evaluation of health of a population th tulchinsky md mph braun school of public health jerusalem,...
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Evaluation of Health of a Evaluation of Health of a PopulationPopulation
TH Tulchinsky MD MPHTH Tulchinsky MD MPH
Braun School of Public HealthBraun School of Public Health
Jerusalem, Jan 2006Jerusalem, Jan 2006
Goals of Public HealthGoals 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
Public Health MethodsPublic 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.
Assessing Health of an Individual IAssessing 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
Assessing Health of an Individual IIAssessing 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
Assessing Population HealthAssessing Population Health
1. Population, demography, geography2. Socio economic and cultural background3. Public health infrastructure – sanitation,
nutrition4. Health care prepayment system and equity5. Health care resources6. Utilization of services7. Outcomes – morbidity, mortality, functionality8. Quality of care – peer and external review9. KABP – knowledge, attitudes, beliefs and
practices10. Costs and benefits
Basics of EvaluationBasics 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
Population Health MeasurementsPopulation Health Measurements
Descriptive, Descriptive, health statushealth status
Evaluative, Evaluative, Process, Process, outcomesoutcomes
Predictive, Predictive, risk estimationrisk estimation
Explanatory, Explanatory, Etiology, determinantsEtiology, determinants
AJPH March 2004
Etiologic Etiologic epidemiologyepidemiology
Evidence Evidence based policybased policy
Evidence based Evidence based medicinemedicine
Health services Health services researchresearch
The Land of XThe Land of X
• Trinidad
Population and SocietyPopulation 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
Public Health InfrastructurePublic 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
Health ResourcesHealth 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
Health System OrganizationHealth 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
Outcomes: Mortality Related IndicatorsOutcomes: 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
Outcomes or Burden of DiseaseOutcomes or Burden of Disease
• Risk factors e.g. smoking, nutrition • Morbidity• Mortality• Functional• Physiologic• Quality adjusted life years (QALYs)• Disability adjusted life years (DALYs)
Morbidity Outcome IndicatorsMorbidity 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
Functional Indicators:Functional Indicators: Risk Factor Prevalence 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
Functional IndicatorsFunctional Indicators
• Work and school absence
• Psychomotor function
• Work capacity
• School attendance and performance
• Fitness test performance
• Activities of daily living (ADL)
Nutrition StatusNutrition 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
Utilization of Services: Performance Utilization of Services: Performance IndicatorsIndicators
• 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
Hospitalization DataHospitalization 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
Knowledge, Attitudes, Beliefs and Knowledge, Attitudes, Beliefs and PracticesPractices (KABP)(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
Costs and BenefitsCosts 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
Regional Health ProfilesRegional 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
Quality of CareQuality of Care
• Training• Accreditation
– Governmental– Non-governmental
• Research• Publications• Peer review• Quality assurance organization • Tracer conditions e.g. amputation of LL
Tracer ConditionTracer 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
SummarySummary
• 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
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