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Intersection of Clinical Care and Public Health

Intersection of Clinical Care and Public Health. AcademyHealth 2007 Annual Research Meeting June 4, 2007 / Orlando. Ron Davis, MD President-elect American Medical Association. 1847 – Founding of the AMA and Publication of the Code of Medical Ethics.

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Intersection of Clinical Care and Public Health

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  1. Intersection of Clinical Care and Public Health AcademyHealth 2007 Annual Research Meeting June 4, 2007 / Orlando Ron Davis, MD President-elect American Medical Association

  2. 1847 – Founding of the AMA and Publication of the Code of Medical Ethics “Physicians, as conservators of the public health, are bound to bear emphatic testimony against quackery in all its forms.…”

  3. AMA mission • To promote the science and art of medicine and the betterment of public health • Unchanged since 1920

  4. AMA’s health care advocacy agenda for 2007 • Expand medical coverage for the uninsured • Reform the Medicare physician payment system • Reform the medical liability system • Improve the quality and safety of health care • Improve public health through … • Healthy lifestyles • Reducing health disparities • Disaster preparedness

  5. Topics • Medicine and Public Health Initiative • Clinical preventive services • Health promotion & disease prevention in managed care • Examples • Prevention activities in the medical sector • Collaboration between medicine and public health • Tobacco, alcohol, and obesity

  6. Medicine and Public Health Initiative (MPHI) Hippocrates urged physicians to recognize the environmental, social, and behavioral determinants of disease: • the airs “peculiar to each particular region” • the “properties of the waters” inhabitants consume • their “mode of life … whether they are heavy drinkers, taking lunch, and inactive; or athletic, industrious, eating much and drinking little”

  7. Medicine and Public Health Initiative (MPHI) – continued Rudolf Virchow (1821–1902), founder of cellular pathology: “Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of all.”

  8. Medicine and Public Health Initiative (MPHI) – continued • Formed in 1994 by the AMA and APHA to bridge the gulf between medicine and public health • National Congress in March 1996 (> 400 delegates from both disciplines) • RWJF and AHCPR formed the “Cooperative Actions for Health” Program, which funded 19 state MPHI projects • NPO: UT-Houston Health Science Center

  9. Medicine and Public Health Initiative (MPHI) – continued • NY Academy of Medicine examined the history of collaboration between medicine and public health • Identified 414 discrete examples • Medicine & Public Health: The Power of Collaboration monograph sent to all medical schools in the U.S. • Pocket Guide to Cases of Medicine & Public Health Collaboration www.cacsh.org/mphguide.html

  10. Medicine and Public Health Initiative (MPHI) – continued LM Beitsch et al, AJPM 2005; 29: 149-53 “The Medicine & Public Health Initiative: 10 Years Later” • “Although (the) MPHI was embraced in some states and localities, it was unable to bridge the cultural and institutional divide in others.” • There has been “difficulty in sustaining the momentum of (the) MPHI.”

  11. Medicine and Public Health Initiative (MPHI) – continued To reinvigorate the MPHI, Beitsch et al recommend: • Visible renewal of the shared commitment to partnership among AMA, APHA, ACPM, APTR, CDC, and others • Professional education to integrate elements of public health and medicine into each other’s curriculum • Research into effective strategies to overcome barriers across the medicine-public health chasm • Leadership by local medical and public health communities to translate the MPHI into action

  12. Medicine and Public Health Initiative (MPHI) – continued • State and local medical societies should establish public health committees • Organized medicine should be represented on public health advisory committees and boards of health • Medical societies should form foundations to expand their work in public health RM Davis, AJPM 2005; 29: 154-157 “Marriage Counseling for Medicine & Public Health”

  13. Medicine and Public Health Initiative (MPHI) – continued • Leaders in medicine and public health should offer speaking opportunities to their counterparts at meetings and conferences • Public health and preventive medicine physicians need to join their county and state medical associations and the AMA RM Davis, AJPM 2005; 29: 154-157 “Marriage Counseling for Medicine & Public Health”

  14. Medicine and Public Health Initiative (MPHI) – continued RM Davis, AJPM 2005; 29: 154-157 “Marriage Counseling for Medicine & Public Health” “An Issue to Rally Around” – work together to bolster the funding of each sector • Tobacco taxes • Tobacco settlement funds • Alcohol taxes • Taxes on non-diet soft drinks

  15. Clinical Preventive Services • Guidelines for clinical preventive services issued by the U.S. Preventive Services Task Force • Administered by the Agency for Healthcare Research & Quality (AHRQ) • Based on a rigorous review of evidence • Services are divided into categories of screening, counseling, immunization, and chemoprophylaxis

  16. Clinical Preventive Services– continued • Recommendations have been issued for ~ 75 services • Guidelines are updated and new guidelines are released on an ongoing basis • www.ahrq.gov/clinic/uspstfix.htm • AHRQ website includes “Put Prevention Into Practice” program – tools and information aimed at improving implementation of clinical preventive services guidelines • www.ahrq.gov/clinic/ppipix.htm

  17. Clinical Preventive Services– continued • Yarnall et al estimated that primary care physicians, in order to fully satisfy the USPSTF recommendations, would need to spend 7.4 hours per working day(Am J Public Health 2003; 93: 635-641) • National Commission on Prevention Priorities prioritized clinical preventive services based on the clinically preventable burden and cost-effectiveness(Am J Prev Med 2006; 31: 52-61)

