Transcript The Preventive Services Toolkit

AAPHP
Preventive Services Toolkit
Epidemiology as a Policy Tool
--how to insert science into policy and
political deliberations
10/10/06
AAPHP PSTK Epidemiology
Module 5, Slide 1
Teaching Objectives
 Identify and use patterns of illness, risk
and likely response
 Use multiple data models
 Insert science into policy
 Understand time intervals and program
life cycles -- and use this understanding
to help long term survival of programs
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AAPHP PSTK Epidemiology
Module 5, Slide 2
Epidemiology
-- using what we know about determinants of
wellness, illness, disability and death to
improve outcomes
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Etiology
Risk profile
Natural history
Efficacy of preventive and therapeutic measures
Practicability of preventive and therapeutic measures
Intended and other consequences – social, cultural,
economic and other
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AAPHP PSTK Epidemiology
Module 5, Slide 3
Epidemiologic Process
 Determine who is at risk
 Stratify groups by level of risk
 Determine why they are at risk
 Craft interventions to reduce that risk
 Track progress against projections
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AAPHP PSTK Epidemiology
Module 5, Slide 4
Numerators and Denominators
 Numerator = the number sick
 Denominator = the number at risk
 The secret to success for preventive
services is figuring out how best to
define the denominator(s)
o Who
o How many?
o How do we connect with them?
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AAPHP PSTK Epidemiology
Module 5, Slide 5
Policy
 Strategy
 Tactics
 Deciding what to do and how to do it
 Deciding who pays and who benefits
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AAPHP PSTK Epidemiology
Module 5, Slide 6
Politics
 Politics is based on values and
perceptions -- it may or may not consider
science
 Big “P” politics – partisan and electoral
 Small “p” – politics –- inter and intra agency
 Decided on basis of stakeholder conflict and
negotiation
 -- politics is often (but not always) the process
by which policy is decided
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AAPHP PSTK Epidemiology
Module 5, Slide 7
Science and Policy
 Policy should be based on both
politics and science
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Science is needed
o
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o
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Health professionals need to insert science into
the policy dialogue at every level
o
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To identify problems amenable to interventions
To select interventions
To project efficacy and cost efficiency
To assure positive outcomes
Within the organization
Community
Political jurisdiction
Epidemiology is the basic science of public health
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AAPHP PSTK Epidemiology
Module 5, Slide 8
Inference and Causation
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Causation
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Biological plausibility
Sequence of cause and effect
Determination of who is at risk, and why
Impact of interventions
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Biological plausibility
Sequence of cause and effect
Determination of efficacy
AAPHP PSTK Epidemiology
Module 5, Slide 9
Direct Benefits of Preventive Services
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Improved health outcomes
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Persons served (process) (denominator)
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Illness/healthcare services averted (outcome)
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Better understanding and increased personal
responsibility by patients (system)
(numerator)
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AAPHP PSTK Epidemiology
Module 5, Slide 10
Indirect Benefits of Preventive Services

Better adherence to medical recommendations
for other health conditions
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Other improvements in lifestyle
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Improved member/patient and staff
satisfaction and loyalty
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Possible competitive advantage in the
marketplace
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AAPHP PSTK Epidemiology
Module 5, Slide 11
Other Consequences of Preventive Services
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Increased outpatient costs
o
Longer visits (health ed and counseling)
o
More visits
•
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Better adherence to prescribed regimens of care
Alerted to early signs
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Low morale if by doctors and nurses not compensated
for extra counseling/screening etc.
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Adverse reactions to preventive medications (statins,
ACE inhibitors, etc)
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Adverse patient selection (from health insurance
perspective)
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AAPHP PSTK Epidemiology
Module 5, Slide 12
Projecting Costs and Benefits –
Special Issues
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Healthcare system
o
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Fiscal/healthcare utilization
Patient
o
Rates of illness, complications and death
o
Rates of long-term disability
o
Quality of life – for patient and for family members
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Quality-adjusted Life Years (QALY’s)
Disabilty-adjusted Life Years (DALY’s
Employer
o
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Absenteeism and on-the-job productivity)
AAPHP PSTK Epidemiology
Module 5, Slide 13
Small-Numbers Epidemiology
 Statistical significance impossible with
community-level planning and evaluation
 Rely on baselines and trends
 p < 0.2 guideline can be used for program
evaluation and use of GIS, Epi, and Statistical
software
 NEVER base a local or state policy decision on
a test of statistical significance
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AAPHP PSTK Epidemiology
Module 5, Slide 14
Syndemics

Definition: an ecological/systems approach to
the study of simultaneous and possibly
synergistic epidemics affecting a specified
community or sub-population
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Examples
o
Youth – STDs, AIDS, Substance Abuse, Unplanned or
undesired pregnancy
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Elderly – diabetes, metabolic syndrome,
cardiovascular and cerebrovascular disease
o
Urban inner city – Household Lead Poisoning
o
Suburban sprawl - Obesity
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Module 5, Slide 15
Data Models
 Medical
 Public Health
 Community, Mental Health and Behavioral
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Module 5, Slide 16
Medical Data Model
 ICD9 Codes (illustrated as Leading Causes of Death in
2000, with Rates per 100,000)
o
Heart disease
258.2
o
Malignant neoplasm
200.9
o
Cerebrovascular disease
60.9
o
Chronic lower respiratory tract disease
44.3
o
Unintentional injuries
35.6
o
All Causes
873.1
 Medical Procedure Codes
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Per Mokdad et al, JAMA 2004; 291:1238-1245
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AAPHP PSTK Epidemiology
Module 5, Slide 17
Public Health Data Models
 Risk factors (illustrated as Major Causes of Preventable
Death in 2000 with percent of deaths)
o
Tobacco
18.1%
o
Poor diet and physical inactivity16.6%
o
Alcohol consumption
o
Microbial agents
o
Toxic agents
3.5%
3.1%
2.3%
 Skilled use of public data sets
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Census and demographics
Vital records
National surveys
Per Mokdad et al, JAMA 2004; 291:1238-1245
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AAPHP PSTK Epidemiology
Module 5, Slide 18
Community Data Models
 Social inequalities
o
Poverty/indigency
o
Race/ethnicity/discrimination
o
Literacy
 Social isolation - lack of family/friends
 Mental illness – temporary or long term
 Cultural acceptance of high risk activities
 Lack of access to healthcare and other services
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AAPHP PSTK Epidemiology
Module 5, Slide 19
Life Cycle of a Chronic Disease (“DM”)
Program in a Healthcare Setting
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Start-up
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Initiation of service to saturation of need
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(0 to 6 months)
all cost and little or no outcome/benefit
(3 months to 3 or 4 years)
year to year reductions in healthcare costs
Stabilization of benefit
o
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(year 4 or 5 and beyond)
continuation of maximum benefit,
no more year-to-year reductions in cost
AAPHP PSTK Epidemiology
Module 5, Slide 20
Final Comments
 Supplemental Materials appended
to Instructor’s Manual
o
http://www.aaphp.org, under “Preventive
Services ToolKit”
 Q and A
10/10/06
AAPHP PSTK Epidemiology
Module 5, Slide 21