

he central purpose o all o the indicator reports is to improve health through a variety o mechanisms—more

inormed citizens and decision makers, better planning and priority setting, better unctioning systems, and

targeted investments, or example. However, the indicators reviewed have varied abilities to communicate with broad

proessional, much less public, audiences.

A critical concern or the committee charged with selecting the indicators or the State o the USA is how the

indicators will be communicated based on what the American public wants and needs to know. Te choices as to how

the indicators are ramed and communicated will certainly need to be based upon pressing concerns in order to engage

inquiry on the part o site visitors. How these concerns are dened is the subject o other work, however, at least three

contextual considerations emerge rom the landscape o health indicator reports reviewed:

• First, is that the current rate of spending on health is not sustainable. Furthermore, Americans and public ocials at

all levels o government are extremely concerned about rising health care costs and the impact on budgets as well as

access.

• Second, is that our level of health, quality of life, and performance of our health system are not consistent with our

level o spending. Nor is health always equitably distributed, especially among all racial/ethnic and income groups.

Many opportunities or prevention, and increasing the health return on investment exist.

• Tird, the evidence that social factors such as poverty, poor educational attainment, and degraded community

environments contribute to poor health is increasingly acknowledged in health indicator reports. Tese actors also

contribute to many other problems in our society, including crime and violence.

Some o the more engaging examples use goals or desired results to rame and select the indicators, and this can be

accomplished in a variety o ways. Seattle-King County in Community Counts, used responses to a biennial public

survey to rame “valued conditions” or their community, which then rame the indicators. Valued conditions as stated

by the community dier rom traditional conceptual rameworks, and include statements such as “People create a

balanced daily liestyle with adequate time or interaction with amilies, riends, or leisure activities, and or volunteer

activities in the community”. Another is that businesses and corporations are “amily and community riendly…” and

“quality daycare is available or all who need it”. As such, these valued conditions orm a compelling basis not only or

indicators but or a collective agenda to address them.

Valued conditions share many similarities with Results-based Accountability (RBA; Friedman 2005), or example,

where groups agree upon a set o goals. RBA provides a structure and denition or goals (e.g., conditions or status

we want or our children, communities, etc.), indicators (e.g., how these conditions will be measured), and strategies

(approaches based on evidence) and links these with perormance measurement and budgeting measures (e.g.,

governmental or private perormance and investments). Many local indicators eorts are summarized by Friedman,

in addition to providing guidance as to various raming approaches. Project Trive, a national eort to improve and




standardize indicators tracked by state early childhood programs, exemplies the RBA approach. Friedman oers

guidelines or assessing the qualities o indicators. In addition to “data power” and “proxy power,” “communication

power” assesses whether you could stand in ront o a crowd in the town square and make a statement about your

indicator that will be readily understood by all. New York City’s “ake Care New York” community health proles

speak directly to lay persons in their indicator raming approach (see Exhibit 4.2.4).

Indicators can also be ramed and linked with civic agendas, as is shown in the comprehensive indicator systems at

the local level such as Te Boston Indicators Project as well as the Jacksonville County Community Indicators Project.

Whereas citizen’s interest eed into what is measured, what is measured eeds back to the community to join together

to promote responses or interventions. For example, in Jacksonville, local meetings about what is and should be done

in response to crime is a process organized in response to indicators o increased crime and community perceptions o

being unsae.

Te rust or America’s Health has developed “op en Priorities or Prevention” (shown in Section 5.0, Figure 12).

Tese priorities share similarities with the approaches described above in that they set goals as well as attach themselves

to uture directions and actions. Te Prevention Institute has developed a prototype set o indicators or primary

prevention ramed around social indicators—equity o opportunity, people, place, and health system actors (Section

5.0, Figure 13). Sample indicators to accompany this ramework are shown in Section 4.0, Exhibit 4.5.2.

Rankings/Grades

Several reports employ rankings by state, city, or county (e.g. America’s Health Rankings, Kids Count, Big Cities

Health Inventory). Kids Count employs two sets o rankings or states, one or “Right Start” which is based upon 10

indicators related to birth outcomes, and another or Kids Count based upon 10 indicators related to children and youth.

Big Cities Health Inventory includes rankings or the 54 largest cities in the U.S. An example o an eective graphic or

a comparative ranking is shown in Section 5.0, Figure 14, which shows the percentage dierence between lung cancer

mortality rate and the Healthy People 2010 goal or each city. Tese can be useul as summary indicators or several

individual indicators when comparing states or local areas.

Te Health o Wisconsinreport is broken down into our lie stages: Inants (<1 year); children and young adults (ages

1–24 years); working aged adults (25–64 years); and, older adults (age 65 +). Within these categories, overall grades are

assigned or health and disparity. Grades are also assigned or gender, educational attainment, type o county, and racial/

ethnic categories (Section 5.0, Figure 15).

A more in-depth use o rankings is shown in the State o Georgia Health Disparities report which uses grades to rate

each o the state’s counties on indicators o health disparities, and uses comparative rankings with other counties in

Georgia (Section 5.0, Figure 16).





Use o the Index

he index is a useul means o communicating complex concepts in a single measure. Some indexes are useul

or acilitating comparisons. An example o this kind o index that was mentioned earlier is in the Dartmouth

Atlas, called the Health Care Intensity (HCI). Te HCI provides one measure o the level o health care resources

used during the last 2 years o lie, and provides a basis upon which to make comparisons by type o service, hospital,

geographic area or other categories o health care. It is useul or benchmarking because at varies greatly across dierent

health care systems and locations, and a high HCI is associated with both excessive costs and poor outcomes (clinical

and patient experience) (personal communication with John Wennberg). Another index is the composite measure

o incidents o medical error used in HealthGrades report on patient saety. It allows the 16 patient saety indicators

developed by AHRQ to be easily tracked over time and compared among dierent regions and hospital systems.

Recently, the Gallup-Healthways Index o Well-being made news with its “index o health and happiness” constructed

rom the results o daily surveys o 1,000 Americans (Index o Well-Being, 2008). It observed that while 49% o the

U.S adult population is happy and healthy, 47% are “struggling” and 4% are “suering”. Te ongoing survey that inorms

this index is being conducted all over the world with the hope o making regular international comparisons. Te Child

Well-being Index (Foundation or Child Development, 2007) is another eort to measure relative child well-being,

while keeping cohort eects constant, and to acilitate national comparisons. On the one hand, while indexes are

simple and proound (i.e., worries about money, ood, jobs, poor health lead to suering), they can over simpliy. Good

indexes can also obscure important patterns o health and poor health obtained by capturing variation, and can also be

insensitive to changes over time, depending on how they are constructed (i.e., quality and sensitivity o the variables

that are included in them). Furthermore, it is at times dicult to attach meaning to a number—what does a child well-being result o “5” really mean?




Use o Maps and Geographic Inormation Systems

he availability o GIS has allowed or reliable health indicators, such as premature mortality and lie expectancy,

to be analyzed by geographic and demographic actors. GIS methods provide powerul tools or analyzing trends

and disparities in county-level lie expectancy (Ezzati, 2008) as well as relative gains and losses in health (mortality) by

social actors such as income, a variable that is not available rom Vital Records (Krieger, 2008). Such methods are not

only important or research but provide examples about how to communicate complex patterns and trends in health

in a manner that can be easily understood. Highlights rom both studies were summarized in the New York imes, as

shown in Section 5.0, Figure 17.

Several reports including Community Health Status Indicators, and New York City’s Community Health Proles, and

Te Dartmouth Atlas provide examples o the use o maps. Te Dartmouth Atlas is perhaps the most prominent amongeorts to show variation in measures o health services use and outcomes by geographical areas—jurisdictional, hospital

service, or other boundaries. Community Health Status Indicators will also employ small area analysis at the county level,

and will include peer county comparisons and maps on approximately 200 indicators. New York City Community

Health Proles show statistics and thematic maps based upon 10 health indicators or New York’s 42 community areas.

Several reports serve as examples o presentation approaches that aid in the dissemination and communication o

indicators. For example, RWJ’s “What drives health” eatures charts that can be downloaded as PDFs or Powerpoint

slides. CHSI compiles county and comparative statistics into a user-riendly brochure that can be used to duplicate or

meetings or or groups without access to the Internet.

Indicators directed to Consumers

E xamples o health system perormance indicators designed or use by consumers include the Hospital Compare

and Nursing Home Compare sets (CMS). Te ederal HEDIS health plan report cards also provide data or the

consumers, and, although it is not included in this review, may be a possible indicator source or quality.





3.4 Gaps in Indicators

In spite o the importance o health and health data, many gaps in our national statistical system exist (NCVHS

2002). For example, while a large body o evidence has accumulated about the importance o conditions and

experiences early in lie, robust data sources on early childhood health and social and community environments are

not well developed. Te National Survey o Early Childhood health is an important eort to ll these gaps but has

not received steady nancial support. Te National Center on Childhood Poverty’s Project Trive (Exhibit 4.5.4) is in

its early stages and is attempting to ll the gap o indicators at the state (and national) level related to early childhood

based upon potential early childhood indicators rom major national and state sources. For youth, the YRBS provides

very ew state and local estimates.

Consistent with the growing interest in early childhood indicators (RWJ, 2008; IOM, 2003) are Lie Courseindicators, which would refect optimized health over the entire lie course. A modest set o lie course can be ound

in the Healthy People 2010 leading indicators (Chrvala and Bulger [eds.], 1999). Social indicators to monitor “school

readiness,” ocused on health and developmental optimization were used in Los Angeles County (Wold and Nicholas,

2007). And yet, practical examples o indicator reports organized by lie course are not readily ound. able 9 shows

a hypothetical example o indicators organized by lie course. Tese indicators are ocused on protective actors (e.g.,

sae, nurturing and positive social environments in amilies and in communities) and risks (maternal depression, amily

violence, social isolation) that are important determinants or child health and relate to improving health trajectories

over time, well into adulthood, as depicted in Section 5.0, Figure 18 (Halon, 2005).

Physical environmental conditions are also important determinants o health, although somewhat limited tomonitored exposures and illness (e.g., lead poisoning) as well as drinking water and air quality—important, but small

slivers o environmental health interactions. Environmental public health indicators rom the National Center or

Environmental Health are provided in a ramework that is organized along a continuum o such interactions, including

indicators related to hazards, exposures, health eects, and interventions related to the physical environment. Disaster

preparedness planning may also be generating some important indicators related to human interactions with the

natural physical environment (see Exhibit 4.5.3).

Another notable gap is related to older people and indicators o long term care needs, availability o services, and

quality o services. Nursing Home Compare (CMS) is one attempt to provide such data, but represents a airly narrow

slice o the long term care universe. Te need or indicators or health in aging is emphasized by projections that the

number o people over 65 will more than double over orty years—rom approximately 34 million in the year 2000 to

80 million by 2040.

3.4 Gaps in Indicators



Table 9: example indicaToR seT—

meRGinG liFe couRse and deTeRminanTs appRoacHes

F ct ct:

Povrty

inco

Vonc

stb epoynt

edcton

Hon—xpor to toxn, crowdn

Food crty

Rc/thncty—dprt n opportnt nd bovndctor

Prnt dcton ttnnt t brth nd ry nchdhood

Prnt thn 18 yr

Prntn prctc

Prnt dpron or oton/bhvor prob

itrt th hth r t (r

thrght):adqt prnt cr

inzton

Rcpt o w-chd cr, dvopnt pport,

Rcpt o prvntv rvc

mnnt o chronc condton

avodb hoptzton

itrt th thr t—r thrght (h r, t, j

jt, h r t):

Pr-choo ttndnc

low/Hh prorn choo

Hh choo copton

Co ttndnc

Prptrtor/vct o cr

Chd trtntPrnt or y br n crn jtc yt

Hth Trjtr ot:

sokn

acoho/Dr b

Phyc ctvty

Dt nd ntrton

actvty tton

Poor hth dy

Obty

ath

injr

incto D

Chronc Hth Condton

Prtr Dth

l xpctncy





4.1 General Health—National Reports

4.1.1 ameRica’s HealTH RanKinGs:

a call To acTion FoR people and THeiR communiTies

c : ut Hth Ft, ar p Hth at, th

prtrh r prt

Last published: 2007

http://www.unitedhealthoundation.org/media2007/shrmediakit/ahr2007.pd

ctt: Stated purpose: Te ultimate purpose o America’s Health Rankings is to stimulate action by individuals,

communities, public health proessionals, health industry employees and public administration and health ocials to improve the health o the population o the United States.

