Evaluation of Health of a Population

1. Evaluation of Health of a Population TH Tulchinsky MD MPH Braun School of Public Health Jerusalem, Jan 2006

2. Goals of Public Health • To eliminate or reduce health problems and their consequences • To prevent their occurrence or recurrence • To promote duration and quality of life 

3. Public Health Methods 1. Describe the distribution and size of disease problems in human populations 2. Identify etiological (the cause of disease) factors in the pathogenesis of disease 3. Provide data essential to the planning, implementation and assessment of services for the prevention, control and treatment of disease and to establish priorities among these services Source: The International Epidemiologic Association, 1996.

4. Assessing Health of an Individual I • Current chief complaint • History of the present illness • Personal data - age, sex, ethnicity, education, marital status, children, living situation • Occupational history • Family history • Personal history • Functional enquiry - systems review; • Summary of risk factors • Physical examination

5. Assessing Health of an Individual II • Differential diagnosis • Other medical problems • Investigation: laboratory, cardiographic, imaging, other • Presumptive or working diagnosis • Treatment and its effects • Definitive diagnosis • Long term management

6. Assessing Population Health • Population, demography, geography • Socio economic and cultural background • Public health infrastructure – sanitation, nutrition • Health care prepayment system and equity • Health care resources • Utilization of services • Outcomes – morbidity, mortality, functionality • Quality of care – peer and external review • KABP – knowledge, attitudes, beliefs and practices • Costs and benefits

7. Basics of Evaluation • No single measure • Multi factorial • Quantity, quality, cost and efficiency • Input, process, outcome • Direct and indirect measures • Monitoring is integral part of health system

8. Population Health Measurements Descriptive, health status Health services research Evidence based policy Evaluative, Process, outcomes Predictive, risk estimation Evidence based medicine Etiologic epidemiology Explanatory, Etiology, determinants AJPH March 2004

9. The Land of X • Trinidad

10. Population and Society • Population, demography • Fertility, age distribution • Geographic, ethnic, religion mix • Socio economic conditions • GNP per capita • Average family income • Education • Social security system e.g. pensions, workman’s compensation, drug benefits

11. Public Health Infrastructure • Ministry of Health – national, provincial • Local Health Authority • Sanitation, water, sewage, garbage • Housing/urban planning, zoning • Business licensing /regulation • Professional licensing/regulation • Laboratories • NGOs • Nutrition – fortification, supplememntation

12. Health Resources • Total $$$ per capita spent on health all sources, all services • % GNP spent on health • % for hospitals • % for primary care • Hospital beds/1,000 • Medical and nursing personnel/1,000 • Primary, secondary, tertiary care facilities • Organized preventive care, MCH, immunizations

13. Health System Organization • Health care pre-payment system • Universal • Consumer co-payments • Organization of health services • Preventive • Curative • Distribution e.g. urban/rural • Integration – vertical, lateral • Regional services systems • Population or individual based

14. Outcomes: Mortality Related Indicators • Infant mortality rates (IMRs); • Maternal mortality rates (MMRs); • Crude mortality rates (CMRs); • Age-specific mortality rates; • Cause-specific mortality rates - infectious, non-infectious diseases, trauma; • Life expectancy (LE) at age 0, age 1, total • Years of potential life lost (YPLL), by cause

15. Outcomes or Burden of Disease • Risk factors e.g. smoking, nutrition • Morbidity • Mortality • Functional • Physiologic • Quality adjusted life years (QALYs) • Disability adjusted life years (DALYs)

16. Morbidity Outcome Indicators • Incidence of vaccine-preventable disease • Incidence of waterborne disease • Incidence of food-borne disease • Incidence/prevalence of tuberculosis • Incidence/prevalence of STDs/AIDS/hepatitis • Incidence of malaria, other tropical diseases • Prevalence of non-infectious diseases e.g. CVDs • Prevalence of disabling conditions • Birth defects registry • Neurological disease registry • Cancer registry

17. Functional Indicators: Risk Factor Prevalence • Smoking - age specific rates • Sexual behavior – unsafe sex • High risk behavior re motor vehicles • Violence and injury - domestic, homicide, suicide • Alcohol use • Drug use

18. Functional Indicators • Work and school absence • Psychomotor function • Work capacity • School attendance and performance • Fitness test performance • Activities of daily living (ADL)

19. Nutrition Status • Food supply per person by type of food • Food intake surveys (e.g. NHANES) • Anthropometric indicators- • growth patterns of infants and children; • body mass index of adults • Dietary patterns • Biochemical - blood sugar, cholesterol, lipids • Micronutrient deficiency conditions - vitamins A, B, C, D, iodine, iron status • Hematologic indicators - anemia and lead among infants, children and women, environment pollutants

20. Utilization of Services: Performance Indicators • Immunization rates • Visits to doctors per person per year • Hospitalization by cause/1,000, ALOS • Surgical rates/1,000 • Hysterectomy, tonsillectomy rates • Caesarian rates • Mammography rates • Pap smear rates

21. Hospitalization Data • Sentinel event in health and health economics • Limited size of data • ALOS • Admission rates • Days of care per 1,000 popualtion • Measure of efficiency of health system • Can identify special health problems • E.g. amputation of lower limb, Beersheva • Case reviews e.g AMI management • Infection, incident rates • Case mix

22. Knowledge, Attitudes, Beliefs and Practices(KABP) • Community, patient and provider • What do people know • What do they think • What do they believe • What do they do • Crucial for control of AIDS, TB, risk behavior reduction

23. Costs and Benefits • How much is spent on health • How is it spent or mis-allocated • How are health issues monitored • Value gained in reduced burden of disease for specific expenditures • How are services paid for • Hospitals • Primary care • Health promotion

24. Regional Health Profiles • Geographic medicine • Geographic information system • Monitor equity • Small areas analysis • Think global, act local • Services are provided locally • Need to know local health conditions • Used for payment between national and local services e.g. Scandinavian countries, UK

25. Quality of Care • Training • Accreditation • Governmental • Non-governmental • Research • Publications • Peer review • Quality assurance organization • Tracer conditions e.g. amputation of LL

26. Tracer Condition • Peer review internal • External review • Common, treatable/preventable • Marker for outcome measure • Indicator of quality of care • Appendectomy with positive pathology • AMI/post AMI completeness of care • Incident reviews • Maternal and infant death reviews

27. Summary • Population at risk – geographic or sample • Multi-factorial • Measures of input • Measures of process • Independent variables • Measures of outcome or dependant variable • Costs and benefits • Monitoring population health is integral part of health system