PRHS I Final Flashcards
study of how care is delivered
health systems science
understanding how healthcare professionals, with difference scopes and roles, work together to deliver care
health systems science
Identifying ways in which the health system can improve patient care and delivery
health systems science
why is it important to understand health systems science now?
- Rapid changes and challenges in healthcare
- Technology and ease of access
- Expanding and diverse patient populations
- Underserved
- Very young and very old
- Chronic illnesses
- Co-morbidities
- Old style of diagnosis and treatment won’t do moving forward
- Care must be patient-focused and quality delivery
- Must remain adaptive
- Directly affect your billing and revenue
- There are federal, state, and contractual laws you do not want to violate
Triple Aim
- Population Health
- Experience of Care
- Per Capita Cost
Triple PEP
Quadruple Aim
- Population Health
- Care Experience
- Lowest Possible Cost
- Healthcare Professional Wellness
qUad includes Us
definition of healthcare quality
STEEEP:
- Safe
- Timely
- Effective
- Efficient
- Equitable
- Patient-Centered
Core Functional Domains include:
- Patient, Family, Community
- Health Care Structure and Process
- Health Care Policy and Economics
- Clinical Informatics and Health Technology
- Population, Public, and Social Determinants of Health
- Value in Health Care
- Health Systems Improvement
Patient, Family, Community core functional domain includes:
- behaviors
- experience (previous surgery of self or family member)
- values
- influence from others
- motivations (money, shortened life span)
Health Care Structure and Process core functional domain includes:
- all elements of how care is provided
- individuals, institutions, resources, and processes for delivery
- collaboration, coordination
Health Care Policy and Economics core functional domain includes:
- Decisions, plans, and actions
- Looking to meet specific health care goals
- Involves efficiency, effectiveness, value, and behavior relative to production and consumption of health care
Clinical Informatics and Health Technology core functional domain includes:
- Application of informatics and technology to deliver services of health care
- Clinical decision support
- Documentation
- Technology and tools
- Utilization of data to improve health
Population, Public, and Social Determinants of Health core functional domain includes:
- Issues related to traditional public health, preventative medicine
- Encompasses entire population, not just sick patients
- Improvement for an entire population, identification of gaps
- Organized assessment, monitoring, measurement
- Prevention of disease and injury, promotion of health, prolongation of life
- Aimed at groups of individuals, communities, ethnic groups, etc.
- Includes access and distribution of outcomes, interrelationships amongst personal, socioeconomic, environmental factors
- Fear related to previous procedure or illness
- Large co-pay to see a specialist
- Will family bring patient back for follow-up
- Does the prospect of a shortened life and co-morbidities motivate to stop smoking, manage diabetes, blood pressure
- Unwilling to get a flu shot because it made other family members ill
examples of which core functional domain
Patient, Family, Community
- Knowledge of clinical settings
- Inpatient vs outpatient requirements
- Fragmented or insufficient care encountered along continuum
- Ability to identify the need for teamwork and health care communities
examples of which core functional domain
Healthcare Structure and Process
- History and core principles of health care policy
- Basics of how care is financed and the impact on insurance and reimbursement
- Incentives for providers and hospitals within different US payment models.
examples of which core functional domain
Healthcare Policy and Economics
- Core principles of informatics sciences
- Biomedical
- Patient security and rights protection
- Real-time data viewing and decision support
- Data registries
- Clinical report analyzation
- Functionality and challenges in current health information exchange
examples of which core functional domain
Clinical Informatics and Health Technology
- Identification of common risk factors among a certain group
- Cultural skills training for providers
examples of which core functional domain
Population, Public, and Social Determinants of Health
Value in Health Care core functional domain includes:
- Performance of a health system in terms of quality of care
delivery, cost, waste, service requirements - Understanding epidemiology, identifying and classifying gaps in care or delivery
- Stakeholder definition and perspective of value in health care
- Components of high-value health care systems
- Correlations between quality/safety and patient outcomes
- Identification, reporting, and analyzation of safety events
- Relationship between quality and cost, and efforts to address
examples of which core functional domain
Value in Health Care
Health Systems Improvement core functional domain includes:
- Content related to identification, analyzation, or implementation of changes in policy, health care delivery, or by function that improves the performance of any component of the system
- Also related to scholarship approach –
- discovery that is consistent with traditional research, integration across disciplines
- Application demonstrating interaction between research, practice, teaching
- Quality improvement project
- Interprofessional education
examples of which core functional domain
Health Systems Improvement
Foundational Domains include:
- Change Agency, Management, and Advocacy
- Ethics and Legal
- Leadership
Change Agency, Management, and Advocacy
foundational domain includes:
- Knowledge and skills of health care professionals enable a higher quality of care
- Agents of change to improve systems
- Advocate for patients to receive best care possible
- Knowledge of how other health care professionals can impact and change the system
- Possess skills to advocate for patients at multiple levels
- Identify and address barriers to change
Ethics and Legal foundational domain includes:
- Ethical and legal issues, factors involved in health care delivery and health systems science
- Relationship between law and ethics in the design and operation of health care in the United States
- Understand transition underway that moves us from one-patient-one-doctor, to one doctor supporting a team, organization, or population – this is a systems approach
- Challenges for health law and ethics with this approach
Leadership foundational domain includes:
- Inspiration and motivation
- Team-based care
- QI projects
- What skills are needed to become a true leader
- Personal goals, life goals
- Alignment between personal and institutional values
Collaboration and team science includes:
- Working together to achieve shared goals
- Interprofessional education
- Understanding the roles and skills of others
- Communication at a higher level in an integrated/coordinated system
- Possess skills to function in a team
- Application of reflective practice relative to quality improvement and patient safety
Linking Domain
Systems Thinking
Content that links the core domains and subcategories to contents of the broader medical school curriculum
Linking Domain: Systems Thinking
Ability to apply a comprehensive, holistic approach to care and health care issues
Linking Domain: Systems Thinking
Awareness of the whole, not just the parts
Linking Domain: Systems Thinking
Recognize multidirectional cause-and-effect relationships
Linking Domain: Systems Thinking
“Health systems science consists of knowledge and concepts that are ___-centric rather than ___-centric.”
patient;
physician
which framework:
Patients do not heal or recover in isolation. As physicians work to understand their patients diagnostically, physicians are also being asked to consider the patient’s psychological and social conditions to have the greatest impact on processes and outcomes of care.