  18. 2006 Prevention Priorities Short Name CPB CE Total Aspirin Chemoprophylaxis – “high risk” 5 5 10 Childhood Vaccination Series 5 5 10 Tobacco-Use Screening & Intervention 5 5 10

  19. 2006 Prevention Priorities Short Name CPB CE Total Colorectal Cancer Screening 4 4 8 Hypertension Screening 5 3 8 Influenza Immunization – adults 4 4 8 Pneumococcal Immunization – adults 3 5 8 Problem Drinking Screening & Brief Counseling 4 4 8 Vision Screening – adults 3 5 8

  20. 2006 Prevention Priorities Short Name CPB CE Total Cervical Cancer Screening 4 3 7 Cholesterol Screening 5 2 7 Breast Cancer Screening 4 2 6 Chlamydia Screening 2 4 6 Calcium Chemoprophylaxis 3 3 6 Vision Screening – children 2 4 6

  21. High-Priority, Low-Use Services Short Name Total Score National Delivery Rate Tobacco Cessation Counseling 10 35% Colorectal Cancer Screening 8 25% Pneumococcal Immunization – adults 8 56% Chlamydia Screening 6 40% Aspirin Chemoprophylaxis 10 ? Vision Screening – adults 8 ? Problem Drinking Screening 8 ?

  22. Health promotion & disease prevention in managed care Several forces are pushing prevention in managed care • National Committee for Quality Assurance (NCQA) accreditation • Health Plan Employer Data and Information Set (HEDIS) “report card” • Pressure from purchasers — public (eg, Medicaid) and private

  23. Preventive Services in HEDIS • Pap tests (21-64 years old) • Mammograms (52-69 y/o) • Colorectal cancer screening (50-80 y/o) • Childhood immunization • DTP (4), polio (3), MMR (1) • Hib (2), hep B (3), varicella (1) • Adolescent immunization (13 y/o) • MMR (2), hep B (3), varicella (1) • Influenza immunization (> 50 y/o)

  24. Preventive Services in HEDIS – continued • Smoking cessation advice/assistance • Initiation/engagement of alcohol & other drug treatment (> 18 y/o) • Chlamydia screening (women 16-26 y/o) • LDL cholesterol after acute CV event • Diabetes care (HbA1c, LDL cholesterol, screening for eye and kidney disease) • Prenatal and postpartum care • Glaucoma screening (> 65 y/o)

  25. Parallels between Public Health and Managed Care Public Health Managed Care • Primary prevention • Secondary prevention • Tertiary prevention • Demand management • HEDIS measures (mammogram, Pap) • Disease management

  26. The language of managed care • Risk management • Utilization management • Quality management • Disease management • Demand management • Physician management?

  27. Tobacco Control – AMA • AMA SmokeLess States program (funded by RWJF) gave grants to state coalitions for advocacy for tobacco control policies • > $90M provided to > 40 state coalitions during 1994-2004 • AMA worked with “Partnership for Prevention” and CTFK to successfully petition CMS to provide Medicare coverage for tobacco cessation counseling • AMA has joined amicus briefs in support of tobacco control litigation in many states

  28. Tobacco Counteradvertising Contest for Schoolchildren in Michigan • Sponsored by Wayne County Medical Society Foundation and Henry Ford Health System • Funded by the Community Foundation of Southeastern Michigan and other sources • Conducted contests in 2002 and 2005 • A third contest is now underway • www.counteradvertising.com

  29. Omar Paulk Grade 8: “In the neighborhood, the phrase ‘to smoke’ means to kill someone. ‘He got smoked’ means he got killed. When smokers finish a cigarette, they say they are killing the cigarette. My drawing asks the question, Who’s Smoking Who? It means the cigarette is killing the smoker.”

  30. James Robinson Grade 11 Cass Technical High School

  31. Damardre Williams Grade 11 Detroit High School for the Arts

  32. Edwin Andrews Grade 12 Renaissance High School

  33. Tobacco Control –Health Partners (Minneapolis)

  34. Tobacco Control –Health Partners (Minneapolis)

  35. Tobacco Control –Health Partners (Minneapolis)

  36. Alcohol Control – AMA • Two AMA programs funded by RWJF • Reducing Underage Drinking through Coalitions: Youth and Adults United for a Change • A Matter of Degree: The National Effort to Reduce High-Risk Drinking Among College Students • www.ama-assn.org/go/alcohol

  37. Alcohol Taxation • AMA Resolution 438 (A-05) • RESOLVED, That our American Medical Association support increases in federal taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the prevention of alcohol abuse and drunk driving, treatment of persons with alcohol dependence or at-risk drinking patterns, and public health and medical programs that serve vulnerable populations; and be it further RESOLVED, That our AMA encourage state and local medical societies to support increases in state and local taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the purposes noted above …

  38. Chronicle of Higher Education • College newspapers DePaul Univ Univ of WI (Madison) Univ of Iowa Georgia Tech Indiana University Ole Miss

  39. AMA Primer on Assessment and Management of Adult Obesity • Available in 3-ring binder, on CD-ROM, and the web • 10 booklets • Assessment • Dietary management • Physical activity mgmt • Pharmacologic mgmt • Surgical mgmt • Office environment • Communication/counseling

  40. American Academy of Orthopaedic Surgeons

  41. American Academy of Orthopaedic Surgeons

  42. Henry Ford – on partnership “Coming together is a beginning; keeping together is progress; working together is success.”

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