Framework: Determinants o health and health outcomes. Focus is on our areas “that we can aect” combined with

outcomes related to those our determinants, which are stated as ollows:

1. Personal behaviors…everyday decisions we make that aect our personal health. It includes habits and practices we develop as

individuals and amilies that have an eect on our personal health and on our utilization o health resources.

2. Community environment refects the reality that the daily conditions in which we live our lives have a great eect on

achieving optimal individual health.

3. Public and health policies are indicative o the availability o resources and the extent o reach o public and health programsinto the general population.

4. Clinical care refects the quality, appropriateness and cost o the care we receive at doctors’ oces, clinics and hospitals.

ctt:

Number o indicators: 20

Number o measures: 20

Indicator selection criteria: Indicators represent a broad range o issues that aect a population’s health; individual

components need to use common health measurement criteria; data had to be available on a state level; and data had to

be current and updated periodically. Te selection o indicators and measures used a reputable process and individuals.

For example, there was a rigorous review by a scientic advisory committee.

4.0 Summary o Health Reports



Primary measures:

All states are ranked on measures – comparisons among states and statistics within each state.

rend analysis provides historical context and perspective on selected indicators.

Disparities by race/ethnicity in premature death (YPLL) shown.

ct: Report includes commentaries rom Te Commonwealth Fund (State Health System Perormance),

the Caliornia Medical Association Foundation (Addressing Health Disparities by Engaging Ethnic Physicians); Te

National Alliance or Hispanic Health (A Call to Action or Healthier Communities); and the National Business

Group on Health (Te Nation’s Quality o Lie and Standard o Living are at Serious Risk: We Must Act Now).

pr bhr

sokn

Bn drnkn

Obty

Hh choo rdton

ct ert

Vont cr

Occpton tt

incto d

Chdrn n povrty

p Hth p

lck o hth nrnc

Pbc hth pndn (pr cpt)

inzton covr

c cr

adqcy o prnt cr

Prry cr phycn

Prvntb hoptzton

ot

Poor nt hth dy

Poor phyc hth dy

innt ortty

Crdovcr dth

Cncr dth

Prtr dth

at:

any o hth dprt by ctd ndctor.

exHibiT 4.1.1: ameRica’s HealTH RanKinGs—HealTH indicaToR seT





4.1.2 communiTy HealTH sTaTus indicaToRs—cHsi (dRaFT FoRm)

c : u.s. ctr r d ctr prt

Link to test site: http://chsi.primescapesolutions.net/HomePage.aspx

ctt: Tis system was initially developed in 2000. It is scheduled or launch in July 2008, now unded by a

new partnership that includes the Centers or Disease Control and Prevention (including NCHS and ASDR),

the National Institutes o Health/National Library o Medicine, the Health Resources Services Administration, the

Public Health Foundation, the Association o State and erritorial Health Ocials (ASHO), National Association

o County and City Health Ocials (NACCHO), National Association o Local Boards o Health (NALBOH), and

Johns Hopkins University School o Public Health.

Te report uses a determinants o health ramework and has the stated purpose o making “health data available to

local areas throughout the U.S.”

Stated goal o Community Health Status Indicators (CHSI) is to provide an overview o key health indicators or local

communities and to encourage dialogue about actions that can be taken to improve a community’s health. Te CHSI report was

designed not only or public health proessionals but also or members o the community who are interested in the health o their

community.

ctt:

Focus areas: Summary Measures o Health, National Leading Causes o Death, Measures o Birth and Death; RelativeHealth Importance; Vulnerable Populations; Environmental Health; Preventable inectious disease; Preventive Services

Use; Access to Care; and, Risk Factors or Premature Death.

Number o indicators: 60+

Number o measures: 200+

Primary measures: Each CHSI report includes comparisons o a given county to peer counties, U.S. rates, and Healthy

People 2010 targets. Te re-launch o CHSI includes 3,141 county health status proles representing each county in

the United States excluding territories. CHSI will include updated data, mapping capabilities o health indicators, and

a website where the public can access and download the data and inormation.




ct: Te CHSI report is accompanied by a companion document entitled Data Sources, Denitions, and

Notes. Tis document gives detailed descriptions on data estimations, denitions, caveats, methodology, and sources .

In addition to the web pages, community proles can be displayed on maps or downloaded in a brochure ormat. Te

CHSI mapping capability allows users to visually compare similar counties (termed peer counties) as well as adjacent

counties with their county. Te downloaded CHSI report allows broad dissemination o inormation to audiences that

may not have access to the internet.

sr mr Hthl expctncy

a C mortty

s-rtd Hth stt

unhthy Dy

nt lg c

dth

ct prg/

brth

Brth dct

injr

Hocd

Cncr

scd

Hrt D

HiV/aiDs

mr brth dth

low brth wht

Vry ow brth wht

Prtr brth

Brth to won ndr 18

Brth to won ovr 40

Brth to nrrd won

No cr n frt trtr

Rt Hth irt(Coprtv tttc;

copron to pr cont)

vr pt

No Hs dpo

unpoyd ndvd

svr work dbty

mjor dpron

Rcnt dr

ert Hth

incto D

Toxc Chc

ar qty tndrd

prt t

aiDs

Tbrco

Haemophilus inuenzae B

Hptt a

Hptt B

m

Prt

Connt Rb syndro

syph

prt sr u

Prvntv srvc u—chdrn

(d, nz, dnt cr n/)

Prvntv rvc —dt

Pp

mor

sodocopy

Pnon vccn

F vccn

a t cr

unnrd ndvd

mdcr bnfcr

mdcd bnfcr

Prry cr phycn

Dntt

Conty hth cntr

Hth proon hort r

Rk Ftr r

prtr dth

No xrc

Fw rt/vtb

Obty

Hh bood prr

sokr

Dbt

exHibiT 4.1.2: communiTy HealTH sTaTus indicaToRs





4.1.3 HealTHy people 2010—leadinG HealTH indicaToRs

c th nt ctr r Hth stttPartners: Federal agencies (13), Healthy People Consortium (over 400 organizations, local health departments, etc.),and MOU partners.

ctt: Maximum set o leading indicators combines determinants, prevention, and lie course sets: Each indicator

exists as an objective in one or more o the 28 HP2010 ocus areas. Te three proposed indicator sets ocus on some o

the most signicant determinants o health disparities as well as the six priority areas o the President’s Initiative on

Race, and the U.S. Department o Health and Human Services’ initiative, Eliminating Racial and Ethnic Disparities in

Heath.

Goal: Healthy People 2010 has our enabling goals (Promote Healthy Behaviors, Promote Healthy Communities,Prevent and Reduce Diseases and Disorders, Improve Systems or Personal and Public Health) and one cross-cutting

goal (Reduce health disparities).

Approach: Te process o selecting the Leading Health Indicators mirrored the collaborative and extensive eorts undertaken

to develop Healthy People 2010. Te process was led by an interagency work group within the U.S. Department o Health and

Human Services. Individuals and organizations provided comments at national and regional meetings or via mail and the

Internet. A report by the Institute o Medicine, National Academy o Sciences, provided several scientic models on which to

support a set o indicators. Focus groups were used to ensure that the indicators are meaningul and motivating to the public.

ctt:

Leading indicators: 20Objectives: 28

Measures: Approximately 430

ct: Healthy People 2010 provides a broad ramework or more detailed measures. Te process o dening

health indicators or HP2020 is currently underway.

Povrty

Tobcco

Dbty

Phyc ctvty

Prvntb dth

Hth cr cc

Cncr crnn nd dtcton

Phyc nvronnt

Hs rdton

Weight

Hth inrnc

sbtnc ab

Contv dvopnt

Vonc

low brth wht

Chdhood nzton

Hyprtnon crnn

Dbtc y x

exHibiT 4.1.3: HealTHy people 2010 leadinG indicaToRs—

HealTH indicaToR seT (maximum seT)




4.1.4 RobeRT wood JoHnson FoundaTion—

commission To build a HealTHieR ameRica

itle: What drives health?

http://www.commissiononhealth.org/WhatDrivesHealth.aspx

ctt: Te stated purpose o the Robert Wood Johnson Foundation Commission to Build a Healthier America:

A national, independent, non-partisan group o leaders that will raise visibility o the many actors that infuence health,

examine innovative interventions that are making a real dierence at the local level and in the private sector, and identiy

specic, easible steps to improve Americans’ health. America’s public debate on “health” has mostly centered on access to and

aordability o care, even though a large body o evidence tells us that, in most cases, whether or not a person gets sick has little

to do with seeing a doctor. Tis Commission will ocus on those actors beyond medical care that have an enormous infuence on

health and will ask what we can do about it.

ctt: Charts and slides showing relationship between social actors—including income level, educational

attainment, and race/ethnicity. Focus is on three health conditions (or risks): early lie experience, adult chronic disease,

and obesity. OECD country comparisons in inant mortality rankings (1980 and 2002) and health care expenditures vs.

lie expectancy are provided.

Number o indicators: 13 (shown in approx. 30 charts on web site)





s Ftr

inco

Work

Hon

Conty

Rc nd thncty

Th econoy

K Hth ct

innt nd Chd HthObty

adt Chronc D

itr

% dr povrty v (4 ctor)

chd povrty (OeCD contr)

dcton ttnnt ( nd prnt)

xpctncy

nnt ortty

-rportd hth tt (dt nd chdrn)

ctvty tton (HRQl)

ctvty tton d to chronc condton

hth cr xpndtr (OeCD cont)prvnc o dbt

prvnc o chd

phyc nctvty

okn

exHibiT 4.1.4: commission on a HealTHieR u.s.




4.1.5 ameRica’s cHildRen

c : itrg Fr ch F sttt (over 40 ederal departments,

agencies and oces).

Link to 2007 report: http://www.childstats.gov/americaschildren/

ctt: Stated Purpose and rationale: “America’s Children: Key National Indicators o Well-Being, 2007 is a

compendium o indicators—drawn rom the most reliable ocial statistics—illustrative o both the promises and the diculties

conronting our Nation’s young people. Te report presents 38 key indicators on important aspects o children’s lives. Tese

indicators are easily understood by broad audiences, objectively based on substantial research, balanced so that no single area o

children’s lives dominates the report, measured regularly so that they can be updated to show trends over time, and representative

o large segments o the population rather than one particular group.”

As stated, America’s Children draws upon several conceptual rameworks to characterize the well-being o a child and

infuence the likelihood that a child will grow to be a well-educated, economically secure, productive, and healthy adult.

Criteria or indicator selection stated that indicators should be:

• easily understood by broad audiences;

• objectively based on substantial research connecting them to child well being, and easily estimated based upon

reliable data;

• balanced so that no single area of children’s lives dominates the report; measured regularly; and,

• representative of large segments of the population.

ctt: Focus areas (number o indicators): Seven sections that cover amily and social environment (8), economic

circumstances (3), health care (4), physical environment and saety (7), behavior (5), education (6), and health (6).

otal number o indicators: 39

Number o measures: Approximately 65

Overall geographic level: nation with some breakdowns by race/ethnicity and income (% o Federal Poverty Level).

Uses standard categories or race and ethnicity and includes category or two or more races as reported in the Census.

ct: Identies critical data gaps or indicators needed and challenges the agencies involved to “do better”

at providing the data. Tis process has been ongoing with several improvements to data noted over the ten years o

collaboration, including data or child maltreatment, drinking water quality, and the mental health o children.

