U.S healthcare exam 3 Flashcards
for Germany
- what is mandatory
- is the health insurance public or private
- does the government mandate insurance, does employment provide it
how much does each employee get?
Mandatory sickness funds
Predominantly private
Government-mandated, employment-based private insurance
7.3% is employer responsibility; 7.3% withheld from pay; equals 14.6% for each employee
2009-government run health fund distributes health funds based on risk adjustment
Not allowed to exclude, or raise rates according to age or medical condition- which would be experiential rating
Remain in fund if ill, retired, lose job
Higher income can select private insurance
Germany
what kinds of appointments are common
how can you see a specialist?
how many generalists are there
what is there little coordination between
the patient receives no bill for what
Appointments with Primary Care is common
Allowed to make appointments with specialists without a referral
Over 40% of physicians are generalists
Little coordination between hospitalists and generalists
Appointments, labs, prescriptions, hospitalization=No bill to the patient
Germany
who. does a primary physician bill
how often are physicians reviewed?
how often are hospitalists billed
Primary physician Bills regional Association of Physicians
1986- began to cap spending- Rationing
Physicians are reviewed quarterly, with each quarter affecting the following quarter
Hospitalists are billed upon Episode- Based funding or Bundle payment
Germany cost control
what are the parts of concerted action?
what does it control
despite the best healthcare effort, what still continues to rise
Concerted Action
- Guideline Fees
- Hospital Rates
- Pharmaceuticals
Controls physician fees, capping physician fees
Throughout time still Germany has Gross Domestic Product (GDP) that has been rising since 1990
Canada
to get health insurance what must you show
for the Hospital Insurance Act who is and who is not covered
when was universal medical insurance made available
how is health care system financed
is it attached to employment
how does everyone contribute to health care
who gets no bill
what does private insurance allow for
Health insurance: show provincial government card
Hospital Insurance Act: Hospital coverage but no MD coverage
Universal medical insurance 1966
Tax financed, public, single-payer health care system
Funded with provincial and federal tax revenues
Not attached to employment at all
Everyone contributes through taxes-everyone benefits
No bill if part of provincial health service
Private insurance allowed for gaps: some pharmaceutical coverage or private hospital rooms
Canada
who refers to a specialist?
what happens to specialists who receive a referral
what is waiting like for elective procedures
what happens per capita
what still remains despite everyone being covered
Family physician referral to specialist
Specialists get paid best if referred
Longer waiting for elective procedures
Less services per capita than US for example: MRIs and surgery
Despite everyone being covered, inequities still happen
Canada
who does physician bill
how are they paid in full
who can the physician not bill and what must they agree with
what kinds of methods are used
what is the rate of the hospital services and hwy
what di hospitals not need to do
Physician bills provincial government
Paid in full according to fee schedule
Physicians must agree with payment, cannot bill patient
methods:
- Blended models
- Fee-for-service
- Capitation
Hospital services slow - not enough money to pay extra
Hospitals do not need to prepare itemized bills
Approval process for capital projects of hospitals
Regulation of pharmaceutical prices
what is the difference between Canada vs. US
Canada vs. US
Less administrative costs
Less expensive high tech costs
Lower pharmaceutical prices
Caps on payment (Similar to Germany)
Changes in 2010 due to lack of confidence
UK
what entitles you to healthcare
what is the NHS
what can compete with NHS
how many buy health insurance
who can pay for private hospitals
Being on the “soil” entitled to receive tax supported medical care through NHS –National Health Service
Private health insurance can compete with NHS
11% buy private health insurance
Private insurance can pay for care of private hospitals not NHS facilities
Britain
what do you need to see a specialist
what must you have
what does your GP act as
where are the GPs
how is home health care
NHS – need referral to specialist
Must have general practitioner
GP is primary care, local hospital is secondary care, regional/national hospitals is tertiary care
GPs not in hospitals, but with social services
Home care is highly developed in UK, doctors home visits
UK
what does home health care warrant
how does a doctor see their patient
what do consultants equal
what is awarded
Capitation for MD & Preventive care fee for service
Home visits, nights and weekends, fee for service
Consultants = Specialists
Quality is awarded
UK
what is lengthened
what is limited
what are there fewer of
how do they view technology?
Queues lengthened
Capitation and salary for physicians
Limited consultant slots- controls supply of personnel and facilities
Fewer surgeons
Fewer meds
Fewer x-rays
More skeptical of new technology than US
Japan
what must large companies provide
what health insurance do smaller companies have
what health insurance do self employed and retirees have
what health insurance do government workers have
what do they all have
what is the insurance a mix of
Large companies- required to operate self-insured plan for employees and dependents
Smaller companies-single national health insurance plan
Self-employed workers and Retirees- National Health Insurance or Citizen’s Health Insurance
Government workers- society managed insurance
All have standard comprehensive coverage
Mix of employment-based insurance, social insurance, universal insurance
Japan
are there pre-authorizations
are there restrictions
are there more hospitalizations
is there more surgery
how long are their hospital stays
No pre-authorizations
No restrictions
Less hospitalizations
Less surgery
Longer hospital stays
Japan
what is the basis
how are hospitals paid in 2003
what does government strictly regulate
what volume do physicians see their patients
what is the average amount of physician visits
who many times have physicians see their patients
what can physicians do for meds
what do patients also see physicians for
Fee-for service was the basis
2003 hospitals paid per diagnosis, physicians still paid fee-for-service
Government strictly regulates physician fees, hospital payments, medication pricing, number of expensive services
Physicians have high volume of seeing patients
Average physician visits: 13 per capita in Japan versus 4 per capita in US
Physicians may see 60 patients in a day
Physicians can dispense medications and profit from medications dispensed
Some patients see physicians just for refills
Japan
how is the GDP looking
what does health care system rely on
what is problematic for this structure
are the elderly decreasing and at what rate
how about for the U.S how is the elderly pop. looking
how are costs contained
GDP increasing 7.7% in 2000 to 10.3% in 2012
Healthcare system relies greatly on employer taxes
Low birth rate and longer life expectancy is problematic for this structure
Japan estimated 65 and older population is projected to increase from 12% 1990 to 39% in 2050
US 65 and older population also growing but not as quickly from 13% in 1990 to 21% in 2050
Costs are contained with strict fee schedules but may not be able to sustain
with older facilities and potential underfunding of the healthcare system
Benefit Package:
the additional perks and benefits a company provides to its employees in addition to the employee’s base wage or salary
Patient Cost Sharing:
The share of costs covered by your insurance that you pay out of your own pocket.
Effects on existing health care coverage
Cost Containment:
a process of judiciously reducing costs in a business or limiting them to a constant level
Reform Health Care Delivery:
a process of change involving the what, who, and how of health sector action
which label is best for patients and why
second one is better for reading and understanding
Spacing, information being available, name is easily found, directions is higher up
what do patients like and don’t like
like:
color, bolding, large font
white space
what drug is for
The most important info on top
name of medicine
prescriber name
don’t like
info for pharmacists
confusing dates
addresses
clutter
unclear directions (twice daily)
all capital letters
Health Literacy
Word Choice
What info they can use to understand their own health
Things related to them to help them decide their health
Numeracy is saying, I’m going away and how much do I need, when is my next refill
Take medicine is different than. Give, give for giving to child so parent should not take It
Take once in morning and at night is different than Twice a day so that the first one is better
Can be very important
Can be difficult for people to understand
Health Literacy and Numeracy
From 2013
Majority of people are below the proficient level of understanding their health and health brochures
Try to get convo. To 5th grade level, fewer syllables is better
Break things down for folks
Patient Literacy Assessment Tools
Zone in one this
Use to assess someone’s ability to understand material
Look at these tests
How many grams of total carbs are in ½ cups: 13g
Have to teach people these things cause not everyone can do these word problems
Things to know to counsel patient
Health literacy tools
make sure student can say these words and you will see how literate they are based on the words they say
Is kidney more associated to urine or fever?
Health Literacy Readability Assessment Tools
SMOG (“Simple Measure of Gobbledygook”) Readability Test
Fry Readability Test
Flesch-Kincaid Grade Level Readability Formula
SAM (Suitability Assessment of Materials)
SMOG Conversion Chart
For looking at a booklet
Take 30 sentences and see how many words have 3 or syllables
Put hand on chin, every time your jaw drops then it is a syllable
Fry Graph
what does it show you
how does it do it
what do you want on in a pamphlet
more syllables equals what
what do we want for sentences
Average # of sentences and average # of syllables per 100 words
Section 100 words and how many sentences are made for 100 words
Least amount of sentences
More syllables = more difficult for person to read
Want short sentences and fewer syllables
how to do Flesch-Kinaid assessment
word
file
options
show readability stats
Making a Difference
how can you fix the label
where do we need to improve labeling
Label is not easy to see
Patient centered labelling
We need to improve labelling of OTC
Health Literacy and drug coverage
what do people not tend to understand
can a lot of people figure out cost of hospitalization
what must we make sure a patient knows
what can “take 1 tablet every day” mean
when is the best time to take statin
what must pharmacists be in order for there to be better outcomes
Rx label instructions
Ppl did not understand their health insurance
Only 11% of people could figure out the cost of hospitalization
Make sure that we know if the patient understands the med
Take 1 tablet every day- can take it anytime
Best time to take statin - at night time because cholesterol is made at night so you take at night to reduce how much is made in the body
Tell them when to take it
Be more specific for better outcomes
Based on Rx directions, effects health outcomes
Four Major Actors in Conflicts, Change, Tensions, and Challenges
who are they
how do they relate to each other
Purchasers supply the funds
Insurers receive the funds, pay providers
Providers provide the care, all health care providers
Suppliers provide the treatments and supplies to providers
who makes up the healthcare industry
what was this like in the past
what is it like now and is there a discrepancy
Insurers, providers, and suppliers make up the healthcare industry.
