ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin Islands
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
10 Essential Public Health Services, Cont’d
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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.
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Evaluate effectiveness, accessibility, and quality of personal and
population- based health services.
„
Research for new insights and innovative solutions to health problems.
10 Essential Public Health Services
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Monitor health status to identify community problems.
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Diagnose and investigate health problems and health hazards in
the community.
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Inform, educate, and empower people about health issues.
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Mobilize community partnerships and action to identify and solve
health problems.
„
Develop policies and plans that support individual and
community health efforts.
MCH Pyramid
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Medical Visit
„
Transportation
„
Newborn Screening
„
Systems of Care
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Ten Great Public Health Achievements -- United States, 1900-1999
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„
„
Determinants of Health
Vaccination
Motor-vehicle safety
Safer workplaces
Control of infectious diseases
Decline in deaths from coronary heart disease and stroke
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco use as a health hazard
‰
Determinants of Health
Debisette, et. al., 2005
US Spending on Health
(by percent contribution)
National Health Spending (2005)
100%
90%
80%
Government Public Health
Activities
5
$56.60
$126.80
$143.00
80%
15
Investment (Research and
Equipment)
70%
30
50%
Medical Care
50%
Government
Administration and Net
Cost of Private Health
Insurance
Social Circumstances
Genetic Predispositions
40%
70%
60%
Environmental Exposures
60%
Behavioral Patterns
40%
$1,661.40
30%
20%
30%
20%
100%
90%
10
Personal Health
(Hospital/Clinical
Services, Nursing Home,
Home Health Care,
Medical Products)
40
10%
0%
„McGinnis
10%
0%
$1,987.80
Per Capita Total
et. al., 2002
Determinants of Health
„
Clinical Interactions
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Year one and two: 13 visits
All ages: 3.1 visits
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Typical patient with a Chronic illness
„
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‰
‰
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.
The Real Threats to Our Health
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
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Prevention in the Clinical Setting
Prevention
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Primary prevention/Universal
‰
Primary Prevention: services provided to individuals to prevent the
onset of a targeted condition
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Reduction or control of causative factors for a health
problem and includes reducing risk and environmental
exposures
‰
‰
Secondary Prevention: services to identify and treat asymptomatic
persons who have already developed risk factors or preclinical disease
but in whom the condition has not become clinically apparent.
„
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Secondary prevention/Selective
‰
Early detection and treatment
‰
‰
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‰
Tertiary prevention/Indicated
‰
Appropriate supportive and rehabilitative services to
minimize morbidity and maximize quality of life
Pap smear to detect cervical dysplasia before the development of cancer
mamography
Screening for high blood pressure
Tertiary Prevention: treatment and management of persons with
clinical illnesses
„
‰
‰
‰
routine immunization of healthy children and adults
Anticipatory guidance
cholesterol reduction in patients with coronary heart disease
insulin therapy to prevent the complications of diabetes mellitus
CDC, 1992
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Prevention in Public Health
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US Preventive Services Task Force, 1996
Example: Smoking Interventions*
Policy
Development and
Implementation
Population-based
Services
Direct Services
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Clean Indoor Air Legislation
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Tobacco Price Increases
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Mass Media Campaigns
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Telephone Quitlines
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Provider reminders with
Provider education
*Recommended with Strong Evidence by the Guide to Community Preventive Services
Smoke-Free Laws
Effects of a 10% Increase in Tobacco Price
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Nearly 7% decline in youth prevalence
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A 2% decline in adult prevalence
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A 4% decline in overall consumption
Restaurants & Bars
Restaurants
* Arizona law effective 5/1/07; New Mexico law effective 6/15/07
* The Montana and Utah laws extend to bars in 2009.
March 2007
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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.
Provider reminders with provider education
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Patient telephone quitlines
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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.
Poor Diet and Physical Activity
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
Obesity Is Linked To A Significant Increase In Chronic Conditions
Increased Risk of Obesity-Related Diseases with Higher
BMI
% increase in chronic conditions
70
60
50
40
30
20
10
0
es
Ob
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
Disease
ity
g
in
Ag
0
-5
30
g
g
ng
rty
in
in
ki
ve
ok
ok
in
Po
Dr
Sm
Sm
t
y
s
av
Pa
He
Baseline –
comparable
normal weight
individuals with
no history of
smoking or
heavy drinking
Centers for Disease Control. Third National Health and Nutrition Examination Survey. Analysis by The Lewin Group, 1999.
Sturm R. Health Affairs. 2002; 21 (2): 245-253
Public Health. 2001; 115:229-295
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Reducing diabetes deaths: options
Reducing diabetes deaths:
The Vermont Blueprint Approach!
Deaths from comp per thousand Adults
2.50
Deaths Per Thousand Adults
No Change
2.50
No Change
2.25
2.25
Better Care
2.00
2.00
Obesity
Prevention
1.75
No major changes –
status quo
1.75
Obesity
Care and
Prevention
reductionand
in Better Care
caloric intake
1.50
1.50
1.25
1.25
1980
1990
2000
2010
2020
2030
2040
1980
2050
1990
2000
Time (Year)
2010
2020
2030
2040
2050
Time (Year)
Systems Dynamic Change Model
America’s Obesity Epidemic
Connecting Health & the Environment
The percentage of overweight
children has more than
doubled in the past 20 years.
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65% of U.S. adults are
overweight.
30% are obese.
„
Modern American communities are
designed for cars, not walking, recreation, or
physical activity.
Overweight adolescents
have a 70% chance of
becoming overweight or
obese adults.
Kids Don’t Walk Anymore!
The Built Environment Influences Health
ASTHO’s Policy Statement
„
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
„
State and local governments, private developers, and
community groups can promote physical activity by
increasing access to:
‰
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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.
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Public Health Focus
New York’s Healthy Heart Program
Comprehensive Approaches to Promote Activity
‰
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School-based interventions
Worksite interventions
Healthcare system interventions
Community-wide interventions
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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
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„ 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
Self Management
99.98%
Source: Vermont Department of Health, Agency of Human Services, 2007
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Healthier Living Workshop
„
Stanford University Stanford Patient Education Research Center
Kate Lorig
•11 Hospital Service Areas
•80 Certified Professional and Lay leaders
•Over 300 Vermonters
http://patienteducation.stanford.edu/programs/cdsmp.html
Linking Public Health and Clinical Medicine
Vermont Blueprint for Health
Self Management Participants
Source: Vermont Department of Health, Agency of Human Services, 2007
The Vermont Blueprint for Health
Core System
Risk Factors
Diabetes
CAD
Depression
Public Policy
SelfManagement
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Information
Systems
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Health Care
Practice
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Health
Systems
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Tobacco
Community
Obesity
Substance
Abuse
Chronic Condition
Competencies
Paul E. Jarris, MD, MBA Vermont Department of Health
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