Data gaps are noted or each ocus area are noted and include data on child homelessness, long-term poverty, disability,

and early development.





F s

Fy trctr nd chd vn rrnnt

Brth to nrrd won

Chd cr

Prnc o orn-born prnt

ln pokn t ho nd dfcty pkn

enh

adocnt brth

Chd trtnt

e crt

Chd povrty nd y nco

stb prnt poynt

Food ncrty nd dt qty

Hth cr

Hth nrnc

u orc o cr

inzton

Or hth

ph ert st

Otdoor nd ndoor r qty

Drnkn wtr qty

expor to d

Hon prob

Yoth vct o ro vont cr

Chd nd docnt njry

mortty

bhr

Rr crtt okn

acoho ,

ict dr

sx ctvty

Prptrton o ro vont cr.

et

Fy rdn to yon chdrnmth nd rdn chvnt

Hh choo cdc conn

Hh choo copton

yoth not n choo nor workn

Co nront

Hth

low brthwht

innt ortty.

eoton or bhvor dfct

Ovrwht

ath

exHibiT 4.1.5: ameRica’s cHildRen—indicaToR seT




4.1.6 Kids counT

c th a e. c Ft

Link to Kids Count en leading indicators, Right Start Indicators, and City, State, Regional Proles:

http://www.kidscount.org/datacenter/compare.jsp?pc=kc

ctt: Casey collects and publishes data on the condition o kids and amilies nationally and or every state

through their network o state grantees; in some cases, these grantees provide county and city-level data. Kids Count

is updated annually, and the website provides interactive databases and display tools to create customized charts or a

wide variety o applications.

ctt: As stated on the web site: Te new KIDS COUN Data Center, launched in January 2008, contains… the most recent data available on

Education, Employment and Income, Poverty, Health, Basic Demographics, and Youth Risk Factors or the U.S., all

50 states, D.C., Puerto Rico and the U.S. Virgin Islands and eatures data or the 50 largest U.S. cities. Depending on

availability, three to ve years o trend data is currently available or most indicators. [Te] online database allows you

to generate custom reports or a geographic area (Proles) or to compare geographic areas on a topic (Ranking, Maps,

and Line Graphs).

Geographic level: Data on children and amilies at the county-level can be ound on the Community-Level

Inormation on Kids System (CLIKS). Additional inormation or many other geographies including congressional

districts, American Indian homelands, state legislative districts, etc. are available rom the 2000 Census on the KIDSCOUN Census Data Online

Number o indicators: Kids Count (10); Right Start (10) and more than 100 in the Data Center.

ct: Te oundation believes strongly in the promotion o results-based accountability through its

commitment to data-driven planning and innovations in system reorm and community building.





Rght strt

Brth, by rc

Brth to orn-born othr

Prcnt brth to thn 20 yr o

Tn brth to won who wr rdy othr

Brth to nrrd won

Brth to othr wth thn 12 yr o dcton (1989 tndrd brth crtfct)

Brth to won rcvn t or no prnt cr (1989 tndrd brth crtfct)

Brth to othr who okd drn prnncy (1989 tndrd brth crtfct)low-brthwht bb

Prtr brth

K ct dt bk - lg itr

low-brthwht bb

innt ortty

Chd dth

Tn dth ro c

Tn brth, by rop

Tn who r hh choo dropot

Tn not ttndn choo nd not workn

Chdrn vn n whr no prnt h -t, yr-rond poynt

Chdrn n povrty (100%)

Chdrn n n-prnt

F ar (t rth thrght hh):

Chdrn n irnt F

edcton

epoynt nd inco

Hth

Hth inrnc

Popton nd Fy Chrctrtc

Povrty

Yoth Rk Fctor

exHibiT 4.1.6: Kids counT—indicaToR seTs




4.1.7 oldeR ameRicans 2008: Key indicaToRs oF well-beinG

c : itrg Fr agg-Rt sttt

http://agingstats.gov/agingstatsdotnet/Main_Site/Data/Data_2008.aspx

ctt: As stated in the introduction: Te Forum hopes that this report will stimulate discussions by policymakers and

the public, encourage exchanges between the data and policy communities, and oster improvements in Federal data collection

on older Americans. By examining a broad range o indicators, researchers, policymakers, service providers, and the Federal

government can better understand the areas o well-being that are improving or older Americans and the areas o well-being

that require more attention and eort.

Stated selection criteria or the indicators:• Easy to understand by a wide range o audiences.

• Based on reliable, nationwide data (sponsored, collected, or disseminated by the Federal government).

• Objectively based on substantial research that connects them to the well-being o older Americans.

• Balanced so that no single area dominates the report.

• Measured periodically (not necessarily annually) so that they can be updated as appropriate and show trends over

time.

• Representative o large segments o the aging population, rather than one particular group.

ctt: Focus areas: Five ocus areas including population (6), economics (7), health status (7), health risks and

behaviors (8), health care (10), plus one special indicator (literacy/health literacy).

Number o Indicators: 39

Number o Measures: Approximately 80

ct:





pt

Nbr o odr arcn

Rc nd thnc copoton

mrt tt

edcton ttnnt

lvn rrnnt

Odr vtrn

ePovrty

inco

sorc o nco

Nt worth

Prtcpton n th bor orc

Tot hohod xpndtr

Hon prob

Hth stt

l xpctncy

mortty

Chronc hth condton

snory prnt nd or hth

s-rportd hth tt

Dprv ypto

Fncton tton

Hth Rk bhr

Vccnton

morphy

Dt qty

Phyc ctvty

Obty

Crtt okn

ar qty

u o t

Hth cr

u o hth cr rvc

Hth cr xpndtr

Prcrpton dr

sorc o hth nrnc

Ot-o-pockt hth cr xpndtr

sorc o pynt or hth cr rvc

Vtrn’ hth cr

Nrn ho tzton

Rdnt rvc

Pron tnc nd qpnt

s Ftr

ltrcy

Hth trcy

exHibiT 4.1.7: oldeR ameRicans




4.2 General Health—State and Local Health Reports

4.2.1 communiTies counT—seaTTle/KinG counTy, wasHinGTon

c : p Hth—stt Kg ct.

ctt: Communities Count is a partnership between public and private organizations, including the ollowing

ounding partners: City o Bellevue Parks and Community Services Department, City o Seattle Human Services

Department, King county Children and Family Commission, Public Health-Seattle and King County, Sustainable

Seattle, Te Seattle Foundation, and United Way o King County.

Te 2005 report is the third (rst report release in 2000). It provides “a common set o 38 social, health, environmentaland arts indicators or use by all city and county governments, public agencies, oundations, human service unders,

non-prot agencies, community-based organizations, and residents.” Te ollowing three stated principles guided the

project:

1. Prevention and a long-term view o change are emphasized.

2. A data-based approach inorms our understanding o what creates and sustains healthy communities and amilies.

3. Eective eorts involve citizens and experts, dierent disciplines, dierent parts o government, private and public

sectors.

ctt:

Focus areas (number o indicators): Basic Needs and Social Well-being (7), Positive Development through Lie Stages(8), Saety and Health (19), Community Strength (4), Natural and Built Environment (5), and Arts and Culture (4),

plus a description o the data on “valued conditions” relating to each ocus area.

Number o indicators: Approximately 47


ct: Te ollowing description regarding the community input process is excerpted rom the report:

Trough an extensive process, residents expressed their opinions on what they value in their amilies and communities, what they think creates and sustains healthy people and strong neighborhoods, and what social, health and economic problems they are

concerned about. Over 1,500 King County residents participated through a random digit dial telephone survey, a series o ocus

groups, and seven public orums held across the county. Teir opinions were recorded and are expressed as “valued conditions.”

4.2 General Health—State and Local Reports




Te ollowing inormation concerning the integrity o the data was excerpted rom the report:

At the same time, technical advisors were discussing the scientic side o choosing a strong list o social and health indicators.

Tey considered the valued conditions expressed by residents and were concerned with the scientic quality o the inormation

available issues o validity, reliability, consistency o measurement, whether data are available or the county only or or smaller

areas, such as school districts, cities, regions, or or dierent age groups, ethnic groups, income levels and genders. Te indicators

selected were the most meaningul to residents and those considered most important to the overall health and wellbeing o people

and communities.

st Hth

Prcvd nhborhood ty

Cr—vont cr rt

Cr—rdr rt

Fy vonc—dotc vonc

Fy vonc—CPs rrr

motor-vhc crh dth

motor-vhc crh hoptzton

Poton n nhborhood

innt ortty

Tn brth

str

Tobcco nd coho—dt tobcco

Tobcco nd coho—yoth tobcco

Tobcco nd coho—dt coho

Tobcco nd coho—yoth coho

Phyc ctvty nd wht—ctvty

Phyc ctvty nd wht—wht

Restricted activity due to poor physical/mental health

Hth nrnc covr nd cc

ct strgth

Nhborhood oc cohon

invovnt n conty ornzton

inttton pport or conty rvc

e o cc to hop nd rvc

ntr bt ert

ar qty

Water quality

lnd covr

Frnd trtd wth chc

Cot choc

art ctr

Prtcpton n rt nd ctr

Prnc o rt nd ctr

epoynt n rt nd ctr

Fndn or rt nd ctr ctvt

exHibiT 4.2.1: communiTy counTs—indicaToR seT




4.2.2 GeoRGia HealTH dispaRiTies RepoRT

c : stt Grg p Hth

http://dch.georgia.gov/vgn/images/portal/cit–1210/21/33/111684019Georgia_Health_Equity_Initiative_Health_

Disparities_Report_2008.pd

ctt: Te approach o the report is to “look holistically at the major actors that infuence dierences in health

status and their relationship to racial and ethnic characteristics.” Te report provides a statewide and county-by-county

assessment or the indicators. Each indicator is graded or each county on the basis o how much inequity (or disparity)

by race and ethnicity exists.

ctt: Four ocus areas: Social and economic well-being; Health status (disease, premature death); Quality andaccess to care; Health proessional workorce.


Rates or indicators are provided by race/ethnicity, graded, and compared to grouped (peer) county averages using an

inequality ratio.

Te report provides clear criteria as to the meaning o the grade and how that grade might be improved as well as

action steps—guidelines or how to use and disseminate the data.

ct: Limited or no inormation is available at the county level about disparities in groups other than Black/

White due to data limitations.





s e itr

Povrty

Prcnt o vn bow th dr povrty v

Prcnt npoyd

mdn y nco

Prcnt o ho ownr occpd

et

Prcnt thn 9th rd dctonPrcnt ntcy otd

mrtt

a-djtd dth rt

YPll (d to prtr dth)

Qt a t cr

Hth proon dvrty—phycn

Hth proon hort r (prry cr, nt hth, dnt hth)

a/r rt

Rt o nnrd

Hth cr vb or nnrd pop (ty nt cnc)

erg r htt rt

avodb rncy roo vt

avodb hoptzton

exHibiT 4.2.2: GeoRGia HealTH dispaRiTies RepoRT: indicaToR seT




4.2.3 los anGeles counTy public HealTH

Report: Key Indicators o Health

c : l ag ct p Hth

Most recent publication 2007 (updated every 2 years):

http://publichealth.lacounty.gov/ha/reports/Key05Report_FINAL.pd

ctt: Purpose o the report is to monitor key health conditions and to engage a broad community o stakeholders

in health improvement work. Te ramework used is broad health determinants (including Social and Physical

Environments, Health Behaviors, Health Status, Health Outcomes). Te indicators emphasize social determinants,

especially those related to child well being and the prevention o chronic conditions, and well as health status and

outcomes.

Te criteria or the selection o indicators was based on standard criteria and involved a consensus process with health

department and key stakeholders.

ctt:

Focus areas: Social and Physical Environments, Health Behaviors, Health Status, and Health Outcomes.



