1
Q
Morbidity
A
- illness.
- pt can have co-morbidities
- prevalence is a measure often used to determine the level of morbidity in a population.
2
Q
- Mortality
2. life Expectancy at birth
A
- -Deaths.
- A mortality rate is the number of deaths due to a disease divided by the total population. - Life expectancy at birth reflects the overall mortality level of a population.
- It summarizes the mortality pattern that prevails across all age groups in a given year – children and adolescents, adults and the elderly.
3
Q
Incidence
A
- a measure of disease that allows us to determine a person’s probability of being diagnosed with a disease during a given period of time.
- is the number of newly diagnosed cases of a disease.
- incidence rate is the number of new cases of a disease divided by the number of persons at risk for the disease.
- acute disease, studies of causation
- If, over the course of one year, five women are diagnosed with breast cancer, out of a total female study population of 200 (who do not have breast cancer at the beginning of the study period), then we would say the incidence of breast cancer in this population was 0.025. (or 2,500 per 100,000 women-years of study)
4
Q
Prevalence
A
- a measure of disease that allows us to determine a person’s likelihood of having a disease.
- the number of prevalent cases is the total number of cases of disease existing in a population.
- A prevalence rate is the total number of cases of a disease existing in a population divided by the total population.
- chronic disease & implications
5
Q
Crude mortality rate
A
- Mortality rate among all age groups and due to all causes.
- -A mortality rate is the number of deaths due to a disease divided by the total population.
6
Q
Age-adjusted mortality:
A
- Mortality rate that takes into account the age structure of the population to which it refers.
- Used to compare mortality in populations with very different age structures
7
Q
Infant mortality rate: age specific mortality
A
-# of infants below one year of age dying per 1000 live births in a given year
8
Q
Describe the five areas for measuring population health
A
The five Ds
- Death (mortality)
- Disease (morbitity)
- Disability
- Discomfort & 5. Distress (physical & mental components)
- physical function
- role physical
- bodily pain
- general health
- mental health
- role emotional
- social function
- vitality
9
Q
Health status
A
-The state of health of a person or population assessed with reference to morbidity, impairments, anthropological measurements, mortality, and indicators of functional status and quality of life
10
Q
Population health
A
- the health outcomes of a group of individuals, including the distribution of such outcomes within the group.
- These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
- The health outcomes of such groups are of relevance to policy makers in both the public and private sectors.
11
Q
what is health?
A
is a state of complete physical, mental, social well-being and not merely the absence of disease or infirmity
12
Q
Disability-Adjusted Life Years (DALY)
A
YLL due to premature mortality in population
- DALY is a health gap measure that extends the concept of potential years of life lost (YLL) due to premature death to include equivalent years of ‘healthy’ life lost by virtue of being in states of poor health or disability (YLD).
- DALY combines in one measure the time lived with disability and the time lost due to premature mortality.
- One DALY can be thought of as one lost year of ‘healthy’ life and the burden of disease as a measurement of the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability
13
Q
To define social determinants of health (SDH)
A
-“The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. -These social structures and economic systems
include the social environment, physical environment, health services, and structural and societal factors.
-Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.”
-“Conditions in which people are born, grow, live, work & age.”
14
Q
absolute poverty
A
- basic needs
- poverty in relation to the amount of money necessary to meet basic needs such as food, clothing, and shelter.
- The concept of absolute poverty is not concerned with broader quality of life issues or with the overall level of inequality in society.
- The concept therefore fails to recognise that individuals have important social and cultural needs
15
Q
relative poverty
A
- basic needs + quality of life
- poverty in relation to the economic status of other members of the society: people are poor if they fall below prevailing standards of living in a given societal context.
16
Q
socioeconomic status
A
-position within social hierarchy, based on prestige and access to resources 1. income & wealth 2. education 3. occupation
17
Q
social capital
A
-Resources that can be accessed through membership in networks and other social structures” – Trust – Social organizations/support – Collective action – Diffusion of information
-refers to the institutions, relationships, and norms that shape the quality and quantity of a society’s social interactions.
- increasing evidence shows that social cohesion is critical for societies to prosper economically and for development to be sustainable.