Bio-Psycho-Social (BSP)
which framework:
System theories suggest that every level of organization (molecular, cellular, organic) affects every other levels such as personal, interpersonal, familial and societal. These systems are not independent of each other but instead work together to produce desired outcomes of care.
Bio-Psycho-Social (BSP)
Systems Thinking in healthcare include:
Patient-centered, surrounded by provider system, patient’s system, and healthcare system
clinic, hospital, office, admin and processes
part of which system in systems thinking
provider system
family, friends, communities, faith-based groups, personal resources
part of which system in systems thinking
patient’s system
clinical programs, centers, hospitals, group practices, specialists, integrated systems
healthcare system
process failure with current (broken) system
- patient becomes ill, injured, needs care
- PMD, walk-in clinic, ED, Telehealth
- insurance? restrictions where patient can be seen?
- HC provider assesses, gathers info, examines
- are additional modalities required? labs, imaging, monitoring, urgent med administration?
- communication of working diagnosis
- treatment plan (Rx, PT, procedure, repeat imaging or labs, specialists, education supplies)
- outcomes? was safe, HQ care provided? effectiveness?
- follow-up and referrals
“The complex US health care system is not the product of a deliberate, thoughtful, coordinated, and evidence-based approach to maximizing the health of a society. “
health care delivery system
why is there a need for change in our current healthcare system?
- poor integration of care
- payment misalignment
- unnecessary variation in care
poor integration of care includes:
academic, public, private, for profit, nonprofit, community-based, specialty-based, government-based, medical homes
payment misalignment includes:
- the more you do for a patient, the more the provider, institution, etc., is compensated
- Fee-for-service model
- Misallocation of resources and waste
- Reimbursement happens regardless of efficacy or value
unnecessary variation in care includes:
- the foundation is that of an “apprentice” model - Focus is centered on individual learning and preferences of the master teacher
- This leaves patient outcomes dependent upon the individual physician and apprentice
what to do about this variation in care
- Healthcare has been compared to other industries
- What can be learned from an airline company or the hospitality industry
- Institute of Medicine (IOM), “To Err is Human.”
- “Silence Kills”
- “The Josie King Story”
- What do you think about when you hear, “Care Pathways,” “Evidence-Based Practice,” “Standards of Care?”
- what about professionalism, the art of medicine, compassion, individual needs, trusting relationships?
legislation includes:
- value based payment
- Affordable Care Act of 2010 (ACA)
- Medicare Access and CHIP Reconciliation Act of 2015 (MACRA)
- Merit-Based Incentive Payment System (MIPS)
- Providers accountable for performance
- Measures quality, service, cost
- Financial penalties and rewards
value based payment
- Expanded eligibility for Medicaid
- “The Exchange,” individuals and small groups could purchase insurance
Affordable Care Act of 2010 (ACA)
legislated new provider performance metrics and payment models
Medicare Access and CHIP Reconciliation Act of 2015 (MACRA)
provides additional pay based on hitting targets for quality, safety, using EHRs, etc.
Merit-Based Incentive Payment System (MIPS)
responsible for the federal healthcare laws
Congress
examples of federal healthcare laws
HIPAA, EMTALA
goal of mandates and legislation
- Improve and reward higher quality of care delivered
- Lower costs
- Improve outcomes in care
The Joint Commission includes:
- patient care and safety
- higher quality staff
- fulfill local and state requirements
- satisfies CMS
- liability insurance rates, contracts with insurance payors,
- quality care and confidence
provision of care through newer models reason
push toward higher quality care, at a lower cost, and better outcomes
Newer Models for Provision of Care include:
- Patient Care Medical Homes (PCMH)
- Accountable Care Organizations (ACOs)
which newer model for provision of care includes:
- Coordinated, ongoing care
- Health maintenance and wellness
- Acute and chronic health care needs
- Team based model
- Optimizing roles
Patient Care Medical Homes (PCMH)
which newer model for provision of care includes:
- Fragmented care = errors and gaps in quality and care
- Provider-led, manage the entire continuum of care, costs, quality of care for a defined population
- A sort of “medical home”
Accountable Care Organizations (ACOs)
CMS Accountable Care Performance Requirements
- High value system
- Meets goals of patients
- Meets goals of Triple Aim
- Timely measurement to evaluate quality of care provided
- Alignment between financial metrics and performance metrics
- Must stop working in silos
- A real paradigm shift in moving from a production model to a collaborative, integrative type of care system
Assessing health care quality is based on using three components:
structure, processes, outcomes
which health care quality component includes:
- settings in which care occurs (hospitals, clinics)
- material resources (facilities, equipment, and money)
- human resources (personnel)
- Organizational structure (medical staff organizations, peer review, and revenue cycles)
structure
which healthcare quality component includes:
- action taken by care teams and staff as they deliver care to patients; and
- processes which support the needs of the business
processes
which healthcare quality component includes:
- patient’s experience as a result of the care provided
outcomes
Care delivered in the past focused on the ___ as the center of the team
medical provider
Care delivered in the present focuses on the ___ as the central member with all members of the health care team being critical components to optimizing patient health outcomes
patient
Primary care delivery teams which have include MDs, RNs, LPNs, desk and administrative staff are changing to ___ population health teams
“core”
Population health core team has expanded to include ___ as care manager roles, social workers, behavioral/mental health specialist, pharmacists, dieticians, and other health specialist as needed to implement processes of care delivery that allows the member to perform at the maximum of his or her licensure
PAs, RNs
Reinforces need for collaboration and discontinuation of the “silo” model of care
accountable care and population health
management and payment for healthcare services for a discrete or defined population
population management
the design, delivery, coordination, and payment of high-quality health care services to manage the Triple Aim using the best resources available
Population medicine
Figuring out which group is neediest or at higher risk is required for
population management
registries, data bases, ability to benchmark, supporting Triple Aim (content analytics and deployment), predictive medicine or healthcare
information technology
“The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development.”