Disparities or each indicator are shown along with a comparative measure as to whether the indicator is statistically dierent--better or worse—in each o the sub-county areas as compared to the county average. Racial/ethnic disparities

and other important ndings by age, income or other actors are provided in the narrative.

ct: Availability o social indicators including parenting practices, child care, community conditions as well

as indicators or health behaviors, health related quality o lie, and mental health are unique because o the availability

o large local survey data. Data are more rich given that this is a large local health department and the critical

importance o providing sub-county data—eight “Service Planning Areas”, many o which are larger than most U.S.

states.





Hth bhr

acoho nd Dr u

Tobcco u

Ovrwht Chdrn

Ovrwht/ob dt

Phyc ctvty

Ntrton

s ph ertar qty

Povrty

Nhborhood ty

Pc to py

edcton

Rdn to chd

TV vwn

Prnt pport

Chd cr

Hth stt

Prcvd hth

actvty tton on dt

Dbty—dt

Dbty nd pc hth cr nd—chdrn

Hth cr a

inrnc

Rr orc o cr

Prvntv hth rvc

Prnt cr

inzton

Coorct cncr crnn

Crvc cncr crnn

morphyacc to dnt cr

Hth ot

ath

Dbt

Hyprtnon

Dpron

aiDs

syph

Tbrco

low brth wht

Tn brth

innt ortty

Cncr ortty

Brt cncr ortty

Crvc cncr ortty

ln cncr ort

Crdovcr d ortty

Dbt ortty

strok ortty

scd

unntnton njry

Hocd

exHibiT 4.2.3: los anGeles counTy Key HealTH indicaToRs




4.2.4 new yoRK ciTy communiTy HealTH pRoFiles

c : n yrk ct drtt Hth mt Hg

http://www.nyc.gov/html/doh/html/data/data.shtml

ctt: Indicators or local report cards were generated based upon priorities or public health intervention. Te

measures are based upon high-quality data primarily rom the NY City Department o Health.

Te approach was to engage broad audiences with health indicators, and included a series o community meetings. Te

report is prepared to serve as a brochure suitable or dissemination to community stakeholders including the lay public.

Report cards or 42 neighborhoods, or communities, ramed around the ollowing “ake Care New York” goals:1. Have a regular doctor

2. Be tobacco ree

3. Keep your heart healthy

4. Know your HIV status

5. Get help or depression

6. Live ree o alcohol and drugs

7. Get checked or cancer

8. Get the immunizations you need

9. Make your home sae and healthy

10. Have a healthy baby

ctt:



Ranked comparisons to other neighborhoods (low average, average, or above average) are provided in addition to

comparisons to sub-regions o the City and to New York City as a whole.

ct: NY City conducts a periodic health survey which makes the local data related to these goals very rich.





indicaToRs

How rdnt rt thr own hthPrtr dth

gOals:H rgr tr r thr Hcp

b T Fr

K r hrt hth

K r Hiv stt

Gt h r dr

l r h rg

Gt hk r cr

Gt it n

mk r h s Hth

H Hth b

nghrh hth hghght(hhhtd hth or n nhborhood)

measuRes

s-rportd hth ttDth rtPrtr dth (ldn YPll)

No pron doctorgo to eD whn ck or nd dvcHth nrnc tt

soknattptn to qt

Hrt d hoptztonHrt d orttyObtyDbtPhyc ctvty

HiV/aiDs cHiV ttnCondo

Pychooc dtr (-rportd)Hoptzton or nt n

Bn drnknacoho-rtd hoptzton

Dr-rtd hoptztonDr-rtd dth

Crvc cncr crnn (Pp)Brt cncr crnn (or)Coon cncr (coonocopy)Cncr dth rt (dn typ)

F ( 65+)Pnococc ( 65+)ld poonn c on chdrn

ath (dt nd chdrn)ath hoptzton (dt nd chdrn)

Prnt cr n frt trtrBrth to tnlow brth whtinnt ortty rt

exp: Rb

exHibiT 4.2.4: new yoRK ciTy communiTy pRoFiles




4.2.5 new yoRK ciTy HealTH dispaRiTies RepoRT

c : n yrk ct drtt Hth mt Hghttp://nyc.gov/html/doh/downloads/pd/epi/disparities-2004.pd

ctt: Approach: Health determinants and health disparities by geographic community, income, and race/

ethnicity. Dierences that are statistically signicant are highlighted.

ctt:



Analysis o neighborhood variation is conducted by categorizing neighborhoods into our groups based on average

(median) household income. Health indicators are compared in some cases or all our groups and in some cases by

showing the indicator or the highest and lowest income neighborhoods. Ratios are also used to describe the excess

burden experienced by one or the other group—usually the lowest.

Other indicators are presented or the major racial/ethnic groups. Selected indicators where signicant sub-group

dierences were observed (or possible to analyze) are shown, or example, dierences in lie expectancy among Puerto

Ricans vs. other Hispanics.

ct: Introductory material includes careul explanation about how social actors are measured and about the

relationship o income, race/ethnicity, and living in poor neighborhoods and health.

inco nd Rc/thncty

inco nd povrty

Nhborhood nco

Rc nd thncty

irton

drt Hth

HiV/aiDs

sokn

exrc, obty, nd dbt

Crdovcr dCncr

ath

innt nd trn hth

Hth bhvor on

docnt

drt th s

ph ert

acc to mdc Cr

Hon

exHibiT 4.2.5: new yoRK ciTy dispaRiTies RepoRT





4.2.6 HealTH oF wisconsin RepoRT caRd 2007

c : urt w pt Hth ittt

http://www.pophealth.wisc.edu/UWPHI/research/report_card_2007/report_card_2007.htm

ctt: Stated purpose o report:

“Overall, the health o Wisconsin residents is improving. However, the creators o the report noticed that Wisconsin’s

rankings relative to other states were dropping. Furthermore, they considered the need to understand and address

health disparities.”

ctt: Te report uses a limited number o measures (age-specic mortality and health related quality o lie basedupon poor health days). Focus is overall health and health in dierent lie stages: Inants (<1 year); children and young

adults (ages 1-24 years); working aged adults (25-64 years); and, older adults (age 65 +). Within these categories, overall

grades are assigned or health and disparity. Grades are also assigned or the same two health measures (mortality and

unhealthy days) by gender, educational attainment, type o county, and race/ethnicity.


Hth Rt Qt l

unhthy dy

mrtt

a-pcfc dth rt

exHibiT 4.2.6: HealTH oF wisconsin RepoRT caRd




4.2.7 THe bosTon paRadox: loTs oF HealTH caRe; noT enouGH HealTH. indicaToRs oF

HealTH, HealTH caRe and compeTiTiveness in GReaTeR bosTon.

c : n eg Hthr ittt r Th bt Ft

ctt: Unique pairing o health care economic inormation and health determinants.

Content: 30 indicators

ct: Te ollowing excerpts rom the report describe the juxtaposition o the state o the health care economy

and the state o physical well-being explored through the indicators:

“o remain competitive in our increasingly global economy, we must have the resources to invest wisely in innovation o all kinds, and that requires us to understand and meet the challenge contained within this report. Te Boston Paradox describes a

double threat—to our physical health, and also to our economic wellbeing, as the cost o a rising tide o preventable

chronic illness threatens to submerge other crucial priorities, including education, transportation and the quest or aordable

housing.

Greater Boston and the Commonwealth are vulnerable to this trend because we have an older workorce, as well as persistent

racial, ethnic and socio-economic health disparities. On the economic side, we have a cost o living that already makes Greater

Boston the most expensive place in the country to live or a amily o our. And health costs are rising aster than our

economic growth. Unless we can reverse these trends, Greater Boston will lose ground, becoming less healthy and less competitive.

How can it be that here, in the hub o American medicine, we enjoy a world-class health care system, and yet do not have enough

health? As this report details, some o the most important health strategies, are preventative, including good diet and exercise. Te

Boston Paradox demonstrates that it is now imperative or Greater Boston to become as innovative in public

health strategies as we have been in medical technologies.”





dtrt Hth

edcton

mdn inco

Cn ar

Clean Water

Conty sty: Vont Cr, Yoth Vonc

nd Dotc Vonc

Tobcco u

exrc nd FtnDt nd Ntrton

Ovrwht nd Obty

acc to Hth Cr: Hth inrnc Covr

Hth stt

Low Birth Weight

Hyprtnon

Dbt

Hrt D

Cncr

ath

sr Hth cr Fg

epoyr-ponord Hth inrnc

Cot o epoyr-ponord Hth inrnc

stt expndtr or Hth nd Hth Cr

Fdr expndtr or Hth nd Hth Cr

u o Hth Cr Fndn

Pbc Hth Pror

Phycn srvc

u Hth cr Fg

Hopt srvc

Prcrpton Dr

Ho Hth Cr

Nrn Ho srvc

Rt itr

Hth inrnc indtry

mdc nd Nrn edcton

Hth-rtd Rrch nd Tchnooy Trnr

l scnc indtr

exHibiT 4.2.7: THe bosTon paRadox: loTs oF HealTH caRe; noT enouGH HealTH.




4.3 Quality o Lie (Comprehensive Indicator Systems)

4.3.1 QualiTy oF liFe FacTbooK 2008

c : Th orgt r e crt dt (oecd)

http://www.oecd.org/dataoecd/58/45/40327657.pd

4.3.2 bosTon indicaToRs pRoJecT

c Th bt Ft

Te partners or the Boston Indicators Project include: Te Boston Foundation; Te John LaWare Leadership Forum;

Te City o Boston, Tomas M. Menino, Mayor; the Boston Redevelopment Authority; and the Metropolitan Area

Planning Council.

http://www.bostonindicators.org/IndicatorsProject/Health/AtAGlance.aspx?id=3532

Comprehensive indicator system with the ollowing stated purpose:

Te Boston Indicators Project oers new ways to understand Boston and its neighborhoods in a regional context. It aims to

democratize access to inormation, oster inormed public discourse, track progress on shared civic goals, and report on change

in 10 sectors: Civic Vitality, Cultural Lie and the Arts, the Economy, Education, the Environment, Health, Housing, Public

Saety, echnology, and ransportation.

Focus areas: Te health ramework is organized around eight goals, 20 indicator areas, and approximately 40 individual

measures.

ct: Te presentation is very dierent rom more static reports. Te Boston Indicators system presents both

health data and contextual inormation (e.g., links to other inormation resources) in a navigable snapshot.

l xpctncy

innt ortty

Obty

exHibiT 4.3.1: oecd QualiTy oF liFe—HealTH indicaToRs





One o a our-part civic agenda is “World class human resources” which prioritizes high-quality early care and

education, and reducing obesity and its attendant disease burden.

http://www.bostonindicators.org/IndicatorsProject/SummaryReport.aspx?id=4764

Rtg th Rg’ ctt eg th

Hth str

Rrch ndn, mchtt nd tro Boton

“Right Start” rank in child health outcomes, Boston

v. 50 rt u.s. ct

u a t Hth cr

Rdnt wthot hth nrnc

mnt hth rvc cpcty or chdrn nd

dt

ln pokn t jor hopt nd hth

cntr

l Rt d mrtt

ldn c o hoptzton nd dthDr nd vonc rtd njr

Dr nd vonc rtd dth

sTD

Hptt C

aiDs ortty

et R/eth Hth drt

Hth ot

innt ortty

Brth wht

ath hoptzton

Hoptzton by rc/thncty

mortty by rc/thncty

itt Hth chr

at

adqt prnt cr

up-to-dt vccnton

scd rt on yoth

Yoth who n n rky bhvor

Yoth who rport tron rtonhp wth

prnt or dt ntor

Hth bhr

Rdnt who n n hthy bhvor

l Rt ert Hr

locton o chdrn nd rcrton r v.

xpor

p Fg r p Hth

Trnd n cty, tt, nd dr pbc hth

ndn v

exHibiT 4.3.2: bosTon indicaToRs pRoJecT: HealTH indicaToR seT




4.3.3 JacKsonville QualiTy oF liFe pRoGRess RepoRT

c : Jk ct ct itr

http://www.jcci.org/statistics/statistics.aspx (2007)

ctt:

Framework: Quality o lie, progress. JCCI has been collecting data and tracking trends or 22 years.

