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Public Health and Clinical Medicine
Natural Partners
Paul Jarris, MD, MBA
Executive Director
Association of State and Territorial Health Officials
ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin Islands
ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin islands
10 Essential Public Health Services
Monitor health status to identify community problems.
Diagnose and investigate health problems and health hazards in the community.
Inform, educate, and empower people about health issues.
Mobilize community partnerships and action to identify and solve health problems.
Develop policies and plans that support individual and community health efforts.
10 Essential Public Health Services, Cont’d
Enforce laws and regulations that protect health and ensure safety.
Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
Assure a competent public health and personal health care workforce.
Evaluate effectiveness, accessibility, and quality of personal and population- based health services.
Research for new insights and innovative solutions to health problems.
Determinants of Health
Debisette, et. al., 2005
Determinants of Health (by percent contribution)
40
30
15
10
5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Determinants of Health
Environmental Exposures
Medical Care
Social Circumstances
Genetic Predispositions
Behavioral Patterns
McGinnis et. al., 2002
US Spending on Health
Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis, and U.S. Bureau of the Census.
National Health Spending (2005)
$1,661.40
$143.00
$126.80$56.60
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
$1,987.80
Per Capita Total
Government Public HealthActivities
Investment (Research andEquipment)
GovernmentAdministration and NetCost of Private HealthInsurance
Personal Health(Hospital/ClinicalServices, Nursing Home,Home Health Care,Medical Products)
Clinical Interactions
Year one and two: 13 visits All ages: 3.1 visits
Typical patient with a Chronic illness 4 visits/year X 30 minutes = 120 minutes 365 X 24 X 60 = 525,600 minutes per year 120/525,600 = 0.02% of time
The Real Threats to Our Health
Prevention
Primary prevention/Universal Reduction or control of causative factors for a health
problem and includes reducing risk and environmental exposures
Secondary prevention/Selective Early detection and treatment
Tertiary prevention/Indicated Appropriate supportive and rehabilitative services to
minimize morbidity and maximize quality of life
CDC, 1992
Prevention in Public Health
Policy Development and Implementation
Population-based Services
Direct Services
Example: Smoking Interventions*
Clean Indoor Air Legislation
Tobacco Price Increases
Mass Media Campaigns
Telephone Quitlines
Provider reminders with Provider education
*Recommended with Strong Evidence by the Guide to Community Preventive Services
Smoke-Free Laws
March 2007* The Montana and Utah laws extend to bars in 2009. * Arizona law effective 5/1/07; New Mexico law effective 6/15/07
Restaurants
Restaurants & Bars
Effects of a 10% Increase in Tobacco Price
Nearly 7% decline in youth prevalence
A 2% decline in adult prevalence
A 4% decline in overall consumption
Mass media campaigns when combined with other interventions
Median decrease in tobacco use initiation in youth exposed to mass media campaigns was eight percentage points.
Studies evaluating the impact of mass media campaigns on statewide tobacco consumption found a median decrease of 15 packs per capita per year.
Patient telephone quitlines
Median improvement in quit rates among smokers who used telephone support when compared with smokers who did not was 41 percent.
When combined with other interventions such as medical therapies, telephone quitlines were found effective in helping smokers quit in both community and clinical settings.
Provider reminders with provider education
Studies that evaluated healthcare systems interventions to encourage provider efforts to advise patients on tobacco use cessation showed that: Median absolute
percentage increase in the number of patients who received provider advice on cessation was 20 points
the median absolute percentage increase in the number of patients who quit was 4.7 points.
Provider reminders alone were only found to be recommended with sufficient evidence
Poor Diet and Physical Activity
Obesity Is Linked To A Significant Increase In Chronic Conditions
010203040506070
Obesity
Aging 30-
50
Poverty
Smokin
g
Heavy
Drin
king
Past S
mokin
g
% increase in chronic conditions
Baseline – comparable normal weight individuals with no history of smoking or heavy drinking
Sturm R. Health Affairs. 2002; 21 (2): 245-253Public Health. 2001; 115:229-295
Increased Risk of Obesity-Related Diseases with Higher BMI
Disease
BMI of 25 or less
BMI between 25 and 30
BMI between 30 and 35
BMI of 35 or more
Arthritis 1.00 1.56 1.87 2.39
Heart Disease 1.00 1.39 1.86 1.67
Diabetes (Type 2)
1.00 2.42 3.35 6.16
Gallstones 1.00 1.97 3.30 5.48
Hypertension 1.00 1.92 2.82 3.77
Stroke 1.00 1.53 1.59 1.75
Centers for Disease Control. Third National Health and Nutrition Examination Survey. Analysis by The Lewin Group, 1999 .
Deaths Per Thousand Adults
2.50
2.25
2.00
1.75
1.50
1.25
1980 1990
2000
2010
2020
2030
2040
2050Time (Year)
No Change
Obesity Prevention
Better Care
Reducing diabetes deaths: options
Systems Dynamic Change Model
Deaths from comp per thousand Adults
No major changes – status quo
Care and reduction in caloric intake
2.50
2.25
2.00
1.75
1.50
1.25
1980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Obesity Prevention and Better Care
No Change
Reducing diabetes deaths:The Vermont Blueprint Approach!
America’s Obesity Epidemic
Overweight adolescents have a 70% chance of becoming overweight or obese adults.
The percentage of overweight children has more than doubled in the past 20 years.
65% of U.S. adults are overweight. 30% are obese.
Connecting Health & the Environment
Modern American communities are designed for cars, not walking, recreation, or physical activity.
Kids Don’t Walk Anymore!
Only 13% of kids walk to school today Up to 90% who lived a mile away walked to
school in the ‘70s
Fear of crime and safety concerns are top reasons parents don’t allow kids to walk to school – each year 5,000 pedestrians die
The Built Environment Influences Health
ASTHO’s Policy Statement
State and local governments, private developers, and community groups can promote physical activity by increasing access to: Sidewalks, playgrounds, parks, bike
paths, and safe streets & neighborhoods.
Community groups and local governments can work together to increase capital improvement projects that promote physical activity.
Public Health Focus
School-based interventions Worksite interventions Healthcare system interventions Community-wide interventions
New York’s Healthy Heart Program Comprehensive Approaches to Promote Activity
Developed toolkit to promote walking and biking trails.
Conducted over 15 Walkable Community workshops in the state With NY DOT and law enforcement.
Convenes local decision makers, health and planning professionals, to learn how to make communities more pedestrian friendly and safer
Goals Create walking and bicycle
trails Increase physical activity
options in after-school programs
Open schools for physical activity use by residents before and after school hours
Arkansas Addresses Childhood Obesity
Three years of statewide assessments of student BMIs reveals that the progression of the childhood obesity epidemic has been halted in Arkansas.
Linking Public Health and Clinical Medicine Vermont Blueprint for Health
Source: Vermont Department of Health, Agency of Human Services, 2007
Self Management
99.98%
Healthier Living Workshop
Stanford University Stanford Patient Education Research Center
Kate Lorig
http://patienteducation.stanford.edu/programs/cdsmp.html
•11 Hospital Service Areas•80 Certified Professional and Lay leaders•Over 300 Vermonters
Self Management Participants
Linking Public Health and Clinical Medicine Vermont Blueprint for Health
Source: Vermont Department of Health, Agency of Human Services, 2007