SYLLABUS POPULATION HEALTH CORE COURSE

DUKE FAMILY MEDICINE PHIT CURRICULUM

AUTHOR: MINA SILBERBERG,PH.D. AND THE DUKE FAMILY MEDICINE PHIT CURRICULUM GOVERNANCE COMMITTEE

Course Texts:

1. Leedy, P.D. and J.E. Ormrod (2013). Practical Research: Planning and Design, 19th edn. Boston:

Pearson.

a. Copies available on loan from family medicine lending library (Diane Spell).

b. Can be purchased through normal channels.

2. Nash, D.B. et al (2011). Population Health: Creating a Culture of Wellness. Sudbury, MA: Jones

and Bartlett Learning.

a. Available from family medicine lending library or passed on by PGY3s and core residency

faculty.

b. Can be purchased through normal channels.

3. We will be reading several sections of the Institute of Medicine’s 2012 report Primary Care and

Public Health: Exploring Integration to Improve Population Health. The report can be obtained

through: http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx. You can

download the pre-print copy for free or order the print copy for a fee.

4. CTSA Community Engagement Key Function Committee Task Force on the Principles of

Community Engagement. Principles of Community Engagement, 2nd edition. Bethesda, MD:

National Institutes of Health, 2011. Free copies available for distribution at Family Medicine or

Community Health

Discussion Sessions and Preparation:

You are expected to have completed the readings or modules listed below prior to the discussion

session date. Questions are provided to help you with preparation.

2013

July 23: What is population health? Why does it matter? Core course introduction.

Required preparation:

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David Kindig and Greg Stoddart (2003). What Is Population Health? American Journal of Public Health 93 (3):380-383. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.93.3.380

GME/PHIL modules: “Population-Level Determinants of Health 1 and 2” https://duke.qualtrics.com/SE/?SID=SV_eetptWpMlupapRrhttps://duke.qualtrics.com/SE/?SID=SV_7PV3H0eJ4YBjdd3

Recommended:

IOM (2012). Primary Care and Public Health, preface and summary

Nash et al (2011). Population Health, foreword, preface, and “The Population Health Mandate”

Discussion questions:

1. How do Kindig and Stoddart define population health? Do you agree with this definition?2. Why should primary care providers be interested in population health? What role can primary

care providers play in improving population health?3. What do you think are the most useful strategies for improving population health?

July 30: Where are we heading? Innovations in population health.

Required preparation:

GME/PHIL module: “Population-Based Preventive Strategies” https://duke.qualtrics.com/SE/?SID=SV_d5y1UN8Oy7tO0tL

L. James Michener et al (2008). Improving the Health of the Community: Duke’s Experience with Community Engagement. Academic Medicine 83 (4, April): 408-413. http://pm6mt7vg3j.search.serialssolutions.com/OpenURL_local?sid=Entrez:PubMed&id=pmid:18367904

Suzy Hansen (2012). What Can Mississippi Learn from Iran? New York Times Magazine July 27: http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=all&_r=0

Recommended:

From IOM (2012): Chapter 1 (“Introduction”)

From Nash (2012): Chapter 1 (“The Spectrum of Care”)

Discussion questions:

1. What are the key elements of the innovations described in these materials? 2. Which do you find most interesting and why?

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3. What kinds of population health improvement strategies are not illustrated here?4. Where do you think population health improvement needs to go next?

August 13: Where are we heading? Creating a logic model.

Required preparation:

W. W. Kellogg Foundation, “Logic Model Development Guide,” chapters 1-3. Accessed at http://www.ncleg.net/PED/Resources/documents/LogicModelGuide.pdf

Discussion questions:

1. What is a logic model? What is the “logic” in a logic model? 2. Do you have any experience creating or using a logic model?3. How are/might logic models be helpful in planning, implementing, and evaluating population

health improvement initiatives? How are/might they be constraining or less than useful?

August 27: Getting things done: Creating and using a workplan.

Required preparation:

GME/PHIL module: “Creating and Using a Workplan”

Discussion questions:

1. What is a workplan? What are its key elements?2. Do you have any experience creating or using a workplan?3. How are/might workplans be helpful in planning, implementing, and evaluating population

health improvement initiatives? How are/might they be constraining or less than useful? 4. How might a workplan be helpful to you right now in your PHIL work?

September 10: Community engagement. What is it? How does it support population health?

Required preparation:

From Principles of Community Engagement (2011): Foreword, Executive Summary, and Chapter 1.

