European Community Health Indicators (ECHI)

Data Availability

Several data sources are used for international comparisons

Data for international public health comparisons may be retrieved from several data sources. Among them:

• The databases of Eurostat.
• The WHO Health for All database (WHO-HFA database).
• The WHO European mortality database (WHO-MDB database).
• The OECD Health database.
• The database of EUCAN/GLOBOCAN (for cancer).
• European indicator projects, for example:
• The MINDFUL mental health indicator database.
• EUROTHINE - Tackling Health Inequalities in Europe; providing data on health inequalities.
• EUDIP/EUCID - European Diabetes Indicators Project and the European Core Indicators in Diabetes project; providing data on diabetes.

ECHI makes use of international databases. In cases where no regular/adequate data are available in these databases ECHI uses either project results as interim solution and/or national level data.

Availability of data for ECHI shortlist indicators

As shown by ECHIM project’s final report (Kilpeläinen et al., 2008), the availability of ECHI shortlist indicators varies between 60% and 100%, for a set of 18 countries. For quite a few countries, the actual availability turns out to be better when consulting national experts, than is apparent from the international databases of WHO, OECD and Eurostat. This implies that for several topics, countries do have data available, but these have not yet been sent or incorporated into the international databases.

The best available data are not always the best for international comparisons

Sometimes the preferred data for national trends are not the best data for comparisons with other countries. For example, the chronic disease prevalence; for comparability reasons EHIS is preferable, but for validity reasons a register based estimate, as done within the Eurostat morbidity strand, is preferable. The latter therefore will be more informative regarding the actual national situation.

Issues of data comparability

Common comparability issues

Data from different countries on the same indicator may have comparability problems for a variety of reasons. In many cases these problems are specific for a certain data source type:

Causes of death

Although the International Classification of Disease (ICD) is very precise, regional differences in medical practice and training may lead to differences in coding, especially in cases of multi-morbidity. This source of bias is decreasing and ICD-based data on causes of death are nowadays considered among the best comparable within the EU.

Another issue regarding ICD is that the change from ICD-9 to ICD-10 did not take place simultaneously in all countries. This may cause temporary differences (sometimes shown as trend breaks) or differences between specific countries.

Infant and perinatal mortality

There are variations among countries in what circumstances premature infants are reported as live births. Parameters such as gestational age, birth weight and plurality (e.g. twins, triplets) affecting perinatal and infant mortality rates. The interpretation of data is limited when different countries are using different limitation of gestational age and or birth weight to define live birth.

In addition, other factors might influence the variability of pregnancy outcomes e.g., the mother’s age, mother’s alcohol consumption, use of folic acid, whether screening for congenital anomalies widely used within a country etc. (Buitendijk et al., 2003; Lack et al., 2003). The PERISTAT project (Lack et al., 2003) has recommended a number of improvements in this politically sensitive area.

Disease-specific morbidity

In order to produce comparable data, the mechanism of data collection has to be included in the indicator definition. For example, the indicator ‘prevalence of diabetes’ can theoretically be derived from hospital discharge statistics, from primary care contacts, from population surveys (question ‘do you have diabetes?’), or from Health Examination Surveys in which blood glucose is measured and thus also previously unknown diabetes is recorded. These four data sources will produce different figures, as they basically measure different things.

Another problematic group of indicators is in the area of mental health and related conditions (e.g. depression, Alzheimer). Here, the samplings frame of a survey and the response behaviour (how to get mentally ill persons to respond to a questionnaire?), are crucial for the outcome. The ideal instrument for this area is a full-coverage disease register, as is used in many countries for certain cancers and for some communicable diseases.

Items derived from Health Interview Surveys

These normally include perceived and functional health, a range of health determinants, and issues of health services utilization. Problems may include difficulties in translating the same meaning into different languages, as well as cultural differences in interpreting linguistically similar expressions. Apart from that, a major issue is to arrange for representative and similar sampling frames, e.g. in terms of age groups and inclusion of institutionalized persons and minorities.

Data derived from medical registers

Hospital-based data, but especially data from primary care or outpatient registries, may lack precise comparability due to national differences in the organization of the health delivery system. Other sources of bias include different classification systems and coding rules, differences in admission and discharge practices, and different patient populations.

General

Comparability may be hampered by differences in the age composition of populations. For mortality, it is common practice to solve this problem by direct standardization. This is possible because the basic data for mortality are always age structured. For many other health issues the exact age is either unavailable, or the sample sizes are too small to make meaningful calculations.

Issues of data quality

Do the data measure what they intend to measure?

Quality aspects play a role in comparability. Aspects of data quality include:

• ‘validity’: this refers to the question of whether the instrument we use is adequate to measure the phenomenon we want to monitor. For instance, the ‘burden of disability’ can be assessed by measuring the number of people receiving disability benefits, but this tells us nothing about the burden of the disability in terms of functional capacity.
• ‘reliability’: this may relate to issues like sampling frame and size, statistical significance, representativeness, population background of the measurement, sensitivity to seasonal fluctuations, etc. For example do the trends and differences shown reflect real differences, and are they reproducible?

ECHI background and concepts

Comparable health information is a major priority for the European Commission

The ECHI shortlist has resulted from a series of activities under three subsequent EU programmes, i.e. the Health Monitoring Programme (1998-2003), and the ‘Health Information strands’ within the first (2003-2008) and second (2008-2013) Programme of Community Action in the Field of Health.