Previously:
- Gain for health industry Thought of as an investment in economics of the nation
Now:
- Too much to pay, purchasers want to reduce the amount spent while health care wants the number to increase
Provider-Insurance Pact 1945-1970
who formed the alliance of insurers and providers and was their competition
who decided on payment provisions of medicare & medicare
who had the upper hand in negotiating generous payments
who paid without much question
who paid for insurance and recieved tax benefits
were there complaints
what was growing and was profitable
who is able to pay for benefits
who was charged for new facilities and construction?
who is benefitting
Alliance of insurers and providers
Many independent hospitals
Lack of competition
Hospitals and insurers decided payment provisions of Medicare and Medicaid
Providers had the “upper hand” in negotiating generous payments
Insurers paid without much question
Employers paying for insurance and receiving tax benefits; no real complaints of increased costs
Businesses growing and profitable
Able to pay for benefits
Hospitals even charged for facilities and new construction
who benefits: purchasers, insurers, providers, suppliers
Perception of 1970s
what decreases
what does this result in
what becomes a rising concern in healthcare
what is the result
when does regulation begin
what is the result
who begins utilization reviews
who benefits
US share of world industrial production decreasing from 60% in 1950 to 30% in 1980
- Lower profits
- Purchase cash flow decreased
- Inflation and unemployment on the rise
New economic reality of less money for individuals and companies, becomes increased concern for the rising costs of health care
- Hospitals being regulated for new construction
- Government begins health planning agencies
Regulation begins after Blue Cross increase of premiums 25% to 50% in a single year
Utilization reviews begin by insurers
- Provider-insurer tensions rise
- Insurance-provider pact unravels-Blue Cross separates from the AHA
insurers benefits
purchasers and suppliers do not benefit
providers benefit only half way
Coverage Landscape Changes-1990’s
what does the plan become specific to
what do employers shop around for
what do providers lose and why
what power do purchasers have and what was the result
who benefts
Plan become very specific as to where and from whom care can be provided and covered
Employers shop around more for insurers
Providers would lose contracts due to poor rates and unwillingness of insurers to negotiate
Purchasers had some negotiating power with HMOs and saw a drop in premium growth in the earlier 1990’s
providers do not benefit
purchasers benefit
insurers benefit only 50%
suppliers remain steady
1980’s Purchasers Pay Attention
what result did the Costs increase for employer-sponsored health plans result in
what did the Business more attentive to costs and health care issues result in
what rose and who was droped from plans
what did the Selective contracting of purchasers = In-network and Out-of-Network result in
what is tighter controlled
who benefits
Costs increase for employer-sponsored health plans
By 1989 =20.4% of business expenses (it was a fraction of the cost from1945-1970)
Almost a double increase (from 5% to 9%) of payroll spent on health care benefits
Business more attentive to costs and health care issues
Large companies start self-insurance
More companies use managed care options such as HMOs as cost-control
Individuals and labor unions see shift of costs to them; complain of health care costs
Rising premiums and policy cancellations for those with chronic illnesses become media headlines
Selective contracting of purchasers = In-network and Out-of-Network
Insurers choose providers to contract with (those that provide cost containment)
Shift from fee for service to capitated reimbursement-causes providers to cost-control as well
Medicare payments are tighter controlled and Medicaid is scaled back
insurers, purchasers and suppliers dod not benefit at all but suppliers remain steady
what did the Counter-revolution by providers/Consolidation in health care market result in
what did the Growing power of specialists and specialty services
result in
who benefits
Counter-revolution by providers/Consolidation in health care market
Provider and insurance negotiations are intense
Costs accelerate especially for the individual employee-Premiums and deductibles rise 34%
Large HMOs emerge due to buy-outs and consolidation
Growing power of specialists and specialty services
For-profit services, physician owned imaging facilities
Specialist physician groups grow and negotiate for higher payment rates from insurers
Ambulatory centers for day surgery and clinics grew and are physician owned
Hospitalists are a growing specialty
purchasers and insurers benefit
providers and suppliers do not benefit
Pharmaceutical industry criticisms
in 1988, how much of the national health expenses was Rx vs how much in 2009
what happens after that and what did the insurances challenge the pharmaceutical companies to begin
how much did Most profitable companies earn
were there regulations to regulate prices
what tactics were used to continue market share and what act was this
what were the generic manufacturers doing
what was evergreened
what is Pharmacy Benefit Managers (PBM) part of and responsible for what
who benefits
Pharmaceutical industry criticisms
- 1988 Rx was 5.5% of national health expenses versus in 2009 10.1
- Shift of insurance coverage of Rxs occur; Insurances take notice and begin to challenge pharmaceutical costs; Tiers begin
- Most profitable companies: earning 20% of revenues compared to other Fortune 500 companies that earn 5% of revenues
- No regulations by the government to regulate prices
- Brand to generic tactics to continue market share-Hatch-Waxman Act
- Generic manufacturers are consolidating driving up generic costs
- “Evergreening”- Immediate release vs extended release – Rx to OTC
Pharmacy Benefit Managers (PBM)
–Part of the supply chain and responsible for formularies
suppliers benefit
Primary Care Shifts
what method of payment do primary care practices look for
what is payment for
patient-oriented care, is it rising or declining
what is forming
Primary care practices looking at capitation versus fee-for-service
Choosing Wisely campaign spotlights overuse of health care
http://www.choosingwisely.org/patient-resources/
Payment for value versus volume
Patient-Oriented care on the rise
Primary care teams are forming
Suppliers The Perfect Health Care System
is it realistic
what are the important factors of health care systems
Noble aspirations but most likely impossible to attain 100%
Important factors of health care system:
Improve health
Control costs
Prioritize allocation of resources
Enhance quality of care
Distribute services fairly
Blurring of the Actors
Insurers acquiring Providers: UnitedHealthcare acquired DaVita Medical Group
Providers acquiring Insurers: CVS merging with Aetna
Providers acquiring Suppliers: CVS merging with Caremark
Insurers acquiring Suppliers: Cigna merging with ExpressScripts
Companies moving into health care: Amazon
Many conditions have increased during the pandemic.
what are Additional Barriers to Care
Travel costs and arrangements
Childcare
Time off work
Therapy costs and insurance coverage
HEALTHCARE IS CHANGING
what have patients adopted
where is the center of health
do providers meet patients now
Patients have adopted a consumer mentality towards engaging in their health seeking to meet their needs on demand.
Home as the center of health is a quickly growing area of focus in medicine including the ‘Hospital at Home’ model
Meeting patients where they are at is a growing healthcare business structure across multiple care modalities.
Why Digitalize Healthcare?
what issues can they help address the following issues:
Digital tools are giving providers a more holistic view of patient health through access to data and giving patients more control over their health. Digital health offers real opportunities to improve medical outcomes and enhance efficiency.
Reduce inefficiencies
Improve access
Reduce costs
Increase quality
Make medicine more personalized for patients.
how many physicians and federal acute care hospitals (96%) adopted a certfied EHR
As of 2021, nearly 4 in 5 office-based physicians (78%) and nearly all non-federal acute care hospitals (96%) adopted a certified EHR. This marks substantial 10-year progress since 2011 when 28% of hospitals and 34% of physicians had adopted an EHR.
what can you do during. TELEHEALTH
talk to who
message who
Telehealth — sometimes called telemedicine — lets your health care provider care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone.
Talk to your health care provider live over the phone or video chat.
Send and receive messages from your health care provider using secure messaging, email, and secure file exchange.
Majority of payers cover telehealth services for members
Expansion of services available pre-pandemic
Mental and psychological health over state lines
Remote Patient Monitoring (RPM)
what do devices monitor
what does CPT do
what can RPM be used for
what do some patients need
what are some disease states that it monitors
Devices monitor physiological data from patients
CPT codes for setting up and monitoring data available from CMS
RPM can be used for many conditions that require physiological data indicative of disease management
Some patients will need in-person testing, diagnostics, or monitoring. This depends on their condition, Internet capabilities, or personal preferences and abilities.
But there are many ways that remote patient monitoring can help with chronic conditions, pregnancy complications, and short-term illness.
High blood pressure
Diabetes
Weight loss or gain
Heart conditions
Chronic obstructive pulmonary disease
Sleep apnea
Asthma
what is Remote Therapeutic Monitoring (RTM)
what does it cover
Combination of technology like RPM devices and disease management for therapeutic outcomes
This can include medication adherence and physiological data
Interventions can include education and coaching
Currently, CMS covers pulmonary and musculoskeletal conditions
CPT code 98976 - RTM (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days.
