Reforming Disease Prevention and Health Promotion: Population Health Steven Teutsch, MD, MPH Chief Science Officer Los Angeles County Department of Public Health September 15, 2009

Problem: America is Not Getting Good Health for Its Health Care Dollar Copyright 2008 Robert Wood Johnson Foundation/ Overcoming Obstacles to Health. Prepared for the Robert Wood Johnson Foundation by the Center on Social Disparities in Health at the University of California, San Francisco. Source: OECD Health Data Does not include countries with populations smaller than 500,000. Data are for *Per capita health expenditures in 2003 U.S. dollars, purchasing power parity

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Former Leading Causes of Death: Crude Death Rate for Infectious Diseases, U.S., MMWR, CDC, 1999 * Rate is per 100,000 4

The Lifecourse Perspective: Early Childhood Impacts Adult Health Status 5

6 From Neal Halfon Health Influences Over the Life Course

7 From Neal Halfon

The Social and Physical Environments are Among the Most Important Determinants of Health 8

Income is Linked to Longevity Regardless of Race/Ethnicity 9 “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”

Education Matters: Mother’s Education Related to Infant Mortality 10 “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.” Babies born to mothers who did not finish high school are almost twice as likely to die before their first birthday as babies born to college graduates

Education Matters: More Education Means Longer Life Expectancy 11 “Copyright 2008 Robert Wood Johnson Foundation/Overcoming Obstacles to Health.”

12 The Hispanic Paradox: Recent Immigrants have less diabetes and other health problems than those who have had longer exposure to our toxic socioeconomic and physical environment Steven P. Wallace, Xóchitl Castañeda. Migration and Health: Latinos in the United States The Toxic American Environment: Percent of Recent Immagrants and Long-term Residents with Diabetes, United States, 2006

13 Economic Hardship & Childhood Obesity Economic hardship and childhood obesity go hand in hand

Improving Health Requires Actions at Multiple Levels 14

15 Action Model to Achieve Healthy People 2020 Overarching Goals Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health- related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination Interventions Determinants of Health Outcomes

16 Action Model to Achieve Healthy People 2020 Overarching Goals Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health- related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination Interventions Determinants of Health Outcomes Smoking Quitlines

17 Action Model to Achieve Healthy People 2020 Overarching Goals Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health- related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination Interventions Determinants of Health Outcomes Nurse Home Visits Smoking Quitlines

18 Action Model to Achieve Healthy People 2020 Overarching Goals Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health- related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination Interventions Determinants of Health Outcomes Nurse Home Visits Smoking Quitlines Work Safety Healthy Homes

19 Action Model to Achieve Healthy People 2020 Overarching Goals Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health- related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination Interventions Determinants of Health Outcomes Nurse Home Visits Walkable Communities Smoking Quitlines Work Safety Blood Alcohol Laws Healthy Homes

20 Dead Individual Society Well Spectrum of Health and Strategies to Improve It

21 Dead Individual Society Well Spectrum of Health and Strategies to Improve It Population Health Strategies Clinical Strategies

22 Dead Individual Society Well Education Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Worksite Programs School Health Population Strategies

23 Dead Individual Society Well Disease Mgmt Primary Care Clinical Preventive Services Tertiary Care Assisted Living Clinical Strategies

24 Dead Individual Society Well Disease Mgmt Hospital Systems Assisted Living Integrated Health Systems Medical Care System Strategies Medical Home

25 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Spectrum of Health and Strategies to Improve It

How Do We Know What Works? Evidence-based Recommendations

So How Do We Apply Them to Prevention & Control of Diabetes? 27

28 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Spectrum of Health and Strategies to Improve It

29 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Screen hypertensives Behavioral interventions to reduce screen time Worksite programs for overweight and obesity Screen adults for obesity and offer intensive interventions Street-scale urban design/land use Point-of-decision Prompts Enhanced School-based Physical Education Preventing Onset of Diabetes: Reducing Obesity

30 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Worksite programs for overweight and obesity Social Support Interventions in Comm. Settings Case Mgmt/ Disease Mgmt Self-Mgmt Education (home /Community Control BP / Lipids/ Smoking Managing Diabetes

31 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Dialysis Maintaining Function in Diabetes

32 Dead Individual Society Well Education Disease Mgmt Social and Physical Environment: e.g., Jobs, Urban Design, Transportation, Agriculture, Criminal Justice. Hospital Systems Primary Care Clinical Preventive Services Worksite Programs School Health Tertiary Care Assisted Living Integrated Health Systems Screen hypertensives Behavioral interventions to reduce screen time Worksite programs for overweight and obesity Screen adults for obesity and offer intensive interventions Street-scale urban design/land use Point-of-decision Prompts Enhanced School-based Physical Education Social Support Interventions in Comm. Settings Case Mgmt/ Disease Mgmt Self-Mgmt Education (home /Community Dialysis Control BP / Lipids/ Smoking A Comprehensive Approach to Preventing and Controlling Diabetes

What We Are Striving to Achieve Vision A society in which all people live long, healthy lives. Overarching Goals Elimination of preventable disease, disability, injury, and premature death Achievement of health equity, elimination of disparities, and improvement in the health of all groups Creation of social and physical environments that promote good health for all. Promotion of healthy development and healthy behaviors across every stage of life 33 Healthy People 2020

Major Opportunities: Health in All Policies Opportunities in all sectors e.g. agriculture, transportation, housing, environment, commerce, tax policy In both public and private sector Examples: –Menu labeling –Tax on sugared beverages –Transportation systems that encourage mass transit, biking and walking 34

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HIA: Estimation of Health Benefits from a Living Wage Ordinance 36 Bhatia, Katz, AJPH, 2001

Summary Prevention effective in clinical and population applications Large differences between best evidence and current practice Greatest opportunity: policies and programs targeting populations Policies in all sectors affect health Can’t eliminate health disparities without emphasis on social and physical determinants

The Challenge: Closing the Gap Cannot be done by just fixing the health care system Must address the underlying social and physical environment determinants Must build a true population-oriented health system 38