Chronic Disease - CDNR Winter/Spring/Summer 2004 - California: How Are California Counties Using HRQOL Data?

CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 16 • Number 2/3 • Winter/Spring/Summer 2004

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In two of California’s more populous counties, the Behavioral Risk Factor Surveillance System’s Healthy Days measures have been used to assess the impact of chronic physical and mental health conditions on people’s daily lives and estimate the economic burden of chronic disease in the county.

Los Angeles County
CDC’s Healthy Days questions (see sidebar) were used in the 1999–2000 Los Angeles County Health Survey (a random-digit–dialed telephone survey of 8,354 noninstitutionalized adult residents) to assess the substantial toll that chronic health conditions impose at both the personal and societal level.

“Our leadership has been a strong supporter of adding health-related quality of life questions to this survey,” said Paul Simon, MD, MPH, director of L.A. County’s Office of Health Assessment and Epidemiology. “Our health officer has really pushed our department to develop a more active presence [in this area].”

After adding CDC’s Healthy Days questions to its biannual survey, researchers found that county residents reported higher average numbers of both unhealthy and activity limitation days than were reported overall in California and in the United States. However, it was unclear whether these differences reflected true disparities in health status or demographic variations between the populations.

L.A. COUNTY Healthy Days Measures

The following questions were asked in the 1999–2000 Los Angeles County Health Survey (random-digit–dialed telephone survey of 8,354 adult residents):

Would you say that in general your health is excellent, very good, good, fair, or poor?
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

Responses to the second and third questions were added together to estimate the total number of days in the past month that the respondent felt that either his or her physical or mental health was not good, a summary measure referred to as “unhealthy days.” Responses to question four were used to estimate the number of days in the past month that activity was limited because of poor physical or mental health, referred to as “activity limitation days.”

The survey findings also reinforced a large body of research linking poor health outcomes with lower socioeconomic status—those county residents at the lower end of the socioeconomic scale reported poorer health and function than those with higher income and education levels. The county’s report states, “[Prior] research has provided strong evidence of the importance of the physical and social environments on overall health and of the importance of considering these environments in developing community health improvement strategies. For example, efforts to improve the quality of primary school education, increase adult literacy, expand employment opportunities, and strengthen local economies can all be considered potential interventions to improve community health.”

The burden of chronic disease is highlighted by survey findings showing that more unhealthy and activity limitation days are reported among those suffering from chronic conditions such as heart disease, diabetes, depression, arthritis, and asthma.

Dr. Simon stated, “The survey has been a powerful tool for our department. We use it to advocate for areas where we don’t think enough is being done. We also analyze disability-adjusted life years (DALYs) and put out a report on disability.”

In a presentation at CDC’s 2003 Chronic Disease Conference, Dr. Simon reported that even though chronic diseases are the leading cause of premature death and disability worldwide, most local health jurisdictions have limited data on the burden of chronic diseases. Available information generally includes mortality statistics and not much more.

To address some of the knowledge gaps in this area, Los Angeles County conducted a study to explore the combined impact of multiple chronic conditions on functional status and health-related quality of life (HRQOL).

The county limited its study to nonelderly adult residents (18 to 64 years of age) and assessed the impact in this population of selected chronic health conditions on people’s functional status based on activity limitation days (ALDs), a validated measure of HRQOL. Researchers also examined countywide variation in chronic disease impact by age, sex, and race/ethnicity. The analysis was restricted to 1999 survey data from 7,121 adults in the selected age group who reported that they had ever been diagnosed by a health care provider with heart disease, diabetes, arthritis, depression, or asthma, conditions that cause the most ALDs in the county.

Based on their analysis, researchers concluded that at least one in four nonelderly adults in Los Angeles County has been diagnosed with a chronic disease and that the five chronic conditions included in the analysis account for at least 40% of all ALDs in this population. Furthermore, they found that although the prevalence of adults with multiple chronic conditions is relatively low, this group accounts for a disproportionately high burden of ALDs.

As might be expected, the study confirmed that chronic disease impact increases with age. Investigators also found a higher impact among women than men, and a lower impact among Hispanics (possibly reflecting a younger age distribution and higher level of undiagnosed disease) than among whites and blacks.

Dr. Simon reported that such findings present significant opportunities for reducing the burden of chronic diseases in the nonelderly adult population. For more information about study findings, call the Los Angeles County Office of Health Assessment and Epidemiology at 213/240-7785 or visit its Web site at http://www.lapublichealth.org/ha/.*

San Diego County
The United Way of San Diego County established the Outcomes and Community Impact Measurement Program after eight task forces representing county residents and community leaders developed the following list of desired countywide outcomes in 1995:

Based on these desired outcomes, the United Way designed a program to examine the impact of community assets and services on meeting people’s needs and expectations. This program, the Outcomes and Community Impact Program, then conducted a health survey among 3,711 randomly selected county residents. Part of the survey focused on the perceived general health status and quality of life of county residents. Findings were examined by the respondents’ geographic location, age, race and ethnicity, educational level, income, and other characteristics, and projections based on these findings were made for the entire current population of San Diego County.

Overall findings from the survey revealed that within each demographic subgroup, from 37.4% to 82.1% of respondents reported their perceived level of health as very good or excellent. Hispanic respondents were the least likely to report very good or excellent health, whereas whites were significantly more likely than either Hispanics or blacks to report very good or excellent health.

Other groups more likely to report very good or excellent health were college graduates and persons with commercial or military insurance coverage. The percentage of those reporting their health as very good or excellent increased with annual household income, ranging from 44.5% for those with incomes of $20,000 or less to 82.1% for those with incomes of $100,000 or more annually.

The majority of county residents (59.8%) reported no days of poor physical health in the 30 days preceding the survey, but 4.8% said their physical health had not been good for the entire past month. By demographic subgroup, the average number of days respondents reported their physical health as not good ranged from 2.0 days for persons with $100,000 or more in annual household income to 6.2 days for those covered by the state’s Medi-Cal health insurance program. Persons who were widowed reported a significantly higher mean number of days in poor physical health than persons of other marital status.

Overall, survey respondents reported an average of 3.0 days of poor mental health and an average of 1.9 days when they were prevented from doing their usual activities due to poor physical or mental health within the past 30 days. Nearly 7% reported being physically disabled.

Findings such as these help policy makers determine whether the large annual investment in improving the health and well-being of San Diego County residents is making a difference.

Future Directions
Other large California counties are expressing interest in using CDC’s Healthy Days measures. In a 2001 Orange County Health Department newsletter, Health Officer Mark Horton, MD, MSPH, wrote:

According to Holly Hoegh, Director, California Behavioral Risk Factor Survey, most California counties have not used BRFSS data for Healthy Days measures to date because of the small sample sizes. Instead, they rely on findings from the biannual California Health Interview Survey (CHIS), a collaborative project of the UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute.

Surveying more than 55,000 Californians in 2001, CHIS is the largest health survey ever conducted in any state, and one of the largest health surveys in the country. Its findings give health planners, policy makers, county officials, and other interested groups and communities a detailed picture of California’s diverse population’s health and health care needs. The survey is conducted by telephone in numerous languages and in 2003 included some of the health-related quality of life questions in CDC’s BRFSS. For more information about CHIS, visit http://www.chis.ucla.edu/.*