DIGITALIZATION OF DEVICES
what does the Integration of health devices do
what is also integrated
what are the ongoing issues
Integration of health devices into the ‘Internet of Things (IoT) landscape
approaches include:
Integration of Bluetooth to tether to an external device (e.g., smartphone or peripheral)
Mobile app integration for data collection and user engagement
Enabled the movement towards:
Remote Patient Monitoring (RPM)
Remote Therapeutic Monitoring (RTM)
Ongoing Issues:
Accuracy, data interoperability, coverage, patient education, user adherence
RISE OF CGM
what does it result in fewer of
what is the accepted use for
what are the limitations
Increased desire amongst PwD to utilize CGM over other BGM interventions due to fewer finger pricks and convenience
Visually impaired patients have benefited from easier BGM
Digital affinity closely related towards acceptance of the use of CGM technologies
- This is likely to increase over time with digital natives
Increased recommendation of CGM use in clinical practice guidelines influencing clinician behavior
Limitations still present:
Cost barriers
Clinician and patient buy-in
Technology barriers
what is the center of healthcare or the ____ at ____ model
hospital at-home model
home is the center of care
ER/provoder identificaton of patient identification of valid patient
conditions of defined treatment protocols
- HF, COPD, CAP, cellulitis
patient home is within hospital range to provide emergent care
home must have space and fit patient needs - food, heat/cooling, water
health staff visit patients in the home (ex. respiratory therapist, nursing)- kinda like UK!
tests conducted in the patient home and therapy (ex. medications) given as well
RPM will play a significant role
Why is PH Controversial?
19th century public health closely tied to social reform movements: campaigns for improved housing, trade unions, abolition of child labor, child and maternal health
Public Health viewed as a broad social movement
Winslow’s 80 yr old definition: the role of PH is the development of the social machinery to ensure every individual in the community a standard of living adequate for maintenance of health.
Why is PH Controversial?
Contrasting views that direct the production and equitable distribution of scarce health care resources
Distribution of benefits/burdens and responsibilities within a society
Free market vs government responsible for allocation and delivery of resources
Health care access a right vs ability to pay
Health care an individual vs collective responsibility
Role of PH in society, broad and expansive vs restrictive
Social Justice in PH
Health is a collective responsibility
Emphasizes community well-being
Views health care as a social resource
Allocation and delivery of health care resources governed by need
Minimum levels of income, housing, employment, education and health care are fundamental rights
PH closely tied to social reform movements (public hygiene, improved housing, abolition of child labor, maternal and child health, trade unions
Social Justice in PH
what two things does it emphasize
what is it a strong obligation to
is access to healthcare universal or limited
what does it propose
Emphasizes collective responsibility for health
Emphasized community well-being
Strong obligation to the collective good
Access to health care universal
Proposes public solutions to social problems (drug abuse, homelessness, violence)
Market Justice. in PH
Health is an individual responsibility
Emphasis on individual well-being
Views health care as an economic good
Allocation and delivery of health care resources governed by demand
Powerful forces of environment, heredity, social structure prevent equitable distribution of the burdens and benefits of PH
Market Justice in PH
what does PH aim to control
who encourages it
what does it limit
how is medical care distributed
PH is an enterprise focused on controlling communicable disease or as a safety net that provides medical care to the indigent
Encouraged by MD’s
Limits federal health funding to programs run by local health departments
Medical care distribution based on the ability to pay
Market Justice access to medical care
how is access to medical care viewed
what is the role of the government and public health
Access to medical care is viewed as an economic reward for personal effort and achievement
Role of government and public health
- Restricted, narrow
- Limited to a technical enterprise
Sources of Controversy
Economic impact
Individual liberty
Moral and religious concerns/values
Political interference with science
Economic Impact in PH
PH measures may have negative impact on segment of population or industry
Those paying for PH measures may not benefit from those measures
Costs are measurable/benefits are often not
Costs may be short-term while benefits may not be immediately seen
Example of a PH initiative with significant economic impact? Discuss in groups of 3 to 4.
Economic Impact industries
Tobacco industry: product labeling, bans on smoking in public places, restaurants
Lumber industry: regulations cost jobs to preserve a long term stable climate
Standing orders for Narcan in community pharmacies: high cost to insurance companies
Mandatory immunizations
Individual Liberty in PH
what is the role of the gov’t in this
what are restrictions on
what may the restrictions benefit
To what extent can and should the government restrict
individual freedom for the purpose of improving the community’s health
Restrictions on behaviors that may cause direct or indirect harm to others
Restrictions may benefit the individual or the community
Example of PH initiative affecting individual liberty?
Individual Liberty
what do people have a say in
Seat belts
Bike helmets
Extra large soft drinks
Removal of vending machines in public areas
Additional driving tests for elderly
Mandatory health screenings
Mandatory immunizations
Moral and Religious Concerns in PH
what do some PH initiatives do
are discussion of PH issues always comfortable to have
how may some religions react to PH initiatives
Some PH initiatives provoke moral or religious objection
Discussion of some PH issues are offensive or
embarrassing to discuss (sex and reproduction, alcohol and drug addiction, suicide and end of life decisions)
Can the government determine and enforce moral behavior?
Some religions may prohibit some common PH initiatives (birth control, immunizations)
Politics vs. Science
Presidential administrations criticized for misrepresenting and/or distorting scientific information and evidence to support its policies and political agenda
Examples:
Bush admin pressured CDC to promote abstinence only programs for preventing teen pregnancy
Promoted condom failure rates rather than place in prevention of spread of AIDS and other STD’s
Prevented publication of research on agriculture affect on antibiotic drug resistance
Handling of the AIDS crisis
Handling of drug/alcohol addiction crisis
Health Statistics in PH
how do PH workers monitor health of a community
what does health statistics deal with
Public health workers monitor the health of a community by collecting and analyzing health data
Health statistics
- Identify special risk groups
- Detect new health threats
- Determine success of disease state management
- Help plan and evaluate success of public health programs
- Are considered when preparing government budgets
Health Statistics for research
Provide raw data for research on
Epidemiology
Environmental health
Social and behavioral factors in health
The health care system
Essential for the Assessment Function in public health
NCHS
what does it stand for
what does it do
what is it a part of
how many ways does it collect data and what does it do
National Center for Health Statistics
Primary agency that collects, analyzes and reports data on the health of Americans
Part of the CDC
Collects data in two ways
- States and local agencies periodically transmit data they have compiled from local records: vital stats, births and deaths
- Conducts periodic surveys of representative samples of the population on health status, lifestyle, health-related behaviors, onset and diagnosis of illness and disability, use of health care resources
Vital Statistics
Births and deaths are the most basic and reliable and complete data set
Causes of death subject to uncertainties
Utilize birth and death certificates
Vital Statistics also include information on marriage, divorce, spontaneous fetal deaths and abortions
The state health department is generally responsible for collecting these reports and transmitting them periodically to the NCHS
Birth Certificates
who supplies info about baby
who supplies medical and health info
Mother supplies information about the baby’s family (names, address, ages, race, ethnicity, education level)
Medical and health information supplied by hospital, doctor, birth attendant (prenatal care, birth weight, medical risk factors, complications during delivery, OB procedures, abnormalities in the newborn)
The Census
what is the # of people in society important
what is used as a numerator and what is used as a denominator
how do you calculate age adjusted or age specific rates
The number of people in the population is necessary in order to convert the data collected through vital statistic systems into rates per number of people
The number of people in the population serves as the denominator when a vital statistic is used as the numerator.
To calculate age-adjusted or age-specific rates it is necessary to know how many people are in each age group
The Census what does it determine
how often does the constitution require that the population of the U.S be counted to determine the state representatives
what are the two controversial issues presented
To determine sex-specific or race-specific rates, we need to know how many males and females there are in a population as well as the breakdown of races within the population
The Constitution requires that the population of the United States be counted every 10 years to determine each state’s representation in the House of Representatives
2 controversial issues
- How race is determined
- Ability to accurately count every individual household
The Census.
what is the major change
what is the American Community Survey (ACS)
was it different than the long form
who was it sent to
what was it designed for
A major change in the way the 2010 census was conducted was that only
- the most basic data was collected using a short form (included name, sex, race and ethnicity, and relationship of everyone living in the household)
American Community Survey (ACS) launched in 2005 by the Census Bureau
- Same information as long form
- Sent to 3 million households selected to be representative of the populations of local jurisdictions
- designed to help communities plan for transportation systems, zoning, schools, healthcare facilities, housing and social services
National Center for Health Statistics Surveys
In addition to collecting data from the states, NCHS actively conducts a number of surveys to gather additional information on the health of the American public
Two ongoing NCHS surveys
The National Heath and Nutrition Examination Survey (NHANES)
Designed to obtain detailed and accurate information
Doctors and nurses conduct physical and dental exams and lab tests on a carefully selected sample of the population
Data collected determines prevalence of chronic conditions and risk factors as well as nutritional status and its association with chronic disease
NCHS Surveys
what does the BRFCC do
Two ongoing NCHS surveys
The Behavioral Risk Factor Surveillance Survey (BRFSS)
- Largest telephone survey in the world
- Self reported data (may be less reliable)
- The only available source of timely, accurate data on health-related behaviors
- Conducted by the states which report their findings to the CDC
- Asks questions about health status, high risk behaviors, physical activity, preventive medical care
NCHS Surveys examples
National Youth Fitness Survey
National Survey on Family Growth
National Immunization Survey
National Asthma Survey in collaboration with the CDC National Center for Environmental Health
National Infant Feeding Practices Study
Other Governmental Surveys
EPA surveillance for health hazards in the environment
National Cancer Institute monitors long-term trends of cancer incidence and mortality through a program called Surveillance, Epidemiology, and End-Results (SEER)
The Centers for Medicare and Medicaid Services utilize billing records for research on utilization and outcomes of medical care
Is so much data necessary?
