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ESTABLISHING HEALTH INTERVENTION PRIORITIES FOR LOCAL PUBLIC HEALTH AGENCIES. Alexandre Klementiev. aklementiev@tpchd.org. Tacoma-Pierce County Health Department, WA. GOAL 2.

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establishing health intervention priorities for local public health agencies

ESTABLISHING HEALTH INTERVENTION PRIORITIES FOR LOCAL PUBLIC HEALTH AGENCIES

Alexandre Klementiev

aklementiev@tpchd.org

Tacoma-Pierce County Health Department, WA

goal 2
GOAL 2

“To identify three broad-based, behavioral risks to health which, if reduced, will offer a tangible reduction in the burden of preventable illness and death in the Pierce County population*.”

j

* Tacoma - Pierce County Health Department Strategic Plan, 1996-2000 (Tacoma, WA)

goal 2 contd
GOAL 2 (contd)

This presentation demonstrates the method designed for identification of the leading behavioral risks to health.

If these risks were reduced, the method would allow to estimate the resulting reduction in the burden of preventable illness and death.

risk factor
RISK FACTOR

If a disease/cause of death (D) is more common among those with a certain characteristic (C) than among those without it, then there is an association between Cand D.

If Coccurs, or is present, prior toD, the characteristic C is a risk factor for the disease (cause of death) D.

slide5

D

D

D

D

C

is not

present

C

is

present

D

D

D

D

D

burden of health risk
BURDEN OF HEALTH RISK

The burden of a health risk is composed of:

  • Disabled years lived with preventable

illnesses (morbidity component)

  • Deaths associated with specific risk

behaviors (mortality component)

slide7

FROM ROUTINELY COLLECTED HEALTH DATA TO MILLER’S INDEX

In 1970, J.E.Miller offered the Q-index which allows integrating of morbidity and mortality data, so that a fairly consistent ranking of the classes of disease could be made.

q index definition
Q-INDEX: DEFINITION

Qk = (MTk/MRk)*Pk*Dk

+ 100,000*Ak /365 /N

+ 100,000*Bk /(3*365)/N

q index definition contd
Q-INDEX: DEFINITION (contd)

MTk(MRk) : age-/sex- adjusted mortality rate

in target (reference) population;

Pk :years of life lost due to premature death,

average per one death;

Dk : crude mortality rate;

Ak : number of inpatient days, per year;

Bk : number of outpatient visits, per year;

N : size of the target population.

___________________________________________________________________________________________________________________________

k indicates disease/cause of death.

q index discussion
Q-INDEX: DISCUSSION
  • Q-index provides a rationale for combining mortality and morbidity components in a single index number which is used for ranking
  • This rank pertains to a given class of disease/cause of death
  • In reality, the risk factor is associated with more than one class of disease/cause of death
slide11

FROM Q-INDEX TO THE RISK PRIORITY INDEX

The Q-index cannot be used for prioritizing health programs when those programs pertain to the behavioral health risks associated with multiple classes of diseases

visualizing health risk
VISUALIZING HEALTH RISK

JDIS

F

D

Morbidity Effect

B

C

A

JDTH

Mortality Effect

risk priority index definition
RISK PRIORITY INDEX: DEFINITION

The Risk Priority Index (RPI) is defined as the sum of all partial impacts of the health risk of interest on the population health.

Partial impacts of diseases and deaths in RPI are measured with the use of the Q-index.

calculating rpi
CALCULATING RPI
  • The method of calculating the RPI components depends on the availability of relevant data
  • The direct method is based upon data collected on relative risks and prevalence pertaining to the risk factor of interest, along with mortality, bed-days, and the outpatient visits
  • If some of the data for the direct method is unavailable, experts best estimate can be used for the lacking data
candidate risk factors
CANDIDATE RISK FACTORS

1. Violence/Firearms 8. Alcohol misuse

2. Physical inactivity 9. Air quality

3. Food quality 10. Tobacco use

4. Water quality 11. Dietary habits

5. Unsafe sexual behavior 12. Hazardous waste

6. Seat belt use 13. Workplace hazards

7. Cycle helmet use 14. Immunization levels

tobacco list
TOBACCO LIST

There are 25 entries in Tobacco List. Among them:

