Wednesday, March 4, 2009

[EQ] A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults

A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults

 

 Andrew P. Wilper, MD, MPH; Steffie Woolhandler, MD, MPH; Karen E. Lasser, MD, MPH; Danny McCormick, MD, MPH; David H. Bor, MD; and David U. Himmelstein, MD

Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts.

August 2008 | Volume 149 Issue 3 | Pages 170-176

The Annals of Internal Medicine - American College of Physicians

 

Available online at: http://www.annals.org/cgi/content/full/149/3/170

 

Editor Notes:


Context

·         Although many Americans lack health insurance, some policymakers claim that persons without insurance are largely healthy. However, the rates of chronic illness among those without insurance have not been well documented.

Contribution

·         By using data from the National Health and Nutrition Examination Survey (1999–2004), this study estimates that more than 11 million working-age Americans with cardiovascular disease, hypertension, diabetes, dyslipidemia, obstructive lung disease, or previous cancer do not have health insurance. Individuals without health insurance were more likely than those with insurance to report problems with access to health care.

Implication

·         Many uninsured Americans have health conditions that require ongoing care.

Abstract:

 

Background: No recent national studies have assessed chronic illness prevalence or access to care among persons without insurance in the United States.

Objective: To compare reports of chronic conditions and access to care among U.S. adults, by self-reported insurance status.

Design: Population-based survey.

Setting: National Health and Nutritional Examination Survey (1999–2004).

Participants: 12 486 patients age 18 to 64 years.

Measurements: Estimates of national rates of cardiovascular disease, hypertension, diabetes, hypercholesterolemia, active asthma or chronic obstructive pulmonary disease, previous cancer, and measures of access to care.

Results: On the basis of National Health and Nutrition Examination Survey (1999–2004) responses, an estimated 11.4 million (95% CI, 9.8 million to 13.0 million) working-age Americans with chronic conditions were uninsured, including 16.1% (CI, 12.6% to 19.6%) of the 7.8 million with cardiovascular disease, 15.5% (CI, 13.4% to 17.6%) of the 38.2 million with hypertension, and 16.6% (CI, 13.2% to 20.0%) of the 8.5 million with diabetes. After the authors controlled for age, sex, and race or ethnicity, chronically ill patients without insurance were more likely than those with coverage to have not visited a health professional (22.6% vs. 6.2%) and to not have a standard site for care (26.1% vs. 6.2%) but more likely to identify their standard site for care as an emergency department (7.1% vs. 1.1%) (P <0.001 for all comparisons).

Limitation: The study was cross-sectional and used self-reported insurance and disease status.

Conclusion: Millions of U.S. working-age adults with chronic conditions do not have insurance and have poorer access to medical care than their insured counterparts.

 

Related article:

M. H. Chin Improving Care and Outcomes of Uninsured Persons with Chronic Disease ...
Ann Intern Med, 2008; 149(3): 206 - 208. [Full Text] [PDF]

 

 

 

 

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[EQ] Health research: measuring the social, health and economic benefits

Health research: measuring the social, health and economic benefits

 

Cyril Frank and Edward Nason

Department of Surgery, University of Calgary (Frank), Calgary, Alta.; and the Canadian Policy Research Network (Nason), Ottawa, Ont.

CMAJ • MARCH 3, 2009 • 180(5) - Canadian Medical Association Journal

 

Available online at: http://www.cmaj.ca/cgi/content/full/180/5/528?etoc

 

URL: http://www.cmaj.ca/cgi/reprint/180/5/528

 

"…… the authors discuss two approaches to measure return on investment in health research. The "payback model," which was recently adopted and modified by the Canadian Institutes of Health Research, is favoured and may help optimize future evaluations.

 

"……..despite intense interest in defining the social, health and economic impacts of health research investments globally 1�5 and in Canada 6�10 as proof of value for- money, no validated method for measuring return on investments yet exists. Until now, issues of complexity combined with major gaps in methodology have limited the ability to link health research products to outcomes at a relevant level (e.g., to be useful to stakeholders: individual funders, decision-makers, institutions, researchers or clinicians).

In this article, we discuss current approaches to measuring returns on investment, analyze key issues and gaps that need to be bridged to improve returns on investment, and present a new method that may help overcome them………"

 

Key points

• Health research is expensive, and its explicit social, health and economic impacts are hard to define.

• There are many challenges and assumptions in defining specific returns on investment in health research.

• There is no common approach to tracking health research impacts.

• The payback model can be populated with validated indicators to track overall outcomes or outcomes in a specific health research area.

• Collaboration among funders will ensure cost-effective implementation of the new framework to quantify return on investment.

• The framework can be fine-tuned as necessary to improve indicator sets, overcome gaps and progressively define returns on investment in health research.

 

This analysis article comments on

 

MAKING AN IMPACT

A Preferred Framework and Indicators to Measure Returns on Investment in Health Research

 

Report of the Panel on the Return on Investments in Health Research

Canadian Academy of Health Sciences/Académie canadienne des sciences de la santé
January 2009

 

Volume 1 available online PDF file [136p.] at: http://www.cahs-acss.ca/e/pdfs/ROI_FullReport.pdf


Apendices available online as PDF [340p.] at: http://www.cahs-acss.ca/e/pdfs/ROI_Appendices.pdf

 

"……Twenty three different organizations sponsored this assessment. They all share an interest in defining the impacts of health research and learning how to improve the returns on investments in health research. Our remit from these sponsors was: Is there a "best way" (best method) to evaluate the impacts of health research in Canada, and are there "best metrics" that could be used to assess those impacts (or improve them)?