The Health Monitoring Programme has aimed at ‘the establishment of a Community health monitoring system’, in order to:

• Measure health status, its determinants, and trends therein throughout the Community.
• Facilitate the planning, monitoring and evaluation of Community Programmes and actions.
• Provide Member States with appropriate health information to make comparisons and support their national health policies.

ECHI long list of indicators

As a first step towards the implementation of these aims, a comprehensive set of over 200 indicators was proposed by the ECHI-1 project (i.e., ECHI long list). These indicators originated from a large number of indicator projects under the coordination of EU Health Monitoring Programme. The following criteria guided the selection of these indicators:

• Cover the entire public health field. See also Conceptual model of the basic principles governing public health (De Hollander et al., 2007).
• Meet user needs: serve policy actions for MS, EU
• Where possible use earlier work of international organizations (Eurostat, OECD and WHO-Europe) in defining indicators, but also allow for innovations

The formation of ECHI shortlist

As ECHI long list expanded too much to be practical, the ECHI-2 project selected the so-called ECHI shortlist, in order to prioritize and focus the European Commission’s work for harmonization of data collection by EU Member States.

The indicators on the shortlist were selected from the long list by a panel of public health generalists, discussed and amended in all Working Parties operated under the Public Health Programme (2003-2008) and finally adopted by DG Sanco as a central basis for further work.

The shortlist selection was guided by two additional criteria:

• The indicator should be relevant from the point of view of the ‘general public health official’.
• The indicator should be oriented towards the ‘large public health problems’, the ‘large health inequalities’ and the ‘large possibilities for improvement’, in terms of health impact and options of (cost-)effective intervention.

Preparing for implementation of the shortlist

During 2005-2008, the ECHIM project has continued the work on the ECHI shortlist by:

• Improving and expanding the definitions, data source description and documentation of each indicator, laid down in ‘documentation sheets’.
• Mapping the availability of the indicators and underlying data at national level, by analyzing the existing international databases (WHO-HFA, Eurostat, OECD), and by a survey among the Member States.
• Setting up a network of national health information specialists

Starting the implementation process

In 2009 the work is continued in a so-called ‘Joint Action’, in which DG Sanco works together with the Member States and Eurostat, to further improve the implementation of the ECHI shortlist and other indicators throughout the EU. Main areas of work within the Joint Action for ECHIM will be:

• Finalisation of indicator development and documentation
• Implementation of shortlist indicators in the Member States (i.e., introducing the indicators to national (and possibly regional/local) administrators and decision makers and modifying existing data sources and creating new data sources in order to improve national data availability and quality).
• Description of data flow & pilot for data collection and reporting for those ECHI shortlist indicators for which no regular and adequate data are available in the international databases.

Click here for more information on the products of ECHI(M) projects and the Joint Action for ECHIM. In addition, the website of the current Joint Action of ECHIM is accessible here.

Utilizing ECHI shortlist

The use and dissemination of the ECHI shortlist is increasing

The ECHI shortlist is an important cornerstone in building the envisaged ‘European health information and knowledge system’. It has already adopted as a basis for several activities:

• The European Commission (DG Sanco as well as Eurostat) have started to use the ECHI shortlist as a basis for activities connected to the harmonization of data collection by Member States. DG Sanco is publishing data according to the shortlist on its website. More comprehensive and interactive ECHI data presentations are currently being developed by the European Commission and the ECHIM experts for publication on the Sanco site. Hyperlinks have been established between the EU Public Health Portal and the EUPHIX website .
• Several European countries (e.g. Ireland, Latvia and Cyprus) use the ECHI shortlist to guide data collection in their country.
• The importance of the shortlist is also underlined by the European regulation on community statistics on public health and health and safety at work that takes the ECHI shortlist as one of the starting points (EC, 2008b).
• The Council of the European Union has welcomed the new European Health Strategy 2008, which emphasizes the importance of a ‘System of European Community Health Indicators with common mechanisms for collection of comparable health data at all levels’ (EC, 2007; Council, 2007).
• The Council ‘calls upon the Member States and the Commission to build upon existing work on health indicators and select and measure the relevant ones for monitoring and evaluation of the Health Strategy’ (Council, 2007).

WHO

The World Health Organization (WHO) is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

For more information see WHO-Europe website.

WHO has several statistical databases. ECHI makes use the European health for all database (WHO-HFA) which contains data on about 600 health indicators and allows analysis of trends and international comparisons to support the formulation and monitoring of health policy at national and international levels.

Examples for indicators in which WHO-HFA serves as the preferred source for ECHI are “total alcohol consumption”, and “vaccination coverage in children”.

OECD

The Organisation for Economic Co-operation and Development (OECD) brings together the governments of countries committed to democracy and the market economy from around the world to support economic growth and raise living standards. OECD has 30 member states; 23 of them are European. It is a source of comparable statistics in economic and social data. OECD also collects data and monitors trends, analyses and forecasts economic developments and researches social changes or evolving patterns in trade, environment, agriculture, technology, taxation and more. OECD has a dedicated database for health data, which is updated annually.

Examples for indicators in which OECD Health Data serves as the preferred source for ECHI are “insurance coverage”, and “30-day in-hospital case-fatality AMI and stroke”.

For more information see OECD website.

EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) provides the EU and its Member States with a factual overview of European drug problems and a solid evidence base to support the drugs debate. It offers policymakers the data they need for drawing up informed drug laws and strategies. It also helps professionals and practitioners working in the field pinpoint best practice and new areas of research.

EMCDDA is the preferred data source for ECHI for indicators such as “drug-related deaths” and “use of illicit drugs”.

For more information see EMCDDA website.