Reforming Disease Prevention and Health Promotion: Population Health

1. Reforming Disease Prevention and Health Promotion:Population Health Steven Teutsch, MD, MPH Chief Science Officer Los Angeles County Department of Public Health September 15, 2009

2. Problem: America is Not Getting Good Health for Its Health Care Dollar Prepared for the Robert Wood Johnson Foundation by the Center on Social Disparities in Health at the University of California, San Francisco. Source: OECD Health Data 2007. Does not include countries with populations smaller than 500,000. Data are for 2003. *Per capita health expenditures in 2003 U.S. dollars, purchasing power parity Copyright 2008 Robert Wood Johnson Foundation/ Overcoming Obstacles to Health.

4. Former Leading Causes of Death:Crude Death Rate for Infectious Diseases, U.S., 1900 - 2000 * Rate is per 100,000 4 MMWR, CDC, 1999

5. The Lifecourse Perspective:Early Childhood Impacts Adult Health Status 5

6. Health Influences Over the Life Course From Neal Halfon

7. From Neal Halfon

8. The Social and Physical Environments are Among the Most Important Determinants of Health

9. Income is Linked to Longevity Regardless of Race/Ethnicity “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”

10. Education Matters:Mother’s Education Related to Infant Mortality Babies born to mothers who did not finish high school are almost twice as likely to die before their first birthday as babies born to college graduates “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”

11. Education Matters: More Education Means Longer Life Expectancy “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”

12. The Toxic American Environment: Percent of Recent Immagrants and Long-term Residents with Diabetes, United States, 2006 The Hispanic Paradox: Recent Immigrants have less diabetes and other health problems than those who have had longer exposure to our toxic socioeconomic and physical environment Steven P. Wallace, Xóchitl Castañeda. Migration and Health: Latinos in the United States. 2008

13. Economic Hardship & Childhood Obesity Economic hardship and childhood obesity go hand in hand

14. Improving Health Requires Actions at Multiple Levels

15. Action Model to Achieve Healthy People 2020 Overarching Goals Determinants of Health Interventions Outcomes • Behavioral • outcomes • Specific risk factors, • diseases, &conditions • Injuries • Well-being & health- • related Quality of Life • Health equity • Policies • Programs • Information Assessment, Monitoring, Evaluation & Dissemination

16. Action Model to Achieve Healthy People 2020 Overarching Goals Determinants of Health Interventions Outcomes • Behavioral • outcomes • Specific risk factors, • diseases, &conditions • Injuries • Well-being & health- • related Quality of Life • Health equity • Policies • Programs • Information Smoking Quitlines Assessment, Monitoring, Evaluation & Dissemination

17. Action Model to Achieve Healthy People 2020 Overarching Goals Determinants of Health Nurse Home Visits Interventions Outcomes • Behavioral • outcomes • Specific risk factors, • diseases, &conditions • Injuries • Well-being & health- • related Quality of Life • Health equity • Policies • Programs • Information Smoking Quitlines Assessment, Monitoring, Evaluation & Dissemination

18. Action Model to Achieve Healthy People 2020 Overarching Goals Work Safety Determinants of Health Nurse Home Visits Healthy Homes Interventions Outcomes • Behavioral • outcomes • Specific risk factors, • diseases, &conditions • Injuries • Well-being & health- • related Quality of Life • Health equity • Policies • Programs • Information Smoking Quitlines Assessment, Monitoring, Evaluation & Dissemination

19. Action Model to Achieve Healthy People 2020 Overarching Goals Work Safety Determinants of Health Walkable Communities Nurse Home Visits Healthy Homes Interventions Outcomes • Behavioral • outcomes • Specific risk factors, • diseases, &conditions • Injuries • Well-being & health- • related Quality of Life • Health equity • Policies • Programs • Information Smoking Quitlines Blood Alcohol Laws Assessment, Monitoring, Evaluation & Dissemination

20. Spectrum of Health and Strategies to Improve It Society Well Dead Individual

21. Population Health Strategies Spectrum of Health and Strategies to Improve It Society Clinical Strategies Well Dead Individual

