Health and Preventive Medicine

Paul Dassow, MD, MSPHMD 815

November 10, 2006

Objectives

1. Gain a historical perspective on the determinants of health

2. Be able to identify the most common causes of death in America

3. Be able to identify age specific differences in mortality

4. Know the principles of Preventive Medicine and their common application

Health – what is it?

What is “Health”

• World Health Organization– Health is a complete state of physical,

emotional, and social well-being, not just the absence of disease

What makes someone healthy?

• Who’s dying, who’s getting sick, and why?

– Money? (Access to care, SES) – Behavior? – Genetics?– Luck?

Life Expectancy – 20th Century

A Historical PerspectiveDeaths 1900

Infant Mortality – 20th Century

Life Expectancy – 20th Century

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

Life Expectancy – 20th Century

Cause of Death - 2004

1.4

1.8

2.6

2.7

3

4.5

5.2

6.3

22.8

27.3

0 5 10 15 20 25 30

Septicemia

Kidney dz

Pneumonia

Alzheimer's

Diabetes

Injuries

Chronic lung

Stroke

Cancer

Heart dz

percent

A Historical PerspectiveDeaths 1900

The Fall in Infectious Diseases

0

500

1000

1500

2000

2500

1870 1890 1910 1930 1950 1970Scarlet fever

Scarlet feverWhooping cough

ImmunizationAntibiotics

Organism identified

The Fall in Infectious Diseases

0

500

1000

1500

2000

2500

3000

1870 1890 1910 1930 1950 1970Tuberculosis

TuberculosisPneumonia

BCG vaccinationChenotherapy

Organism identified

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

Cause of Death - 2004

1.4

1.8

2.6

2.7

3

4.5

5.2

6.3

22.8

27.3

0 5 10 15 20 25 30

Septicemia

Kidney dz

Pneumonia

Alzheimer's

Diabetes

Injuries

Chronic lung

Stroke

Cancer

Heart dz

percent

Deaths, by age group 2004

Age under 1 Age 15-24

- birth defects - Unintentional injuries- premature births - Homicide- SIDS - Suicide

Age 1-4 Age 25-44

- Unintentional injuries - Unintentional injuries- Birth defects - Cancer- Cancer - Heart disease

Age 5-14 Age 45-64

- Unintentional injuries - Cancer- Cancer - Heart disease- Birth defects - Unintentional injuries

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

Summary - Determinants

GeneticsBehaviorsEnvironmentPublic healthMedical careProvidence

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

Preventive Medicine

• The core components of Preventive Medicine:– Vaccinations– Screening– Counseling

• Future components?– Genetic screening

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)

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

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

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

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.

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

Counseling

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

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

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

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)

Questions?