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Reforming Disease Prevention and Health Promotion:
Population HealthSteven Teutsch, MD, MPH
Chief Science Officer
Los Angeles County Department of Public Health
September 15, 2009
Problem: America is Not Getting Good Health for Its Health Care Dollar
Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.
Prepared for the Robert Wood Johnson Foundation by the Center on Social Disparities in Health at the University of California, San Francisco. Source: OECD Health Data 2007.Does not include countries with populations smaller than 500,000. Data are for 2003.*Per capita health expenditures in 2003 U.S. dollars, purchasing power parity
3
Former Leading Causes of Death:Crude Death Rate for Infectious Diseases,
U.S., 1900 - 2000
MMWR, CDC, 1999
* Rate is per 100,000
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The Lifecourse Perspective:Early Childhood Impacts Adult
Health Status
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From Neal Halfon
Health Influences Over the Life Course
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From Neal Halfon
The Social and Physical Environments are Among the
Most Important Determinants of Health
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Income is Linked to Longevity Regardless of Race/Ethnicity
9“Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”
Education Matters:Mother’s Education Related to Infant
Mortality
10“Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”
Babies born to mothers who did not finish high school are almost twice as likely to die before their first birthday as babies born to college graduates
Education Matters: More Education Means Longer Life Expectancy
11“Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”
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The Hispanic Paradox:
Recent Immigrants have less diabetes and other health problems than those who have had longer exposure to our toxic socioeconomic and physical environment
Steven P. Wallace, Xóchitl Castañeda.Migration and Health: Latinos in the United States. 2008
The Toxic American Environment: Percent of Recent Immagrants and Long-term Residents
with Diabetes, United States, 2006
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Economic Hardship & Childhood Obesity
Economic hardship and childhood obesity go hand in hand
Improving Health Requires Actions at Multiple Levels
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Action Model to Achieve Healthy People 2020 Overarching Goals
• Behavioral outcomes• Specific risk factors, diseases, &conditions• Injuries • Well-being & health- related Quality of Life• Health equity
•Policies •Programs•Information
Assessment, Monitoring, Evaluation & Dissemination
Interventions
Determinants of Health
Outcomes
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Action Model to Achieve Healthy People 2020 Overarching Goals
• Behavioral outcomes• Specific risk factors, diseases, &conditions• Injuries • Well-being & health- related Quality of Life• Health equity
•Policies •Programs•Information
Assessment, Monitoring, Evaluation & Dissemination
Interventions
Determinants of Health
Outcomes
Smoking Quitlines
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Action Model to Achieve Healthy People 2020 Overarching Goals
• Behavioral outcomes• Specific risk factors, diseases, &conditions• Injuries • Well-being & health- related Quality of Life• Health equity
•Policies •Programs•Information
Assessment, Monitoring, Evaluation & Dissemination
Interventions
Determinants of Health
Outcomes
Nurse Home Visits
Smoking Quitlines
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Action Model to Achieve Healthy People 2020 Overarching Goals
• Behavioral outcomes• Specific risk factors, diseases, &conditions• Injuries • Well-being & health- related Quality of Life• Health equity
•Policies •Programs•Information
Assessment, Monitoring, Evaluation & Dissemination
Interventions
Determinants of Health
Outcomes
Nurse Home Visits
Smoking Quitlines
Work Safety
Healthy Homes
19
Action Model to Achieve Healthy People 2020 Overarching Goals
• Behavioral outcomes• Specific risk factors, diseases, &conditions• Injuries • Well-being & health- related Quality of Life• Health equity
•Policies •Programs•Information
Assessment, Monitoring, Evaluation & Dissemination
Interventions
Determinants of Health
Outcomes
Nurse Home Visits
Walkable Communities
Smoking Quitlines
Work Safety
Blood Alcohol
Laws
Healthy Homes
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Dead
Individual
Society
Well
Spectrum of Health and Strategies to Improve It
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Dead
Individual
Society
Well
Spectrum of Health and Strategies to Improve It
Clinical Strategies
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Dead
Individual
Society
Well
Education
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Worksite ProgramsSchool
Health
Population Strategies
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Dead
Individual
Society
Well
Disease Mgmt
Primary CareClinical Preventive Services Tertiary Care
Assisted Living
Clinical Strategies
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Dead
Individual
Society
Well
Disease Mgmt
Hospital Systems
Assisted Living
Integrated Health Systems
Medical Care System Strategies
Medical Home
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Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Spectrum of Health and Strategies to Improve It
How Do We Know What Works?Evidence-based Recommendations
So How Do We Apply Them to Prevention & Control of
Diabetes?
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Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Spectrum of Health and Strategies to Improve It
29
Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Screen hypertensives
Behavioral interventions to reduce screen time
Worksite programs for
overweight and obesity
Screen adults for obesity and offer
intensive interventions
Street-scale urban design/land use
Point-of-decision PromptsEnhanced School-based Physical Education
Preventing Onset of Diabetes: Reducing Obesity
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Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Worksite programs for
overweight and obesity
Social Support Interventions in Comm. Settings
Case Mgmt/ Disease Mgmt
Self-Mgmt Education (home /Community
Control BP / Lipids/ Smoking
Managing Diabetes
31
Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Dialysis
Maintaining Function in Diabetes
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Dead
Individual
Society
Well
Education
Disease Mgmt
Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal
Justice.
Hospital Systems
Primary CareClinical Preventive Services
Worksite ProgramsSchool
Health
Tertiary Care
Assisted Living
Integrated Health Systems
Screen hypertensives
Behavioral interventions to reduce screen time
Worksite programs for
overweight and obesity
Screen adults for obesity and offer
intensive interventions
Street-scale urban design/land use
Point-of-decision PromptsEnhanced School-based Physical Education
Social Support Interventions in Comm. Settings
Case Mgmt/ Disease Mgmt
Self-Mgmt Education (home /Community
Dialysis
Control BP / Lipids/ Smoking
A Comprehensive Approach to Preventing and Controlling Diabetes
What We Are Striving to Achieve
VisionA society in which all people live long, healthy lives.
Overarching Goals• Elimination of preventable disease, disability, injury, and
premature death • Achievement of health equity, elimination of disparities, and
improvement in the health of all groups • Creation of social and physical environments that promote
good health for all. • Promotion of healthy development and healthy behaviors
across every stage of life
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Healthy People 2020
Major Opportunities:Health in All Policies
• Opportunities in all sectors e.g. agriculture, transportation, housing, environment, commerce, tax policy
• In both public and private sector
• Examples:– Menu labeling– Tax on sugared beverages– Transportation systems that encourage mass
transit, biking and walking34
35http://www.ph.ucla.edu/hs/health-impact/
HIA: Estimation of Health Benefits from
a Living Wage Ordinance
36Bhatia , Katz, AJPH, 2001
Summary
• Prevention effective in clinical and population applications
• Large differences between best evidence and current practice
• Greatest opportunity: policies and programs targeting populations
• Policies in all sectors affect health• Can’t eliminate health disparities without
emphasis on social and physical determinants
The Challenge: Closing the Gap
• Cannot be done by just fixing the health care system
• Must address the underlying social and physical environment determinants
• Must build a true population-oriented health system
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