Measuring health status: information for primary care decision making

Abstract

Primary Care Trusts (PCTs), charged with improving the health of their population, need to measure the extent to which patients actually benefit from the health care that is provided for them. One way of achieving this is to measure health status of patients over time. The study described here reports on the feasibility of administering the EQ-5D in general practitioner (GP) surgeries and identifies how the results might be used by practices and PCTs to improve the health of their populations. The study took place in an opportunistic sample of 1942 patients attending GP surgeries. One year later, patients who had provided contact details were sent another EQ-5D together with a request for additional information about their use of health care services in the intervening time period. A total of 770 patients completed this follow-up questionnaire. There were significant age effects associated with variation in self-reported health status and also associated with top-level Read diagnostic codes in some groups of patients. The results showed that EQ-5D could be used by individual GP practices to identify patients with specific health problems. This knowledge can also be used by PCTs and other primary care organisations, to better target scarce health resources.

Introduction

In England, newly constituted Primary Care Trusts (PCTs), based on groups of general practices, are charged with delivering three core functions: improving the health of the population, developing primary and community services and commissioning community and hospital services [1]. None of these functions can be properly discharged if PCTs are unable to measure the extent to which patients actually benefit from the health care that is provided for them. Improving the health of local populations requires specific knowledge of current levels of health status, which can be compared with similar observations at a future date. Commissioning health care services carries with it the need to prioritise and, by implication, the need to make efficient use of scarce health care resources. To do otherwise is to fail the legitimate interests of the community. The functions of the PCT mirror similar responsibilities of other organisations concerned with health and health care. The new Strategic Health Authorities that oversee the PCTs have similar information needs. Local Authorities too, with their specific responsibility for social care and new joint working arrangements, share a common focus of interest. All of these agencies confront a central recurring theme, namely the need to measure the impact of the services that they provide.

There is political and managerial pressure for such measurement, as can be seen by the emphasis currently given to performance indicators and league tables. However, the limited usefulness of such indicators as mortality rates or waiting list size points to the urgent need for a practical means of generating more relevant and direct measures of outcome. Measuring outcomes is not merely an aspirational objective for managers; it is a key element of clinical practice, providing essential information about a patient’s response to treatment. Sometimes such information is elicited informally, as an incidental part of the patient encounter with health care professionals but over the past decade there has been a growing acceptance of the need for a more systematic record [2], [3]. Generic measures [4], [5], [6], [7], [8], [9] have been developed as a means of systematically recording health status in individual patients and groups of patients. EQ-5D is one such measure. Developed by the EuroQoL Group, an international multidisciplinary research network [10], EQ-5D was designed as a brief measurement instrument for recording self-assessed health status. It defines health in terms of five dimensions—mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension is divided into three levels representing no problem, some problem and extreme problem. A total of 243 health states are defined by combining one level from each of the five dimensions. An additional two states (unconscious and dead) are included in the full set of EQ-5D health states but for obvious reasons are excluded from the self-completion questionnaire.

The EQ-5D questionnaire consists of two pages, the first of which records the respondent’s level of problem on each of the five designated dimensions. The second page records the respondent’s overall health status on a 20 cm visual analogue scale (EQ-5D_vas) graduated between 0 (indicating worst imaginable health state) and 100 (indicating best imaginable health state). Data from the EQ-5D questionnaire can be presented as a profile simultaneously indicating levels of problem on the five component dimensions. A patient’s responses to the five dimensions identify the unique EQ-5D health state into which they should be assigned. A weighted index (EQ-5D_index) can be computed for each of these states based on the values of the general public elicited previously in a UK national survey [11].

This paper reports on a study in which the EQ-5D was used to monitor changes in health status in a general practice setting in England. Using the EQ-5D individual practices, PCTs and other agencies with an interest in health can identify variations within the patient population, comparing local data with normative population levels, and monitor changes in health status by diagnostic sub-group over time. This is a far-reaching agenda and the study reported here provides an early indication of what might be expected from a larger, more ambitious replication.