Health and Preventive Medicine

1. Health and Preventive Medicine Paul Dassow, MD, MSPH MD 815 November 10, 2006

2. Objectives • Gain a historical perspective on the determinants of health • Be able to identify the most common causes of death in America • Be able to identify age specific differences in mortality • Know the principles of Preventive Medicine and their common application

3. Health – what is it?

5. What is “Health” • World Health Organization • Health is a complete state of physical, emotional, and social well-being, not just the absence of disease

6. What makes someone healthy? • Who’s dying, who’s getting sick, and why? • Money? (Access to care, SES) • Behavior? • Genetics? • Luck?

7. Life Expectancy – 20th Century

8. A Historical PerspectiveDeaths 1900

9. Infant Mortality – 20th Century

10. Life Expectancy – 20th Century

11. Calculation of life expectancy: • 100 persons born • You expect 80 to die at age 80, 20 to die at 6 months: • (80x80) + (20x0.5)/100 = 64.1 years • You expect 95 to die at age 80, 5 to die at 6 months: • (95x80) + (5x0.5)/100 = 76 years

12. Life Expectancy – 20th Century

13. Cause of Death - 2004

14. A Historical PerspectiveDeaths 1900

15. The Fall in Infectious Diseases Organism identified Antibiotics Immunization

16. The Fall in Infectious Diseases Organism identified Chenotherapy BCG vaccination

17. The Answer – Prevention • For the case of infectious diseases, this has mostly been public health measures • Clean Drinking Water • Sewage management • Building Codes • Food Surveillance • Milk was at one time the item most likely to spread disease

18. Cause of Death - 2004

19. Deaths, by age group 2004 Age under 1Age 15-24 - birth defects - Unintentional injuries - premature births - Homicide - SIDS - Suicide Age 1-4Age 25-44 - Unintentional injuries - Unintentional injuries - Birth defects - Cancer - Cancer - Heart disease Age 5-14Age 45-64 - Unintentional injuries - Cancer - Cancer - Heart disease - Birth defects - Unintentional injuries

20. Summary - Determinants • Determinants of health have changed over time • Determinants are age and population dependent • Factors such as race and gender continue to be important determinants of health • Degree that each factor determines health is an ongoing area of research

21. Summary - Determinants

22. Preventive Medicine • Behaviors undertaken by a clinician to prevent the onset of disease or to detect disease prior to the occurrence of illness • Primary Prevention: Activities aimed at preventing the initial occurrence of disease • Ex. Counseling about seat belt use • Secondary Prevention: Activities aimed at preventing further damage once a disease has been diagnosed • Ex. Cholesterol lowering after a myocardial infarction

23. Preventive Medicine • The core components of Preventive Medicine: • Vaccinations • Screening • Counseling • Future components? • Genetic screening

24. Vaccinations • We now routinely vaccinate children against 12 diseases • Tetanus, diptheria, pertussis, polio, H flu, Hepatitis B, pneumonia, measles, mumps, rubella, chicken pox, influenza • We routinely vaccinate older adults against 2 diseases • Influenza, pneumonia, tetanus (booster) • New vaccines • Human Papilloma Virus, Shingles (herpes zoster)

25. Vaccinations • How is this accomplished? • For kids, vaccinated at regularly scheduled visits • 2, 4, 6, 12, 15 months • For adults, physician needs to incorporate into chronic disease management visit, or routine physical exam • HPV vaccine indicated for females aged 9-26 • All routine vaccinations covered by insurance

26. Screening • What is screening? • Screening involves performing a test or evaluation on a person who currently has no signs or symptoms of disease for the express purpose of finding pathology (disease) at its earliest stages

27. Screening • Screening tests are most actively used in the adult population. Most comprehensive National Guideline on screening (who, when, why, how): • United States Preventive Services Task Force report (USPSTF), published every year or two, available online at: http://www.ahrq.gov/clinic/uspstfix.htm

28. Screening • Mammography • The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older. Rating: B recommendation.

29. Counseling • Counseling has become a major expectation among both patients and 3rd party payers • Physicians can bill for time spent counseling • Well adult and well child visits must contain evidence of counseling regarding health related behaviors • Significant research supports the role of the physician as counselor

30. Counseling • Typical topics of counseling include: • Use of recreational substances (tobacco, Etoh) • Nutrition • Weight loss strategies • Maintaining sexual health • Cancer avoidance • Exercise

31. Counseling • For the parents of children, counseling would include: • Safety, safety, safety • Accepted parenting techniques • Age appropriate nutrition • Basics of virus care • Basics of newborn care

32. How is this all done? • Some have estimated that if all the recommended preventive care was delivered, it would take 12 hrs/yr of a physicians time. • Obviously, alternate strategies are needed • Web based information • Use of ancillary staff • Patient handouts

33. Preventive Medicine • For a Primary Care Physician such as myself who provides a Medical Home for patients, striving to provide the optimal in preventive care is paramount. • The US system is slowly recognizing and making changes to reward excellence in Preventive Care (Pay for Performance)

34. Questions?