Chapter 8: Environmental Health & Safety Topics •All-Hazards Approach: an approach to public health preparedness that uses the same approach to preparing for many types of disasters, including use of surveillance systems, communications systems, evacuations, and an organized healthcare approach. •Altered Environment: Impact of chemicals, radiation, and biological product that humans introduce into the environment. - Industrial chemicals: pesticides, benzene, chlorofluorocarbons. - Elements mined from the earth: mercury, lead. - Radiation from nuclear energy and medical waste. •Unaltered Environment: - Natural Disasters: Floods, earthquakes, volcanoes, hurricanes - Daily exposure to communicable diseases in water and food. - Radon is a naturally occurring breakdown product of uranium and increases risk of lung cancer. - Sunlight increases risk of skin cancer. •Built Environment: Includes all the impacts of the physical environment as a result of human construction. - Transportation system, the way we build and heat our buildings and cook our food. - Indoor air pollution, motor vehicle injuries, noise pollution. - Affects our moods, social interactions, social attitudes. - Most evident in urban areas. •Risk Assessment Definition: Aims to measure the potential impact of known hazards. - makes the assumption that each exposure stands on its own. • RISK ASSESSMENT STEPS: 1. Hazards Identification: the process of determining whether exposure to a stressor can cause an increase in the incidence of specific adverse health effects (e.g., cancer, birth defects). 2. Dose-Response Relationship: describes the likelihood and severity of adverse health effects (the responses) are related to the amount and condition of exposure to an agent (the dose provided). 3. Exposure Assessment: the process of measuring or estimating the magnitude, frequency, and duration of human exposure to an agent in the environment. 4. Risk Characterization: conveys the risk assessor's judgment as to the nature and presence or absence of risks, along with information about how the risk was assessed • Hazards: inherent dangers of the exposure. •Public Health Assessment: Goes beyond risk assessment by including data on actual exposure in the community. - Potential for major impacts on large numbers of people but takes years/decades to complete. -Focuses exclusively on health impacts of humans. •Ecological Assessment: not just focused on humans, but also plants, animals, and ecosystems. - Environmental contamination or pollution on plants/animals and ecosystems they exist in. •Interaction Analysis: Takes into account the effect of two or more exposures •Multiplicative interaction: type of interaction where overall risk when two more exposures are exposures are present is best estimated by multiplying the relative risk of each exposure Ex: •RRsmoking+radon ≈ 9 x 4.5 = more than 40 times the risk of lung cancer (9 represents the RR of smoking which is 9x the risk of lung cancer. 4.5 represents RR of radon which is 4.5 times the risk of lung cancer) •Health Equity: underlying concept of culture of health action, address a wide range of social issues from house to employment, crime social interactions, and recreational activities •Healthy Communities: Healthy Cities: “creating a culture of health” by addressing a wide range of social issues (housing, employment, crime, social interactions, recreational opportunities) •Intentional Injuries: brought about on purpose, by intention, self-inflected or meant for others (murder, suicide, bioterrorism) •Unintentional Injuries: not on purposes, not by intentions (car accidents, drownings, falls, fires, unintentional poisoning) - Motor vehicle accidents and other unintentional injuries are the no. 1 cause of death of people 1-24 years of age • National Incident Management System (NIMS): An incidence command system (ICS) widely used by police, fire, and emergency management agencies - Part of Homeland Security - Establishes uniform procedures/terminology and an integrated communication system. • Air pollution: occurs when particulate matter, a mix of tiny solid and liquid particles, is suspended in the air. - Comprised of acids, organic chemicals, metals, dust, and pollen and mold spores. - Fine particles are also the main cause of reduced visibility (haze) in parts of the United States - Particles <10micrometers into lungs and bloodstream. - Particles <2.5micrometers, fine particles, PM2.5, pose the greatest risk. • Air quality index (AQI): index created by EPA for reporting daily air quality - Four major air pollutants regulated by Clean Air Act: ground level ozone, particle pollution, carbon monoxide, sulfur dioxide. - 0 is good, 301+ bad. - Small Particle Air Pollution: children/adults, short term (ENT, SOB, asthma, bronchitis), long term (lung function, choleric bronchitis, premature death), linked with CAD. • Body Defenses Against the Environment •Skin - protects against radiation, organisms, physical contact, and temperature •Respiratory tract - protect by mucous and cilia (hair-like structures) •Digestive tract - salvia, mucus, stomach acid •Phagocytes - consume large particles and organisms • Issues that Affect Risk •Route of Exposure – skin, respiratory tract, digestive tract •Timing of Exposure – short-term high dose, long-term low dose •Stage of Life – children, older individuals, pregnant women •Other diseases – chronic lung disease, suppressed immune system (e.g., AIDS) •Special sensitivities – hypersensitive to some exposures