Batalden and Davidoff on continued improvement
To assess the quality of care provided in medical settings
Donabedian Model
Donabedian Model:
facilities, equipment, staffing, qualifications, licensing, accreditation
structure
Donabedian Model:
- technical care (screening, prevention, diagnosis, treatment, follow-up care)
- interpersonal care (respect, communication, knowledge and information)
process
Donabedian Model:
- acute recovery, restoration of function, survival, efficiency
outcome
- Physician who specializes in inpatient care
- Stays in hospital majority of time
- PMDs trying to be in multiple care settings at once
- Safety considerations – “To Err is human: Building a Safer Medical System.” (Focused on medical errors in the hospital setting.)
hospitalist
- NPs, must have minimum Bachelor’s in Nursing and then Master’s program. State and National Boards. Apply for controlled furnishing license through DEA.
- PAs, program started initially for military medics to become licensed to practice in civilian environment. Currently, must have minimum required number of hours in medical field in some capacity and can apply for program. Master’s prepared.
- Examine, interpret, diagnose, treat, prescribe
- Some states have full authority, some don’t
- Currently, in California MUST have a supervising physician
- Can work in any setting educated/trained/qualified to provide care
Nurse Practitioners and Physician Assistants
- Most are Master’s prepared
- Transition from one level of care to another – from inpatient to rehab, from rehab to home with home health services, etc.
- Coordination of medications, supplies, durable medical equipment
- Insurance negotiators and mediators
- Placement in shelters, finding housing
- Domestic violence
- CPS/APS
Care Coordinators and Social Workers
- Usually RN, minimum of Bachelor’s Degree in Nursing
- Reviews patient record including all H&Ps, diagnoses, progress notes, treatment plans, nursing notes and interventions, outcomes of surgeries and other procedures to ensure insurance requirements met for continued stay
- Collaborates with care providers and staff
Utilization Management
- Education and experience varies
- Helps patients navigate a chronic or complicated treatment path
- Communicates with other providers and team-members
- Ensures plans are patient-centered
- May help patient advocate for additional services or needs
Patient Navigators
- Jointly funded state and federal program
- Generally serves low income individuals and families
- Each state chooses own qualifying levels, usually below poverty line
- ACA attempted to expand services but ultimately, each state still determines qualifications
Medi-Cal / Medicaid
- most flexible of plans
- may be small / large deductible depending on plan
- co-pays, variable
- required to see “in-network” providers for the best cost benefit
- “out of network” provider, costs are paid at a much lower level
- need prior authorization for some services, but patient can self refer to specialists
PPO
- may see only those providers and utilize services within the contracted network
- monthly premiums are usually less than PPO
- chosen or assigned PMD manages and coordinates your care
- patient must go through PMD for referrals to specialists or other
- limitations but can also be very effective
Health Maintenance Organization (HMO)
- monies can be placed in a certain type of account for patient use
- used only for medically related costs (prescription or office co-pays, glasses or contacts, dressing supplies)
- employers sometimes contribute
- many rules about these accounts
- usually comes with a card much like a credit card or debit card patient can use whenever they choose
Health Savings Account (HSA)
list of medications that are covered under a particular plan
- May be tiers
- Each tier is offered at a different cost point
- If medication is not on formulary, may attempt an authorization to use
Formulary
Health care provider asks permission from insurance company to obtain a CT scan, MRI, schedule a surgical procedure, etc.
Prior Authorization
care is moving from ___ and ___ to ___
fee-for-service; volume-based reimbursement;
Value Based Care
up-to-date services, best practices, evidenced-based care, established best practices
effective
duplication of services, wasted equipment, supplies, resources
efficient
5 Domains of Healthcare
Knowledge, Care Delivery, Payer Domain, Medical-Legal, Regulatory
Kevin Can Pay My Rent
the most important perspective is that of the
patient!
Current Value of US Healthcare
- Battling rapidly rising costs
- Uneven access to services
- Patient outcomes that place the United States at the bottom of the developed world when ranked amongst nations
- Variable value, quality, and cost.
a major factor contributing to poor-quality care
safety
service is moving from assessing by ___ to ___
“patient satisfaction”;
“patient opinion of care received”
US spends significantly more ___ and a higher percentage of ___ on healthcare that other countries spend
per capita;
gross domestic product
Majority of healthcare dollars are spent on
the sickest patients
Little funding goes to ___that have large impact on overall population health
prevention, health promotion, addressing lifestyle, environmental, etc.
one of the largest contributors to US debt
cost of care
___ correlation between cost of care and quality of care
No
Many categories of waste, but two that apply directly to provision of care
unnecessary services and inefficient care
“Price is what you pay, ___ is what you get.”
value;
by Warren Buffett
attributes of high-value healthcare system
- Clear and shared vision that is patient-centered
- Leadership and professionalism from health care providers
- Training that emphasizes teamwork, systems engineering, process improvement
- IT infrastructure that supports development & maintenance of
- Learning health care system
- Information exchange
- Stringent peer review process
- Use of best-practice & evidence-based medicine - Insurance for all with patients owning their own insurance and can choose & access appropriate medical care
- Reimbursement models without incentives for volume-based care & promote integration & coordination, prevention, & health promotion.
barriers to high-value care
- conflicting stakeholder incentives (idea that “more care is better care”)
- lack of share reality
- poor integration
- inadequate education healthcare professionals
- serial nature of health insurance coverage
- perverse provider reimbursement structures
“most expensive piece of medical equipment is the physician’s ___”
pen
other developed countries have an insurance plan that is a
“cradle to grave” type over coverage
Value-based delivery models have transferred risk away from payers like Medicare to the
hospital and surgeon
Ultimately, if the test results will not change the care of the patient, the test should be
reconsidered
Reimbursement for care provided is shifting from a system based on ___ to one based on ___
volume;
providing value
HCV (healthcare value?) is best defined by:
- Quality of care divided by the cost of care over time
- STEEP
- Triple Aim
US continues to struggle with HVC as evidenced by:
- Variation in patient outcomes
- Safety
- Satisfaction
- Cost of care
- Poor integration & coordination of services
- Fragmented and volume-based provider reimbursement
- Conflicting stakeholder incentives
- Social determinants of health
- Micro-inefficiencies (patient-provider interactions)
- Macro-inefficiencies (health policy and the larger system).