ICD Code

Lip, oral cavity, pharynx (140-149)

Esophagus (150)

Pancreas (157)

Larynx (161)

Trachea, lung, bronchus (162)

more ...

tobacco rpi
TOBACCO: RPI

Each year in Pierce County::

  • 1,072 deaths are associated with tobacco smoking
  • The equivalent of 3,275 person-years are lost prematurely due to the causes associated with tobacco smoking
tobacco rpi contd
TOBACCO: RPI (contd)
  • One third of all hospital bed days can be attributed to the effects of tobacco use
  • Residents spend the equivalent of 53 years in Pierce County hospitals due to illnesses related to tobacco
  • About 53,000 outpatient visits are associated with cigarette smoking effects
dietary factors and activity patterns dfap list
DIETARY FACTORS AND ACTIVITY PATTERNS (DFAP) LIST

Heart diseases

Cerebrovascular diseases

Cancers

Diabetes

dietary factors and activity patterns rpi
DIETARY FACTORS AND ACTIVITY PATTERNS: RPI

Each year in Pierce County:

  • 889 deaths areassociated with dietary factors and activity patterns (DFAP)
  • 2,615 years of potential life are lost due to diseases associated with DFAP
  • Approximately 11,680 bed-days and 3,300 outpatient visits are associated withillnesses related to DFAP
alcohol list
ALCOHOL LIST

There are 36 entries in Alcohol List. Among them:

ICD Code

Lip/oral cav/pharynx (140-149)

Esophagus (150)

Stomach (151)

Liver (155)

Larynx (161)

Alcoholic psychoses (291)

more ...

alcohol misuse rpi
ALCOHOL MISUSE: RPI

Each year in Pierce County:

  • 275 deaths areassociated with alcohol misuse
  • 3,793 years of potential life are lost in

association with alcohol misuse

  • Approximately 13,400 bed-days and 48,700 outpatient visits are associated withillnesses related to alcohol misuse
firearms list
FIREARMS LIST
  • ICD Code
  • Unintentional firearms E922
  • Suicide by firearms E955.0 - E955.4
  • Assault by firearms E965.0 - E965.4
  • Legal, other firearms E970, E985.0 - E985.4
violence with firearms rpi
VIOLENCE WITH FIREARMS: RPI

Each year in Pierce County:

  • 95 people die from a firearm wound
  • 2,679 years of potential life are lost
  • Equivalent of 2 years are spent in hospitals
unprotected sex list
UNPROTECTED SEX LIST
          • ICD Code
  • HIV, sexually acquired (042)
  • Hepatitis B infection,
  • sexually acquired (070.2, 070.3)
  • Syphilis and other
  • venereal diseases (090 - 099)
  • Trichomoniasis (131)
  • Cervical cancer (fem) (180)
unprotected sex rpi
UNPROTECTED SEX: RPI

Each year in Pierce County:

  • 54 people die from diseases associated with unprotected sex
  • 1,512 years of potential life are lost
  • The equivalent of 8 years are spent in hospitals
risk priority index calculation results
RISK PRIORITY INDEX:CALCULATION RESULTS

Losses pertaining to risk behaviors

(per one year, Pierce County population)

  • Tobacco DFAP Alcohol Firearms Sex ___________________________________________________________________________________________________________________________________________________________Deaths 1,072 889 275 95 54 __________________________________________________________________________________________________________________________________________________________YPLL/Mort. 3,275 2,615 3,800 2,680 1,500 ___________________________________________________________________________________________________________________________________________________________Bed-days 19,000 11,680 13,400 760 2,900__________________________________________________________________________________________________________________________________________________________Outp.vsts53,000 3,300 48,700 N/A 200
slide28