 

Based on our assessment, we propose a new impacts framework and a preferred menu of indicators and metrics that can be used for evaluating the returns on investment in health research. The CAHS impact framework demonstrates how research activity informs decision making, eventually resulting in changes in health and economic and social prosperity (left to right arrow). The framework also shows how research impacts feed back upstream, potentially influencing the diffusion and impacts of other research, and creating inputs for future research (right to left arrow).

 

This framework builds on the combined logic model and impacts approach of the "payback model" (Buxton, M.J., and Hanney, S.R., 1996 � adapted by CIHR in Canada in 2005 and 2008), revised by our panel into a "systems approach" to capture impacts (this is shown at the bottom of the Figure). It is designed to be used as a roadmap to track healthresearch impacts in five main categories:
1) advancing knowledge,
2) building capacity,
3) informing decision
making,
4) health impacts, and
5) broad socio
economic impacts

 

Content

 

Volume 1

The Chair's Perspective Rationale (and CAHS Prospectus) for this Assessment

Executive Summary

Panel Recommendations

1. Chapter 1: Background

1.1. Defining Health Research

1.1.a. The Canadian Health Research Landscape

1.1.b. What Returns are Expected from Canadian Health Research?

1.1.c. Many Stakeholders, Many Views

1.1.d. Different Evaluation Purposes

1.1.e. Why Measure Returns on Investment for Health Research in Canada?

1.1.f. What Evaluation of "Returns" is Already Taking Place in Canada?

1.2. Are "Health Research Impacts" Already Defined Elsewhere?

1.3. Economic Evaluations to Date

1.4. Summary of the Landscape

2. Chapter 2: Frameworks

2.1. Rationale for a Framework to Understand Health Research

2.1.a. Definitions

2.1.b. Stakeholders Needs

2.2. A Review of Frameworks and Their Use

2.3. Developing a Health Research Evaluation Framework for Canada

2.3.a. Identifying What Should be Modelled

2.3.b. Building a Framework for R&D Uptake

2.3.c. Impact Categories

2.3.d. Impact Categories and the Logic Model

3. Chapter 3: Strategies for Using the Framework

3.1. Using the Framework Appropriately

3.1.a. Avoiding Misuse of the Framework

3.1.b. The Four Pillars and the Framework

3.2. Costs of Evaluation

3.3. Issues in Evaluation: Attribution, the Counterfactual, Timelags and Levels of Aggregation

3.4. Evaluation Methods

3.5. Data Collection

4. Chapter 4: Choosing Sets of Indicators and Metrics

4.1. Overview of Indicators and Metrics and Their Use

4.2. Defining "Appropriate Indicators"

4.3. Identifying Appropriate Indicators

4.3.a. Advancing Knowledge

4.3.b. Capacity Building

4.3.c. Informing Decision Making

4.3.d. Health Impacts

4.3.e. Broad Economic and Social Impacts

4.3.f. Theoretical examples of indicator sets for evaluation

5. Chapter 5: Conclusions

6. References

 

Volume 2: http://www.cahs-acss.ca/e/pdfs/ROI_Appendices.pdf  - Appendices

 

The appendices present commissioned papers in areas where the report is not able to provide details, cover the background for the main report, and present the approach taken to the assessment process. The commissioned papers cover assessing the impacts of research in pillars II, III and IV but do not cover pillar I, since basic biomedical research is the area where most has been said on understanding the impacts of health research.

 

Appendix A: Commissioned Papers

- Pillar II: Clinical Research "How to Optimally Measure the Impact of Health Research Funding in Clinical Research" by Ralph M. Meyer

- Pillar III: Health Services Research "Estimating the Return on Investment from Health Services Research: A Theoretical and Empirical Analysis
   Steven Lewis, Patricia J. Martens and Louis Barre

- Pillar IV: Population and Public Health Research "Assessing the Return on Canada's Public Investment in Population and Public Health Research:
  Methods and Metrics" by Alan Shiell and Erica Di Ruggiero

- MesoLevel Metrics for Impact "Metrics for the Treatment Sector or Meso Level of the Canadian Health Care System" by Jerald Hage

- Ethics and Evaluating Health Research "The Return on Investments (ROI) in Health Research: Ethical Aspects" by Michael McDonald and Bartha Knoppers

- Public Perspective on Health Research Funding "Translating Science into Hope: The Public Perspective on Health Research Funding" by André Picard

- Health Research Evaluation Frameworks: An International Comparison by Philipp Bastian Brutscher, Steven Wooding and Jonathan Grant

Appendix B: The Canadian Landscape for health research

Appendix C: Evaluation frameworks and methods

Appendix D: Issues for research evaluation

Appendix E: Indicators

Appendix F: Glossary

Appendix G: Methods

Appendix H: External Interviewees

Appendix I: Prospectus for a Major Assessment � The Return on Investments in Health Research: Defining the Best Metrics

 

 

 

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This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues.  [DD/ KMC Area]

"Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members".
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