Evaluation of Health of a Population

							Evaluation of Health of a
      Population

    TH Tulchinsky MD MPH
  Braun School of Public Health
      Jerusalem, Jan 2006
          Goals of Public Health

• To eliminate or reduce health problems and
  their consequences
• To prevent their occurrence or recurrence
• To promote duration and quality of life
              Public Health Methods

1. Describe the distribution and size of disease
   problems in human populations
2. Identify etiological (the cause of disease) factors in
   the pathogenesis of disease
3. Provide data essential to the planning,
   implementation and assessment of services for the
   prevention, control and treatment of disease and to
   establish priorities among these services

Source: The International Epidemiologic Association,
  1996.
    Assessing Health of an Individual I

• Current chief complaint
• History of the present illness
• Personal data - age, sex, ethnicity, education,
  marital status, children, living situation
• Occupational history
• Family history
• Personal history
• Functional enquiry - systems review;
• Summary of risk factors
• Physical examination
   Assessing Health of an Individual II

• Differential diagnosis
• Other medical problems
• Investigation: laboratory, cardiographic, imaging,
  other
• Presumptive or working diagnosis
• Treatment and its effects
• Definitive diagnosis
• Long term management
        Assessing Population Health
1. Population, demography, geography
2. Socio economic and cultural background
3. Public health infrastructure – sanitation,
    nutrition
4. Health care prepayment system and equity
5. Health care resources
6. Utilization of services
7. Outcomes – morbidity, mortality, functionality
8. Quality of care – peer and external review
9. KABP – knowledge, attitudes, beliefs and
    practices
10. Costs and benefits
          Basics of Evaluation

• No single measure
• Multi factorial
• Quantity, quality, cost and efficiency
• Input, process, outcome
• Direct and indirect measures
• Monitoring is integral part of health
  system
        Population Health Measurements

                             Descriptive,
                             health status

               Health services
                                         Evidence
                  research
                                        based policy
Evaluative,
 Process,                                                Predictive,
 outcomes                                              risk estimation
              Evidence based              Etiologic
                 medicine               epidemiology

                         Explanatory,
                    Etiology, determinants
                                             AJPH March 2004
             The Land of X

• Trinidad
            Population and Society

• Population, demography
• Fertility, age distribution
• Geographic, ethnic, religion mix
• Socio economic conditions
   – GNP per capita
   – Average family income
   – Education
• Social security system e.g. pensions, workman’s
      compensation, drug benefits
         Public Health Infrastructure

•   Ministry of Health – national, provincial
•   Local Health Authority
•   Sanitation, water, sewage, garbage
•   Housing/urban planning, zoning
•   Business licensing /regulation
•   Professional licensing/regulation
•   Laboratories
•   NGOs
•   Nutrition – fortification, supplememntation
                Health Resources

• Total $$$ per capita spent on health all sources, all
  services
• % GNP spent on health
• % for hospitals
• % for primary care
• Hospital beds/1,000
• Medical and nursing personnel/1,000
• Primary, secondary, tertiary care facilities
• Organized preventive care, MCH, immunizations
          Health System Organization

•   Health care pre-payment system
•   Universal
•   Consumer co-payments
•   Organization of health services
    – Preventive
    – Curative
•   Distribution e.g. urban/rural
•   Integration – vertical, lateral
•   Regional services systems
•   Population or individual based
    Outcomes: Mortality Related Indicators

• Infant mortality rates (IMRs);
• Maternal mortality rates (MMRs);
• Crude mortality rates (CMRs);
• Age-specific mortality rates;
• Cause-specific mortality rates - infectious, non-
  infectious diseases, trauma;
• Life expectancy (LE) at age 0, age 1, total
• Years of potential life lost (YPLL), by cause
      Outcomes or Burden of Disease

•   Risk factors e.g. smoking, nutrition
•   Morbidity
•   Mortality
•   Functional
•   Physiologic
•   Quality adjusted life years (QALYs)
•   Disability adjusted life years (DALYs)
       Morbidity Outcome Indicators
•   Incidence of vaccine-preventable disease
•   Incidence of waterborne disease
•   Incidence of food-borne disease
•   Incidence/prevalence of tuberculosis
•   Incidence/prevalence of STDs/AIDS/hepatitis
•   Incidence of malaria, other tropical diseases
•   Prevalence of non-infectious diseases e.g. CVDs
•   Prevalence of disabling conditions
•   Birth defects registry
•   Neurological disease registry
•   Cancer registry
          Functional Indicators:
          Risk Factor Prevalence

• Smoking - age specific rates
• Sexual behavior – unsafe sex
• High risk behavior re motor vehicles
• Violence and injury - domestic, homicide,
  suicide
• Alcohol use
• Drug use
         Functional Indicators

• Work and school absence
• Psychomotor function
• Work capacity
• School attendance and performance
• Fitness test performance
• Activities of daily living (ADL)
                 Nutrition Status
• Food supply per person by type of food
• Food intake surveys (e.g. NHANES)
• Anthropometric indicators-
  – growth patterns of infants and children;
  – body mass index of adults
• Dietary patterns
• Biochemical - blood sugar, cholesterol, lipids
• Micronutrient deficiency conditions - vitamins A, B,
      C, D, iodine, iron status
• Hematologic indicators - anemia and lead among
  infants, children and women, environment pollutants
      Utilization of Services: Performance
                    Indicators

•   Immunization rates
•   Visits to doctors per person per year
•   Hospitalization by cause/1,000, ALOS
•   Surgical rates/1,000
•   Hysterectomy, tonsillectomy rates
•   Caesarian rates
•   Mammography rates
•   Pap smear rates
               Hospitalization Data
•   Sentinel event in health and health economics
•   Limited size of data
•   ALOS
•   Admission rates
•   Days of care per 1,000 popualtion
•   Measure of efficiency of health system
•   Can identify special health problems
•   E.g. amputation of lower limb, Beersheva
•   Case reviews e.g AMI management
•   Infection, incident rates
•   Case mix
     Knowledge, Attitudes, Beliefs and
           Practices (KABP)

•   Community, patient and provider
•   What do people know
•   What do they think
•   What do they believe
•   What do they do
•   Crucial for control of AIDS, TB, risk
    behavior reduction
             Costs and Benefits

• How much is spent on health
• How is it spent or mis-allocated
• How are health issues monitored
• Value gained in reduced burden of disease for
  specific expenditures
• How are services paid for
   – Hospitals
   – Primary care
   – Health promotion
             Regional Health Profiles

•   Geographic medicine
•   Geographic information system
•   Monitor equity
•   Small areas analysis
•   Think global, act local
•   Services are provided locally
•   Need to know local health conditions
•   Used for payment between national and local
    services e.g. Scandinavian countries, UK
               Quality of Care
• Training
• Accreditation
   – Governmental
   – Non-governmental
• Research
• Publications
• Peer review
• Quality assurance organization
• Tracer conditions e.g. amputation of LL
                Tracer Condition
•   Peer review internal
•   External review
•   Common, treatable/preventable
•   Marker for outcome measure
•   Indicator of quality of care
•   Appendectomy with positive pathology
•   AMI/post AMI completeness of care
•   Incident reviews
•   Maternal and infant death reviews
                      Summary

•   Population at risk – geographic or sample
•   Multi-factorial
•   Measures of input
•   Measures of process
•   Independent variables
•   Measures of outcome or dependant variable
•   Costs and benefits
•   Monitoring population health is integral part of
    health system