Population Health and the Need for Public Health Systems Development and Research

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Population Health and the Need for Public Health
Systems Development and Research

• Ninth Annual Minnesota HSR Conference
• Jeff Etchason, MD
• March 1, 2005

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Ecology of Medical CareWhite, Williams, and
GreenbergNew England Journal of Medicine, 1961

• Adult population at risk (1000)
• Adults reporting one or more illnesses/injuries
  per month (750)
• Adults consulting a physician one or more times
  per month (250)
• Adult patients admitted to a hospital per month
  (9)
• Adult patients referred to another physician per
  month (5)
• Adult patients referred to a Univ. Medical Center
  per month (1)

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What Do We Know About Population Health in the US?

• No single entity responsible / accountable
• Characterized by socioeconomic and racial /
  ethnic disparities
• Limited measures / information systems
• Life Expectancy, Infant Mortality improving
  historically, but worsening relatively in
  international comparisons
• Other measures of population health show
  concerning patterns

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What Do We Know About Population Health in the US?

• Life Expectancy, Infant Mortality
• 50 years ago we were among the world leaders
• Now, multiple comparisons (eg, OECD, WHO) show
  relatively poor performance

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What Do We Know About Population Health in the US?

• Other measures of health show concerning patterns
• Health-related Quality of Life
• Self-rated General Health
• Number of Unhealthy Days
• Frequent Mental Distress
• Childhood Obesity

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Zack MM, Moriarty DG, Stroup DF, Ford ES, Mokdad
AH. Worsening Trends in Adult Health-Related
Quality of Life and Self-Rated Health - United
States, 1993-2001. Public Health Reports Sep/Oct
2004 119(5)493-505.
Unhealthy days (mean)
Total 1994-2001 Excess 5 billion unhealthy days
or 15 million YULs
Year
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Age-adjusted
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Percentage of U.S. adults reporting frequent
mental distress (FMD)---1993-2001 BRFSS
Percent
Year
FMD 14 or more mentally unhealthy days in the
past 30 days Source MMWR. 200453963-966
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Components of Child Well-Being in the Health
Domain

• Infant Mortality Rate
• Low Birth Weight Rate
• Mortality Rate, Ages 1-19
• Rate of Children with Very Good or Excellent
  Heath (as reported by their parents)
• Rate of Children with Activity Limitations (as
  Reported by their Parents)
• Rate of Overweight Children and Adolescents, Ages
  6-17

Index of Child Well-Being The Foundation for
Child Development Duke University, 2004
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Health Domain with and without Obesity Indicator,
1975 to 2001
Index of Child Well-Being The Foundation for
Child Development Duke University, 2004
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Health services research is a multidisciplinary
field of inquiry, both basic and applied, that
examines the use, costs, quality, accessibility
and delivery, organization, financing, and
outcomes of health care services to increase
knowledge and understanding of the structure,
processes, and effects of health services for
individuals and populations.
Institute of Medicine 1995
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Health Care Tab Ready to Explode

• USA Today February 24, 2005
• The nations tab for health care already the
  highest per person in the industrialized world
  could hit 3.6 trillion by 2014, or nearly 19 or
  the entire U.S. economy, up from 15.4 now.
• By 2014, the nation's spending for health care
  will equal 11, 045 for every man, women and
  child, up from 6, 423 each this year, says the
  report released by the Centers for Medicare and
  Medicaid Services.

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GM Repair Health Care

• The Detroit News, February 10, 2005
• General Motors Chairman and CEO is expected to
  call on government and business leaders to
  urgently push for broad reforms to the US health
  care system. The automaker claims rising health
  care costs are severely eroding its bottom line
  and threatens its international competitiveness.

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HSR Raised Questions about the Value of Medical
Care Services

• Geographic Variations in Care
• Appropriateness of Care
• Now international comparisons of population
  health are raising these questions again

16

• Source Economic Policy Institute, 2004

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Who Shall Lead Is there a Future for Population
Health?

• David Mechanic
• Journal of Health Politics, Policy and Law.
  Volume 28, Number 2-3, April 2003
• Population health faces many issues in seeking
  to become legitimized as both a unique field of
  study and as a significant force in public
  policy. Among these are a clear definition of
  the boundaries of the field, a continuing flow of
  resources for development, and attractive career
  structures for new recruits and future leaders.

