Transcript Evaluation of Health of a Population

Evaluation of Health of a
Population
TH Tulchinsky MD MPH
Braun School of Public Health
Jerusalem, Jan 2006
Goals of Public Health
• To eliminate or reduce health problems and
their consequences
• To prevent their occurrence or recurrence
• To promote duration and quality of life
Public Health Methods
1. Describe the distribution and size of disease
problems in human populations
2. Identify etiological (the cause of disease) factors in
the pathogenesis of disease
3. Provide data essential to the planning,
implementation and assessment of services for the
prevention, control and treatment of disease and to
establish priorities among these services
Source: The International Epidemiologic Association,
1996.
Assessing Health of an Individual I
• Current chief complaint
• History of the present illness
• Personal data - age, sex, ethnicity, education,
marital status, children, living situation
• Occupational history
• Family history
• Personal history
• Functional enquiry - systems review;
• Summary of risk factors
• Physical examination
Assessing Health of an Individual II
• Differential diagnosis
• Other medical problems
• Investigation: laboratory, cardiographic, imaging,
other
• Presumptive or working diagnosis
• Treatment and its effects
• Definitive diagnosis
• Long term management
Assessing Population Health
1. Population, demography, geography
2. Socio economic and cultural background
3. Public health infrastructure – sanitation,
nutrition
4. Health care prepayment system and equity
5. Health care resources
6. Utilization of services
7. Outcomes – morbidity, mortality, functionality
8. Quality of care – peer and external review
9. KABP – knowledge, attitudes, beliefs and
practices
10. Costs and benefits
Basics of Evaluation
• No single measure
• Multi factorial
• Quantity, quality, cost and efficiency
• Input, process, outcome
• Direct and indirect measures
• Monitoring is integral part of health
system
Population Health Measurements
Descriptive,
health status
Health services
research
Evidence
based policy
Evaluative,
Process,
outcomes
Predictive,
risk estimation
Evidence based
medicine
Etiologic
epidemiology
Explanatory,
Etiology, determinants
AJPH March 2004
The Land of X
• Trinidad
Population and Society
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Population, demography
Fertility, age distribution
Geographic, ethnic, religion mix
Socio economic conditions
– GNP per capita
– Average family income
– Education
• Social security system e.g. pensions, workman’s
compensation, drug benefits
Public Health Infrastructure
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Ministry of Health – national, provincial
Local Health Authority
Sanitation, water, sewage, garbage
Housing/urban planning, zoning
Business licensing /regulation
Professional licensing/regulation
Laboratories
NGOs
Nutrition – fortification, supplememntation
Health Resources
• Total $$$ per capita spent on health all sources, all
services
• % GNP spent on health
• % for hospitals
• % for primary care
• Hospital beds/1,000
• Medical and nursing personnel/1,000
• Primary, secondary, tertiary care facilities
• Organized preventive care, MCH, immunizations
Health System Organization
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Health care pre-payment system
Universal
Consumer co-payments
Organization of health services
– Preventive
– Curative
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Distribution e.g. urban/rural
Integration – vertical, lateral
Regional services systems
Population or individual based
Outcomes: Mortality Related Indicators
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Infant mortality rates (IMRs);
Maternal mortality rates (MMRs);
Crude mortality rates (CMRs);
Age-specific mortality rates;
Cause-specific mortality rates - infectious, noninfectious diseases, trauma;
• Life expectancy (LE) at age 0, age 1, total
• Years of potential life lost (YPLL), by cause
Outcomes or Burden of Disease
• Risk factors e.g. smoking, nutrition
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Morbidity
Mortality
Functional
Physiologic
Quality adjusted life years (QALYs)
• Disability adjusted life years (DALYs)
Morbidity Outcome Indicators
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Incidence of vaccine-preventable disease
Incidence of waterborne disease
Incidence of food-borne disease
Incidence/prevalence of tuberculosis
Incidence/prevalence of STDs/AIDS/hepatitis
Incidence of malaria, other tropical diseases
Prevalence of non-infectious diseases e.g. CVDs
Prevalence of disabling conditions
Birth defects registry
Neurological disease registry
Cancer registry
Functional Indicators:
Risk Factor Prevalence
• Smoking - age specific rates
• Sexual behavior – unsafe sex
• High risk behavior re motor vehicles
• Violence and injury - domestic, homicide,
suicide
• Alcohol use
• Drug use
Functional Indicators
• Work and school absence
• Psychomotor function
• Work capacity
• School attendance and performance
• Fitness test performance
• Activities of daily living (ADL)
Nutrition Status
• Food supply per person by type of food
• Food intake surveys (e.g. NHANES)
• Anthropometric indicators– growth patterns of infants and children;
– body mass index of adults
• Dietary patterns
• Biochemical - blood sugar, cholesterol, lipids
• Micronutrient deficiency conditions - vitamins A, B,
C, D, iodine, iron status
• Hematologic indicators - anemia and lead among
infants, children and women, environment pollutants
Utilization of Services: Performance
Indicators
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Immunization rates
Visits to doctors per person per year
Hospitalization by cause/1,000, ALOS
Surgical rates/1,000
Hysterectomy, tonsillectomy rates
Caesarian rates
Mammography rates
Pap smear rates
Hospitalization Data
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Sentinel event in health and health economics
Limited size of data
ALOS
Admission rates
Days of care per 1,000 popualtion
Measure of efficiency of health system
Can identify special health problems
E.g. amputation of lower limb, Beersheva
Case reviews e.g AMI management
Infection, incident rates
Case mix
Knowledge, Attitudes, Beliefs and
Practices (KABP)
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Community, patient and provider
What do people know
What do they think
What do they believe
What do they do
Crucial for control of AIDS, TB, risk
behavior reduction
Costs and Benefits
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How much is spent on health
How is it spent or mis-allocated
How are health issues monitored
Value gained in reduced burden of disease for
specific expenditures
• How are services paid for
– Hospitals
– Primary care
– Health promotion
Regional Health Profiles
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Geographic medicine
Geographic information system
Monitor equity
Small areas analysis
Think global, act local
Services are provided locally
Need to know local health conditions
Used for payment between national and local
services e.g. Scandinavian countries, UK
Quality of Care
• Training
• Accreditation
– Governmental
– Non-governmental
• Research
• Publications
• Peer review
• Quality assurance organization
• Tracer conditions e.g. amputation of LL
Tracer Condition
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Peer review internal
External review
Common, treatable/preventable
Marker for outcome measure
Indicator of quality of care
Appendectomy with positive pathology
AMI/post AMI completeness of care
Incident reviews
Maternal and infant death reviews
Summary
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Population at risk – geographic or sample
Multi-factorial
Measures of input
Measures of process
Independent variables
Measures of outcome or dependant variable
Costs and benefits
Monitoring population health is integral part of
health system