Stated purpose:

Measuring progress towards building a better community.

JCCI is a nonpartisan civic organization that engages diverse citizens in open dialogue, research, consensus building, advocacy

and leadership development to improve the quality o lie and build a better community in Northeast Florida and beyond.

ctt: Over 100 indicators in nine areas o quality o lie: education, economy, natural environment, social

environment, arts and culture, health, maintaining a responsive government, moving around eciently (transportation),

and public saety.

ct: An annual survey, donated by American Public Dialogue, provides additional inormation on the

community’s perception o the quality o lie. Detailed reerence data, including charts and graphs, are also provided or

those who wish to explore these trends urther.

stg Hth ct

Dth d to hrt d (pr 100,000)

Cncr dth (pr 100,000)

Nwborn wth hthy brth wht

ery prnt cr

innt dth rt (pr 1,000)

Rc dprty n nnt dth

snor ctzn cd rt

snor who n thr nhborhood

Pop wth no hth nrnc

Jckonv hth cr rt hh qty

Nwy dnod aiDs c pr 100,000 pop

HiV/aiDs rtd dth

Rc dprty n HiV

sxy trnttd d rport

Pck o crtt od pr pron

ln cncr dth pr 100,000 pop

acoho rportd by yoth

exHibiT 4.3.3: JacKsonville QualiTy oF liFe pRoGRess RepoRT





4.3.4 ausTRalia’s measuRes oF pRoGRess

c : atr br sttt

http://www.abs.gov.au/AUSSAS/[email protected]/Latestproducts/1383.0.55.001Main%20Features32008%20(Edition%20

1)?opendocument&tabname=Summary&prodno=1383.0.55.001&issue=2008%20(Edition%201)&num=&view=

Framework or “headline” dimensions o progress are individuals, the economy and economic resources, the

environment, and living together. Health is one o three indicators or the progress o individuals as measured in lie

expectancy at birth, educational attainment, and workorce participation.

(See Section 5.0, Figure 8 or a description o the ramework.)

4.3.5 canadian index oF well-beinG

http://www.atkinsonoundation.ca/ciw/

c thrgh r rt rt th atk Ft

Public launch anticipated in 2008

Te stated purpose o the Te Canadian Index o Wellbeing (CIW) is to report on the wellbeing o Canadians. Although

currently a work-in-progress, when the CIW is ully developed, it will chart and provide unique insights into how Canadians’

lives are getting better—or worse—in areas that matter: health, standard o living, quality o the environment, time use,education and skills, community vitality, civic engagement, and arts and culture. Most importantly, the CIW will shine a

spotlight on how these important areas are interconnected. How, or example, changes in income are linked to changes in health,

or how community engagement and living standards are connected.

ct:

(See Section 5.0, Figure 9 or a description o the CIW ramework.)




4.4 Health System Perormance

4.4.1 commonwealTH Fund sTaTe scoRecaRd on

HealTH sysTem peRFoRmance

c : Th cth F

http://www.commonwealthund.org/usr_doc/StateScorecard.pd?section=4039

ctt: Stated purpose o State Rankings:

Developed to ollow the National Scorecard on U.S. Health System Perormance , published in 2006, the State Scorecard

assesses state variation across key dimensions o health system perormance: access, quality, avoidable hospital use and

costs, equity, and healthy lives. Te ndings document wide variation among states and the potential or substantialimprovement—in terms o access, quality, costs, and lives—i all states approached levels achieved by the top states.

[Tese improvements are then translated into tangible returns, e.g., number o lives saved, and other metrics.] Leading

states outperorm lagging states on multiple indicators and dimensions; yet, all states have room to improve. Te report

presents state perormance on

32 indicators, with overall rankings as well as ranks on each dimension. Te ndings underscore the need or ederal

and state action in key areas to move all states to higher levels o perormance and value.

ctt:

Focus areas (number o indicators): Access (4); Quality (14); Potentially avoidable use o hospitals and costs o care (9);

Equity; Healthy Lives (5). otal Indicators: 32

ypes o measures:

Geographic: state

ct:

Indicators used to compare U.S. with other OECD countries summarized here:

Supplement to the Columbia journalism review march 2008

http://www.commonwealthund.org/usr_doc/CJR_insert_nal.pd?section=4039

Commonwealth und—health measures or journalists

http://www.commonwealthund.org/publications/publications_show.htm?doc_id=671629





Hth cr a

adt <65 nnrd

Chdrn nnrd

adt vtd doctor n pt 2 yr

adt—nt nd

Qt

adt 50+ rcvd prvntv crDbtc rcvd prvntv cr

Chdrn 19-35 onth rc’d vccnton

Chdrn d dnt hth vt

Chdrn oton bhvor dvopnt nd

src ptnt rcvd ntbotc

adt wth orc o cr

Chdrn dc ho

Hrt r wrttn ntrcton

Ptnt tcton

ptt a Ht

ct cr

Hopt don or pdtrc th

athtc wth n rncy roo or rnt cr

vt

mdcr hopt d or aCsC’

mdcr 30 hop rdon rt

Nrn Ho rdnt wth hopt don

Nrn Ho rdnt wth hopt rdon

wthn 90 dy

Tot n pr pr nrod poy t

prvt ctor tbhnt

Tot mdcr (a&B) rbrnt pr poy

eqt

inco v

Rc/thncty

Typ o nrnc

Hth

mortty nb to hth cr

innt orty rtBrt c ortty

Coon c ortty

adt wth ctvty tton

exHibiT 4.4.1: commonwealTH Fund sTaTe scoRecaRd on HealTH sysTem

peRFoRmance




4.4.2 THe daRTmouTH aTlas oF HealTH caRe

c : drtth ittt r Hth p c prt, drtth

m sh

http://www.dartmouthatlas.org/

Executive Summary or 2008 release:

http://www.dartmouthatlas.org/atlases/2008_Atlas_Exec_Summ.pd

Full 2008 report: racking the Care o Patients with Severe Chronic Illness

ctt: Te Dartmouth Atlas is a major research eort that or more than 20 years has documented variations in

how medical resources are distributed and used in the U.S.

As stated: Te project uses Medicare data to provide comprehensive inormation and analysis about national, regional, and local

markets, as well as individual hospitals and their aliated physicians. Tese reports, used by policymakers, the media, health care

analysts and others, have radically changed our understanding o the eciency and eectiveness o our health care system. Tis

valuable data orms the oundation or many o the ongoing eorts to improve health and health systems across America.

ctt:

Major ocus areas: Conditions and procedures (medical and surgical hospital discharges), end-o-lie care (hospital

use, intensive care use), Medicare reimbursements (overall, inpatient stays, outpatient services, Part B reimbursements,

home health services, hospice services, skilled nursing acilities). [Te 2008] edition o the Dartmouth Atlas o HealthCare describes how care or Medicare beneciaries with serious chronic illness varies across U.S. states, regions and

hospitals. Te ocus is on Medicare beneciaries who have severe chronic illnesses and are in their last two years o lie.

ct: Te Dartmouth Atlas o Health Care web site was listed as one o the “op Five Health Care System

Web Resources” by ABC News, the Kaiser Family Foundation and USA oday in the special series “Prescription or

Change.” Dartmouth Atlas Data were used to launch a national campaign by the Robert Wood Johnson Foundation to

improve the quality o health care with intensive projects unded in 14 communities.

http://www.rwj.org/les/research/statedatasheet.pd

Te Atlas website provides access to all reports and publications, as well as interactive tools to allow visitors to view specic

regions and perorm their own comparisons and analyses.





exHibiT 4.4.2: daRTmouTH aTlas

Coponnt o th Bc Rport or mdcr Ptnt wth at lt On o Nn Coon Chronc

Condton:

THe meDiCaRe sPeNDiNg RePORT:

spndn pr mdcr ptnt drn th t two

yr o

Tot mdcr pndn

inptnt t o cr

Otptnt t o crskd nrn/on-tr cr cty

Ho hth cr

Hopc cr

Drb dc qpnt

THe ResOuRCe allOCaTiON RePORT:

Rorc npt pr 1,000 mdcr ptnt drn

th t two yr o

Hopt bd

intnv cr nt (iCu) bd

Hh-ntnty iCu bd

intrdt-ntnty iCu bd

F-t qvnt (FTe) phycn bor

a phycn

Prry cr phycn

mdc pct

Rtrd nr (RN) rqrd ndr propod

dr tndrd

THe PaTieNT eXPeRieNCe RePORT:

Cr drn th t x onth o

avr nbr o dy pnt n hopt pr

ptnt

avr nbr o phycn vt pr ptnt

Prcnt o ptnt n tn or or phycnTrn cr

Prcnt o dth octd wth ntnv cr

Prcnt o ptnt nrod n hopc

avr ptnt co-pynt or phycn cr nd

drb dc qpnt drn th t two

yr o




4.4.3 naTional HealTHcaRe QualiTy RepoRT

c : Th ag r Hthr Qt Rrh

U.S. Department o Health and Human Services (HHS) in collaboration with an HHS-wide Interagency Work

Group

Link to report rom:

http://www.ahrq.gov/qual/qrdr07.htm

Link to PDFs

http://www.ahrq.gov/qual/nhqr07/nhqr07.pd

ctt: Te ollowing is the stated purpose o the National Healthcare Quality Report:

Since 2003, the Agency or Healthcare Research and Quality (AHRQ), together with its partners in the Department

o Health and Human Services (HHS), has reported on progress and opportunities or improving health care quality.

With this th annual National Healthcare Quality Report (NHQR), these reports will have provided more than

50,000 data points about health care quality in the United States. Has it made a dierence? Have Federal and State

governmental agencies, provider organizations, insurers, and employers made progress in improving health care quality

and saety? While every previous release o the NHQR has attempted to summarize the direction in which health care

quality is going, this th report tries to summarize the progress that has been made and the remaining challenges to

improve health care quality in this Nation.

Te NHQR is built on 218 measures categorized across our dimensions o quality—eectiveness, patient saety,

timeliness, and patient centeredness. Tis year’s report ocuses on the state o health care quality or a group o 41

core report measures that represent the most important and scientically credible measures o quality or the Nation,

as selected by the HHS Interagency Work Group. Te distillation o 42 core measures or the 2007 report provides a

more readily understandable summary and explanation o the key results derived rom the data. While the measures

selected or inclusion in the NHQR are derived rom the most current scientic knowledge, this knowledge base is

not evenly distributed across health care. Te analysis in the ollowing pages centers on measures or which data are

available rom the baseline year o 2000 or 2001 and the comparison year o 2004 or 2005.

ctt:

exHibiT 4.4.3: naTional HealTHcaRe QualiTy RepoRT

( ndctor t http://www.hrq.ov/q/nhqr07/Cor.ht)





4.4.4 naTional HealTHcaRe dispaRiTies RepoRT

c : Th ag r Hthr Qt Rrh

on behal o the U.S. Department o Health and Human Services (HHS) and in collaboration with an HHS-wide

Interagency Work Group

Link to both reports rom: http://www.ahrq.gov/qual/qrdr07.htm

ctt: Te National Healthcare Disparities Report states as its purpose the ollowing: Te NHDR provides

a comprehensive national overview o disparities in health care among racial, ethnic, and socioeconomic groups in

the general U.S. population and within specic priority populations, and it tracks the progress o activities to reduce

disparities. Te NHDR tracks disparities related to the quality o and access to health care.

Tis th report attempts to answer the ollowing question: Are we getting better at addressing disparities in the

quality o and access to health care or priority populations in America? o do this, the report examines a set o 42

measures o quality and 8 measures o access. For each measure, the 2007 NHDR attempts to present a snapshot o the

gaps between each racial, ethnic, and socioeconomic priority group and a comparison group. More importantly, where

gaps exist, this report attempts to systematically discuss whether these gaps are getting bigger or smaller.

