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