- Social capital is not just the sum of the institutions which underpin a society – it is the glue that holds them together
18
Q
Maslow’s Hierarchy of Needs
A
bottom most (foundation) to top
- physiologic (health, food, water, shelter)
- safety (security of body, property)
- belonging
- esteem & respect
- achieving potential
-SDHs (social, physical, economic) can weaken or strengthen foundation of pyramid, impacting stability of the entire hierarchy
19
Q
what are the importance of SHD (6)
A
- Impact health of the individual
- Impact health of populations
- Cause/worsen acute conditions
- Cause/worsen chronic diseases
- Gene-environment interactions
- New focus with health reform
20
Q
deconstructing the 3 main points of SDH
A
- social environment
- social capital & cohesion - economic environment
- SES & poverty, resources & access - physical environemnt
- common spaces, parks, exercise centers
- pollution
- housing quality
21
Q
Discrimination & race
-four areas of racial disparities
A
base on race
-institutional:affects access to quality resources, education,health care
– Personally-mediated: differential assumptions and stereotypes
– Internalized: stigmatization of one’s own abilities and worth
racial Disparities:
- housing
- education & labor market
- criminal justice
- health care
22
Q
Poverty impact resources in community
-what is food security refers to?
A
availability & access to healthy nutrition
- resource availability
- access to care, common space
- adverse environmental exposures
- housing quality & asthma
23
Q
SDH strongly associated with:
A
- Injury
- Malnutrition/Obesity
- Infectious diseases
- Preterm birth
- Lead poisoning
- Behavioral/developmental
- Diabetes
- Substance abuse
- Wound healing
- Asthma/resp. illness
24
Q
ID roles physicians have in assisting pts with chronic illnesses
A
- Talk to your health care provider about any issues that can make adherence difficult,
- be sensitive to the role that families, caregivers, and communities play in different cultures.
- use of evidence-based techniques that emphasize patient activation or empowerment, collaborative goal setting, and problem-solving skills.
- support patient self-management efforts by emphasizing the role of the patient, by recommending and using effective interventions, and care-planning and problem-solving to help patients overcome barriers to self-management activities.
25
patient and physician behaviors which facilitate self-management of chronic diseases and adherence
- Treatment adherence means following your treatment regimen closely every day—prevent drug Resistance
- Self-management and adherence encompasses all the activities patients perform to control their illness, prevent future complications, and cope with the impact of both the disease and its treatment on themselves and others, and includes:
- Collaborative goal setting
- Monitoring of symptoms
- Lifestyle behaviors such as eating a healthy diet, getting regular exercise, and smoking cessation
- Taking medication in the dose and frequency prescribed
- Communicating with the health care team, family members, and others
- Ongoing problem-solving to overcome potential barriers
26
five key areas (determinants) include
```
Economic Stability
Education
Social and Community Context
Health and Health Care
Neighborhood and Built Environment
```
27
Define epidemiology
- study of the distribution and determinants of health-related states or events (including disease), and the application of this study to the control of diseases and other health problems.
- epidemiological investigations: surveillance and descriptive studies can be used to study distribution; analytical studies are used to study determinants.
-examine patterns of illness in the population and then try to determine why certain groups or individuals develop a particular disease whereas others do not
28
3 necessary components for a disease to occur –the epidemiological triad (cholera)
-disease progression
```
Disease Progression
1. time
2. place
3. person
epidemiological triad
1. host (humans)
2. vector (contaminated stool)
3. agent (Vibrio Cholerae)
4. environment (water, food)
```
29
endemic
- disease that resides within a population
| - habitually present in human pop steady state
30
epidemic
- A sudden and great increase in the occurrence of a disease within a population is referred to as an epidemic
- disease that are visited upon a population
- occurence of disease in community/region above expected levels depend on location, season, conditions of season
- 2-3X expected levels
31
pandemic
- A rapidly emerging outbreak of disease that affects a wide range of geographically distributed populations is described as a pandemic
- widespread multiple continents
32
Distinguish between a index and sentinel case
INdex case
- case that STARTED the epidemic
- often not known until much later
Sentinel case
- The first few affected patients IDENTIFIED with any outbreak of disease
- not always the case that started the epidemic
33
Disability
-a physical, cognitive, mental, sensory, emotional, developmental (combination) deviation that interferes with normal interaction with environment
disease-->impairment-->disability-->handicap
34
distinguish between incidence, prevalence, disability, morbidity, mortality
1. incidence- # of new cases
2. prevalence- # of cases at one particular time period. dimensionless
3. disability- deviation that interferes with normal interaction with environment
4. morbidity- illnesses
5. deaths
35
what is outbreak
| steps in investigating a disease outbreak
- A sudden, unexpected increase in the occurrence of a disease within a relatively limited geographic area.