Measures o health care quality address the extent to which providers and hospitals deliver evidence-based care or

specic services, as well as the outcomes o the care provided. Tey are organized around our dimensions o quality—

eectiveness, patient saety, timeliness, and patient centeredness—and cover our stages o care—staying healthy,getting better, living with illness or disability, and coping with the end o lie. Measures o health care access include

assessments o how easily patients are able to get needed health care and their actual use o services. Tey are organized

around two dimensions o access—acilitators and barriers to care and health care utilization.

Te NHDR is complemented by its companion report, the National Healthcare Quality Report (NHQR), which uses

the same quality measures as the NHDR to provide a comprehensive overview o the quality o health care in America.

Both reports measure health care quality and track changes over time, but with dierent orientations. Te NHQR

addresses the current state o health care quality and the opportunities or improvement or all Americans as a whole

ctt:

exHibiT 4.4.4: naTional HealTHcaRe dispaRiTies RepoRT

( ndctor t http://www.hrq.ov/q/nhdr07/Cor.ht)




4.4.5 oRGanizaTion FoR economic coopeRaTion and developmenT—

HealTH caRe QualiTy index

http://www.oecd.org/document/34/0,3343,en_2825_495642_37088930_1_1_1_1,00.html

Methods report ( January 2006), including conceptual ramework:

http://www.oecd.org/dataoecd/1/34/36262514.pd

ctt: Te HCQI Project states that it will eventually represent “the largest eort, in terms o the number

o quality indicators and the number o countries, to assess international health care quality that has ever been

undertaken.” Te objective o the HCQI is to track health care quality by developing a set o indicators that are:

• Based on comparable data.

• Can be used to raise questions for further investigation in quality dierences across countries.• Build upon two pre-existing international collaborations (organized by Te Commonwealth Fund of New York (5

countries) and the Nordic Minister Council Working Group on Quality Measurement (6 countries) and currently

involves the ollowing 23 countries: Australia, Austria, Canada, Czech Republic, Denmark, Finland, France,

Germany, Iceland, Ireland, Italy, Japan, Mexico, Netherlands, New Zealand, Norway, Portugal, Slovak Republic,

Spain, Sweden, Switzerland, United Kingdom, and the United States.

Conceptual approach is reerenced in Section 5.0, Figure 6.

Te stated criteria or indicator selection (explained ully in the methods report cited above) includes three main

criteria:“…the importance o what is being measured; the scientic soundness o the measure; and, the easibility/cost o

obtaining data. [Te] methods paper reviews types o indicators, the proposed scope o the measure set, criteria or

selecting indicators and other issues such as: geographical coverage (national representativeness), overall number o

indicators to be considered, changes in the set o indicators over time and composite measures. “

ctt:

Focus: Eectiveness, Saety, and Responsiveness o health care.


ct: Methods paper reviews concepts used to rame health system perormance that were considered during

the process o selecting the ocus areas and indicators (see Arah 2006).





Brt cncr rvv

morphy crnn

Crvc cncr rvv

Crvc cncr crnn

Coorct cncr rvv

Vccn prvntb d

Covr or bc vccnton

ath ortty rt

act myocrd inrcton (ami)

30-dy ortty rt

strok 30-dy c tty rt

Waiting time for femur fracture surgery

Inuenza vaccination for adults over 65

sokn rt

exHibiT 4.4.5: oecd—HealTH caRe QualiTy index

(compaRable amonG 23 counTRies)




4.4.6 Five million lives

c : Th ittt r Hthr irt

In partnership with hospitals throughout the U.S.

ctt: Based upon twelve interventions to prevent medical harm, the ve million lives campaign seeks to prevent

ve million o the estimated 15 million incidents o medical harm expected to occur over a two year period.

ct: Tis is a large private system eort to improve the quality and saety o the U.S. hospital care. It is

aligned with national health care improvement initiatives rom the IOM, AHRQ, CMS, JCAHO, National Hospital

Quality Measures ( JCAHO and CMS), American Heart Association, CDC, National Patient Saety Foundation, and

others. (See IHI website or a listing o quality/saety indicators used by these organizations.)

d (trt):

1. Dpoy rpd rpon t to ptnt t rk

o crdc or rprtory rrt

2. Dvr rb, vdnc-bd cr or ct

yocrd nrcton

3. Prvnt dvr dr vnt throh dr

rconcton (rb docntton o

chn n dr ordr)

4. Prvnt cntr n ncton

5. Prvnt rc t ncton

6. Prvnt vnttor-octd pnon

7. Prvnt prr cr

8. Rdc thcn-rtnt stphyococc

r (mRsa) ncton

9. Prvnt hr ro hh-rt dcton

10. Rdc rc copcton

11. Dvr rb, vdnc-bd cr or

contv hrt r

12. gt bord on bord

p mr

Nbr o ncdnt prvntd

Nbr o hopt prtcptn

s aHRQ nd othr, or pcfc r on

ptnt ty, ctv cr, ptnt cntrd cr,

tc.

exHibiT 4.4.6: Five million lives campaiGn





4.4.7 paTienT saFeTy in ameRican HospiTals sTudy

c : HthGr

http://www.healthgrades.com/media/dms/pd/patientsaetyinamericanhospitalsstudy2006.pd

ctt: Indicators or patient deaths and errors in U.S. hospitals. First report card to evaluate and publish saety

indicators or each state and every non-ederal hospital. Study based upon research by the Agency or Healthcare

Research and Quality (AHRQ) to dene and develop methods or identiying medical error. Evaluation o patient

saety perormance used 16 Patient Saety Indicators (PSIs) developed by the AHRQ.

ctt:

Focus: 16 PSIs, a composite measure to rank states and the perormance o individual hospitals, cost o medical errors.

Ptnt ty ndctor:

accdnt pnctr or crton

Copcton o nth

Dth n ow ortty DRg

Dcbt crFr to rc

Forn body t n drn procdr

itronc pnothorx

sctd ncton d to dc cr

Pot-oprtv horrh or hto

Pot-oprtv hp rctr

Pot-oprtv phyooc nd tboc

drnnt

Pot-oprtv ponry bo or dp vnthrobo

Pot-oprtv rprtory r

Pot-oprtv p

Pot-oprtv bdon wond dhcnc

Trnon rcton

exHibiT 4.4.7: paTienT saFeTy in ameRican HospiTals sTudy




4.4.8 HospiTal compaRe

c : ctr r mr m sr

http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?dest=NAV|Home|Search|Welcome#abop

ctt: Consumer inormation about hospital quality and results on measures o eective care.

Stated purpose: [Hospital Compare is a tool that] provides you with inormation on how well the hospitals care or all their

adult patients with certain conditions or procedures. Tis inormation will help you compare the quality o care hospitals provide.

Hospital Compare was created through the eorts o the Centers or Medicare & Medicaid Services (CMS), the

Department o Health and Human Services, and other members o the Hospital Quality Alliance: Improving Care Trough Inormation (HQA). Inormation on the website has been provided by hospitals that have voluntarily agreed

to submit quality inormation or Hospital Compare to make public.

ctt: Focus o indicators is in our areas: process o care, outcomes o care, patient experiences with care, and

Medicare payment and volume. Comparisons to average o all U.S. hospitals and hospitals in state or region.

ct:

Patient ratings provided by HCAPHS survey.

• All short-term, acute care, non-specialty hospitals are invited to participate in the HCAHPS survey. Most hospitals

choose to participate.• Hospitals that treat only certain types of patients or medical problem, called specialty hospitals, are not included

in the HCAHPS survey. Examples include psychiatric hospitals or children’s hospitals. Children’s hospitals are not

included because the HCAHPS survey asks about adult care only.





Hopt Proc o Cr mr:

• Eight measures related to heart attack care

• Four measures related to heart failure care

• Seven measures related to pneumonia care

• Five measures related to surgical infection prevention

Hopt Otco o Cr mr:

• 30-day mortality (following discharge)

srvy o Ptnt’ Hopt exprnc:

(Tn topc rtd to concton, rponvn, rpct, nvronnt, pn contro, oow-p cr,

ovr rtn)

mdcr Pynt nd Vo:

• Average Medicare payments

• Range of payments—25th–75th percentiles

exHibiT 4.4.8: HospiTal compaRe (cms) indicaToR seT




4.4.9 TRends and indicaToRs in THe cHanGinG HealTH caRe

maRKeTplace cHaRTbooK

c : Th Kr F Ft

http://ww.health08.org/insurance/7031/index.cm

ctt: Inormation on key trends in the health care marketplace including health spending, the structure o the

health care marketplace, and health plan and provider relationships.

ctt: Focus areas: Seven sections including rends in Health Care Spending and Costs (Including Prescription

Drugs), rends in Health Insurance Enrollment, rends in Health Insurance Premiums, rends in Health Insurance

Benets, rends in the Structure o the Health Care Marketplace, rends in Health Plan and Provider Relationships,and Implications o Health Market rends or Consumers and the Saety Net.

Number o indicators: Approximately 80.

exHibiT 4.4.9: TRends and indicaToRs in a cHanGinG HealTH caRe

maRKeTplace cHaRTbooK

( ndctor t http://www.hth08.or/nrnc/7031/t2004-t.c)





4.4.10 woRld HealTH oRGanizaTion’s woRld HealTH sTaTisTics

Includes “en statistical highlights in global public health”

c : wHo irt st

ctt:

Internationally comparative health statistics.

On-line statistics.

ctt: Focus o en Statistical Highlights: Risk Factors, National Health Accounts, Health Systems

Focus o Report: Health status (mortality, morbidity), Health Services Coverage, Risk Factors, Health Systems,Inequities in health, Demographic and socioeconomic statistics.

Number o indicators: Approximately 75.

ct: Selected statistics are comparable among over 190 countries.

Rk Ftr

Chdrn <5 tntd

Chdrn <5 ndrwht

Chdrn <5 ovrwht

Low Birth Weight newborns

Obty— > 15 yr

Drnkn wtr orc—cc to provd

sntton—cc to provd

nt Hth at

Tot xpndtr on hth (% o gDP)

Tot ovrnnt hth xpndtr (% o

ovrnnt pndn)

Pr cpt tot xpndtr on hth t

ntrnton dor rt

Hth st

Hth workorc

Hth xpndtr rto

Hth xpndtr rt

Covr o vt rtrton—dth

Hopt bd

exHibiT 4.4.10: woRld HealTH oRGanizaTion: Ten Key inTeRnaTional measuRes

(compaRable To 193 counTRies)




4.4.11 HealTH caRe cosTs 101

c : Th cr Hthr Ft

http://www.chc.org/topics/healthinsurance/index.cm?itemID=133630

nt Hth sg

tt ( )

hr Gdp

r r

mjor Pror shr o Bdt

spndn n Dvopd Contr

spndn Dtrbton by Ctory

spndn sry

spndn Dtrbton by Contrbtor

Contrbtor, spndn Dt

Pynt sorc, Contrbtor Dt

Htorc Pynt sorc

sg dtrt:

r

. rt

Ot o Pockt v. Prvt inrnc

ann growth Rt

n Nton Hth spndn

spending vs. ination

Drvr o spndn growth

Ctv ipct o growth Rt

ann growth Rt by Hth spndn Ctor

Prcrpton Dr by sorc o Pynt

ipct o mdcr Prt D

ann growth: Prvt Pr v. ann

growth

ann Ot-o-Pockt spndn

exHibiT 4.4.11: HealTH caRe cosTs 101





4.5 Other—Framing Approaches/Gaps/Frameworks

4.5.1 10 Top pRioRiTies FoR pRevenTion

c : Trt r ar’ Hth

http://healthyamericans.org/docs/?DocID=126 (last accessed June 16, 2008)

ct: See Section 5.0, Figure 12

4.5.2 Good HealTH counTs: a 21sT cenTuRy appRoacH To HealTH and communiTy in

caliFoRnia—pRoToType indicaToR seT

c : Th prt ittt

http://www.preventioninstitute.org/documents/GoodHealthCounts_Final.pd (last accessed June 16, 2008)

ct: See Figure 13

exHibiT 4.5.2 cHoice: cHanGinG HealTH oppoRTuniTies in communiTy enviRonmenTs

(Exhibit 4.5.2 continues on next page)