Chapter 9: Health Professions and Health Workforce • Models of Health - Medical: individual, biological/diseased organ perspective - Public Health/Ecological: diseases and other negative health events are seen as a result of an individual’s interaction with his/her social and physical environment. • Accreditation: process of setting standards for educational and training institutions and enforcing these standards using a regularly scheduled institutional self-study and outside review. • Credentialing: the individual rather than the institution, is evaluated, process of verifying if an individual has the desirable or required qualifications to practice a profession. • Certification: methods of credentialing: Profession-led process in which applicants who have completed the required educational process take an examination. Ex: board-certified (specialties or subspecialties) • Licensure: Function of State Responsibilities: Includes the certifications plus, residency requirements, criminal background check, continuing requirements • Primary Care: first contact providers who are prepared to handle the great majority of common problems for which patients seek care. • Secondary Care: specialty care provided by clinicians who focus on one or small number of organ systems or on a specific type of service (e.g., obstetricians/gynecology, dermatology, cardiology, urology) - liaison between patient and advanced medical care. • Tertiary Care: subspecialty care, often delivered in in academic or specialized health centers, may also be defined as type of problem that is addresses (e.g., trauma centers, burn centers, neonatal intensive care units) - referral to patients by primary and healthcare providers. • Method of Financial Compensation to Providers for Health Services (Table 9.3) • Fee-For-Service: Clinician paid for each covered service - Example: Physicians often paid for medical visits and procedure, but may not be paid for counseling for prevention - Advantage: Reward linked directly to work preformed, encourages efficiency of delivery of services - Disadvantage: May encourage delivery of unnecessary services • Capitation: paid a set amount per time period for each patient for whom they are responsible, regardless of level of use of services - Example: Primary care physicians in health plans may be paid a set amount per patient per month and are expected to provide all primary care services - Advantage: Discourages unnecessary care, may encourage preventive care, allows for predictable budgeting - Disadvantage: May discourage necessary care, may encourage referral to specialist unless specialty care is financially discouraged. • Episode of care: Institution or clinician is paid a set amount for providing comprehensive services, such as hospital treatment based on the patient’s diagnosis - Example: Medicare pays for hospital care based on diagnosis-related groups, allowing a defined number of days per condition - Advantage: Encourages rapid and efficient delivery of care - Disadvantage: May encourage discharge prior to the ability to provide self-care • Salary: Set amount per period - Example: Governmental facilities generally pay clinicians on a seniority-based salary - Advantage: May allow focus on quality - Disadvantage: May discourage efficiency • Pay for Performance (P4P): compensation adjusted based on measures of the quality of care delivered - Example: Additional compensation for adherence to evidence-based guidelines, new P4P being instituted as part of Medicare reimbursement - Advantage: Links income with quality, providing strong incentive for quality. - Disadvantage: Difficult to measure quality, outcomes may be related to factors outside clinician’s control Chapter 11: Health Insurance & Healthcare Systems • Medicaid: federal plus state program designed to pay for services for specific categories of poor people and other designated groups: the disabled, children, pregnant women, etc. - Provides for individuals in the designated groups who are below the federal poverty level - States may choose to offer other services, such as drugs, eyeglasses, and transportation services, and the federal government will provide matching funds - Reimbursement rates to clinicians are typically low. - To receive federal matching funding, states must provide basic services such as most inpatient and outpatient services, including preventive services • State Child Health Insurance Program (SCHIP) - Through Medicaid, additional funds to enhance the health care of children. • Medicare: 65+ years of age, expanded to include disabled. - Funded by payroll tax, 1.45% - Income from investments is taxed, self-employed pay both taxes (employee/employer), highincome individuals pay a higher amount. Part A: hospital care, skilled nursing care, home health care after hospitalization. - no premium, covered primarily by the pay roll tax. - annual deductible required before receiving payments. Part B: voluntary supplementary insurance, diagnostic/therapeutic services - Medigap policies are offered by private insurance companies to cover the 20% copayment Part C: Special program designs to encourage Medicare beneficiaries to enroll in prepaid health plans (Medicare Advantage) Part D: Prescription drug coverage - Monthly premium and annual deductible - Once individual pays $5,000, Medicare pays for 95% of additional costs of drugs. • Point of Service Plan (POS): Patients in a HMO may choose to receive their care outside of the system provided by the health plan but will pay