Assessing Value in Upstream Health Interventions: A Case Study of the Dr. Paul Schwann Centre Cardiac Rehabilitation Program
In the past several decades, a major ideological shift has occurred regarding the relative importance of broad socioeconomic factors as determinants of health over access to conventional health services. During this time, public health experts have continually re-emphasized the need to focus attention further “upstream” of disease, in order to prevent populations from developing poor health. While provincial health systems currently integrate some population and public health programming within the basket of services they offer, upstream health interventions represent only a very small proportion. While many factors can explain this pattern, one explanation is key; upstream health interventions must compete against conventional “downstream” services for a single funding pool, and in this evaluation process, three unique challenges arise. First, there must be a convincing argument that governments should intervene in these private markets to produce a socially optimal outcome. Second, there are unique challenges that arise in measuring the outcomes of upstream interventions, as upstream interventions tend to relate to broader social values that occur over the long-term rather than immediate, quantifiable improvements in health. Third, there have been structural challenges within the system of healthcare administration in Canada. As a result of these three challenges, upstream health interventions are often undervalued and can become subject to great financial instability. This is demonstrated by one upstream program in the Regina Qu’Appelle Health Region – the Dr. Paul Schwann Centre Cardiac Rehabilitation Program. This research investigates the policy problem of assessing value in upstream interventions through a case study of this upstream health intervention. Through a three-pronged analysis of program-level data, this thesis explores the question of how evidence in preventative health interventions can be synthesized with greater policy relevance to inform the reallocation of scarce healthcare dollars from downstream illness care interventions to the upstream. To explore these policy-relevant dimensions – effectiveness, client experience, and cost-effectiveness – three methodologies were used: (1) a quantitative analysis of available client health data to assess changes in health status throughout the program’s duration; (2) qualitative interviews with clients and staff to assess perceptions of experience, health impact, and overall value for money in the program; and (3) quantitative assessment of cost-effectiveness using economic evaluation techniques to allow for comparison to other health interventions. By comparing the results of these assessments to other studies from the literature, lessons were drawn regarding the potential health system value of such a program for the regional health system. While various methodological and data-related limitations must be recognized, this study demonstrates the ability to overcome some traditional challenges in the evaluation of upstream health interventions. As one example of this type of evaluation, this research acts as a guiding example for future studies examining health systems value of upstream interventions. By using multiple dimensions of relevance to policy and decision-making, findings of this research suggest that the use of mixed method research and evaluation methodologies may best illuminate the broader social and health-related outcomes of prevention-oriented programs in addition to their quantifiable outcomes.
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Faculty of Graduate Studies and Research, University of Regina