Data is critically important in making up the surveillance systems that form the basis of effective public health practice as well as the planning and evaluation efforts that are increasingly being used in public health programming
The success of intervention programs to confront a problem is evaluated based on whether they improve the statistics
Accuracy and Availability of Data
what is the process of data collection
health info. always relying on survery or voluntary reports are always what
is the census info. always reliable
The process of data collection is always imperfect
Health information relying on surveys or voluntary reports are often incomplete or subject to bias
Census information contains errors and there are political difficulties in attempting to correct these errors
Accuracy and Availability of Data errors
Errors exist in reporting cause of death on death certificates
Maternal deaths are suspected of being underreported because doctors fail to indicate the woman was pregnant on the death certificate
The data collection and reporting processes contain sources of inaccuracy and bias
Accuracy and Availability of Data
New information technology (public health informatics) has vastly improved accessibility of information to public health workers and the general public
Confidentiality of Data
All information collected from individuals by governments for whatever purpose is considered confidential and cannot be divulged without the consent of the individual
Information is generally entered into a database without any names, addresses or personal identifiers
Exception: when someone has been exposed to a communicable disease they must be notified
Data and PH Interventions
PH problems are identified in terms of statistics
Data is the basis of the statistics utilized in PH initiatives
Success of PH initiatives is evaluated based on improvement in statistics
Pharmacist Patient Care Process
C
A
P
I
F
collection of the necessary subjective and objective info. about the patient to understand the relevant medical/medication history and clinical status of the patient
the pharmacist assesses the clinical effects of the patient’s therapy in the context of the patient’s overall health goals to identify and prioritize problems and achieve optimal care
develop a plan to combat the issue that is evidence-based and cost-effective
put a plan into place with other health care professionals and patient or caregivers
evaluate the effectiveness of the plan
Policy Development
what does it help to develop
what does it determine
what does it inform
what does it develop
what does it used to devise strategies
Development of the treatment plan
Determines what will be done
Informs, educates and empowers people about health issues
Mobilizes community partnerships to identify and solve health problems through DPH
Develops policies and plans that support individual and community health efforts
Uses scientific knowledge to devise strategic approaches to improve community health
Public Health
WHAT WE FOCUS ON
The role of the pharmacist
Public Health
what is it a measure of
what else does it measure in regards to bringing and maintaining
Measure of the general, overall state of health of a population or society
Measures that people take to bring about and maintain the health of a population or society
What is Public Health 1920 definition, Charles Edward A. Winslow
The science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the:
Sanitation of the environment
Control of community infections
Education of individuals in principles of personal hygiene
Organization of medical and nursing services for early
diagnosis and prevention of disease
Development of social machinery which will ensure to every individual a standard of living adequate for the maintenance of health
PH From the CDC Foundation
what is PH
what does it improve
Public health is the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases.
CDC works with its partners around the world to do what
monitor health through epidemiology
detect and investigate health problems
conduct research to enhance prevention
develop and advocate sound public health policies
implement prevention strategies like with covid: masks, 6 feet away
promote healthy behaviors
foster safe and healthful environments
provide leadership and training
What is Public Health
what is the mission
what does substance mean
1988 definition, The Future of Public Health by the Institute of Medicine (4 part definition)
Mission: The fulfillment of society’s interest in assuring the conditions in which people (population not individuals) can be healthy
Substance: Organized community efforts aimed at the prevention of disease and the promotion of health
What is Public Health
Organizational framework: encompasses both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations of individuals
3 Core functions of public health (Table 1-1) on exam
Assessment
Policy Development
Assurance that policies are working
Assessment – identify what needs to be done
what does it determine
what does it examine
what does it require
The diagnostic function- what do we need to do
Determines what should be done
Examines the current health status and threats to health that exist in a community
Requires surveillance of disease, identifies needs, monitors trends and analyzes causes
Diagnoses and investigates health problems and health hazards in the community
Assurance
what is it equivalent to
what does it determine
what does it enforce
what does it link.
what does it ensure
what does it evaluate
Equivalent to the actual treatment plan
Determines what is being done
Enforcement of laws and regulations that protect health and ensure safety (interventions)
Link the public to health services and ensure the provision of health care
Assure a competent public health and personal healthcare workforce
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
3 Core Functions
assessment
policy development
assurance
Public Health
Prevents epidemics and the spread of disease
Protects against environmental hazards like hurricanes and such
Prevents injuries
Promotes and encourages healthy behaviors
Responds to disasters and assists communities in recovery
Assures the quality and accessibility of health services
Public Health vs Medical Care
what is the focus of PH
what is the goal
how much does PH account for in health spending
who are the PH decision makers
Public Health:
- The “Patient is the Community”
- The goal or focus is on prevention (abstract, difficult to quantify and recognize)
- Accounts for approximately 3% of health spending
- Decision makers are public health experts, involve scientific recommendation/evidence-based medicine, government intervention
Public Health vs Medical Care
Medical Care
-The Patient is an individual
- The goal or focus is to treat and cure those who are ill (benefits are easier to quantify and recognize)
- Accounts for approximately 97% of health spending
- Decision makers are physicians, mid-level providers, and the individual patient
Public Health vs Medical Care
what are the core functions for each
Public Health core functions: Assessment, Policy Development, Assurance
Medical Care core functions: Diagnosis, Providing Treatment Options, Actual Treatment, easier-to-quantify implementation
PH: Science plus politics
what is science
what is politics
Science: the understanding of threats to health, determining necessary interventions, evaluating efficacy of interventions
Politics: determine policies for development, implementation, and assurance
Six sciences/disciplines of Public Health
Epidemiology
Statistics
Biomedical Sciences
Environmental Health Sciences
Social and Behavioral Sciences
Health policy, management, and administration - need to be thoughtful
Epidemiology
what is it
what is it the study of
what does it seek
what does it aim to control
The basic science of public health - need to know what’s going on in pop. before developing interventions
The study of epidemics (or common exposures, shared characteristics)
Seeks causative factors of acute and chronic diseases and strategies to limit exposure
Aims to control the spread of disease
Statistics
what does it provide and what does it help with
what does the government collect
what does it also assess
Data/numbers are diagnostic tools that aid in the determination of risk
The government collects data on populations
Statistics also assess the benefits of interventions
Biomedical Sciences
how much of disease is caused by microorganisms
what does prevention and control require
what does it lead to
what studies does it include
A major proportion of disease is caused by microorganisms
Prevention and control of diseases requires understanding of infectious agents
Lead to understanding of risk factors for non-infectious chronic diseases
Includes study of genetic predisposition and effects on disease risk, prevention and treatment
Environmental Health Science
what is it concerned with
what does it share concern with
what does it depend on
what can we see in different communties
A component of public health
Concerned with preventing the spread of disease through water, air, and food
Shares concerned about the spread of infectious organisms
Depends on epidemiology to track environmental causes of disease
within certain communities, there might be environmental contributors that can affect life span ex: 84 life expectancy in 1 region and 72 life expectancy in another region
Social and Behavioral Sciences
People are negatively impacted by diseases caused by their behavior and their social environment
There are many disparities in health between subgroups of the population, the causes of the disparities are often unknown
Some subgroups of the population have poorer health overall than others related to social and behavioral sciences
disparities between white and black health outcome
Health policy, management and administration
what does it attempt to address
Attempts to address:
Rising cost of healthcare
Access to healthcare
Quality of healthcare
Role of public health in medical care
3 Core Functions and 6 Disciplines
what are the 3 core functions
How are the 6 disciplines used to accomplish the 3 core functions?
-Assessment
-Policy Development
-Assurance
Prevention and Intervention
what is the 5 step process
5-step process:
1. Define the health problem
- Identify the risk factors associated with the problem
- Develop and test community-level interventions to control or prevent the cause of the problem
- Implement interventions to improve the health of the population
- Monitor those interventions to assess their effectiveness
plan
do
study
act
this is a continuous cycle
Prevention and Intervention
what two things does PH address
what does it require
What are some interventions we see every day?
PH = prevention of disease
PH = keeping a population healthy
Prevention
–Requires development of interventions aimed at specific health problems or behaviors
What are some interventions we see every day?