more out of pocket - require you to choose a PCP and to get referrals - known as the affordable healthcare plan with out-of-network coverage - slightly higher premiums than HMOs, covers out-of-network doctors, pay more than for innetwork. • Employment-Based Health Insurance - Largest single category of insurance coverage . - Fee-for-Service Model • Preferred Provider Organization (PPO): Form the network and agree to a set of conditions that includes reduced payments. - do not require you to choose a PCP, but it's recommended. Referrals to specialists are also not required. - “Most freedom”. - Fee-for-service insurance system decides to only work with a limited number of clinicians - Pricier premiums than an HMO or POS • Health Maintenance organization (HMO): Charge patients a monthly fee designed to cover a comprehensive package of services. - Paid based on number of individuals enrolled (capitation) - require to choose doctors within network - Potential underuse of preventative services, some argue that the fee for service model do a better job of keeping people healthy • Cap: a limit on the total amount that the insurance will pay for a service per year, per benefit period, or per lifetime • Copayment: an amount that the insured is responsible for paying even when the service is covered by the insurance • Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. • Coinsurance: In contrast to copayment, the percentages of the charges that the insured is responsible for paying • Covered service: A service for which health insurance will provide payment or coverage if the individual is eligible – in other words, any deductible has already been paid. • Customary, prevailing, and reasonable: These standards were used in the past by many insurance plans to determine the amount that would be paid to the provider of services - under many employer-based plans, the provider may bill the patients above beyond this amount. This is known as balance billing. • Health Insurance Exchanges: • Premium: The price paid by the purchaser for the insurance policy on a monthly or yearly basis. • Deductible: The amount that an individuals or family is reasonable for paying before being eligible for insurance coverage • Copayment: An amount that the insured is responsible for paying even when the service is covered by the insurance • Out-of-Pocket Expenses: The cost of health care that is not covered by insurance and is the reasonability of the insured. - These costs may be due to caps on insurance, deductibles, copayments, and/or balance billing • Portability: The ability to continue employer-based health insurance after leaving a job – usually by paying the full cost of the insurance. - A federal law, known as the Consolidated Omnibus Budget Reconciliation Act (COBRA), generally ensures employees 18 months of portability but requires the employee to pay the entire costs of the health insurance. • Single Payer: A healthcare system with one source of payment, usually a governmental source. • Cost-Sharing: an effort to reduce healthcare costs by shifting the costs of healthcare to individuals on the assumptions that the individual will spend less when the costs are coming out their own pocket • Medical-Loss Ratio: The ratio of benefit payments paid to the premiums collected – indicating the proportion of the premiums spent on health services. - Lower medical loss ratios imply that a large amount of the premium is retained by the insurance company for administrative costs, marketing, and/or profit. • Factors that Increase the Cost of Health Care - Aging of the population. - Technological innovations that expand treatment options. - Success of medical care has raised patient expectations. • How to US healthcare compare to Canada and Great Britain? What are the characteristics of the US health care? The United States relies most heavily on market justice, whereas the United Kingdom places more emphasis on social justice. Canada is somewhere in between. The United States spends more per person and as a percentage of GDP, has a higher percentage of uninsured, the system is more complex for patients and providers and costs much more to administer, and places greater emphasis on giving patients a wider choice of clinicians. Also, we places more emphasis on specialized physicians with more nurse practitioners and physician assistants providing primary care. The U.S. has a more complex system for ensuring quality and a unique system of malpractice law and encourages rapid adoption of technology. • What is the difference between an HMO, PPO, POS? Which ones require a primary care physician for referrals? Which ones offer out-of-network coverage? - POS requires a primary care physician for referrals - PPO AND POS offer out-of-network coverage • What is the health exchange services? The health insurance exchange services provide a competitive marketplace to help increase access and control the costs of health insurance. It serves as a mechanism available to obtain insurance for those not otherwise eligible for health insurance. Self-employed individuals or those who worked for companies that did not provide comprehensive health insurance were permitted to purchase through the exchange. However, they’re often subsided for low and middle income participants. • Who are uninsured groups? How did the Affordable Care Act address these? Uninsured groups include healthy, often young, individuals who choose not to purchase insurance through employer. Poor or near-poor individuals who