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What role for Health Services Research in
Population Health?

• One of the major drivers of population health is
  the prevalence of chronic, preventable diseases.
  However, are efforts aimed at reducing
  individual-level risk factors (smoking, diet,
  physical activity) sufficient for prevention?
• What is the relative contribution of medical
  services to population health? Are there other
  more important determinants?

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Social Determinants of Health

• Child development / education
• Income, income distribution
• Employment, working conditions, job security
• Social inclusion / exclusion, social support,
  social capital
• Neighborhood environment crime, pollution,
  housing, transportation
• Nutrition, food security

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Social Determinants of Health (SDOH) List
ServeDennis RaphaelYork University

• To subscribe to the SDOH list, send the following
  message to listserv_at_yorku.ca in the text section,
  NOT in the subject header.
• SUBSCRIBE SDOH yourfirstname yourlastname

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Insights Into Causal Pathways for Ischemic Heart
Disease Adverse Childhood Experiences Study
Dong, Maxia MD, PhD Giles, Wayne H. MD, MS
Felitti, Vincent J. MD Dube Shanta R. MPH
Williams, Janice E. PhD Chapman, Daniel P. PhD
Anda, Robert F. MD, MS Circulation. 110 (13) 28
September 2004 pp1761-1766 A CDC study says
children who are abused or neglected grow up to
be adults with a 30 to 70 percent greater chance
of developing heart disease. The study helps
explain why only half the variation in risk of
heart disease can be explained by conventional
risk factors such as diabetes and physical
inactivity.
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Neurohumoral Features of Myocardial Stunning Due
to Sudden Emotional Stress

• Wittstein, Ilan S. Thiemann, David R. Lima,
  Joao A.C. Baughman, Kenneth L. Schulman, Steven
  P. Gerstenblith, Gary Wu, Katherine C. Rade,
  Jeffery J. Bivalacqua, Trinity J. Champion
  Hunter C.
• New England Journal of Medicine. 352(6)539-548,
  February 10, 2005
• Broken Heart Syndrome Real
• Researchers as Johns Hopkins have discovered that
  sudden emotional stress can also result in severe
  heart muscle weakness that mimics a classic heart
  attack.

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Neighborhood Socioeconomic Environment and
Incidence of Coronary Heart Disease a Follow-up
Study of 25,319 Women and Men in Sweden

• Kristina Sundquist, Marilyn Winkleby, Helena
  Ahlen, Sven-Erik Johansson
• Am J Epidemiol 2004 159655-662
• Neighborhood socioeconomic environment (income
  and education) predicts incident coronary heart
  disease, having significant effect beyond that of
  individual-level risk.

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Perception of Unmet Basic Needs as a Predictor of
Mortality Among Community-Dwelling Older Adults
Dan G. Blazer, MDS PhD Natalie Sachs-Ericsson
PhD Celia F. Hybels PhD. J Public Am Health.
95(2)299-305, 2005 Perceived inadequacy in
having ones basic needs met predicted mortality
during a 10-year follow-up among
community-dwelling elderly persons. Needs
measured were personal safety, financial
security, and adequate housing.
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Public Concern Regarding Childhood Obesity

• Based on what you know or have heard, do you
  believe that childhood obesity in the U.S. is?

Health Care Poll, vol.43. Feb. 15, 2005 Harris
Interactive, Inc.
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Public Perceptions Regarding Childhood Obesity
Health Care Poll, vol.43. Feb. 15, 2005 Harris
Interactive, Inc.
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Public Perceptions Regarding Childhood Obesity,
contd.
Health Care Poll, vol.43. Feb. 15, 2005 Harris
Interactive, Inc.
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Poverty and Obesity The Role of Energy Density
and Energy Costs

• Drewnowski and S. Spector, Am J Clin Nutr
  2004,796-16
• Obesity rates are highest among populations with
  the highest poverty rates and least education
• Energy-dense foods composed of refined grains,
  added sugars and fats are lowest in cost, highly
  palatable, and associated with higher energy
  intake
• Poverty and food insecurity are associated with
  lower food expenditures, low fruit and vegetable
  consumption, and lower-quality diets
• Americans are becoming more obese while spending
  less of their disposable income on food