RISK PRIORITY INDEX

Deaths and YPLL/Morbidity

Tobacco

Deaths

DFAP

Firearms

Unprotected sex

Alcohol

Microbial

Years of Potential Life Lost / Morbidity

slide29

RISK PRIORITY INDEX

YPLL/Mortality and YPLL/Morbidity

Alcohol

Tobacco

Firearms

Dietary Factors/

Activity Patterns

Years of Potential Life Lost/Mortality

Microbial

Unprotected sex

Years of Potential Life Lost/Morbidity

from the risk priority index to the health intervention priority index

FROM THE RISK PRIORITY INDEX TO THE HEALTH INTERVENTION PRIORITY INDEX

  • The RPI cannot be used for establishing priorities of health interventions
  • The Health Intervention Priority Index accounts for the partial reduction of the health risks
health intervention priority index definition
HEALTH INTERVENTION PRIORITY INDEX: DEFINITION

The Health Intervention Priority Index (HIPI) is the quantitative measure of improvement of the population health caused by implementation of the health intervention

The improvement is measured in person-years of life saved

tobacco hipi
TOBACCO: HIPI

It was assumed in this study that the relative reduction of smokers in Pierce County by 40% (from about 25% down to 15%) is an achievable goal.

As a result:

  • 240 deaths would be prevented
  • 858 person-years of life would be saved
dietary factors and activity patterns hipi
DIETARY FACTORS AND ACTIVITY PATTERNS: HIPI

It was assumed in this study that relative reduction of the aggregated risk factor associated with dietary factors and activity patterns by 15% is an achievable goal.

As a result:

  • 134 deaths would be prevented
  • 253 person-years of life would be saved
alcohol hipi
ALCOHOL: HIPI

It was assumed in this study that the relative reduction of the aggregated risk factor associated with alcohol misuse by 20% is an achievable goal.

As a result:

  • 55 deaths would be prevented
  • 775 person-years of life would be saved
firearms hipi
FIREARMS: HIPI

A 15% relative reduction of the aggregated risk factor associated with firearms was assumed in this study as an achievable goal.

As a result:

  • 14 deaths would be prevented
  • 402 person-years of life would be saved
unprotected sex hipi
UNPROTECTED SEX: HIPI

A 10% relative reduction of the aggregated risk factor associated with unprotected sex was assumed in this study as an achievable goal.

As the result:

  • 5 deaths would be prevented
  • 160 person-years of life would be saved
anticipated reduction of deaths and ypll
ANTICIPATED REDUCTION OF DEATHS AND YPLL
  • Tobacco DFAP Alcohol Firearms Sex
  • ___________________________________________________________________________________________________________________________________________________
  • Risk Reduction 40% 15% 20% 15% 10% ___________________________________________________________________________________________________________________________________________________
  • Deaths 240 134 55 14 5 __________________________________________________________________________________________________________________________________________________
  • YPLL/Mortality 832 248 759 402 151 ___________________________________________________________________________________________________________________________________________________YPLL/Morbidity
  • (Inpatient) 14 5 7 0.3 0.8 ___________________________________________________________________________________________________________________________________________________
  • YPLL/Morbidity
  • (Outpatient) 12 0.5 9 - -
health intervention priority index deaths vs ypls total
HEALTH INTERVENTION PRIORITY INDEX: DEATHS VS. YPLS/TOTAL

250

Tobacco

S

Deaths

DFAP

125

Unprotected Sex

Alcohol

Firearms

150

300

450

600

750

900

Years of Potential Life Saved (Total)

health intervention priority index ypls mortality vs ypls morbidity
HEALTH INTERVENTION PRIORITY INDEX: YPLS/MORTALITY VS. YPLS/MORBIDITY

Tobacco

24

18

Alcohol

12

Years of Potential Life Saved (Morbidity)

Unprotected Sex

6

DFAP

Firearms

150

300

450

600

750

900

Years of Potential Life Saved (Mortality)

conclusion
CONCLUSION

The 3 leading behavioral risks to health in Pierce County are:

  • Tobacco
  • Alcohol
  • Firearms

Reduction in the burden of preventable illness and death is estimated.