do not qualify for Medicaid. Self-employed persons or employees of small companies who decide not to purchase insurance. The Affordable Care Act of 2010 addressed these by allowing young individuals to stay on their parents’ insurance until age 26 and purchase lower levels of coverage until age 30. Also, states were provided an option to expand eligibility for Medicaid. Self-employed individuals who worked for companies that did not provide comprehensive healthcare plans were permitted to purchase insurance through the health insurance exchanges. • Consequences of being uninsured and underinsured in the U.S. - Less preventive care, diagnosed at more advanced stages of disease, receive less treatment after being diagnosed - Less likely to have a usual source of health care and more likely to use the ER for routine care. - Increased mortality rate • Other Programs Available for Disabled/Injured on the Job? - Complex system of federal and state programs available, categorized as: - Worker’s Compensation and Federal Programs for Workers - Social Security Disability Insurance (SSDI) and Social Security Income (SSI) - Do not replace health insurance but do provide some assistance Chapter 13: Food and Drugs • Cluster: larger number of people than expected appear to have the same illness in a given time period and area. • Outbreak: when ill persons in a cluster are found to have something in common to explain why they have the same illness • Case Definition: Set of criteria to identify who is and is not a case in the outbreak - Person, place, time, and clinical features. • Source Traceback: to trace the origin of food suspected of causing an outbreak. • Steps in an outbreak investigation 1. Detecting the Outbreak. 2. Defining and Finding Cases. 3. Generating Hypotheses about Likely Sources. 4. Testing the hypothesis. 5. Finding the point of contamination and the source of the outbreak. 6. Controlling the outbreak. 7. Deciding the outbreak is over. • Agencies and Their Role in Food Issues (e.g., FDA, USDA, CDC) - Food and Drug Administration: sets safety standards for food processing and distribution. • - United States Department of Agriculture: regulates meat, poultry, and eggs. - Center for Disease Control: collecting data on disease related to food, investigate outbreak. • Food Security: defined as “all people at all times have access to sufficient, safe, nutritious food to maintain a health and active life” - USDA ran programs: 1. Supplemental Nutrition Assistance Program (SNAP): Aims to provide access to healthy diets by making relatively expensive items such as fresh fruits and vegetables accessible to those with low incomes 2. Special Supplemental Nutrition Program for Women (WIC): Federal grands for supplemental foods, healthcare referrals, and nutrition education for low-income pregnant women, postpartum women, and infants and children up to age 5 at nutritional risk • FDA Approval Process: • Pre-clinical Testing: safety assessment on at least two species at high doses prior to initial use on humans. - Assess carcinogenic, teratogenicity, fertility effects. - Limitations: high dose effects might not be applicable to humans. • Phase 1: initial testing of drug on humans, may include healthy volunteers/terminally ill patients but not necessarily those who the drug will be used on - Assess pharmacology (metabolism and excretion), to determine dosage, timing, and route of transmission. Also safety on vulnerable organs (liver, kidney, testicles, bone marrow) - Limitations: small numbers/short-term studies leave rom for effects to be missed. Not helpful in predicting side effects when patients aren’t representative of those the drug will be used on in practice. • Phase 2: initial small-scale, controlled or uncontrolled, trial of efficacy with secondary assessment of safety. - Establishes that there is enough evidence of efficacy to warrant phase 3. - Limitations: primary intent is often “proof of concept” and information to help design and decide whether to pursue randomized controlled trials. • Phase 3: two independently performed randomized controlled trials unless not practical or ethical. - Establish efficacy for one indicator among a homogeneous group of patients compared to conventional treatment. Investigate short-term safety relative to conventional treatment. - Limitations: Randomized controlled trials may be too small, their duration too short, and their participants’ conditions too simple or uncomplicated in terms of their disease(s) or their treatment(s) to observe side effects that will be seen in clinical practice. • Phase 4: post market-surveillance/assessment of safety based on the use of the drug in clinical practice. - Spontaneous reporting system is the traditional basis, but also data bases and formal studies to assess safety in clinical practice. - Detects rare but serious side effects as well as increased frequency of known side effects. - Limitations: Might not detect side effects especially if they simulate commonly occurring effects such as liver or kidney impairment. Also, interactions between drugs or drugs/diseases make it difficult to assess/attribute causation. • Off-label prescribing: the clinician has the authority to use the treatment for indications or at dosages not specifically approved by the FDA. • Ways to expedite process: - Surrogate endpoints: substitute measures of outcomes that do not necessarily reflect the clinically important outcomes that a drug or therapy intends to improve. - Breakthrough Drugs: