Epidemiologic Methods for Health Policy This page intentionally left blank Epidemiologic Methods for Health Policy ROBERTA. SPASOFF New York Oxford OXFORD UNIVERSITY PRESS 1999 Oxford University Press Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape Town Chennai Dar es Salaam Delhi Florence Hong Kong Istanbul Karachi Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris Sao Paulo Singapore Taipei Tokyo Toronto Warsaw and associated companies in Berlin Ibadan Copyright © 1999 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Spasoff, R. A. Epidemiologic methods for health policy / Robert A. Spasoff. p. cm. Includes bibliographical references and index. ISBN 0-19-511499-X 1. Epidemiology. 2. Medical policy. I. Title. RA652.S67 1999 362.1—dc21 98-50116 987654321 Printed in the United States of America on acid-free paper Preface Why another book on epidemiology and health policy? Because as the study of the health of populations, epidemiology can make a unique contribution to health policy, and because no book focusing on the most relevant methods appears to exist at present. Textbooks of general epi- demiology tend to ignore this subject and the descriptive epidemiologic methods that are most relevant to it, and to focus almost entirely on etio- logical research. Several books on epidemiology and health policy have dealt more with examples than with methods, and have aimed at very wide audiences, including both epidemiologists and policymakers; none appears to be in print now. This text is intended for persons who have completed a basic course in epidemiology, especially graduate students and epidemiologists who wish to apply their discipline to the development and evaluation of health policy. I use it as the textbook for a course in epidemiology and health policy. Many readers will work in government, health planning councils, public health units, or policy institutes, although some may work in professional organizations or industry. Others will work in uni- versities, but want their work to be directly relevant to the above organi- zations. The book is intended as a contribution to the development of evi- dence-based policymaking. It is not an introduction to epidemiology for policymakers, although it attempts to introduce policy to epidemiolo- gists. Since there is usually more than one way to look at policy, two or more authorities are quoted in many cases, to give the reader a sense of the range of approaches available. The book is concerned mainly with public policy, the policies of govern- ments, and is oriented toward developed countries. A major decision in producing such a book concerns the distinction between policy and programs, specifically whether to address health services planning and evaluation at the program level. This book does not address the planning and evaluation of specific programs, although it does cover the assess- ment of concepts or approaches that are reflected in specific programs. Thus, the book considers epidemiologic methods that might be used to assess the evidence regarding the community effectiveness of early- vi Preface discharge programs from hospitals, but not methods to evaluate the early-discharge program in a specific city at a specific time. Similarly, it does not directly address personal health services, although it will be more relevant to public health services, which have more of a policy orientation. The book has two parts. Part I deals with general issues. Chapter 1 in- troduces the subject of public policy and its formation, and reviews the potential contribution of epidemiology to it. The chapter then addresses ethical and political issues faced by epidemiologists working in policy and ends with a few comments on communications. Chapter 2 presents selected epidemiologic methods that are relevant to the whole health policy cycle, borrowing heavily from demography and lightly from eco- nomics. In recognition of the readers' (possible) and the author's (un- doubted) limitations, mathematical content is confined to elementary al- gebra. Chapter 3 focuses on health data, important raw material for health policy, reviewing their sources and uses and some methods for handling them. Part II systematically follows the policy cycle, presenting and dis- cussing the epidemiologic methods that are useful at each step, with ex- amples. Chapter 4 addresses measurement of the health of populations, including developing a population health profile, identifying health needs and risks, and assessing the evidence for the causes of health