- billboards
2 Approaches to designing interventions
what are they? :)
Prevention at 3 levels/stages
Chain of causation
Prevention at 3 levels/stages
Primary prevention: aims to prevent an illness or injury from happening at all by preventing exposure to the risk (true prevention) - COVID: having people stay home, could not be exposed to COVID if they did not go anywhere, also masks
Secondary prevention: aims to minimize the severity of the illness or injury when it occurs (early detection and treatment)
Tertiary prevention: aims to minimize disability by providing medical care and rehabilitation. Happened in hospitals, aiming to minimize the severity and disability
vaccinations are secondary preventions: were not designed to prevent COVID-19 but to prevent the severity of the disease if you got covid
Examples of Prevention at 3 levels/stages
did it prevent exposure?
Primary: discouraging teenagers from smoking and efforts to encourage smokers to quit (preventing lung cancer and COPD). Have laws in place to prevent ppl under 18 from getting cigarettes. Stop exposure
Secondary: screening programs for early cancer detection
Tertiary: medical treatment and rehabilitation for cancer patients
Chain of Causation
what are the 4 parts what does each involve
Involves
Agent: could be a disease-causing bacteria or virus. The goal is to eliminate or minimize. For lung cancer: smoke or cigarettes. Anyhting that causes the disease
Host: a human being. The goal is to make less susceptible/strengthen resistance to the agent like with a vaccine
Environment: the means of transmission by which the agent reaches the host. The goal is to make the host less likely to encounter the environment and decrease or eliminate the means of transmission.
For COVID: school, grocery stores, public transportation
goal: make the host less likely to be in an environment
Example of chain of causation
example is suicide
what is the host
what is the agent
what is the environment
what is the PH prevention
what do we need to reduce access to
PH goal: prevent suicides in the age group 15 to 24
Host: susceptible young people
Agent: guns, overdose
Environment: the young person’s social environment (family, school, social media)
PH intervention: change messages in the media, reduce access to guns and drugs for overdose
reduce access to guns, interrupt the chain of causation
something needs to change
Chain of Causation
what is the goal
what must to first think of
identify what
what must you describe
how can you change the host
The goal is to interrupt the chain:
Think of an illness or injury
Identify the agent, host, and environment
Describe how you would interrupt the chain of causation related to the agent, host, and environment
can change host by vaccinating them, educating them
Public Health and Terrorism
Public health response to disasters and terrorism helps control damage and prevent further harm to survivors and rescuers.
What level of prevention is this?-is it primary, secondary or tertiary
Public health response to disasters and terrorism helps control damage and prevent further harm to survivors and rescuers.
What level of prevention is this?
Primary?- prevent exposure to agent
Secondary?- help to reduce the severity of agents like a vaccine
Tertiary?- how we take care of people who have exposure
evacuate from hazard: primary prevention
terrorist attack: no primary prevention
I think this is secondary because the disaster has ALREADY happened (so it cannot be primary because if it was then we would be preventing it from happening at all) and we are trying to prevent FURTHER harm from continuing. If tertiary then we would be providing something for the survivors to RECOVER from the disaster
Why is PH controversial?
do not make a lot of money
costs money
Pharmacist Patient Care Process
also in PH
by collecting
assessing
plan
implement
follow-up
do this for pop. and not just individual
Government’s role in public health
who determines their role
is the body of PH law small
Determined by law
Government’s public health activities must be authorized by legislation at the federal, state, or local levels’
The body of public health law is huge, consisting of all written statements relating to health by any of the three branches of government
The U. S. Constitution
what does it mention about health
what does th 10th amendment state
what does the preamble include
what authority does it give to federal goverment
Does not mention health
Tenth Amendment states that “the powers not delegated to the United States by the Constitution…are reserved to the States respectively.
Preamble includes “to promote the general welfare”
Gives federal government authority to regulate interstate commerce and “to collect taxes…to pay the debts and provide for the common defense and the general welfare:
Federal influence over public health
Interstate commerce provision: justifies the activities of the Food and Drug Administration (FDA)
Power to tax and spend: (1967) lead to federally mandated motorcycle helmet laws as a condition of federal funding for highways
Federal government provides 50 to 80% of Medicaid funding though states and counties administer the programs
Federal influence over public health
From WW II to the 1980s the federal government used its powers to widen its role in public health
Trend reversed in 1980 due to politically hostile climate in government
Movement in Congress and the Supreme Court to cut government regulations and return power to the individual states
New federalism in the 1990s
what did it do to congress
what did the supreme court do
what happened to new federalism after 9/11
what happened in 2003
Limited Congress’s powers and returned authority to the states
Supreme Court struck down a law making gun possession within a school zone a federal offence, rejecting that gun possession was a matter of interstate commerce
New federalism lost much of its momentum after 9/11 when the role of the federal government in public health looked useful and necessary
In 2003 this movement seemed to reverse, giving federal law more power over state law
How the law works
what do the governments have power to do
what are the 3 reasons why police power is invoked
Governments have police power (broad power) to act in ways that curtail the rights of individuals.
Police powers are invoked for 3 reasons
–To prevent a person from harming others (direct or indirect)
–To defend the interests of incompetent persons such as children or the mentally handicapped
–To protect a person from harming him or herself
Examples of police powers
what does it say about vaccines
what about work training
what did some people argue
Mandatory vaccinations
Occupational Safety and Health Act (OSHA)
Some may argue that prior to government implementing PH initiatives a cost benefit and feasibility analysis should be considered.
How public health is organized and paid for
Local Agencies
Have day to day responsibility for public health activities and provide the bulk of services (include collecting statistics, conducting communicable disease control programs, health screenings, immunization clinics, provision of medical care to the indigent)
Organization varies from state to state (most common is county health departments, large cities have municipal health departments, towns have boards of health, rural areas have multicounty health departments )
Funding varies from state to state, including state, federal and local taxes, fees for services
How public health is organized and paid for
what are state agencies primarily responsible for
what do most states have
what does funding depend on
what is it defned to
what is it charged with
State Agencies
- Has primary responsibility and authority for the protection of health, safety and general welfare of the population
Most states have a state health department (Mass Dept of Public Health)
Funding depends heavily on federal money
Define to varying degrees the activities of local health departments
Charged with licensing and certification of medical personnel, facilities and services
Administer Medicaid programs
How public health is organized and paid for
who is the nation’s leading spokesperson on matters of public health
what agencies are included
Federal Agencies
Fall under jurisdiction of the Department of Health and Human Services (HHS)
The Surgeon General is the nation’s leading spokesperson on matters of public health
Agencies include
CDC – the main assessment and epidemiologic agency (figure 3-4)
NIH – the greatest biomedical research complex in the world (Box 3-1)
FDA
The CDC
what is the mission
what does it traditionally focus on
what has the focus changed
Mission is to control and prevent human diseases
Traditionally focus has been on infectious diseases (crisis oriented)
Change in focus and expanded mission includes chronic diseases, genetics, injury, violence and environmental health
NIH
what is it in the world
what does it support
what does it include
The greatest biomedical research complex in the world
Supports research ranging from basic cellular processes to physiological errors that underlie human diseases
Includes the National Library of Medicine, the largest reference library for medical centers around the world
Other federal agencies with public health responsibilities
Environmental Protection Agency (EPA)
Department of Agriculture
Department of Education
Department of Transportation
Department of Labor
Department of Veterans Affairs
Department of Homeland Security
Worcester Department of Public Health (DPH)
what does it work on
what is it comprised of
Your Public Health Division works to protect and improve community well-being by preventing disease and injury while promoting social, economic and environmental factors fundamental to health.
This Division is the foundation of the local public health system that comprises public- and private-sector health care providers, academia, community based organizations, business, the media and other local and state governmental entities.
Worcester DPH
what does it track and investigate
what does it prepare and respon
what does it develop, apply and enforce
what does it lead
Track and investigate health problems and hazards in the community
Prepare for and respond to public health emergencies
Develop, apply and enforce policies, laws and regulations that improve health and ensure safety
Lead efforts to mobilize communities around important health issues
Nongovernmental role in public health
what non-governmental organizations play a role in public health
Many nongovernmental organizations play important roles in public health, especially in education, lobbying and research
American Cancer Society
American Heart Association
Alzheimer’s Disease and Related
Disorders Association
American Diabetes Association
Non-governmental role in public health
what do they conduct
what do they sponsor
what do they include
Conduct campaigns to educate the public
Sponsor research on a particular disease
Include professional membership organizations
Include several major philanthropic foundations providing funding for supporting research or special projects, health care to certain populations and support for health and public policy development
what are the Public Health Cores Sciences?
prevention effectiveness
epidemiology
laboratory
informatics
surveillance
what is epidemiology
what is Descriptive Epidemiology
what is Analytic Epidemiology
what is epidemiology concerned with
the study of
- the patterns of disease occurrence in human populations,
- the factors that influence these patterns
- the application of this study to the prevention and control of health problems
Descriptive Epidemiology:
It looks to find the answers of person (who), place (where) and time (when) of a disease or other health-related event
Analytic Epidemiology
Why and how questions are answered by
Epidemiology is not only concerned with only death, illness and disability; but also positive health states and the means to improve health
what are the 3 Elements of Descriptive Epidemiology
Time:
- Do disease patterns differ by time of year? Are they seasonal?