do your best to
provide leadership (Identify opportunities to improve outcomes, Minimize harms, Reduce health care waste)
divided into experimental and control groups
clinical trials
group given the treatment under investigation
experimental
group treated in the exact same way as the experimental group except not given treatment
control
help to eliminate alternative explanations for a study’s results
Control groups
patients are randomly assigned to different groups (ie. To the experimental and control groups)
Randomization
to equalize the effects of extraneous variables
randomization
Simple descriptive account of interesting characteristics observed in a group of patients
case-series
Observational studies include:
Case-Series;
Case-Control;
Cross-Sectional;
Cohort Studies
Patients seen over a relatively short time
case-series
Do not include control subjects
case-series
Begin with the absence or presence of an outcome andthen look backward in time to try to detect possiblecauses or risk factors
case-control
case-control studies look ___ in time
backward
Individuals selected on the basis of some disease or outcome
cases (case-control)
Individuals without the disease or outcome
controls (case-control)
Analyze data collected on a group of subjects at one time rather than over a period of time.
cross-sectional
Designed to determine what is happening right now.
cross-sectional
group of people who have something in common and who remain part of a group over an extended time.
cohort
looks forward in time
cohort studies
cohort studies look ___ in time
forward
frequency of disease and of risk-related factors are assess in the present
cross-sectional
can show risk factor association with disease, can’t establish causality
cross-sectional
Compares a group of people with disease to a group without disease
case-control
Looks to see if odds of prior exposure or risk factor differs by disease state.
case-control
asks “what is happening?”
cross-sectional
asks “what happened?”
case-control
asks “what will happen?”
cohort
odds ratio
case-control
relative risk
cohort
Compares a group with a given exposure or risk factor to a group without such exposure
cohort
Looks to see if exposure or risk factor is associated with later development of disease
cohort
can be prospective or retrospective
cohort
Compares the frequency with which both monozygotic twins vs both dizygotic twins develop the same disease.
twin concordance study
Measures heritability and influence of environmental factors (“nature vs. Nurture”)
twin concordance study
Compares siblings raised by biological vs adoptive parents.
adoption study
Measures heritability and influence of environmental factors.
adoption study
have one or more groups of patients which are observed and characteristics about the patients are recorded for analysis
observational studies
Easier to identify than observational studies in the medical literature.
experimental studies
Involve an intervention.
experimental studies
Experimental Studies that involve humans (not animals)
clinical trials
purpose is to draw conclusions about a particular procedure or treatment
clinical trials
Epitome of all research designs because it provides the strongest evidence for concluding causation.
randomized controlled trials (RCT)
It provides the best insurance that the results were due to the intervention.
randomized controlled trials (RCT)
clinical trial undergoes 4 phases:
I. “safe?”
II. “effective?”
III. “improvement?”
IV. “stay?”
the gold standard, or reference in medicine
randomized controlled trials (RCT)
Least number of problems or biases
randomized controlled trials (RCT)
best type of study to use when the objective is to establishthe efficacy of a treatment or a procedure.
clinical trials
are the design of choice for studying the causes of a condition, the course of a disease, or the risk factors because they are longitudinal and follow a group of subjects over a period of time.
cohort studies
are appropriate for rare diseases or events, for examining conditions that develop over a long time, and for investigating a preliminary hypothesis
case-control
the quickest and least expensive
case-control
best for determining the status quo of a disease or condition
cross-sectional
easy to write and the observations may be extremely useful to investigators designing a study to evaluate causes or explanations of the observations
case-series
expensive and time consuming
randomized controlled trials (RCT)
the length of time required depends on the problem studied
cohort study
With diseases that develop over a long period of time or with conditions that occur as a result of long-term exposure to some causative agent, many years are needed and it is very costly
cohort study
have the largest number of possible biases or errors and they depend on high quality existing records
case-control
provide only a “snapshot in time” of the disease or process, which may result in misleading information
cross-sectional
common problem with survey research is obtaining sufficiently large response rates
cross-sectional
conclusions are based on a subset of people who agree to participate, and these people may not be representative of or similar to the entire population.
cross-sectional
Is the topic of the study important and worth knowing about?
abstract
What is the purpose of the study?
abstract
What is the main outcomefrom the study?
abstract
Is the population of patients relevant to your practice—can you use theseresults in the care of your patients?
abstract
If statistically significant, dothe results have clinical significance as well?
abstract
read the abstract to know:
topic of study; purpose of study; main outcome; population (whether results can be generalized); clinical significance of results
What research has already been done on this topic and what outcomeswere reported?
introduction
read the introduction to know:
everything from abstract + previous research / outcomes
Is the appropriate study design used?
methods
Does the study cover an adequateperiod of time? Is the follow up longenough?
methods
Are the criteria for inclusion and exclusion of subjects clear? How do thesecriteria limit theapplicability of the conclusions?
methods
Were subjects randomly sampled (or randomly assigned)? Was the samplingmethod adequatelydescribed?
methods
Are statisticalmethods outlined? Are they appropriate?
methods
Is there a statement about power—the number of patients that are needed tofind the desiredoutcome?
methods
read the methods to know:
study design; period of time; criteria (whether results can be generalized); sampling method (randomization?); sample size
Do the reported findings answer the research questions?
results
Are actual values reported—means, standard deviations, proportions—so that the magnitude of differences can be judged by the reader?
results
Are groups similar on baseline measures? If not, how did investigatorsdeal with these differences (confounding factors)?
results
Are the graphs and tables, and there legends, easy to read andunderstand?
results
If the topic is a diagnostic procedure, is information on both sensitivityand specificity (false-positive rate) given? If predictive values aregiven, is the dependence on prevalence emphasized?
results
read the results to know:
answer to research qs;
actual values;
confounding factors;
graphs/tables
Are the research questions adequately discussed?
conclusion / discussion
Are shortcomings and limitations of the research addressed?
conclusion / discussion
occurs when a condition is characterized byearly fatalities or silent cases.
prevalence bias
can result whenever a time gap occurs betweenexposure and selection of study subjects and the worst cases havedied
prevalence bias
Occurs when the study admission rates differ, which causes major distortions in risk ratios.
admission rate bias
This can occur in studies of hospitalized patients when patients who have therisk factor are admitted to the hospital more frequently than either the cases without the risk factor or the controls with the risk factor.
admission rate bias
When patients either volunteer or refuse to participate in studies.
nonresponse bias / volunteer effect
Occurs when treatment assignments are made on the basis of certain characteristics of the patients, with the result that the treatment groups are not really similar
procedure selection bias
Occurs when groups of subjects are not treated in the same manner.