4.5.3 enviRonmenTal public HealTH indicaToRs

c : u.s. ctr r d ctr prt, nt ctr r

ert Hth, ert Hr Hth et prgr

http://www.cdc.gov/nceh/indicators/summary.htm (last accessed June 16, 2008)

ct: See prototype indicators in Exhibit 4.5.3 attached

T:

ar, abnt (Otdoor)

ar, indoorDtr

ld (Pb)

No

Ptcd

sntn evnt

sn nd utrvot lht

Toxics and Waste

Water, Ambient

Water, Drinking

Hr itr (tt r r t

tt r hr t):Crtr potnt n bnt r

Hzrdo or toxc btnc rd n bnt r

Rdnc n non-ttnnt r (or crtr r

potnt)

motor vhc on

Tobcco ok n ho wth chdrn

Residence in a ood plain

Ptcd nd pttrn o

Rd ptcd or toxc contnnt n ood

utrvot ht

Chc p

montord contnnt n bnt nd drnknwtr

Pont-orc dchr nto bnt wtr

Contnnt n hfh nd port nd corc

fh

expor indctor (borkr o xpor)

Bood d v (n chdrn)

Hth et itr (rr rt

r rtt ttrt t r):

Crbon onoxd poonnDth ttrbtd to xtr n bnt tprtr

ld poonn (n chdrn)

No-ndcd hrn o (non-occpton)

Ptcd-rtd poonn nd n

in or condton wth pctd or confrd

nvronnt contrbton ( c or n n

pttrn)

mno

Pob chd poonn (rtn n contton or

rncy dprtnt vt)

Otbrk ttrbtd to fh nd hfh

Otbrk ttrbtd to bnt or drnkn wtrcontnnt

itrt itr (rgr r f

rg rt hr):

Pror tht ddr otor vhc on

atrnt n rtrd otor vhc

avbty o trnt

Poc tht ddr ndoor r hzrd n choo

lw prtnn to ok-r ndoor r

indoor r npcton

erncy prprdn, rpon, nd tton

trnn pror, pn, nd protocoCopnc wth ptcd ppcton tndrd

(on ptcd workr)

actvty rtrcton n bnt wtr (hth-bd)

ipntton o ntry rvy

Copnc wth oprton nd ntnnc

tndrd or drnkn wtr yt

Bo-wtr dvor

exHibiT 4.5.3: summaRy oF coRe enviRonmenTal public HealTH indicaToRssorc: envronnt Pbc Hth indctor Projct; CDC, NCeH, eHHe; Jnry 2006





4.5.4 eaRly cHildHood indicaToRs—pRoJecT THRive pRoToType

c : nt ctr r chh prt, c urt, m sh

s wrk

http://www.nccp.org/publications/pub_822.html (last accessed June 16, 2008)

ct: See prototype indicators in Exhibit 4.5.4 attached.

(Exhibit 4.5.4 continues on next page)





4.5.5 biG ciTies HealTH invenToRy—THe HealTH oF uRban usa

c : nt at ct ct Hth of (naccHo)

http://www.naccho.org/pubs/product1.cm?Product_ID=202 (last accessed June 16, 2008)

ct: See Section 5.0, Figure 14




FiGuRe 1: deTeRminanTs oF HealTH (evans and sToddaT, 1990)

FiGuRe 2: social deTeRminanTs—communiTy Guide (andeRson, 2003)

5.0 Figures




FiGuRe 3: liFe couRse HealTH developmenT (iom, 2004)

FiGuRe 4: eaRly expeRiences and HealTH (RwJ, 2008)

5.0 Figures



FiGuRe 5: six Key dimensions oF HealTH caRe

(iom commiTTee on THe QualiTy oF HealTH caRe, 2001)

ethg a r th 21t-tr Hth cr st

Th cott propo x or provnt to ddr ky dnon n whch tody’ hth cr yt

ncton t r owr v thn t cn nd hod. Hth cr hod b:

• Sae—vodn njr to ptnt ro th cr tht ntndd to hp th.

• Eective—provdn rvc bd on cntfc knowd to who cod bnft nd rrnn ro provdn

rvc to tho not ky to bnft (vodn ndr nd ovr, rpctvy).

• Patient-centered —provdn cr tht rpct o nd rponv to ndvd ptnt prrnc, nd, nd

v nd nrn tht ptnt v d cnc dcon.

• Timely —rdcn wt nd ot hr dy or both tho who rcv nd tho who v cr.

•Efcient —vodn wt, ncdn wt o qpnt, pp, d, nd nry.

• Equitable—provdn cr tht do not vry n qty bc o pron chrctrtc ch ndr, thncty,

orphc octon, nd ococonoc tt.

The CIW will treat benecial activities as assets and harmful ones as decits. It will, for example:

• distinguish between good things like health and clean air, and bad things, like sickness and pollution;

• promote volunteer work and unpaid care-giving as social goods, and overwork and stress as social decits;

• put a value on educational achievement, early childhood learning, economic and personal security, a clean

nvronnt, nd oc nd hth qty; nd,

• encourage a better balance between investment in health promotion and spending on illness treatment.

5.0 Figures




FiGuRe 6: HealTH sysTem peRFoRmance—HealTH caRe QualiTy index (oecd)

5.0 Figures



FiGuRe 7: oecd FacTbooK: QualiTy oF liFe

➚

5.0 Figures




FiGuRe 8: measuRes oF ausTRalia’s pRoGRess

Th econoy nd Th lvn

indvd econoc Rorc envronnt Tothr

Hdn Hth Nton nco Th ntr Fy, conty

dnon ndcp nd oc cohon

edcton econoc hrdhp Th r nd Cr

nd Trnn tophr

Work National wealth Oceans Democracy, governance

nd tr nd ctznhp

Hon

Prodctvty

sppntry Ctr Copttvn Concton

dnon nd lr nd opnn

Ination Transport

FiGuRe 9: canadian index oF well-beinG

5.0 Figures



FiGuRe 10: HospiTal caRe inTensiTy index (THe daRTmouTH aTlas, 2008)

5.0 Figures




FiGuRe 11: example oF sTandaRd selecTion cRiTeRia

Fn Crtr gdn scton o ldn Hth indctor, Cott on ldn Hth indctor or Hthy

Pop 2010 (iOm, 1999)

1. Worth measuring—the indicators represent an important and salient aspect of the public’s health

2. Cn b rd or dvr popton—th ndctor r vd nd rb or th nr popton nd

dvr popton rop

3. undrtood by pop who nd to ct—pop who nd to ct on thr own bh or tht o othr hod b

b to rdy coprhnd th ndctor nd wht cn b don to prov th tt o tho ndctor;

4. inorton w vnz cton—th ndctor r o ch ntr tht cton cn b tkn t th nton,

tt, oc nd conty v by ndvd w ornzd rop nd pbc nd prvt nc;

5. acton tht cn d to provnt r known nd b—thr r provn cton (.., pron bhvor,

pntton o nw poc, tc.) tht cn tr th cor o th ndctor whn wdy ppd; nd

6. Measurement over time will reect results of action—if action is taken, tangible results will be seen indicating

provnt n vro pct o th nton’ hth.

FiGuRe 12: FRaminG example: TRusT FoR ameRica’s HealTH

5.0 Figures



FiGuRe 13: FRaminG example: pRevenTion insTiTuTe pRoToType

CHOiCe: Chnn Hth Opportnt n Conty envronnt (sp ndctor provdd n exhbt 4.5.2)

eqtb opportnty ctor: Do vryon hv cc to opportnt?

Rc jtc

Job nd oc ownrhp

edcton

Pop ctor: ar pop connctd nd nd?

soc ntwork nd trt

Prtcpton nd wnn to ct or th coon ood

accptb bhvor nd tttd

Pc ctor: i th conty nvronnt condcv to hth?

What’s sold and how it’s promoted

look, nd ty

Prk nd opn pc

gttn rond

Hon

ar, wtr nd o

art nd ctr

mdc srvc: Do dc rvc t th nd o th conty?

Prvntv rvc

acc

Trtnt qty, d nnt, n-ptnt rvc, nd trntv dcn

Ctr coptnc

erncy rpon

5.0 Figures




FiGuRe 14: RanKinG example: biG ciTies invenToRy

5.0 Figures



FiGuRe 15: GRades example: wisconsin

5.0 Figures




FiGuRe 16: GRades example: GeoRGia

5.0 Figures



FiGuRe 17: use oF Gis and maps: u.s. liFe expecTancy by counTRy

FiGuRe 18: HealTH TRaJecToRies (HalFon, 2005)

5.0 Figures




6.0 Reerences

Agwunobi JO. 2006. Te Healthy People 2010 Midcourse Review (Executive Summary-Goal 1: Increase quality and years o healthy lie). U.S. Public Health Service , DHHS , Washington, D.C.

Anderson LM, Scrimshaw, SC, Fullilove, M, Fielding, JE, andthe ask Force on Community Preventive Services. 2003. TeCommunity Guide’s Model or Linking the Social Environment toHealth. Am J Prev Med 2003;24(3S).

Arah OA, Westert GP, Hurst J, Klazinga NA. 2006. A ConceptualFramework or the OECD Health Care Quality Indicators Project.Published by Oxord University Press on behal o InternationalSociety or Quality in Health Care. September 2006: pp.5-13.

Braveman P. and Egerter S. (2008) Overcoming Obstacles to Health:Report or the Robert Wood Johnson Foundation to the Commissionto Build a Healthier America. Robert Wood Johnson Foundation.Accessed June 14, 2008 rom http://www.rwj.org/les/research/obstaclestohealth.pd.

Chrvala CA and Bulger, RJ (Eds.). 1999. Institute o Medicine.Leading HealthIndicators or Healthy People 2010: Final Report.National Academy o Sciences. Washington, DC.

Community Health Status Indicators. Permission to access testsite rom Marilyn Metzler, U.S. Centers or Disease Control andPrevention (April 2008).

Simon P and Lee N. Surveillance o Childhood Overweight inLos Angeles County: Use o a School-Based Physical Fitness est-ing Program. Los Angeles County Department o Health Services.Presentation at UCLA, June 16, 2005. Accessed at www.healthychild.ucla.edu/CHNWppts/Simon%20Paul%20presentation.ppt on July 9,2008.

Evans RG and Stoddart GL. Original (1990) determinants o healthmodel accessed in Am J Public Health. 2003;93:371–379).

Ezzati M, Friedman AB, Kulkarni SC, Murray CJL. 2008. TeReversal o Fortunes: rends in County Mortality and Cross-County Mortality Disparities in the United States PLoS Medicine Vol. 5, No.4, e66 doi:10.1371/journal.pmed.0050066

Fahimi M, Link M, Schwartz DA, Levy P, Mokdad A. rackingchronic disease and risk behavior prevalence as survey participationdeclines: statistics rom the Behavioral Risk Factor SurveillanceSystem and other national surveys. Prev Chronic Dis 2008;5(3).http://www.cdc.gov/pcd/issues/2008/jul/07_0097.htm. Accessed June25, 2008.

Five Million Campaign. 2007. Alignment with National HealthcareImprovement Initiatives. Last accessed on June 14, 2008 rom http://

www.ihi.org/NR/rdonlyres/CC960DDD-2BB3-41C1-9D56--957876C9C1B/0/CampaignAlignmentWithNationalHealthcareImprovementInitiatives.pd.

Foundation or Child Development. 2007. Child Well-Being Index(CWI). Last accessed on June 14, 2008 romhttp://www.cd-us.org/initiatives/initiatives_show.htm?doc_id=463963.

Friedman M. 2005. rying hard is not good enough. How to producemeasurable improvements or customers and communities. Victoria(CA): raord Publishing.

Gallup-Healthways Well-Being Index. Last Accessed on June 15,2008 rom http://www.well-beingindex.com/index.html. Newscoverage related to the study ndings accessed on April 30, 2008 romhttp://www.reuters.com/article/latestCrisis/idUSN29370158.