Person:
- Do disease patterns differ by age or gender?
- Are certain groups of people at a higher risk of developing a disease or complications from an illness?
Place:
- Do disease patterns differ on geographical areas?
Combination of time, person, & place
Age groups stratified by location
what is the Purpose of Epidemiology in Public Health Practice
Discover the agent, host, and environmental factors that affect health
Determine the relative importance of causes of illness, disability, and death
Identify those in the population that have the greatest risk from specific causes of illness
Evaluate the effectiveness of health programs and services in improving population health
what is the Epidemiology Triangle?
host
- age
- race
- sex
- genetic profile
- previous disease
- immune status
- religion
- customs
- occupation
- marital status
- family background
agent
- biologic (bacteria, viruses)
- chemical (poison, alcohol, smoke)
- physical (trauma, radiation, fire)
- nutritional (lack, excess)
environment
- temp, humidity, altitude
- crowding, housing, neighborhood
- water, milk, food
- radiation, pollution, noise
Epidemiology Key Terms
Epidemic or outbreak:
Endemic:
Pandemic
Surveillance
Cluster
Epidemic or outbreak: disease occurrence among a population that is more than what is expected in a given time
Endemic: disease or condition present among a population at all times; always there
Pandemic: a disease or condition that spreads over a wide geographic area and affects an exceptionally large population across regions, maybe worldwide–globally
Surveillance: Ongoing systematic collection, analysis, and interpretation of health data needed for planning, implementation, and evaluation of public health practice
Cluster: a group of cases in a specific time and place that might be more than expected.
A public health approach-Public health problems are diverse
surveillance: what is the problem (problem)
identify risk factors: what is the cause
intervention evaluations: what works
implementation: how do you do it (response)
All of the following illustrate the purpose of epidemiology in public health EXCEPT:
A
Identifying populations who are at risk for certain diseases
B
Assessing the effectiveness of interventions
C
Providing treatment for patients in clinical settings
D
Determining the importance of the cause of illness
Your
C! Providing treatment for patients in clinical settings- Leave it to physician
which is what I put randomly LOL
In March 2021, an outbreak of measles occurred among students at a community college in Boston. This group of cases during this specific time and place is described as a _________________________________.
cluster
HIV/AIDS is one of the worst global diseases in history. It is a/an___________________.
pandemic
The Ebola virus in parts of Africa is in excess of what is expected for this region. This virus is a/an______________________.
epidemic (or outbreak)
the key is EXCESS; the agent is more than what we want
Malaria is present in Africa at all times because of the presence of infected mosquitoes. Malaria is ___________________ in Africa
endemic
Surveillance
what is it in PH
it is warning system for what
Once an outbreak is discovered, what can be done
Epidemiologic surveillance is a major line of defense in protecting the public against disease
It is a warning system that alerts
communities that something is wrong
Once an outbreak is discovered, public health officials can begin to take action to prevent the spread of disease
- Immunizations
- Isolation of an infected person
- Recall of medication or contaminated food
what are the list of disease thata healthcare provider should report to the public health department
does surveillance ever stop
The Federal government has a list of notifiable diseases that a healthcare provider must report to the public health department:
Hepatitis B
HIV
STDs
Tuberculosis
COVID-19
Surveillance is ongoing and systematic
Outbreak Investigations
what are the steps
Construct a working case definition
Perform descriptive epidemiology (Who, Where, When)
Implementing control and prevention measures
Initiate or maintain surveillance
Communicating findings to stakeholders, community etc
Outbreak Investigation
what is step 1?
what is the probable case
what is confirmed case
Step 1- Construct a working case definition
Establish a case definition by using a standard set of criteria
Probable Case: Have signs and symptoms but no confirmed laboratory work
Confirmed Case: Have signs and symptoms with laboratory confirmation
Example: Meningococcal disease for outbreak investigation
what is a clinical case
what is a lab diagnosis
what is probable and what is confirmed
Clinical case definition: An illness with sudden onset of fever (>380C and one or more of the following: neck stiffness, altered consciousness, other meningeal signs or petechial or puerperal rash
Lab diagnosis: Positive cerebrospinal (CSF) fluid antigen detection or positive culture
Case classifications:
Suspected: Meets clinical case definition
Probable: As suspected case and turbid CSF (with or without positive Gram stain) or ongoing epidemic and epidemiological link to a confirmed case
Confirmed: A suspected or probable case with laboratory confirmation
Outbreak Investigation step 2
what kind of epidemiology is performed
how do you suumarize data
what does it provide
what can be inferred
what can it provide clues for
what can begn after this
what can you establish from this
Step 2- Perform descriptive epidemiology- This step is very important because it will:
Summarize data by key demographic variables
Provide trends over time, geographic areas and the population affected
From this information you can infer the population at risk for the disease
Can provide clues about the source, modes of transmission
Can begin interventions and preventative measures to control disease
Establish epidemic curve-shows magnitude of disease over time
Outbreak Investigation
step 3 & 4
what does step 3 do
- what does it control and preventand what is the primary goal
- what kinds of things can be done
step 4
- once control measures are in place, what must be done
Step 3- Implement control and prevention measures
- Control and prevent additional cases is the primary goal. If appropriate measures are known they should be put in place as early as possible.
- Masks for respiratory transmission, spraying or bed nets for mosquito transmission
Step 4- Initiate or maintain surveillance
Once control measures are in place must monitor to see if working or not
Outbreak investigation
step 5
determine what
what are examples of these
determine what about information
what is an example of that
identify what
what next needs to be controlled
Step 5- Communicate findings
Determine who needs to know
Local health authorities. Medical community, general public, lawmakers
Determine how information will be communicated
Oral briefings via news of implementation of control and prevention measures
Identify why information needs to be communicated
Control spread of illness
Outbreak Investigation
New regulations may result from the findings
Legionnaire’s disease led to the development of new regulations worldwide for climate control systems (A/C systems and cleaning requirements)
More recent outbreak that led to changes in regulations:
- Meningitis outbreak of 2012 from New England Compounding Center (NECC)
- Changed continuing education requirements for pharmacists conducting sterile and non-sterile compounding
- Owner of pharmacy found guilty on 57 of 96 charges- serving 9 years in prison
- Chief pharmacist- charged with 25 counts of second degree murder (found not guilty) found guilty on racketeering charges- Serving 8 years in prison
Chronic Diseases
what can it show links between
how does it develop, is there a single cause
Epidemiology is also useful in identifying the causes of some chronic diseases
Can show links between the occurrence of disease with exposure to risk factors
Chronic diseases develop over time and do not have a single cause
Risk factor concept: a particular biologic, lifestyle & social conditions are associated with increased risk for specific chronic diseases
Heart Disease
what was it the first epidemiologic study to do
who was in the study
what are the Three major risk factors for heart disease are:
Framingham Heart Study
- Began collecting data in 1948- still collecting today
- Was the first epidemiologic study of a chronic disease
- > 5000 healthy, middle-aged subjects in Framingham, MA- examined every 2 years
Findings from this study:
Three major risk factors for heart disease are:
- High cholesterol
- Hypertension
- Smoking
heart disease
prospective cohort study
In 1971- the study continued to the off-spring of the original study subjects
In 2001-2002- the grandchildren of the original study subjects became part of the study
This type of study is called prospective cohort study because it follows the subjects through time
Guidelines to treat cardiac conditions such as hypertension and dyslipidemia have been developed based upon the knowledge gained in this study
Heart Disease data
Data from these trials helps us today in medicine for evidence-based recommendations
The Framingham Heart Study found:
- Weight gain and lack of exercise are associated with high blood pressure and high cholesterol levels therefore increasing the risk of heart disease
Expanded studies found;
- Effects of quitting smoking
- “Good” cholesterol versus “bad” cholesterol”
- Alcohol in moderation has beneficial effects
Lung Cancer studies
what are the 2 studies
What link has been associated with lung cancer?
Two landmark studies:
Doll and Hill (UK)
- Death rate from lung cancer was 20 times higher in smokers than in non-smokers
- Death from heart attacks was significantly higher in heavy smokers aged 35-54 than in non-smokers
Hammond and Horn (US)
- Smokers are 10 times more likely to die of lung cancer than non-smokers
- Heavy smokers are 2.4 times more likely to die of heart disease than non-smokers
Case
BW is 59 year old African-American male with atrial fibrillation and hypertension. He currently takes aspirin, lisinopril, hydrochlorothiazide daily.
