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Explaining health outcomes

27 Jun 2016

Dara Gantly on the important ‘bigger picture’ on health data and what we can learn from the EU

The second annual report of the National Healthcare Quality Reporting System (NHQRS) — which highlights major variations between counties in rates of hospitalisation for common chronic diseases such as COPD, asthma, diabetes and heart failure — was praised by the Minister for Health last week for helping his Department “see the bigger picture” and take a broader and longer term view of what is really happening in our health service.

The NHQRS report details how the rate of hospitalisation for heart failure ranged from 111.9 in Kerry, to 282.9 per 100,000 population in Carlow. There was an almost threefold variation in the hospitalisation rate for COPD (244.5 in Kerry, to 632.7 per 100,000 population in Offaly), and a fourfold variation for asthma (16.9 hospitalisation per 100,000 in Monaghan vs 68.6 in Longford). And it is a similar story for survivals after heart attacks or stroke, C-sections, or the uptake of vaccinations or cancer screening.

Why? Well, the Department is cagey: “There can be a number of different reasons behind these variations and it cannot be concluded that higher or lower rates are a reflection on the quality of care provided by primary and community care.”

But it does go on to suggest that the quality of the data, difference in the prevalence of chronic conditions in the population, the availability of services at primary and community care level, and access to specific treatments and the availability of hospital beds may all be factors.

Can I point those in Hawkins House towards the University of East Anglia (UEA), which this week published research confirming that asthma sufferers with poor access to primary care are more likely to experience an emergency hospital admission.

The research — published in the British Journal of General Practice (June 21, Br J Gen Pract 2016; DOI: 10.3399/bjgp16X686089) — examined patient data for more than three million asthma sufferers across 7,806 practices in England (95% — a large survey sample), and compared data on emergency admissions with access to primary care as detailed in the GP Patient Survey — a sample of five million patients (10% of the practice population).

“We found 55,570 asthma-related emergency admissions and a strong link between poor access to care and higher amounts of admissions.

Practices that provided better access to care had fewer emergency admissions for asthma. For every 10 per cent improvement in access there was a 32 per cent reduction in emergency admissions. This research adds weight to the growing association between better access to primary care and lower rates of emergency admissions for a number of other conditions, including heart failure, diabetes, stroke, cancer and epilepsy,” said author Dr Robert Fleetcroft.

Is this what the Department of Health should be investigating? On a simple head count, Monaghan would appear to have more GPs than Longford, but as the above research points out, factors such as practice size, age of population, socio-economic divides, rurality, and distance from nearest hospital can all influence hospitalisations and mortality rates. But would having more GPs, who are better resource and more evenly distributed across the country, not go some way toward addressing these regional failings?

Ireland’s standing internationally on such indicators is of equal concern. While we are good in some areas (e.g. uptake for cervical screening and influenza immunisation for the over-65s), we perform poorly in many others. At 394.9 COPD hospitalisations per 100,000 population, Ireland tops that OECD table, and for cancer survival rates, the figures are below the OECD average for breast, cervical and colorectal cancer, but making progress. Again there may be variations between countries due to differences in their coding practices, in the definitions and disease classification systems used, the DoH explains. All of which means moves last week by the European Commission to strengthen its own country-knowledge on health and to develop synergies with the OECD and the European Observatory on Health Systems and Policies, so as to provide better analytical outputs, should be welcomed.

Following a meeting last week of the Employment, Social Policy, Health and Consumer Affairs (EPSCO) Council, the Commission reiterated its intention to deliver a ‘State of Health in the EU’ package this year and into 2017.

The first deliverable will be a revised Health at a Glance: Europe Report by the OECD, to be published in November. The second development, in November 2017, will be a set of 28 individual country health profiles developed by the OECD and the Observatory in cooperation with the Commission. “These expert-driven, analytical documents will provide complementary data and indicators, and emphasise the particular characteristics and challenges of each Member State,” the Commission noted. Alongside this will be a Commission analysis, accompanying the 28 country health profiles, also in November 2017, which will give an overall view of the two above projects and link them to the broader EU agenda. And finally, the fourth ‘product’, starting November ’17, will see the potential for exchange of best practice between Member States and the various EU institutions.

With the ‘State of Health in the EU’, the Commission will provide Member States with the evidence, without, it stresses, “judging on their comparative performance”. I guess that will be left to us journalists!

We need more data, and more accurate data, if we are to make sense of our health service and learn from our EU neighbours. And also, so that when subsequent reports emerge from the DoH, we have more concrete answers.

Dara Gantly

Click here to view the full article which appeared in Irish Medical Times: Opinion