GAO. 2003 (GAO-03-672SP). Key National Indicators: Assessingthe Nation’s Position and Progress. U.S. Government Accountability Oce. Washington, DC.

GAO. 2004 (GAO-05-01). Inorming our Nation. Improving How to Understand and Assess the USA’s Position and Progress. U.S.Government Accountability Oce. Washington, DC Last accessedon June 14, 2008 rom www.gao.gov/cgi-bin/getrpt?GAO-05-1.

GAO (GAO-07-497). 2007. Health Care Spending. Public Payers

Face Burden o Entitlement Program Growth, While All PayersFace Rising Prices and Increasing Use o Services. estimony Beorethe Subcommittee on Military Construction, Veterans Aairs,and Related Agencies, Committee on Appropriations, House o Representatives. Accessed at http://www.gao.gov/new.items/d07497t.pd

Halon N, Hochstein M. Lie course health development: anintegrated ramework or developing health, policy and research.Milbank Quarterly 2002;80(3):433-79.

Halon, N. 2005. Measuring the Health and Well-Being o Childrenand Youth. New Models. Presented at the Children’s Health, TeNation’s Wealth Meeting, Los Angeles, CA, June 16, 2005. Figureused by permission rom Neal Halon.

Institute o Medicine. 1997. Improving Health in the Community: ARole or Perormance Monitoring. J.S. Durch, L.A. Bailey, and M.A.Stoto, eds. Washington, D.C.: National Academy Press.

Institute o Medicine. 2001. Crossing the Quality Chasm: A New Health System or the 21st Century. Washington, DC: NationalAcademy Press.

Institute o Medicine. 2004. Children’s Health, the Nation’s Wealth.Assessing and Improving Child Health. Washington, DC: NationalAcademy Press.

Krieger N, Rehkop DH, Chen J, Waterman PD, Marcelli E,Kennedy M. 2008. Te Fall and Rise o US Inequities in PrematureMortality: 1960–2002. PLoS Medicine Vol. 5, No. 2, e46 doi:10.1371/

journal.pmed.0050046

McCannon CJ, et al. 2007. Miles to Go: An Introduction to the 5Million Lives Campaign. Te Joint Commission Journal on Quality and Patient Saety. Last accessed on June 14, 2008 rom http://

www.ihi.org/NR/rdonlyres/DA1D43DD-464A-46BC-9D1A-C290EE371DE0/0/MilestoGo.pd.

National Center or Health Statistics (NCHS). 2007. Health, UnitedStates, 2007. Hyattsville, MD. Available on-line at http://www.cdc.gov/nchs/hus.htm.



National Committee on Vital and Health Statistics. 2002. Shapinga health statistics vision or the 21st century.: U.S. Department o Health and Human Services. Washington, D.C.Prevention Institute. 2008. Good Health Counts: A 21 st Century

Approach to Health and Community or Caliornia. Published by TeCaliornia Endowment. Los Angeles, CA.

Robert Wood Johnson Foundation. 2008. Early ChildhoodExperiences: Laying the Foundation or Health Across a Lietime.Issue Brie 1: Early Experiences and Health. Princeton, NJ. Lastaccessed on June 15, 2008 at http://www.commissiononhealth.org/PDF/095bea47-ae8e-4744-b054-258c9309b3d4/Issue%20Brie%201%20Jun%2008%20-%20Early%20Childhood%20Experiences%20and%20Health.pd.

Shonko, JP, Pillips DA, (Eds.). (2000). From neurons toneighborhoods: the science o early childhood development.

Washington (DC): National Academies Press.

Understanding Estimates o the Uninsured: Putting the Dierencesin Context (no date) at http://www.aspe.hhs.gov/health/reports/hiestimates.htm. Last accessed on June 14, 2008.

Walker, DM. 2008. U.S. Financial Condition and Fiscal Future(GAO-08-417CG). Brieng by Te Honorable David M. Walker,Comptroller General o the United States. Last accessed on May 16,2008.http://www.gao.gov/cghome/d08417cg.pd.

Wennberg, JE (personal communication). April 2008.

Wold, CM and Nicholas, W. 2007. Starting School Healthy andReady to Learn: Using Social Indicators to Improve School Readinessin Los Angeles County. Preventing Chronic Disease. 2007(4):4. U.S.Centers or Disease Control and Prevention. Available on-line at

www.cdc.gov/pcd/issues/2007/oct/07_0073.htm.

Reerences or Figures

Figure 1: Evans and Stoddart, 1990

Figure 2: Anderson, et al., 2003. Also on-line at http://www.thecommunityguide.org/social/Social-Environment.pd

Figure 3: IOM, 2003. Also on-line athttp://www.iom.edu/Object.File/Master/23/164/0.pd

Figure 4: RWJ, 2008. Also on-line at

http://www.commissiononhealth.org/PDF/095bea47-ae8e-4744-b054-258c9309b3d4/Issue%20Brie%201%20Jun%2008%20-%20Early%20Childhood%20Experiences%20and%20Health.pd

Figure 5: IOM, 2001

Figure 6: Arah, 2006

Figure 7: OECD Factbook: Quality o Lie. Last accessed on June 15,2008 at http://miranda.sourceoecd.org/vl=2462720/cl=11/nw=1/rpsv/actbook/

Figure 8: Measures o Australia’s Progress Last accessed on June 15, 2008 at http://www.abs.gov.au/AUSSAS/[email protected]/Lookup/1383.0.55.001Main%20Features72008%20(Edition%201)?opendocument&tabname=Summary&prodno=1383.0.55.001&issu

e=2008%20(Edition%201)&num=&view=

Figure 9: Canadian Index o Well-Being Last accessed on June 15, 2008 at http://www.atkinsonoundation.ca/ciw/SkinnedFolder_1191957711895

Figure 10: Hospital Care Intensity Index Last accessed on June 15,2008 at http://cecsweb.dartmouth.edu/atlas08/datatools/hci_s1.php

Figure 11: Example o Standard Selection Criteria. Final CriteriaGuiding Selection o Leading Health Indicators. IOM 1999. (SeeChrvala, et al, 1999).

Figure 12: Framing example: rust or America’s Health Lastaccessed on June 15, 2008 at http://healthyamericans.org/

healthieramerica/10TingsBook.pd

Figure 13: Prevention Institute, 2008.

Figure 14: Big Cities Inventory. Last accessed on June 15, 2008 athttp://www.naccho.org/topics/crosscutting/documents/BCHI07COLORFINAL.pd

Figure 15: Health o Wisconsin. Last accessed on June 15, 2008 athttp://www.pophealth.wisc.edu/UWPHI/research/report_card_2007/report_card_2007.htm

Figure 16: Georgia Health Disparities Report. Last accessedon June 15, 2008 at http://dch.georgia.gov/vgn/images/portal/cit_1210/21/33/111684019Georgia_Health_Equity_Initiative_Health_Disparities_Report_2008.pd

Figure 17: Accessed on April 27, 2008 at http://www.nytimes.com/2008/04/27/weekinreview/27sack.html

Figure 18: Halon, 2005

6.0 Reerences




Appendix A:Links to echnical Data about Data Sources

Overview Of many data sOurcesused fOr health indicatOrs:

Health, U.S. 2007 Chartbook http://www.cdc.gov/nchs/data/hus/hus07.pd#tocappi

links tO variOus data sOurces and methOds repOrts:

National Survey on Drug Abuse and HealthSubstance Abuse and Mental Health Services Administrationhttp://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/appG.htmandhttp://www.icpsr.umich.edu/cocoon/SAMHDA/SUDY/21240.xml

American Community Survey http://www.census.gov/acs/www/index.html andhttp://www.childstats.gov/americaschildren/surveys.asp#acs

National Health and Nutrition Examination Survey (NHANES)http://www.childstats.gov/americaschildren/surveys.asp#nhnes

YRBS -Methodshttp://www.cdc.gov/mmwr/PDF/rr/rr5312.pd

CDC. Selected Metropolitan/Micropolitan Area Risk rends(SMAR). Atlanta,GA: US Department o Health and Human Services, CDC, NationalCenter or Chronic Disease Prevention and Health Promotion, 2004.

Available at http://apps.nccd.cdc.gov/brss-smart/index.asp.

Data Source Descriptions or Indicators used in America’s Childrenhttp://www.childstats.gov/americaschildren/surveys.asp

Data Source Descriptions or Indicators used in Older Americans2008: Key Indicators o Well-Beinghttp://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Appendix_B.aspx

Describes dierences in health insurance estimates rom CPS,MEPS, NHIS and other sources:http://aspe.hhs.gov/health/Reports/uninsur3.htmValidity o BRFSS, NHIS measures (comparisons to NHANES):

Fahimi M, Link M, Schwartz DA, Levy P, Mokdad A. rackingchronic disease and risk behavior prevalence as survey participationdeclines: statistics rom the Behavioral Risk Factor SurveillanceSystem and other national surveys. Prev Chronic Dis 2008;5(3).http://www.cdc.gov/pcd/issues/2008/

jul/07_0097.htm. Accessed June 25, 2008.

links tO references regarding summary measures fOr health (health-relatedquality Of life, etc.):

Stewart S, Woodward RM, Rosen AB, Cutler DM. Aproposed method or monitoring U.S. population health: linkingsymptoms, impairments, and health ratings. NBER Working Papers 2007;11358:1-56. pd (270K)

Agwunobi JO. Te Healthy People 2010 Midcourse Review (ExecutiveSummary-Goal 1: Increase quality and years o healthy lie). U.S.Public Health Service , DHHS , Washington, D.C., 2006. html pd (585K)

Klementiev A. Chapter 5-An alternative measure o years o healthy lie--[rom: Estes RJ (ed.), Advancing Quality o Lie in a urbulent

World]. Social Indicators Research Series, Springer Netherlands2006;29:67?84.

Miller W, Robinson LA, Lawrence RS (Eds); Committee to evaluatemeasures o health benets or environmental, health, and saety regulation board on health care services. Valuing health or regulatory cost-eectiveness analysis. Institute o Medicine , National AcademiesPress, Washington, D.C., 2006:1-364. abstract* html* pd* (222KB)Chang CF, Nocetti D, Rubin RM. Healthy lie expectancy orselected race and gender subgroups: Te case o ennessee. South Med J 2005;98(10):977?984. abstract

Centers or Disease Control and Prevention. Health-Related Quality o Lie, Part II ? State and Local Applications [Internet]. Chronic

Disease Notes and Reports 2004;16:1-48. pd (1200KB)

Andresen EM, Recktenwald A, Gillespie K. Population estimateso utilities: the Health and Activity Limitation Index (HALEX)(Abstract)?presentation at the10th annual meeting o theInternational Society or Quality o Lie Research, Nov 12?15, 2003in Prague, Czech Republic. Qual Lie Res 2003;12(7):737.

Buescher PA, Ziya Gizlice Z. Healthy Lie Expectancy in NorthCarolina, 1996?2000. SCHS Studies; North Carolina Departmento Health and Human Services, State Center or Health Statistics,Raleigh, NC 2002; No.129: 17. pd (65K)

Gold M. Summary measures o population health and beyond: alook at U.S. ederal activities in measuring the health o populations.

WHO Conerence. Statistical Commission and Economic Commission or Europe 2000. Working paper No. 11. Ottawa Canada, 23?25. pd*(41K)

Harwell S, Spence MR. Population surveillance or physical violence among adult men and women, Montana. Am J Prev Med 2000;19(4):321?324. abstract

U.S. Department o Health and Human Services. Healthy People 2010. 2nd ed. With understanding and improving health andobjectives or improving health. 2 vols. Washington, DC: U.S.Government Printing Oce 2000. html

Te ollowing links and reerences provide additional inormation about the characteristics (e.g., technical details,

methods, quality) about data sources and health indicators.



Appendix B:Selected Indicators and Data Sources



Health Indicators A Review o Reports Currently in Use

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