GME/PHIL modules: Defining Community: https://duke.qualtrics.com/SE/?SID=SV_5oQeklguwUa0Wzj

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Characteristics of Communities: https://duke.qualtrics.com/SE/?SID=SV_egkMI3cXYAqTvYF

Intro to CEnR: https://duke.qualtrics.com/SE/?SID=SV_08ob8iRVhGCWO5n

Discussion questions:

1. What is community engagement as defined by the CDC? Do you think this definition is adequate? What does it “look like” on the ground? What are its implications?

2. Why is community engagement important? Why do you think the designers of this curriculum consider it to be a “pillar” of population health?

3. What are some of the challenges/complexities of community engagement?

September 24: The process of community engagement.

Required preparation:

GME/PHIL modules: “Principles of Community Engagement 1 and 2, ” “CEnR Methods,” “Windshield tour,” “Powersharing/Community Roleplay”

From Principles of Community Engagement (2011): Chapter 2.

Recommended:

From Principles of Community Engagement (2011): Chapters 4 and 6.

Discussion questions:

1. What are the CDC’s principles of community engagement? What do you think about these principles? Is anything missing?

2. What would it look like to follow these principles as you carry out your PHIL project?3. What are some of the challenges/complexities of carrying out these principles?

October 8: Critical thinking/research/analytics/QI. What are they? How do they support population health? What ethical issues are encountered in research?

Required preparation:

From Leedy and Ormrod (2013): Ch. 1.

GME/PHIL modules: “Ethics” and “Issues in Ethics”

Institute for Healthcare Improvement (IHI) Open School Course QI 101 (Fundamentals of Improvement).

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Complete the two basic CITI modules.

Recommended:

Complete required number of CITI modules.

Discussion questions:

1. What is research? What is QI? How are they the same and/or different?2. How might you use research, QI, and data analysis in general to support population health

improvement efforts?3. What are the basic principles of ethical research conduct? What ethical complexities arise when

conducting community-engaged research?

October 22: When do you use research? When do you use QI?

Required preparation:

From Nash (2011): Ch. 10.

GME/PHIL module: “Quality improvement” [Sarah Weaver will provide URL]

Duke University Health System Human Research Protection Program (2013). “Quality Activities in Healthcare vs. Research” http://irb.duhs.duke.edu/wysiwyg/downloads/QI_policy_and_checklist_4-30-2013jw.pdf

Paul Glasziou et al (2011). Can Evidence-Based Medicine and Clinical Quality Improvement Learn From Each Other? BMJ Qual Saf (20): i13-i17http://qualitysafety.bmj.com/content/20/Suppl_1/i13.full

Recommended:

Frank Davidoff (2011). Systems of Service: Reflections on the Moral Foundations of Improvement. BMJ Qual Saf (20):i5-i10http://qualitysafety.bmj.com/content/20/Suppl_1/i13.full

Discussion questions:

1. From the IRB’s point of view, what is the difference between research and QI?2. What do Glasziou et al see as the important distinctions between traditional research and

QI? Are these the right “classifications”? 3. Under what circumstances do you think traditional research is most appropriate? Rapid

cycle QI?

October 29: Defining a research question and a research plan.

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Required preparation:

From Leedy and Ormrod (2013): Ch. 2.

Recommended:

You have three chapters to read for the next session. Might want to get started now!

Discussion questions:

1. Think about the project you are doing for PHIL. Pretend for a moment that you were doing a research project instead. What might your research problem be? How does that differ from the question you are answering through your PHIL project.

2. What would be subproblems of that problem? 3. What would be your hypotheses or research questions?

November 12: Internal Validity and Research Design.

Required preparation:

From Leedy and Ormrod (2013): Ch. 5, 8, and 9

Discussion questions:

1. What is the problem of internal validity? 2. What are threats to internal validity?3. What is descriptive research? What is an experimental design? What is an ex post facto design?4. How can we strengthen our confidence in the internal validity of our research?

November 26: External validity.

Required preparation:

Review section on external validity from Leedy and Ormrod (2013), ch. 4. Review section on Solomon 4-group design from Leedy and Ormrod (2013), ch. 9.

Recommended:

Allan Steckler and Kenneth R. McLeroy (2008). The Importance of External Validity. Am J Public Health 98(1): 9–10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2156062/pdf/0980009.pdf

Discussion questions:

1. What is external validity?2. What are threats to external validity?3. How can we strengthen external validity?

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4. In what ways can there be tradeoffs between internal and external validity?

December 10: Construct validity and other measurement issues. Guest speaker: Bernard Fuemmeler

Required preparation:

Review section on the nature and role of data in research from Leedy and Ormrod (2013), ch. 4.

From Nash (2011): ch. 15.