- Lipid panel: TC 201, LDL 160, HDL 30, TG 180,
- Blood pressure 170/90
- Smoked 1 pack of cigarettes a day for 30 years
What is his ASCVD 10-year risk Score? Lifetime score?
of epidemiology
Summary
whatis epidemiology important for
what do Epidemiologists investigate
what does it provide
what is the role in identifying causes of disease
what does it want to achieve
what do agences build
what do they help with
Epidemiology is an important component of the assessment function of public health
Epidemiologists investigate epidemics by counting the number of cases and how they are distributed by person, place, and time
Epidemiology also provides information on the cause of chronic diseases
Epidemiology’s role in identifying causes of disease leads directly and indirectly to prevention and control
To achieve improvements in public health:
Agencies build on the information from
information gathered from epidemiological studies to develop policies
They help plan programs aimed at reducing risk and promoting health in the population
Important Terminology for Chapters 5- 6-7Epidemiologic Principles and Methods
Case Control
Cohort
Epidemic curve
Incidence
Intervention Study
Probability
Relative Risk
Surveillance
Bias
Confounding variable
P-value
Significance
Statistics
Conducting studies
why are studies conducted
Studies are conducted in an attempt to discover associations between an exposure or risk factor and a health outcome
Epidemiology Study Types
can be either:
can be either:
observational
or
experimental
observational can be either:
descriptive - who, when, where, hypothesis
or
analytic - how, tests hypothesis
Descriptive vs Analytic Epidemiology
Descriptive epidemiology asks
- When was the population affected?
- Who was affected?
Analytic epidemiology asks
- How was the population affected?
Descriptive epidemiology asks
- Where was the population affected?
Analytic epidemiology asks
- Why was the population affected?
Distribution
who
when
when
where
Who: age, sex, race and economic status
When: trends of disease frequency over time (is it increasing?, decreasing?, remaining stable?)
When: tracking an outbreak. Use epidemic curves to plot the number of cases over some time.
Where: compares disease frequency in different counties, states or countries or other geographic areas. Can also compare urban vs. rural areas
Distribution
what does the info. collected provide
and what can determinants be
The information gathered on the distribution of disease gives clues about the determinants of disease.
Determinants can be any underlying social, economic, cultural or environmental factors that are responsible for health and disease.
what are the Three study designs are commonly used in epidemiology (Observational)
what experimental studies are used to test for
3 study designs:
Cross-sectional
Cohort
Case-control
Experimental studies to test efficacy of medications
- Randomized Controlled Studies are used
Determinants
when you have clues, what can you do
what can you do with hypothesis
what can it do
When you have clues to the determinants of disease you can generate a hypothesis
The hypothesis can be tested by formal/systematic epidemiologic studies
These can confirm or disprove the hypothesis
Cross Sectional study
what does it analyze
why are the subjects selected
what does it provide
Analyzes data of variables collected at one given point in time across asamplepopulation or a pre-defined subset.
Subjects are selected because they are members of a certain population at a certain period
Provides a “snapshot” of exposures and outcomes
Cohort Study
what does it study
what type of people does it start with
what does it provde
are Prospective or retrospective usually short
A study of a group of people, or cohort, followed over time to see how some disease or diseases develop
The study typically begins with healthy subjects who are asked about their exposures
These studies provide the best information about the causation of disease and the most direct measurement of the risk of developing a disease
Prospective or retrospective and can take years to complete
Cohort Studies
what are the advantages and disadvantages
Advantages
Can study multiple outcomes
Study uncommon & multiple exposures
Provides clearer sequence of events
Selection bias is not likely
Directly calculate disease incidence
Disadvantages
Expensive & time consuming
May take years to complete study
Inefficient for rare outcomes or disease with long latent periods
Data on some confounding variable may be missing
Source of error
Loss to follow-up
Case-Control study
what does it compare
what are case-patients
what are control-patients
how do epidemiologists work
what are cases and controls compared with
how long does it take to do this study
how are subjects matched
A study that compares individuals affected by a disease with a comparable group of persons who do not have the disease to determine possible causes or associations
Those with the disease or condition are case-patients
Those without the disease or condition are control-patients
Epidemiologists work backward from the illness or health condition (retrospective in nature) to determine any associations
Cases and controls are compared for the presence or absence of one or more specific exposures or risk factors
Takes a shorter amount of time to complete
All subjects are matched as much as possible (age, race, gender, other factors relative to the disease)
match case/experiment patients with those that do not have the disease, one has the disease and one does not have one
is retrospective
tries to link the disease with exposure
how to Design of Case-Control Study
what does it start with
what does it spearate
what are done to both groups
start with population
separate into cases and controls
have both groups each be exposed and not exposed
so in total tested 4 groups:
1 exposed and not exposed for case = 2
1 exposed and not exposed for control = 2
2 + 2 = 4
Case Control Studies advantages and disadvantages
Advantages
Can study multiple exposures
They are efficient for rare diseases or diseases with a long latency period between exposure and disease manifestation
Faster and easier to conduct than other studies
Less expensive
the more people, the more reliable data
Disadvantages
Bias can be a source of error
Recall Bias
Information Bias- will have to remember and they may not be able to recall
Reporting bias
Selection bias
They are inefficient for rare exposures
Experimental Study
what does it deal with
what are the types of studies used for
what are the two groups that are started with and what will each get
what may the two groups be
how are subjects assigned into groups
what can occur
deals with Randomized Controlled Trials (RCT)
These types of studies are used to test new drugs for safety and efficacy before they are approved for marketing
Start with two groups:
Experimental group-will get the new treatment
Control group-may get placebo
Can be blinded or double blinded
Subjects are randomized into groups
Have an intervention occur (subjects given counseling and drug or no counseling with placebo)
Randomized Controlled Studies
what are advanatges and disadvantages
Advantages
Convincing
Can control for confounders (known and unknown)
Disadvantages
Very expensive- millions of $$
Artificial environment
Ethical issues- like will not do on pregnant women
Difficult to conduct logistically
Measurements used in epidemiology
rate
PAR
Incidence
prevalence
mortality rate
Rate is the number of cases but this number must be relative to the size of the of the population being studied.
Population at risk (PAR): This number should only include people who are potentially susceptible to the disease being studied.
Incidence is the rate of new cases of a disease in a defined population over a defined period of time
Measures the probability that a healthy person in that PAR will develop that disease during that specific time
Incidence-Expresses the risk of becoming ill.
Must always include a unit of time- such as cases per 10^ n per day, week, month or year.
Prevalence is the total number of cases of a disease existing in a defined population at a specific time
Rates change slowly-not useful for epidemiologic studies
Useful in assessing social impact of disease-affects planning
Prevalence- Estimates the probability of the population being ill at the period of time being studied
Prevalence is often expressed as cases per 100 (percentage) or per 1000 population.
Mortality rate is the incidence of death per unit of time (usually per year) in a population, which can look at all deaths or a specific cause of death. With COVID, measure how many passed form COVID
: Measurements of Association
how does epidemiology identify association
what are the 2 types of measurements used in epidemiology studies
Epidemiology identifies associations between exposures and outcomes
Salt intake → Hypertension (direct association)
Salt in take → Hypertension → Coronary artery disease (in-direct association)
Types of measurements used in epidemiologic studies:
Relative Risk
Odds Ratio
Measurements of Association: Relative Risk (RR)
what does it measure
what ratios does it measure
what does RR = 1.0 mean
what does RR > 1.0 mean
what does RR < 1.0 mean and is it sometimes called
where is this typically used
measures: If an association exist, how strong is it?
What is the ratio of the risk of disease in exposed individuals to the risk of disease in unexposed individuals?
RR = 1.0 = no association between exposure and the disease. Cannot confirm or deny that exposure leads to outcome
RR > 1.0= shows a positive association (increased risk from exposure)
RR < 1.0 = Shows a negative association (decreased risk from exposure)- sometimes called a “protective effect”
Typically used in COHORT (follow a group for a certain time) studies
Measurement of Association: Odds ratio (OR)
what study uses this
can it directly calculate the risk?
what does
OR = 1
OR > 1
OR < 1
mean
What are the odds that the disease will develop in an exposed person? Association of an exposure and a disease
Used in case-control studies
Can not directly calculate the risk since subjects already started with the disease- it is an approximation of the relative risk
OR = 1 no association, OR >1 positive association, OR < 1 negative association
Measurement of Association: 95% Confidence Interval
what is the 95% CI used for
what does a high and low CI indicate
what is the 95% CI used for
Is wide or Narrow CI more reliable
what is range includes 1
a range of numbers and we are 95% sure that the true number falls in that range
The 95% confidence interval (CI) is used to estimate the precision of the OR (also used in RR).
A large CI indicates a low level of precision of the OR, whereas a small CI indicates a higher precision of the OR.
In practice, the 95% CI is often used as a proxy for the presence of statistical significance if it does not overlap the null value (e.g. OR=1).
Will look like this: RR=3 (95% CI 1.67-4.2); p<0.5 is a range of numbers
narrow shows a really high precision and shows more confidence than wide
if includes 1 it is not statically significant and we cannot say that there is an association because the true number could be 1 and for OR & RR there is no association
1.67 is higher than 1 so there is a positive assoication, it has to be 1.0 for it to really be 1
Sources of Error
what are confounding variables?
what us bias
what is selection bias
what is recall bas
Confounding variables:
Is a factor or explanation that may affect a result or conclusion.
Bias- is a systematic error in the design, conduct or analysis of a study that results in a mistaken estimate of an exposure’s effect on the risk of disease.
Selection bias: there is an error in choosing the individuals or groups to take part in a study
This is often a problem in case-control studies
Recall Bias: An error caused by differences in the accuracy or completeness of the recollections retrieved (“recalled”) by study participants regarding events or experiences from the past.
