Download Preventive Medicine - Dassow - 11-10

Health and Preventive Medicine
Paul Dassow, MD, MSPH
MD 815
November 10, 2006
Objectives
1. Gain a historical perspective on the
determinants of health
2. Be able to identify the most common
causes of death in America
3. Be able to identify age specific differences
in mortality
4. Know the principles of Preventive
Medicine and their common application
Health – what is it?
What is “Health”
• World Health Organization
– Health is a complete state of physical,
emotional, and social well-being, not just the
absence of disease
What makes someone healthy?
• Who’s dying, who’s getting sick, and why?
–
–
–
–
Money? (Access to care, SES)
Behavior?
Genetics?
Luck?
Life Expectancy –
th
20
Century
A Historical Perspective
Deaths 1900
Infant Mortality –
th
20
Century
Life Expectancy –
th
20
Century
Calculation of life expectancy:
• 100 persons born
• You expect 80 to die at age 80, 20 to die at 6
months:
– (80x80) + (20x0.5)/100 = 64.1 years
• You expect 95 to die at age 80, 5 to die at 6
months:
– (95x80) + (5x0.5)/100 = 76 years
Life Expectancy –
th
20
Century
Cause of Death - 2004
Heart dz
27.3
22.8
Cancer
6.3
Stroke
Chronic lung
5.2
4.5
Injuries
percent
3
Diabetes
Alzheimer's
2.7
Pneumonia
2.6
1.8
Kidney dz
1.4
Septicemia
0
5
10
15
20
25
30
A Historical Perspective
Deaths 1900
The Fall in Infectious Diseases
Organism identified
Scarlet fever
Whooping cough
2500
2000
Antibiotics
1500
Immunization
1000
500
0
1870
Scarlet fever
1890
1910
1930
1950
1970
The Fall in Infectious Diseases
Organism identified
Tuberculosis
Pneumonia
3000
2500
2000
Chenotherapy
BCG vaccination
1500
1000
500
0
1870
Tuberculosis
1890
1910
1930
1950
1970
The Answer – Prevention
• For the case of infectious diseases, this has
mostly been public health measures
–
–
–
–
Clean Drinking Water
Sewage management
Building Codes
Food Surveillance
• Milk was at one time the item most likely to spread
disease
Cause of Death - 2004
Heart dz
27.3
22.8
Cancer
6.3
Stroke
Chronic lung
5.2
4.5
Injuries
percent
3
Diabetes
Alzheimer's
2.7
Pneumonia
2.6
1.8
Kidney dz
1.4
Septicemia
0
5
10
15
20
25
30
Deaths, by age group 2004
Age under 1
Age 15-24
- birth defects
- premature births
- SIDS
- Unintentional injuries
- Homicide
- Suicide
Age 1-4
Age 25-44
- Unintentional injuries
- Birth defects
- Cancer
- Unintentional injuries
- Cancer
- Heart disease
Age 5-14
Age 45-64
- Unintentional injuries
- Cancer
- Birth defects
- Cancer
- Heart disease
- Unintentional injuries
Summary - Determinants
• Determinants of health have changed over
time
• Determinants are age and population
dependent
• Factors such as race and gender continue to
be important determinants of health
• Degree that each factor determines health is
an ongoing area of research
Summary - Determinants
Genetics
Behaviors
Environment
Public health
Medical care
Providence
Preventive Medicine
• Behaviors undertaken by a clinician to prevent the
onset of disease or to detect disease prior to the
occurrence of illness
– Primary Prevention: Activities aimed at preventing the
initial occurrence of disease
• Ex. Counseling about seat belt use
– Secondary Prevention: Activities aimed at preventing
further damage once a disease has been diagnosed
• Ex. Cholesterol lowering after a myocardial infarction
Preventive Medicine
• The core components of Preventive
Medicine:
– Vaccinations
– Screening
– Counseling
• Future components?
– Genetic screening
Vaccinations
• We now routinely vaccinate children against 12
diseases
– Tetanus, diptheria, pertussis, polio, H flu, Hepatitis B,
pneumonia, measles, mumps, rubella, chicken pox,
influenza
• We routinely vaccinate older adults against 2
diseases
– Influenza, pneumonia, tetanus (booster)
• New vaccines
– Human Papilloma Virus, Shingles (herpes zoster)
Vaccinations
• How is this accomplished?
– For kids, vaccinated at regularly scheduled
visits
• 2, 4, 6, 12, 15 months
– For adults, physician needs to incorporate into
chronic disease management visit, or routine
physical exam
– HPV vaccine indicated for females aged 9-26
– All routine vaccinations covered by insurance
Screening
• What is screening?
– Screening involves performing a test or
evaluation on a person who currently has no
signs or symptoms of disease for the express
purpose of finding pathology (disease) at its
earliest stages
Screening
• Screening tests are most actively used in the
adult population. Most comprehensive
National Guideline on screening (who,
when, why, how):
– United States Preventive Services Task Force
report (USPSTF), published every year or two,
available online at:
http://www.ahrq.gov/clinic/uspstfix.htm
Screening
• Mammography
– The U.S. Preventive Services Task Force
(USPSTF) recommends screening
mammography, with or without clinical breast
examination (CBE), every 1-2 years for women
aged 40 and older. Rating: B recommendation.
Counseling
• Counseling has become a major expectation
among both patients and 3rd party payers
– Physicians can bill for time spent counseling
– Well adult and well child visits must contain
evidence of counseling regarding health related
behaviors
– Significant research supports the role of the
physician as counselor
Counseling
• Typical topics of counseling include:
–
–
–
–
–
–
Use of recreational substances (tobacco, Etoh)
Nutrition
Weight loss strategies
Maintaining sexual health
Cancer avoidance
Exercise
Counseling
• For the parents of children, counseling
would include:
–
–
–
–
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Safety, safety, safety
Accepted parenting techniques
Age appropriate nutrition
Basics of virus care
Basics of newborn care
How is this all done?
• Some have estimated that if all the
recommended preventive care was
delivered, it would take 12 hrs/yr of a
physicians time.
• Obviously, alternate strategies are needed
– Web based information
– Use of ancillary staff
– Patient handouts
Preventive Medicine
• For a Primary Care Physician such as
myself who provides a Medical Home for
patients, striving to provide the optimal in
preventive care is paramount.
• The US system is slowly recognizing and
making changes to reward excellence in
Preventive Care (Pay for Performance)
Questions?