procedure bias
when the procedures used in an investigation may lead to detection of other problems in patients in the treatment group and make these problems appear to be more prevalent in this group
procedure bias
when the patients in the treatment group may receive more attention and be followed up more vigorously than those in another group.
procedure bias
Occurs when patients are asked to recall certain events, and subjects in one group are more likely to remember the events than those in the other group.
recall bias
people take aspirin commonly and for many reasons, but patients diagnosed as having peptic ulcer disease may recall the ingestion of aspirin with greater accuracy than those without gastrointestinal problems.
recall bias
solution to recall bias
confirmation
Can occur because a new diagnostic technique is introduced that is capable of detecting the condition of interest at an earlier stage.
detection bias
Occurs when patients find it easier or more pleasant to comply with one treatment than with another.
compliance bias
information is gathered in a manner that distorts the information
measurement bias
Measuring patient satisfaction with their physicians by using leading questions
measurement bias
Subjects’ behavior is altered because they are being studied; this is only a factor when there is no control group in a prospective study
measurement bias (Hawthorne effect)
solution to measurement bias
control group
The factor being examined is related to other factors of less interest.
confounding bias
Unanticipated factors obscure a relationship or make it seem like there is one when there is not
confounding bias
More than one explanation can be found for the presented results
confounding bias
solution to confounding bias
combine the results from multiple studies, meta-analysis
Gives a false estimate of survival rates
lead-time bias
patients seem to live longer with the disease after it is uncovered by a screening test
lead-time bias
solution to lead-time bias
use life-expectancy to assess benefit
Severe diseases that tend to be rapidly fatal are less likely to be found by a survey
length-time bias
Neyman bias or late-look bias
length-time bias
tend to find (and select for) less aggressive illnesses because patients are more likely to be found by screening.
length-time bias
solution to length-time bias
stratify by severity
nonrandom sampling or treatment allocation of subjects such that study population is not representative of target population
selection bias
most commonly a sampling bias
selection bias
study population selected from hospital is less healthy than general population
Berkson bias (selection bias)
participating subjects differ from nonrespondents in meaningful ways
non-response bias (selection bias)
solution to selection bias
randomization; ensure the choice of the right comparison/reference group
research’s belief in the efficacy of a treatment changes the outcome of that treatment
observer-expectancy bias
the study of the distribution and determinants of health-related states within a population
epidemiology
refers to the patterns of disease and the factors that influence those patterns
epidemiology
the usual, expected rate of disease over time; the disease is maintained without much variation within a region
endemic
occurrence of disease in excess of the expected rate; usually presents in a larger geographic span than endemics
epidemic
study of epidemics
epidemiology
Worldwide epidemic
pandemic
visual description (commonly histogram) of disease cases plotted against time
epidemic curve
classic signature of an epidemic is a
“spike” in time
actual cases / potential cases =
rate
promote health, preserve health, restore health when it is impaired, and minimize suffering and distress. These goals aim to minimize both morbidity and mortality
goals of prevention in medicine
promotes health at both individual and community levels by facilitating health-enhancing behaviors, preventing the onset of risk behaviors, and diminishing exposure to environmental hazards
primary prevention
decrease disease incidence
Primary prevention efforts
ex: implementation of exercise programs and healthy food programs in schools.
primary prevention
screens for risk factors and early detection of asymptomatic or mild disease, permitting timely and effective intervention and curative treatment
secondary prevention
decrease disease prevalence
Secondary prevention efforts
ex: recommended annual colonoscopy for patients age > 65 and HIV testing for health care workers with needlestick injuries
secondary prevention
reduces long-term impairments and disabilities and prevents repeated episodes of clinical illness.
tertiary prevention
prevent recurrence and slow progression
Tertiary prevention efforts
ex: physical therapy for spinal injury patients and daily low-dose aspirin for those with previous myocardial infarction
tertiary prevention
average number of years of life remaining at a given age
life expectancy
frequency of occurrences of disease, injury, or death—that is, the number of transitions from well to ill, from uninjured to injured, or from alive to dead—in the study population during the time period of the study.
incidence
looks at new cases (incidents)
incidence
during a specified time period
incidence
new cases / #people at risk
incidence
all persons who experience an event in a population
prevalence
portion of people in a population who have a particular disease at a specified point in time (or over a specified period of time)
prevalence
looks at all current cases
prevalence
at a point in time
prevalence
existing cases / total #people in a population
prevalence
prevalence / 1-prevalence =
incidence rate x avg duration of disease
unusually sensitive to maternal health practices (especially maternal nutrition and use of tobacco, alcohol, and drugs), environmental factors, and the quality of health service
health of infants
used as an overall index of the health status of a nation.
infant mortality rate (IMR)
rate with added advantage of being both age specific and available for most countries
infant mortality rate
deaths to infants / #live births ((at a given place / time period)) x 1000
infant mortality rate
measure of the progress of a nation in providing adequate nutrition and medical care for pregnant women
maternal mortality rate
pregnancy-related deaths / #live births ((at a given place/time period)) x 100,000
maternal mortality rate
deaths due to particular cause / midperiod population x 100,000
cause specific death rate
- Greater attention to quality of patient care,
- Patient safety
- Rapidly increasing cost of health care.
shift from individual care towards population health
There is an ___ relationship between health care cost and improved health outcomes
inverse
focus on both disease management and prevention
population health
the health outcomes of a group of individuals, including the distribution of health outcomes within the group
population health
product of multiple determinants of health
population health outcomes
goes beyond the individual patient focus of traditional medical care and includes the health outcome of groups, communities, or populations of individuals
population health
define populations within a specific geographic area or communities
public health systems
define populations within a designated clinical setting or with a particular medical diagnoses
physicians and other in the health care setting
define their population based on who is need of their services (e.g., support of a medical condition, health care coverage, economic security, housing, transportation, food access or other nonhealthy areas that can greatly impact health and their outcomes).
community organizations
Population Health has 4 major pillars:
- Chronic care management
- Quality and safety
- Public health
- Health Policy
includes multiple stake holders such as those in health care delivery, the public health system, community organizations, health policy, employers, insurers and those generating evidence through research and other initiatives
population health
strongly focused on analysis of outcome to drive process change and new policy
population health
significant driver to influence change in many stakeholder groups as well as across groups
health policy
multiple factors that influence an individual’s health and the health of the population
determinants of population health
determinants of population health include:
behavior; genetics; social circumstances; physical and environmental; healthcare
determinant that includes:
smoking, risk taking, exercise, nutrition
behavior
determinant that includes:
age, biologic sex, inherited health conditions
genetics
determinant that includes:
income, social support, education
social circumstances
determinant that includes:
natural environment, green spaces, built environment, housing quality, conditions, exposures
physical and environmental
determinant that includes:
availability of quality healthcare, access and health insurace
healthcare
broadly encompass the social circumstances, environmental exposures, and health care determinants of health
social determinants of health (SDOH)
The social environment, physical environment, and health care services all contribute to the
“social patterning of health, disease and illness.”