Recommended:

Pestronk RM. Using metrics to improve population health. Prev Chronic Dis 2010;7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0018.htm.

Bilheimer LT. Evaluating metrics to improve population health. Prev Chronic Dis 2010;7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0016.htm.

Parrish RG. Measuring population health outcomes. Prev Chronic Dis 2010;7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0005.htm.

Mokdad AH, Remington PL. Measuring health behaviors in populations. Prev Chronic Dis 2010;7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0010.htm

Discussion questions:

1. What are the attributes of a “good” measure? 2. Pick one or two measures of population health that appeal to you. Why did you pick those?

January 14: Statistical validity.

Required preparation:

From Leedy and Ormrod (2013): ch. 11.

Recommended

You have a few sessions with heavy preparation coming up. You might want to start preparing for those.

Discussion questions:

1. What are descriptive statistics?2. What are inferential statistics?3. What is the problem of statistical validity?4. What does “statistical significance” mean? What doesn’t it mean?

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5. Bonus question: What is the relationship between statistical significance, sensitivity/specificity in screening, and positive predictive value/negative predictive value in screening?

January 28: Existing data sources

Required preparation:

From Nash (2011): Ch. 9

New York State Department of Health. “National Public Health Data Resources.” At http://www.health.ny.gov/statistics/chac/national.htm. Revised July 2012. Accessed July 11, 2013.

From Partnership for a Healthy Durham (2011). Community Health Assessment: Ch. 1.http://www.healthydurham.org/docs/CHA%202011_web.pdf

From Principles of Community Engagement (2011):pp.68-70, 75-77

Recommended:

North Carolina State Center for Health Statistics. “Data to Action: Examples of how data at the state center for health statistics is used to improve health!” At http://www.schs.state.nc.us/schs/pdf/SCHSData2Action.pdf. Accessed July 1, 2013.

Discussion questions:

1. What are some of the major types of existing data sources for population health improvement?2. What are some of the things you need to consider when selecting a data source for your work?3. Review the overview list of data sources at the NY State Department of Health site. Pick one

data source to research further. What are its strengths? What are its weaknesses? 4. Pick one of the data sources used for the 2011 Durham Community Health Assessment. What

are its strengths? What are its weaknesses? 5. Identify one type of existing data you are using for your PHIL project. What are its strengths?

What are its weaknesses? 6. How can community engagement be an important part of strengthening existing data sources

and how these data are used for population health improvement?

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February 11: Generating new data: quantitative and qualitative methods.

Required preparation:

From Leedy and Ormrod (2013): Chs. 6 and 10

From Principles of Community Engagement (2011): pp.60-61, 73-74, 81-82

Discussion questions:

1. What are qualitative vs. quantitative data? What are some methods of generating qualitative data? Quantitative data? What are the strengths and weaknesses of quantitative data? Qualitative data?

2. Identify one type of new data (e.g., quantitative patient attitude data from a survey, focus group with providers) you have decided to generate or could generate for your PHIL project. Why did you choose that type of data?

3. How can community engagement be an important part of strengthening the quality of new data, the benefit of data collection to the community, and how data are used for population health improvement?

February 25: QI methods.

Required preparation:

From the Institute for Healthcare Improvement: Complete QI102, QI103, and QI104.

Recommended:

From IHI: Complete QI106 and QI107.

Discussion questions:

1. What is the model of QI? What are the tools?2. What is a PDSA cycle?3. What does it take to do good QI?4. How can you apply and modify the QI process to address population health beyond the

clinic walls?5. How are considerations of internal validity, external validity, measurement, and statistical

validity dealt with in QI?

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March 11: Needs and assets assessment, geomapping

Required preparation:

Kretzmann, J. and J. McKnight (1996). Assets-based community development. National Civic Review 85(4): 23.

From Partnership for a Health Durham (2011). Community Health Assessment: Executive Summary http://www.healthydurham.org/docs/CHA%202011_web.pdf

Dulin MF et al. (2010). Using geographic information systems (GIS) to understand a community’s primary care needs. J Am Board Fam Med 2010;23(1):13–21 http://www.jabfm.org/content/23/1/13.full.pdf+html

Recommended:

Tamara Calise et al (2013). Do Neighborhoods Make People Active, or do People Make Active Neighborhoods? Preventing Chronic Disease 10: http://www.cdc.gov/pcd/issues/2013/12_0321.htm

Discussion questions:

1. What is a health needs assessment?2. What is assets assessment, and why do some people argue that it is an important additional

to needs assessment?3. What were the major findings of the Durham 2011 Community Health Assessment? What

were they based on? What were the strengths and weaknesses of the assessment process used in Durham?