22. Population Strategies Society Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Education Well Dead Worksite Programs School Health Individual

23. Clinical Strategies Society Well Dead Disease Mgmt Assisted Living Clinical Preventive Services Primary Care Tertiary Care Individual

24. Medical Care System Strategies Society Well Dead Hospital Systems Integrated Health Systems Disease Mgmt Assisted Living Medical Home Individual

25. Spectrum of Health and Strategies to Improve It Society Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Education Well Dead Worksite Programs School Health Hospital Systems Integrated Health Systems Disease Mgmt Assisted Living Clinical Preventive Services Primary Care Tertiary Care Individual

26. How Do We Know What Works?Evidence-based Recommendations

27. So How Do We Apply Them to Prevention & Control of Diabetes? 27

28. Spectrum of Health and Strategies to Improve It Society Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Education Well Dead Worksite Programs School Health Hospital Systems Integrated Health Systems Disease Mgmt Assisted Living Clinical Preventive Services Primary Care Tertiary Care Individual 28

29. Preventing Onset of Diabetes: Reducing Obesity Society Street-scale urban design/land use Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Enhanced School-based Physical Education Point-of-decision Prompts Behavioral interventions to reduce screen time Education Well Dead Worksite Programs Worksite programs for overweight and obesity School Health Hospital Systems Integrated Health Systems Disease Mgmt Screen adults for obesity and offer intensive interventions Assisted Living Screen hypertensives Clinical Preventive Services Primary Care Tertiary Care Individual 29

30. Managing Diabetes Society Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Education Social Support Interventions in Comm. Settings Well Dead Worksite Programs Worksite programs for overweight and obesity Self-Mgmt Education (home /Community School Health Hospital Systems Control BP / Lipids/ Smoking Integrated Health Systems Case Mgmt/ Disease Mgmt Disease Mgmt Assisted Living Clinical Preventive Services Primary Care Tertiary Care Individual 30

31. Maintaining Function in Diabetes Society Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Education Well Dead Worksite Programs School Health Hospital Systems Integrated Health Systems Disease Mgmt Dialysis Assisted Living Clinical Preventive Services Primary Care Tertiary Care Individual 31

32. A Comprehensive Approach to Preventing and Controlling Diabetes Society Street-scale urban design/land use Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Enhanced School-based Physical Education Point-of-decision Prompts Behavioral interventions to reduce screen time Education Social Support Interventions in Comm. Settings Well Dead Worksite Programs Worksite programs for overweight and obesity Self-Mgmt Education (home /Community School Health Hospital Systems Control BP / Lipids/ Smoking Integrated Health Systems Case Mgmt/ Disease Mgmt Disease Mgmt Screen adults for obesity and offer intensive interventions Assisted Living Screen hypertensives Clinical Preventive Services Primary Care Dialysis Tertiary Care Individual 32

33. What We Are Striving to Achieve Vision A society in which all people live long, healthy lives. Overarching Goals • Elimination of preventable disease, disability, injury, and premature death • Achievement of health equity, elimination of disparities, and improvement in the health of all groups • Creation of social and physical environments that promote good health for all. • Promotion of healthy development and healthy behaviors across every stage of life 33 Healthy People 2020

34. Major Opportunities:Health in All Policies • Opportunities in all sectors e.g. agriculture, transportation, housing, environment, commerce, tax policy • In both public and private sector • Examples: • Menu labeling • Tax on sugared beverages • Transportation systems that encourage mass transit, biking and walking 34

35. 35 http://www.ph.ucla.edu/hs/health-impact/

36. HIA: Estimation of Health Benefits from a Living Wage Ordinance 36 Bhatia , Katz, AJPH, 2001

37. Summary • Prevention effective in clinical and population applications • Large differences between best evidence and current practice • Greatest opportunity: policies and programs targeting populations • Policies in all sectors affect health • Can’t eliminate health disparities without emphasis on social and physical determinants

38. The Challenge: Closing the Gap • Cannot be done by just fixing the health care system • Must address the underlying social and physical environment determinants • Must build a true population-oriented health system 38