They are recognized as interacting with and influencing behavior and contributing substantially to differences in health outcome between groups of people.
social determinants of health (SDOH)
5 Key Elements of social determinants of health (SDOH):
economic stability; education; social and community context; health and health care; neighborhood and built environment
social determinant of health that includes:
poverty, food security, employment
economic stability
social determinant of health that includes:
rate of high school graduation, secondary education, early childhood education and development
education
social determinant of health that includes:
civic participation and sense of community, perceptions of discrimination and equity, incarceration
social and community context
social determinant of health that includes:
access to health care and insurance, health literacy, prescription coverage
health and healthcare
social determinant of health that includes:
access to healthy food and areas to exercise, quality of housing, crime and violence
neighborhood and built environment
“The iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement while reducing costs.”
population health management
“The iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement while reducing costs.”
population health management
“The design, delivery, coordination, and payment of high-quality health care services to mange the Triple Aim for a population using the best resources we have available within the health care system.”
population medicine
“What we as a society do collectively to assure the conditions in which people can be healthy.”
public health
a long-standing discipline focused on the health of entire populations, communities, states, countries, and even regions of the world
public health
organized through agencies at federal, state, local, and tribally levels.
public health
include prevention of disease, promotion of health, protection against environmental hazards, disaster preparedness, and assurance of health care quality and accessibility.
Important public health fundamentals
not focused on individual medical care and private sector health care delivery.
public health system
3 Core Functions of Public Health:
- assessment
- policy development
- assurance
extensive and include public, private, and voluntary entities
the reach of public health
core function of public health that includes:
monitors health status to identify, diagnose, solve, and monitor health problems or hazards in the community.
Assessment
core function of public health that includes:
informs, educates and mobilizes individuals and community partners to identify and solve health problems by developing and and supporting new and existing policies and plans
Policy Development
core function of public health that includes:
enforces laws and regulations that protect health; links individuals to health services if needed; and evaluates effectiveness, accessibility, and quality of individual and population health services
Assurance
ex: national tobacco public health surveillance
Federal - Assessment
ex: smoking ban on commercial flights
Federal - Policy Development
ex: grants for antismoking research
Federal - Assurance
ex: monitor state tobacco use
State - Assessment
ex: increase tobacco tax
State - Policy Development
ex: funding for campaign though Prop 99
State - Assurance
ex: report on local tobacco use
Local - Assessment
ex: county laws prohibiting smoking in bars
Local - Policy Development
ex: resources to help smokers quit in multiple languages
Local - Assurance
partners in the public health system ensuring the conditions for population health include:
community, clinical care delivery system, employers and business nongovernment organizations, the media, academia, government public health infrastructure
“A law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.”
health policy
plays an important role in driving change such as in the case of national-level policy producing change on reimbursements and requirements for extensive quality and cost reporting.
health policy
interventions tend to be at higher organizational levels than the individual or practice
public health
What we do as a collective society to improve the health of the general population.
- Monitors community health status
- Investigates health problems
- Develops programs and initiatives focused on health
- Primarily community based
- Involves public, private and voluntary entities that contribute to delivery of essential public health services within its jurisdiction
- Connected to government health departments
- Enforces laws and regulations that protect health
public health
What we do to improve the health outcomes of a group of individuals.
- Reaches more broadly into the delivery arena
- Encompasses disease prevention, health promotion
- Involves participants in areas of prevention, health care delivery, medical intervention, public health, and policy for a population.
- Less connected to government health department
- Includes community engagements and resources
- “To manage the health of a specific population using a network of financially incented providers and community partners”
population health
- A focus on sick care over prevention and wellness. Clinical training has traditionally focused acute illness and chronic disease care over prevention and wellness.
- The fee-for-service reimbursement system has been more heavily based on acute care and procedures.
- Prevention, chronic disease management, nutrition, and behavioral health have been traditionally undervalued and reimbursed at rates lass than acute care.
- There is minimal reimbursement for non-clinic follow-up such as telephone calls used more for surveillance in chronic disease prevention and management.
- Preventative services for patients are generally more difficult to receive than acute care.
- In addition, the public health sector with its focus on prevention and health promotion has been relatively underfunded as compared to acute care reimbursement.
limitations in US healthcare that need to be overcome to achieve improved population health
- Health care delivery is often organized and prioritized around health care delivery than the patient.
- Patients typically must initiate contact and access many different points in order to receive care.
- Lack of coordination, integration and communication between the different points of a patient’s care contribute to fragmentation of the health care system.
- In addition, connections between medical care, public health, and community resources for patients to support their health and health care have been limited.
Siloed and fragmented efforts for health and health care
- Communication and sharing information between the various parties involved in the care of the patient is often limited.
- Barriers to greater communication and coordination of care include limitations in electronic health records limitation in health information exchange.
Inadequate assimilation and use of data
- Lack of defined teams for patient care, lack of tools, and time constraints on an individual physician impact the ability for greater engagement of patients in their health care.
- Patient-centeredness and shared decision making have not typically been robust areas of clinical training.
- Patient education resources and tools are often inadequate and most care delivery via an in-clinic setting may not be feasible for patients to take time away from work, school, family or other obligations.
Suboptimal patient engagement
- Where people live, their socioeconomic status, their race, ethnicity, gender, age, sexual orientation, and disability status have historically impacted health and outcomes.
- Comprehensive solutions that address the impact of SDOH and health outcomes have been difficult to develop.
- Root causes are often complex, and policy, funding, and support targeted at these areas have not been robust.
Inequality and inequity in health and health outcomes
- A fee-for-service reimbursement system often reinforces fragmented efforts as individual physicians are paid separately for their part of the patient’s care.