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Political Context of Social Determinants of Health

• Navarro, V., Shi, L. (2001). The political
  context of social inequalities and health. Social
  Science Medicine, 52, 481-491.
• Social Democratic (Sweden, Finland, Norway,
  Denmark)
• Christian Democratic (Belgium, Netherlands,
  Germany, France, Italy, Switzerland)
• Liberal Anglo-Saxon (UK, Canada, US)

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• Source Economic Policy Institute, 2004

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Child Poverty in Lone-Parent and Other Families
in Five Comparison Countries, 2000
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Percentage of Persons Living in Poverty in
Lone-Parent Working and Non-Working Families in
Five Comparison Countries, 1994
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Priorities in Public Spending Public Expenditure
on Education and Health as a Percentage of GDP in
Five Comparison Countries, 1995-1998
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Public Social Expenditure by Broad Social Policy
Areas as Percentage of GDP in Five Comparison
Countries, 1997. Source Society at a Glance,
OECD, 2001
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Nordic Countries Come Out Near the Top in Two
Business Surveys

• New York Times, October 14, 2004
• Global Competitiveness Rankings of the World
  Economic Forum
• 1. Finland
• 3. Sweden
• 5. Denmark
• 6. Norway
• World Bank Rankings Place the Same Countries Near
  the Top

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Public Health Systems

• The Vision of HP2010 Healthy People in Healthy
  Communities
• IOMs The Future of the Publics Health in the
  21st Century

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Public Health Systems

• Key assumptions in IOM report
• Health is a public good and a social product
• Healthy people depend on healthy communities
• Public Health Agencies alone cannot assure the
  publics health
• Conditions for health are a shared social
  responsibility

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IOM Actions for Public Health Systems

• Adopt a population health approach
• Strengthen governmental public health agencies
• Build inter-sectoral partnerships
• Develop systems of accountability
• Use evidence for decision-making
• Enhance and facilitate communication

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Develop Health Systems and Measure Organizational
Performance

• Aggregate data at community level
• Address information gaps with new sources of data
  
• Develop indicators through community-based
  participatory and social network research
• Focus efforts and track performance of health
  systems and achievement of population-level goals

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Atlanta Regional Health Forum(http//www.arhf.net
)

• An Inclusive, Results-Oriented Coalition
• Vision Healthy local communities assuring the
  highest health potential for each person
• Mission Connect/coordinate activities for
  healthy communities
• Values Justice should drive health decisions,
  focused especially on increasing access to
  quality healthcare and eliminating disparity
  in health status

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Atlanta Regional Health Forum(http//www.arhf.net
)

• Partners with the Atlanta Regional Commission
  (ARC) to integrate Health Impact Assessments into
  its land use and transportation planning and
  policy activities
• Received funding from NALBOH for the co-creation
  with ARC of a Guide to Land Use Planning for
  Local Boards of Health
• Creating Healthy Neighborhoods report on our
  web site, funded by the Community Foundation for
  Greater Atlanta
• Regional Database of Community Health Indicators

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NIH Funds Eight Centers for Population Health and
Health Disparities

• The discoveries in basic medical sciences will
  not reach their full potential without an
  effective long-term strategy for gaining
  knowledge and preventing disease at the
  population level. This strategy must integrate
  research in the natural sciences with that in the
  behavioral and social sciences to create a more
  comprehensive understanding of disease pathways
  from a molecular to a societal level.

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WHO Research Priorities

• Global factors and processes that affect health
  equity
• Specific societal and political structures and
  relationships that differentially affect peoples
  chances to be healthy
• Inter-relationships between individual factors
  and social context
• Health care system factors that influence health
  equity
• Documenting and widely disseminating effective
  policy interventions to reduce health inequity

WHO Priorities for Research to Take Forward the
Health Equity Policy Agenda Report from the WHO
Task Force on Health System Research Priorities
for Equity in Health Oct. 15, 2004
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Summary

• International comparisons of population health
  indicate that the US performs poorly
• Lack of population-based, small-area information
• Research into population health should be based
  on an ecological model

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Summary

• Research should be carried out to elucidate the
  mechanisms through which ecological determinants
  influence health.
• Population Health is a social product and a
  measure of the health of a society.
• An ecological paradigm relies less on medical
  care for population health.