prob- lems (with emphasis on the role of ecological studies). Chapter 5 consid- ers the assessment of evidence on the effectiveness, efficiency, potential coverage, and feasibility of potential interventions available to address health problems, and discusses the contribution of meta-analysis to health policy. Chapter 6 tackles the difficult area of making choices among the available alternatives, beginning with the choice between pre- vention and treatment, proceeding to the use of disease modeling, and ending with the setting of priorities. Chapter 7 deals with policy imple- mentation, including definition of health goals, allocation of health re- sources, and ensuring that the necessary data are collected for monitoring and evaluation. Finally, Chapter 8 closes the policy loop by considering the evaluation of policy and the continuing monitoring of health, includ- ing the role of surveillance in the identification of emerging problems. This book grows from more than 25 years of teaching epidemiology and working with persons in governments, public health departments, and health planning councils. I hope that it will help other epidemiolo- gists to stumble less often and make their epidemiologic contributions more efficiently. Marchl999 R.A.S. Ottawa, Ontario Acknowledgments The University of Ottawa granted a sabbatical leave during which the ini- tial hard thinking for this book was conducted, and allowed the writing of a textbook as a legitimate academic activity. Louise Gunning-Schepers provided a wonderfully supportive environment during that year at the Institute of Social Medicine, University of Amsterdam, not least through her inspired demonstrations of the possibilities for applying epidemiol- ogy to health policy. A WHO Travel Fellowship permitted additional study of European experience. My colleagues at the University of Ottawa, Nick Birkett, John Last, Andreas Laupacis, Ian McDowell and Rama Nair, allowed me to bounce ideas off them and corrected many misapprehen- sions. The students in my graduate course on Epidemiology and Health Policy have enjoyed identifying fuzzy thinking and opaque writing. Parts of Chapter 3 are based on a Community Health Research Unit Working Paper, prepared in 1993 with Geoff Dunkley and David Gilkes. Louise Gunning-Schepers and Menno Reijneveld read an earlier draft of the en- tire book, and provided much useful advice on both content and organi- zation. Doug Angus and Don Wigle read and corrected the first chapter. Jeffrey House at Oxford University Press provided continuing guidance and exhibited great patience, while the comments from the readers re- tained by the Press improved the book immensely. Beyond that, the usual disclaimers. This page intentionally left blank Contents I. Concepts, Methods, and Data, 1 1. Policy, Public Policy, and Health Policy, 3 1.1 What is policy?, 3 1.2 Who makes policy?, 5 1.3 How is policy made?, 10 1.4 The policy cycle, 12 1.5 Policy studies, 17 1.6 Epidemiology and health policy, 20 1.7 Ethics and advocacy, 25 1.8 Legal issues: access to data and protection of privacy, 27 1.9 Communication skills, 28 2. Some Tools of the Trade, 32 2.1 Demography and vital statistics, 32 2.2 Composite indicators of health, 41 2.3 Epidemiologic indicators of effect, 47 3. Population Health Data, 57 3.1 Conceptualizing health, 57 3.2 Health data, health information, and health intelligence, 59 3.3 Population (denominator) data, 68 3.4 Health (numerator) data, 72 3.5 A population health information system, 82 II The Policy Cycle, 87 4. Assessment of Population Health, 89 4.1 Developing a population health profile, 89 4.2 Assessing health needs, 105 4.3 Risk and risk assessment, 114 4.4 Assessing causes of health problems, 118 x Contents 5. Assessment of Potential Interventions, 125 5.1 Assessing evidence from intervention studies, 125 5.2 Synthesizing evidence: systematic reviews and meta-analysis, 128 5.3 Assessing suitability for policy, 131 6. Policy Choices, 143 6.1 Prevention and disease control, 143 6.2 Predicting the effect of a policy on a population, 150 6.3 Priority setting, 156 7. Policy Implementation, 169 7.1 Goal Setting, 169 7.2 Allocating health resources, 172 7.3 Information systems, 179 8. Policy Evaluation, 182 8.1 Evaluating a current policy, 182 8.2 Monitoring health status, 189 8.3 Monitoring health care utilization, 195 References, 207 Index, 223 I CONCEPTS, METHODS, AND DATA Epidemiologists need to understand the policy process and to pos- sess relevant expertise if they are to work effectively within it.