- In many systems, physicians are not held accountable and often not reimbursed for the quality of care provided for care coordination in a traditional fee-for-service system.
- Incentives are misaligned in health care as care and procedures are reimbursed at a greater rate then preventative care.
Reimbursement systems, incentives, education, and culture that support the status quo
the US still lags in key outcomes measures, including
life expectancy and prevalence of chronic disease.
necessitates coordinated care along with the use and exchange of data and patient engagement.
optimal disease management
“a particular type of health difference that is closely linked with social, economic, and or environmental disadvantage.”
health disparity
adversely affect groups of people who have systematically experienced greater obstacles to health based on their ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation, gender identity, geographic location or other characteristics of discrimination or exclusion.
health disparities
provided comprehensive, team-based, patient centered, coordinated accessible care focused on quality and patient safety
The Primary Care Medical Home (PCMH) model of primary care
an entity in formal agreement with a payer to care for a population of patients is accountable for quality, cost, and outcomes for its patient population.
Accountable Care Organizations (ACOs)
have the capability to share information with other health care providers and medical professionals. Patient’s information (diagnosis, prescribed medication) and data values (labs) allow for data to be analyzed on how well clinicians are managing both acute and chronic disease processes for individual patients and populations of patients.
Electronic Health Records (EHRs)
not all EHR systems communicate with each other thereby limiting relaying data or receiving data outside the population being served by the EHR.
Often HER may not provide data on social determinants of health and therefore this limited opportunity to obtain the whole picture of the patient population’s health status beyond the medical care.
limitations of EHRs
- Integrate data from multiple health sources across the continuum of care (EHRs) and other sources such as mobile applications, wearable technology and other data sources with which a patient may interact.
- Develop then integrate clinical risk algorithms into the care of the patients and populations to ensure that those who need treatment receive and while others who do not treatment are not overtreated.
- Deliver the analysis of the data to those who must act on it such ad health care administrators who allocate resources based on the populations need. Clinicians who receive the data to improve clinical care of the patient populations, and individuals who can advocate for their own health care needs.
Risk Stratification and Analytic Software
are secure websites that can interface with an EHR and serves as a 24/7 access point for patients
can provide two-way communication between patients and practices which includes many members of the health team.
Patient Portals
- Summaries of recent physician visits
- Hospital discharge summaries
- Medications
- Immunizations
- Allergies
- Laboratory results
can be accessed through patient portals
mobile electronic devices that can be unobtrusively embedded in the user’s outfit as part of the clothing or accessory.
Wearable Devices and Biosensors
allows for monitoring of factors influencing an individual’s health, including monitoring of vital signs or number of steps taken in which the information taken can be integrated with other health care data to more effectively manage the health of the population.
Wearable technology
is the use of medical information that is exchanged from one site to another through electronic communications.” There are varying types of processes and services intended to enrich the delivery medical care and improve the health status of patients.
Virtual Health
coordinate and organize clinical care around individual patients as well as populations of patients.
serve as the bridge between patients and their physicians and health care professionals.
- Act as a conduit between patient and physician
- Answer patient questions
- Assist in managing chronic medical conditions
- Facilitate the transfer of information among a patient’s providers, including specialty physicians
- Conduct home or hospital visits
Nurse Care Managers
defined as “frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.”
role is adapted to the needs of the community they serve.
role is expanding to integrate hospital and clinic health care teams with a greater focus on chronic disease management.
Community Health Workers (CHW)
defined as “a member of the health care team who helps patients ‘navigate’ the health care system and get timely care.”
- Help coordinate patient care
- Connect patients with resources
- Help patients understand the health care system
- Often found in physician’s offices to help patient navigate through one or more chronic health condition
Patient Navigators
Their work includes:
- Initial consults
- Ongoing management
- Medication management
Integrated Behavioral Health Specialist – behavioral health specialist (psychiatrists, psychologist, social workers, and other mental health works)
“process that uses quantitative and qualitative methods to systematically collect and analyze data to understand health within a specific community”.
“community health needs assessment” (CHNA)
Structural Determinants of Health Inequities include:
class, gender, race / ethnicity, education
Social Determinants of Health include:
Material Circumstances; Socio-environmental Circumstances; Psychosocial Intermidiaries; Behavioral / Biologic Factors; Health System
social determinant of health that includes:
- neighborhood and built environment
- food environment
material circumstances
social determinant of health that includes:
- early childhood development and adverse childhood experiences
- populations subject to societal discrimination
socio-environmental circumstances
social determinant of health that includes:
- health literacy
- physician workforce
health system
“higher ___ are associated with poorer health outcomes in both general and clinical populations”
allostatic load (accumulated stress) and overload
How Structural and Social Determinants Lead to Adverse Health Outcome
- allostatic load
- negative impacts in neuroanatomy and neuroplasticity
- immune dysregulation
- epigenetic changes
Often measured as a combination of education, income, and occupation
class
Fresno has a ___ portion of middle income households and ___ portion of lower income households than the United State
smaller;
larger
Significant health disparities by race and ethnicity, even when controlling for socioeconomic status are mostly about
structural racism (housing policies, criminal justice, educational funds)
County demographics vary by
geographic location
___ is biological; ___ is a social construct
sex;
gender
A person’s zip code is a better predictor of health outcomes than [their] genetic code.”
material circumstances
three key considerations for material circumstances include:
- physical conditions within homes (mold, lead)
- conditions in the neighborhoods surrounding the homes
- housing affordability
Policies and practices from 1880s onward are still ___ impacting the health of Fresnans.
negatively
Neighborhood and built environment was the ___ highest SDOH priority by focus group participants, both rural and urban
third
89% of those living in the 20 most polluted Census tracts of Fresno County are people of
color
About ___ of households in Fresno County cannot afford to rent housing
25%
The number of people experiencing homelessness in Fresno City rose by ___ in Fresno City and by ___ in Fresno County from 2019 to 2020
69%;
15%
the strongest predictors of homelessnes
Availability of low-income housing and mental health care
Unhoused persons have shorter life expectancy by ___ than their housed peers, most commonly due to ___
30 years;
preventable and treatable chronic medical conditions
Food security for a household means access by ___ for an active, healthy life
all members at all times to enough food
food security at a minimum includes:
- Availability
- Access
- Utilization
food security measured on a continuum:
high – marginal – low – very low
In 2019, Fresno County had ___ rates of overall food insecurity than California and the U.S.