1. case definition
2. validate existence of outbreak
3. examine distribution of cases
4. look for interactions of relevant variables
5. generate & test hypotheses of transmission
6. recommend control measures
36
disease surveillance
- Monitoring the patterns of occurrence of a disease within a population
1. help identify the new outbreak
2. provide clues possible causes of the condition,
3. used to suggest strategies to control or prevent the spread of disease
4. used to measure the impact of disease prevention and control efforts
5. provide information on the burden of illness, data that are necessary for determining health and medical service needs.
37
Distinguish between descriptive, analytic and experimental types of epidemiological data
Descriptive- time, place, person information on cases
Analytic- risk factor information on cases and controls
1. case-control
2. cohort studies
Experimental- randomized control trials
```
Surveillance & descriptive studies
1. who
2. what
3. when
Analytical & experimental
1. why
2. how
```
38
Define an attack rate,
- attach rate= # ppl at risk who develop dx/ total number ppl at risk
- a proportion
- a special form of incidence rate used when disease occurrence increases over short period (during outbreak, often related to incubation period of disease).
39
case-control
- help determine if an exposure is associated with an outcome
- Cases vs. Control group, compare frequency
- retrospective study
40
cohort studies
- for estimating risk of disease, incidence rate or relative risks
- longitudinal or prospective studies
- use to study causes
41
randomized control trials
-individuals are assigned randomly to be in the exposed or unexposed groups
42
cross-tabulation
compares attack rates to exposures
- can be used with categorical (discrete items) epidemiological data
- grouping data this way allows for bio-stat comparisons
43
Windshield surveys
-systematic observations made from a moving vehicle
44
key informants
-people in both formal & informal leadership roles representing diverse stakeholder groups, community historians, trusted people who keep track of everyday events in neighborhood and are often at center of informal helping networks
45
asset maps
-geographic map on which physical assets such as schools, landmarks, playground, public gathering places, churches, airports, recreation areas may be designated
46
focus groups vs. individual interview
focus group
-more breadth to answers, good for learning the widest range of options
interview
-more depth to answers; good for learning how people really feel about issues
47
community
- any group sharing something in common
- location, race, religion, collection of pt with same dz, population defined by multiple characteristics
- virtual community
- health care organization, clinics
48
community assessment
- individual/group gathers info on current strengths, concerns, conditions of community
- needs
- resources or assests
49
qualitative methods for assessment:
- Observations
- review of existing materials
- interviews/focus groups
- survey/questionnaire
50
Choosing participants for qualitative methods
-
51
(1) Identify how the complexities of the US health care system have informed reform activities
-
52
(2) Describe the major elements of health care reform activities 2008-present
```
2010
-young adults
-small business tax credits
-pre-existing condition insurance plan (PCIP)
-insurance new rules
-CHIP
-doughnut hole rebates
-preventative care
-payment reform
-workforce improvement
-quality improvement
-access to care
-annual review of premium increases
-early retirees
2011
-limits on nonmedial spending by health plans
-doughnut hole discounts
-physician quality reporting
-new payment & delivery approaches
-long term care insurance program
-pharmaceutical manufacturer fee
-OTC drug reimbursement restrictions
-benefit disclosure
2012
-hospital readmission reduction payments
-accountable care-quality target
-hospital value based purchasing program
-understanding health disparities
```
53
(3) Explain how future developments of reform may affect the US health care system and the physician practices of tomorrow
-medicaid & private insurance are eliminated in their current form and are melded into a single insurance program that resembles a Medicare-type program for all Americans
-Cost containment--limit % of health insurance premiums that can be retained by company overhead & profits
-redesign health care delivery to achieve better value
-
54
(6) Describe how Medicare and Medicaid change in 2013 and 2014 with the Affordable Care Act
1. children covered until 26 yo
2. 2014 buy insurance on a health insurance exchange plan
3. 2014 income below 400% FPL gets subsidy
4. 2014 under 65 make less than 133% FPL (12,305 pp) can get medicaid
Consumer protection
1. insurance cannot canceled unless you lie/fraud
2. 2014 children cannot be denied because of health problem
3. new pre-exisiting condition insurance plan
4. 2011 insurance cannot have lifetime limits for essential health benefits--> 2014 cannot have annual limits
5. insurance spends less than 80cent of every premium dollar on members' healthcare, it will refund part of premium
6. 2014 insurance will pay full cost of preventative services
7. 2014 out of pocket expenses will be limited based on income
8. 2013 income >$200,000 (pp), Medicare payroll tax increase
9. healthcare spending accounts & flexible spending accounts taxable income slightly increase
10. no longer buy OC drugs with accounts
11. 2014 must have health insurance or pay fine
12. independent payment advisory board- identify areas of waste and federal budget savings in Medicare
13. Medicaid expansion up to 133% of FPL
14. 4/5 star Medicare private plans wil receive 5% bonuses as reward for providing better clinical quality & pt experiences
55
Health reform
- primary goal as modifying the medthods of financing health care to achieve universal coverage
56
Medicaid
- public assistance program that does not require recipients to make contributions but instead is financed from general tax revenues
57
Medicare
-social insurance program, families make social secuirty conribution to gain eligibility to the plan
58
individual mandate
- -residents required to purchase individual health insurance policies
- tax credit available on sliding scale
- neither employer nor government insurances would continue to play a role in financing health care
- massachusetts state level universal health coverage bill implementing individual mandate
59
accountable care organizations
- groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.
- ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program
- Accountable Care Organizations provide coordinated care and chronic disease management while lowering costs
60
patient centered medical home
-provides primary health care that is relationship-based with an orientation toward the whole person
61
employer mandate
-federal government requires employers to purchase provate health insurance for their employees
62
affordable care act
- signed by Obama March 23, 2010
- aims to increase the quality and affordability of health insurance,
- lower the uninsured rate by expanding public and private insurance coverage
- reduce the costs of health care for individuals and the government.
- It provides a number of mechanisms—including mandates, subsidies, and insurance exchanges—to increase coverage and affordability
1. individual mandate
2. employer mandate
3. medicaid explansion
4. insurance market regulation
63
cost-sharing
-patients pay for a portion of health care costs not covered by health insurance.[1] Examples include copays, deductibles and coinsurance.
64
single-payer health care
- government, rather than private insurers, pays for all health care costs.
- Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the UK).
- describes the funding mechanism—referring to health care financed by a single public body from a single fund—and does not specify the type of delivery, or for whom doctors work
65
employer-based health care
-health insurance is paid for by businesses on behalf of their employees as part of an employee benefit package.
66
IHI triple AIM
-Institute for health Improvement
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
67
employer-based health care
-health insurance is paid for by businesses on behalf of their employees as part of an employee benefit package.
68
benefit package
- hospital care, physician visits, labs, x-rays, physical & occupational therapy, inpatient pharmacy, acute acre
- Medicare Part D added 2003 Mental health services
- Mental health parity act of 1996, mental health parity and Addiction equity act of 2008
69
Identify sources of standardized data
-
70
Identify how to establish causation
-
71
AOEC
ATSDR
EPA
- association of Occupational & environmental Clinics
- Agency for Toxic Substances & Disease Registry
- Environmental Protection Agency
72
incubation period
-interval of time from receipt of infection to onset of clinical illness
73
Data of morbidity & mortality come from?
1. disease reporting= CDC
2. insurance plan data
3. public assistance & medicaid/medicare
4. hospitals & clinics= Ohio Department of Health, City of Cincinnati
5. absenteeism records
6. case-finding programs
7. morbidity surveys
74
Limitation of sources of data
- hospital records not always precise enough
- not all illness reported
- not all cases are defined same
- duplicate records if looking at multiple sources of data
75
difficulty establishing causation
- epidemiology are observatioanl
- limited compared to animal studies
- ethical issues regarding exposing populations
76
etablishing causation
1. temporal relationship
2. strength of association
3. dose response relationship
4. replication of findings
5. biologic plausibility
6. consideration of alternate explanations
7. cessation of exposure
8. consistency with other knowledge
9. specificity of association
77
calculating risk
-comparing 2 or more incidence rates
78
case definition
-clinical criteria, in setting of an outbreak investigation, certain restriction on time, place, person
79
Norwalk-like virus
transmission- fecal-oral, person-person, fomite contamination, aerosolized vomit
- incubation- 24-48 hrs
- symptoms-- N/V, diarrhea
- account for 50% foodborne outbreaks
- food handlers implicated 48%
- self-limited dz, resolve 24-60 hrs
Physician & Society
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