4. What does geomapping add to need/assets assessment?5. Do you see any downside to a geomapping approach?

March 25: Defining a population to work with

Required preparation:

Marmot M (2001). Economic and Social Determinants of Disease. Bulletin of the World Health Organization 79(10): 988-989.

Rose G (1985). Sick Individuals and Sick Populations. International Journal of Epidemiology (14):32-38.

Both these articles are provided in this pdf.

Benach J et al (2013). A New Typology of Policies to Tackle Health Inequalities and Scenarios of Impact Based on Rose’s Population Approach. J Epidemiol Community Health (67):286-291http://jech.bmj.com/content/67/3/286

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Discussion questions:

1. What is Rose’s argument about defining a population for intervention? Do you agree or disagree?

2. What factors should you consider when defining a population to work with?

April 8: Understanding the problem

Required preparation:

Community Toolbox. “Defining and Analyzing the Problem.” At http://ctb.ku.edu/en/tablecontents/sub_section_main_1124.aspx

Complete IHI module PS104.

From Principles of Community Engagement (2011): pp. 60-62, 71-72, 78-80, and 88-89.

Recommended:

Community Toolbox. “Analyzing the Root Causes of Problems.” At http://ctb.ku.edu/en/tablecontents/sub_section_main_1124.aspx

Discussion questions:

1. How do you define and analyze a problem to work on?2. What are “root causes” of a problem and how do you understand them?3. How do you decide which part of a problem to work on? 4. What were the strengths and weaknesses of the approaches to problem definition/analysis used

in the Principles of Community Engagement case studies?

April 22: Defining an intervention

Required preparation:

Review material and notes from August 13th.

Mechanic D (2005). Policy Challenges in Reducing Disparities and Improving Population Health. Health Aff 24 (2): 335-338 http://content.healthaffairs.org/content/24/2/335.full

Concordia University Office of Quality Programs. “Decision Matrix/Selection Matrix.” http://web2.concordia.ca/Quality/tools/10decision.pdf

From Principles of Community Engagement (2011): pp.71-72, 78-80, 83-84, 85-87

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Discussion questions:

1. What should you consider when deciding on the intervention, program, or strategy you will use?2. In your experience, how does real-life decision-making correspond or not correspond to the

decision/selection matrix process? What can we learn from that process?3. What are the strengths and weaknesses of the interventions represented in the case studies and

how they were decided upon?

April 29: Creating financial sustainability.

Recommended:

You may want to start preparing for the session on May 13th.

Discussion questions:

1. What are the most important figures to know when preparing a financial sustainability plan? 2. How do you set the stage to create financially sustainable programs and interventions?

May 13: Advocacy.

Required preparation:

From Nash (2011): Ch. 12 and 17.

From IOM (2012): Ch. 4

Discussion questions:

1. What is the role of policy in population health and population health improvement?2. In what policy arenas do you think PCPs can be important advocates?3. What do advocates need to know/do to be effective?

May 27: Evaluation. Co-facilitator: Lorraine Sease

Required preparation:

From Principles of Community Engagement (2011): ch. 7

Recommended:

W. W. Kellogg Foundation, “Logic Model Development Guide,” ch. 4. Accessed at http://www.ncleg.net/PED/Resources/documents/LogicModelGuide.pdf

Discussion questions:

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1. What are the purposes of evaluation?2. How does traditional evaluation differ from QI? How is it similar? Do these classifications make

sense?3. How would you go about designing an evaluation? How would you use your logic model in

designing your evaluation? What are particular considerations when designing evaluation of a community-engaged project?

June 10: Project management

Required preparation:

Review materials and notes from August 27th.

Complete IHI modules PS103 and QI105.

Recommended:

From Principles of Community Engagement (2011): ch. 4

Discussion questions:

1. What are the essential tasks of project management?2. What are the essential skills of project management?3. During this year, what have you done well in managing your PHIL project? What was more

challenging for you? 4. Have you tried using a workplan? What worked for you? What didn’t?5. What are the special challenges and needs for managing a community-engaged project?

June 24: Project dissemination

Required preparation:

From Leedy and Ormord(2013): ch. 12

Tao Xie. “Oral Presentation Skills: A Practical Guide.” http://people.engr.ncsu.edu/txie/publications/oral_presentation_skills.pdf

Discussion questions:

1. Did the readings provide you with any new considerations or ideas relative to preparing oral and written reports on your projects?

2. You are doing population health projects, not research projects. What do you think the implications are for: the purpose of your reports, who is reading/listening to your reports, what kinds of reporting you do, how you format reports, report content, or other issues?

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