greater
Fresno County has the ___ highest rate in CA of food stamp recipients as a percentage of all households
fourth
Fresno County has the ___ highest rate in the United States of food stamp recipients as a percentage of all households.
seventh
3 Main Adverse Childhood Experiences (ACEs):
Abuse;
Household Challenges;
Neglect
- emotional
- physical
- sexual
abuse
- mother treated violently
- substance abuse
- mental illness
- parental separation / divorce
- incarcerated household member
household challenges
- emotional
- physical
neglect
3 most reported ACEs:
- emotionally abused
- lived with someone who abused substance
- parents separated / divorced
ACEs negatively impact health and well-being from
conception to death
is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions)
disability
the direct and indirect costs of caring for a family member with a disability can lead to financial difficulties or loss of socioeconomic status
intersectionality
The rate of Fresno County adults reporting a disability is ___ than the state and national rate
higher
“health conditions involving changes in emotion, thinking or behavior (or a combination of these”
mental illness
When writing patient education materials or surveys, aim for a ___ grade reading level
6th
avoid chairman, chairwoman
prefer chair, chairperson
avoid mothering
prefer parenting, nurturing, caregiving
avoid transgender
prefer transgender person
“describe one of several very broad categories that people are divided into that are biologically arbitrary yet considered to be generally based on ancestral origin and shared physical characteristics”
race
“a person’s cultural identity, which may or may not include a shared language, shared customs, shared religious expression, or a shared nationality”
ethnicity
avoid indian, black, asian
prefer Native American / American Indian, Black / African American, Asian American
avoid seniors, elderly, the aged, aging dependents, old-old, young-old
prefer older person, older people, older adults, older patients, older individuals, persons 65 years and older, the older population
avoid the poor, the homeless / vagrant
prefer no income / low income / limited income / resource limited / resource poor, homeless people / people without housing / unhoused person / houseless person / person experiencing homelessness
avoid wheelchair bound, the blind / visually impaired, retarded adult, disabled child
prefer wheelchair user, blind people / persons with visual impairment, adult with an intellectual disability, child with a physical disability
avoid alcoholic, schizophrenic, noncompliant
prefer person with alcohol use disorder, person with schizophrenia, unable to adhere
In the past, medical leadership was based on:
- Clinical skills
- Scholarly product
- Research excellence
Present day health leadership requires not only current clinical knowledge but also:
- Creative thinking
- Ability to work across multiple disciplines
- Engage, motivate, and problem-solve in team
- Utilize operational skills
- Understand the culture of the organizational
4 Mental Models for health care leaders:
- Individuals and their families as partners in care
- Focus on value (quality per cost)
- Service alignment with payment systems
- Empowerment of all participants as improvers
Influential Leadership Theories include:
- Transformational (how leaders transcend own self-interest for higher-order goals and visions)
- Situational
- Servant
Transformational theory includes:
- Idealized influence
- Inspirational motivation
- Intellectual stimulation
- Individualized consideration
Situational theory includes:
directing, coaching, supporting, delegating
Servant theory includes:
listening, empathizing, accepting stewardship, actively developing others’ potential
6 Domains of Health Care Leadership Competencies include:
- Health Care Foundations (patient-centeredness, professionalism)
- Self-Management (emotional intelligence, pursuing excellence)
- Team Management (relationship management, human resources)
- Influence and Communication (advocacy, having challenging conversations)
- Systems-Based Practice / Management (business knowledge and skills)
- Executing Toward a Vision (creating culture and sustainable solutions)
two or more individuals brought together by an organization who are interactively working on one or more institutional goals/tasks and are assigned different roles and responsibilities…with linkages to the broader system or task environment
teams
cooperative or coordinated effort on the part of a group of persons acting together as a team
teamwork
an understanding of teams, their structures, and critical elements
team science
physicians and health care professionals from other disciplines and specialties work together with patients, families, caregivers, and communities to deliver high quality care
interprofessional practice
organizations that operate in complex, hazardous environment’s making few mistakes over long periods of time; focus on teams.
High-reliability Organizations (HROs)
characteristics of an effective team include:
achieve the goals;
clearly define each member’s role and outline expectations;
team cohesion and low levels of conflict
Selecting which members to include on a team depends on the
possible member’s knowledge, skill set, and attitudes to accomplish the defined goal
4 Stages of Team Development (Bruce Tuckman’s Model of Development)
- Forming
- Storming
- Norming
- Performing
the stage of exploration and building trust; team members are identified, group goals are set, and team members begin to understand the capabilities of other members
Stage 1 - Forming
attitude changes, competitiveness and tension, disunity; roles and responsibilities are delineated and patterns of communication are established. This can be a difficult phase if tension and disunity develop. Strong leadership is essential to ensure transparency and open communication
Stage 2 - Storming
satisfaction, respect development, decision-making; trust is established, members can rely on one another, and disagree respectfully as the team aims towards achieving their goals
Stage 3 - Norming
high level of interaction, performance increased and optimize, and confidence within the team; the common goal has been established, trust is the norm, and productive work is performed with efficiency
Stage 4 - Performing
4 Interprofessional Domains include:
- Values / Ethics for Interprofessional Practice (mutual respect and shared values)
- Roles / Responsibilities (shared acknowledgement)
- Interprofessional Communication (responsible manner that supports approaches)
- Teams and Teamwork (relationship-building values and principles of team dynamics)
- Intention to honor another individual’s beliefs, customs, values
- Self-willingness to explore, examine, critique own beliefs and values
- Open to learning from other
cultural humility
- Understandings that are taught, trained, or achieved
- necessary for working effectively with diverse patients
- The more knowledge an individual has regarding another culture, potentially, the more competent they are considered
cultural competence
doesn’t rely on acquisition of formal knowledge relative to another culture, rather it focuses on interpersonal sensitivity, openness, avoidance of stereotyping, equalizing power inequities
humility
consists of criteria or components: –Cultural awareness –Knowledge –Skill –Desire –Encounter
competence
- Synergistic process between the two
- Allows meaningful connection with others as an individuals
- Diverse perspective, cultures, lifestyles
- Awareness of our own biases and viewpoints
competemility