intended to treat a serious condition and preliminary clinical evidence indicates that the drug may demonstrate substantial improvement on a clinically significant endpoints over available therapy - N-of-1 Trial: one patient (or small group of patients) are observed off the treatment, on the treatment, and subsequently, off the treatment again to determine whether they clearly benefit from the drug Chapter 14: Systems Thinking • Systems Thinking: an approach that examines multiple influences on the development of an outcome(s) and attempts to bring together in a coherent whole - Goes beyond by focusing on multiple factors and how they fit together. • Reductionist Thinking: an approach to problem solving that looks at each of the components of a problem one at a time - One-and-only answer to why, or etiology - One-and-only answer to what should be done to improve outcome - “magic bullet or miracle cure approach” - Useful for establishing speci c factors as contributory causes • System v. Heap 1. A system is a series of interconnected parts that function as a whole. A heap is merely a collection of parts. 2. A system will change if you take away or add pieces (cutting a system in half doesn’t create 2 smaller systems, it creates a non-functioning system). A heap can be divided into pieces, each which can function on their own. 3. A system must arrange the pieces in a specific and crucial way. A heaps arrangement is irrelevant. 4. A system has parts that are connected to each other and work together. The arrangement of pieces in a heap is irrelevant. 5. The behavior of a system depends on its overall structure. In a heap, behavior is determined by size rather than structure. •System Analysis: Using systems analysis to understand disease and its outcome starts with identifying the most important influences on the outcome(s) of influence. - diagrams and graphics that visually display the relationships between the parts and allow us to better understand how the parts fit together and work together. • In uences: factors or determinants that interact with each other to bring about outcomes, such as disease or the results of disease •Systems Diagram: A graphic means of displaying the way we understand systems to be structured and/or to function - For each factor you must: indicate the direction in which it operates (what way should the arrow point) and whether it operates to reinforce/increase (+) or dampen/decrease (-) •Feedback loops (positive vs. negative): the impact of changes in one influence (or factor) on other influences in a positive or negative direction. - (+): reinforce/accentuate the process - Ex: Reduction in the percentage of people who smoke due to higher taxes lead to changes over time in social attitudes, which themselves may set the stage for greater enforcement of public smoking regulations - (-): dampen/slow down the process - Ex: Raising cigarette taxes might reduce the money available to low-income individuals to pay for smoking cessation programs if these services are not paid for by health insurance. fi fl • Bottlenecks: A point at which events are slowed, presenting obstacles to the success of an intervention. - Step 5 • Leverage Points: A point in the system in which successful interventions produce better than expected outcomes. - Step 6 • One Health: About the larger system the world we live in and asserts that human health is dependent on animal health and the heath of ecosystem. • Zoonotic Diseases: exist in animals but can be transmitted to humans. • Syndemic: occurrence of two or more diseases that interact to magnify the occurrence and or burden of disease. • Syndromes: a pattern of risk factors or symptoms that tend to occur together •Example: syphilis and herpes genitals increase the risk of HIV; gonorrhea increase the level of HIV in semen •HIV predisposes individuals to other infections, such as TB •How do pets affect human health? Positive and negative ways? The human-animal relationship is a mutually beneficial and dynamic relationship between people and animals that is influenced by behaviors that are essential to the health and well-being of both. Benefits: • Reduced Blood Pressure • Reduced Cholesterol and triglycerides • Reduced feelings of loneliness • Increased opportunities for exercise and outdoor activities • Increased opportunities for socialization • Reduced allergies and asthma in children exposed to pets in first year of life Negative: • Rabies • Toxoplasmosis: can cause severe illness in infants, including vision loss and seizures, when infected from their mothers before birth. The most common way for a pregnant woman to become infected is through contact with a cat’s litter box. • Cat-scratch disease is a bacterial infection spread by cats. The disease spreads when an infected cat licks a person’s open wound, or bites or scratches. • Toxocariasis is a preventable parasitic infection caused by the larval form of the dog or cat roundworms. • What are four ways the physical environment impacts health? How does climate change affect health? • Global movement of populations - Examples: syphilis spread from the American to Europe, smallpox spread to Europe to the Americas • Agriculture changes and changes in food distribution • Pesticide use, antibiotic use • Ecological changes in land and resource use • Building dams = schistosomiasis, Lyme disease = increase exposure to forests, increase in deer and white footed mice; chagas decreased as housing improvements mad in South America • Climate change
