Hard, harder, hardest: principal stratification, statistical identifiability, and the inherent difficulty of finding surrogate endpoints

Doing it hard in the bush: Aligning what gets measured with what matters

What gets measured gets managed. Funding of health services is substantially determined by operational activity and specific outcome indicators. In day-to-day clinical decision-making, surrogate markers, such as glycosylated haemoglobin and blood pressure, are commonly used to modify risks of 'hard' outcomes that include kidney failure, ischaemic cardiac events, stroke and all-cause mortality. In many settings, surrogates are all we have to go on. As a consequence, current health funding models heavily rely on surrogate-based key performance indicators [KPIs]. While surrogates are convenient and provide immediate information, there is an obligation to ensure that they are appropriate, reliable and validated in context. In contrast, hard outcomes, the real consequences of illness, are usually realised over an extended timeframe. Additionally, and for a host of reasons, hard endpoints have the greatest social, emotional and economic impact for people at the far end of the health system; those in rural and remote settings - 'in the bush' - especially Indigenous Australians. We propose a health service assessment approach that aligns short-term decision-making with patient-centred and longer term hard outcomes, one that takes into account community, cultural and environmental factors, especially remoteness. Communities should have a major say in determining what health indicators are measured and managed.