Is an issue in case-control studies
P-value
what is it
what P-value is used in clinical trials
what does that number mean
are we comfortable with that number, is it that same for physics?
The P-value is the probability that the observed results occurred by chance alone
In clinical trials, a p-value of 0.05 is often used
This means if the study was conducted 100 times- the result would be the same 95 times and 5 times would have a different result
We are comfortable with a 5% error but other disciplines have a much higher p-value (i.e. physics might set a p-value at 0.001)
Proving Cause and Effect
Epidemiological studies usually speak of risk factors than causes.
To make the results of a study stronger it is important to show a cause and effect relationship
Elements of Cause and Effect
what does a study with a lot of subjects lead to
The Framingham Heart Study has thousands of participants. This makes the results much more valid than another study with how many subjects
what does a stronger association between exposure and disease result in
which has a stronger association, an RR of 20 or RR of 1
A study with a large number of subjects is more likely to yield a valid result
The Framingham Heart Study has thousands of participants
This makes the results much more valid than a study of only 30 subjects
The stronger the association measured between the exposure and disease the more likely there is a cause-and-effect relationship
A RR of 20 in regards to smoking and lung cancer is a much stronger association than a RR of 1. So 20x more likely to get lung cancer from smoking than if I do not smoke. 20 shows a stronger association
Elements of Cause and Effect
what relationship does exposure and risk have
the more exposure equals what
what happens if you have a lot of exposure to the disease
Dose-response relationship between exposure and risk of disease
The more exposure you have the more likely you are to get the disease.
A nurse caring for patients with Avian Influenza compared to a nurse in a calling station answering patient’s questions. LOTS of exposure to the virus more likely to contract the flu than a nurse not exposed to the flu virus.
have to get exposure to disease to get the disease
elements of cause and effect
what two things are needed for this
A known biological explanation between exposure and a disease
- Is the epidemiological findings consistent with the current biological knowledge?
- Rubella causing congenital cataracts
Results are consistent with other investigations
- Studies conducted in different populations still have similar results
- If an association is found it is expected to see the same results within subgroups of the population and in different populations (unless there is a clear reason to expect differently)
Use in pharmacy practice
what kind of medicine is used
what studies are used
how are studies communicated?
do physicians use it?
Evidence-based medicine is used widely today to make sound medical decisions.
Pharmacoepidemiology studies can be used in the drug therapy decision process.
Studies are published to show that drugs are safe and effective.
Physicians use these studies for treatment guidelines.
What are the rates of physician visits and practicing physicians in the U.S. compared to other nations?
The U.S. has among the lowest rates of physician visits and practicing physicians
What are the hospital stays of the U.S. & Netherlands compared to other nations? How many beds does the U.S have compared to other nations
hospital stays are shortest in the Netherlands and the U.S. The u.S has among the lowest number of hospital beds
compared to other countries, how much does the U.S. spend on admin. costs
do they spend more or less on LTC than other countries
the U.S spends more on administrative costs but less on long-term healthcare than other wealthy countries
Subjects with lung cancer are compared to subjects without lung cancer
A
Cross Sectional
B
Cohort
C
Case Control
C
case control
A study of children age 10-16 in a community located near high tension wires for 2 months
A
Cross Sectional
B
Cohort
C
Case Control
B
cross-sectional
specific pop. at one point in time
Subjects who have received exercise & nutritional sessions followed for 5 years to measure health outcomes
A
Cross Sectional
B
Cohort
C
Case Control
B
cohort
Group is followed through time so prospective cohort
which one is statically significant
RR 0.5 p < 0.001
OR 2.5 (95% Cl -2.5 to 5)
RR 2.5 (95% Cl 2 to 5)
OR 1.5 p = 0.8
p < 0.001 is statically significant
OR 2.5 (95% Cl -2.5 to 5) is not because it includes 1
RR 2.5 (95% Cl 2 to 5) is because it does not include 1
OR 1.5 p = 0.8 is more 0.05, has to be less of it to be statistically significant
endemic
illness that is around all the time
disease or condition present among a population at all times
Epidemic or outbreak:
disease occurrence among a population that is in excess of what is expected in a given time
Pandemic:
a disease or condition that spreads over a wide geographic area and affects an exceptionally large population across regions, may be worldwide.
Surveillance:
: Ongoing systematic collection, analysis, and interpretation of health data needed for planning, implementation, and evaluation of public health practice
chronic disease
develop over time
Risk factor concept: a particular biologic, lifestyle & social conditions are associated with increased risk for specific chronic diseases
a disease that you have for a long time
incubation period
the period between exposure to an infection and the appearance of the first symptoms.
risk factors
characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes.
what do epi curves show
what does it allow you to distinguish
what does the shape tell you
The epi curve shows the magnitude of the epidemic over time
It permits the investigator to distinguish epidemic from endemic disease
The shape of the epidemic curve may provide clues about the pattern of spread in the population
what is an endemic curve
what does the horizontal axis show
Epidemic curve (epi curve) shows progression of an outbreak over time
The horizontal axis represents the date when a person became ill, also called the date of onset.
what about the epidemic does the epi curve show you
what can it be used for
The curve shows where you are in the course of the epidemic
- Still on the upswing, on the down slope, or after the epidemic has ended.
The curve can be used for evaluation, answering questions like:
- How long did it take for the health department to identify a problem?
- Are intervention measures working?
A similar group of subjects with lung cancer are compared to subjects without lung cancer to determine possible associations
Cross-sectional
Case-control
Cohort
case control
case: with lung cancer
control: without lung cancer
Subjects who have received exercise & nutritional sessions are followed for 5 years to measure health outcomes
Cross-sectional
Case-control
Cohort
cohort
A study of children age 10-16 in a small community located near high tension wires for a total of 2 months
Cross-sectional
Case-control
Cohort
cross sectional
is the p-value statistically significant?
OR 1.83 (95% CI 1.50 to 2.24); p=0.05
RR 1.66 (95% CI 1.37 to 2.00)
OR 0.83 (95% CI 0.61 to 1.08
RR 0.87 (95% CI 0.66 to 1.15)
RR 2.23; p<0.001
OR 1.83 (95% CI 1.50 to 2.24); p=0.05 - Yes! The 95% CI does not include 1 and the p-value is statistically significant
RR 1.66 (95% CI 1.37 to 2.00) - Yes! The 95% CI does not include 1
OR 0.83 (95% CI 0.61 to 1.08) - No! the 95% CI includes the number 1
RR 0.87 (95% CI 0.66 to 1.15) - No! the 95% CI includes the number 1
RR 2.23; p<0.001 - Yes! The p-value is less than 0.05
RR > 1 positive association
RR < 1 negative association
RR = 1 no association
cross-sectional
vs
cohort
both deal with a certain group BUT
Cross-sectional
- measure at ONE time
cohort
- measure over a certain period of time (like over 5 years
The cross-sectional study has an identical structure to the cohort study except that the exposures and outcomes are measured at the same time (i.e. cross-sectionally), whereas in a cohort study outcomes are typically measured after the exposure/s have been measured (i.e. longitudinally).
rate
An expression of the frequency with which an event occurs in a defined population
the number of cases in a population
Population Attributable Risk (PAR)
This number should only include people who are potentially susceptible to the disease being studied.
the porportion of the incidence (the number of case) of a disease in the population (exposed and nonexposed) that is due to exposure–so the proportion of cases that is due to (or can be attributed to) exposure
Incidence
the rate of new cases of a disease in a defined population over a defined period
Measures the probability that a healthy person in that PAR will develop that disease during that specific time
Incidence-Expresses the risk of becoming ill.
Must always include a unit of time- such as cases per 10^ n per day, week, month or year
prevalence
a measure of disease that allows us to determine a person’s likelihood of having a disease
Mortality rate
the incidence of death per unit of time (usually per year) in a population, which can look at all deaths or a specific cause of death. With COVID, measure how many passed form COVID
prevalence
Rates change slowly-not useful for epidemiologic studies
Useful in assessing social impact of disease-affects planning
Prevalence- Estimates the probability of the population being ill at the period of time being studied
Prevalence is often expressed as cases per 100 (percentage) or per 1000 population.
prevalence vs incidence
both have to do with cases in a population
Incidence is a measure of the number of new cases of a characteristic that develop in a population in a specified time period (the number of new cases in a pop. so 14 people in a population have COVID)
prevalence is the proportion of a population who have a specific characteristic in a given time period, regardless of when they first developed the characteristic. (the proportion of cases in a population so 20% of people in a population have COVID)
prevalence example
You talk to all 200 people in your town on a spring day and find 60 of them have allergy symptoms. The point prevalence of allergies in your town would be 30% or 3 in 10 individuals calculated as:
(60 people with allergy symptoms) / (200 people at risk) = 0.3 = 30%
incidence example
newly identified cases of a disease or condition per population at risk over a specified timeframe.
[1] An example of incidence would be 795,000 new strokes in the United States, annually.
PAR simplified
Population Attributable Risk
the proportion of the incidence (the number of case) of a disease in the population that is due to exposure–so the proportion of cases that is due to (or can be attributed to) exposure
how many of the cases are actually due to exposure to the agent? OH OKAY GOTCHA!
