1. ESTABLISHING HEALTH INTERVENTION PRIORITIES FOR LOCAL PUBLIC HEALTH AGENCIES Alexandre Klementiev aklementiev@tpchd.org Tacoma-Pierce County Health Department, WA

2. GOAL 2 “To identify three broad-based, behavioral risks to health which, if reduced, will offer a tangible reduction in the burden of preventable illness and death in the Pierce County population *.” j * Tacoma - Pierce County Health Department Strategic Plan, 1996-2000 (Tacoma, WA)

3. This presentation demonstrates the method designed for identification of the leading behavioral risks to health. If these risks were reduced, the method would allow to estimate the resulting reduction in the burden of preventable illness and death. GOAL 2 (contd)

4. RISK FACTOR If a disease/cause of death (D) is more common among those with a certain characteristic (C) than among those without it, then there is an association between C and D. If C occurs, or is present, prior to D, the characteristic C is a risk factor for the disease (cause of death) D.

5. C is present C is not present D D D D D D D D D

6. BURDEN OF HEALTH RISK The burden of a health risk is composed of: l Disabled years lived with preventable illnesses (morbidity component) l Deaths associated with specific risk behaviors (mortality component)

7. FROM ROUTINELY COLLECTED HEALTH DATA TO MILLER’S INDEX In 1970, J.E.Miller offered the Q-index which allows integrating of morbidity and mortality data, so that a fairly consistent ranking of the classes of disease could be made.

8. Q-INDEX: DEFINITION Q k = (MT k /MR k )*P k *D k + 100,000*A k /365 /N + 100,000*B k /(3*365)/N

9. Q-INDEX: DEFINITION (contd) MT k (MR k ) : age-/sex- adjusted mortality rate in target (reference) population; P k : years of life lost due to premature death, average per one death ; D k : crude mortality rate; A k : number of inpatient days, per year; B k : number of outpatient visits, per year; N : size of the target population. ___________________________________________________________________________________________________________________________ k indicates disease/cause of death.

10. Q-INDEX: DISCUSSION  Q-index provides a rationale for combining mortality and morbidity components in a single index number which is used for ranking  This rank pertains to a given class of disease/cause of death  In reality, the risk factor is associated with more than one class of disease/cause of death

11. FROM Q-INDEX TO THE RISK PRIORITY INDEX The Q-index cannot be used for prioritizing health programs when those programs pertain to the behavioral health risks associated with multiple classes of diseases

12. VISUALIZING HEALTH RISK Morbidity Effect Mortality Effect A B D C F J DIS J DTH

13. RISK PRIORITY INDEX: DEFINITION The Risk Priority Index (RPI) is defined as the sum of all partial impacts of the health risk of interest on the population health. Partial impacts of diseases and deaths in RPI are measured with the use of the Q-index.

14. CALCULATING RPI  The method of calculating the RPI components depends on the availability of relevant data  The direct method is based upon data collected on relative risks and prevalence pertaining to the risk factor of interest, along with mortality, bed-days, and the outpatient visits  If some of the data for the direct method is unavailable, experts best estimate can be used for the lacking data

15. CANDIDATE RISK FACTORS 1. Violence/Firearms 8. Alcohol misuse 2. Physical inactivity 9. Air quality 3. Food quality 10. Tobacco use 4. Water quality 11. Dietary habits 5. Unsafe sexual behavior 12. Hazardous waste 6. Seat belt use 13. Workplace hazards 7. Cycle helmet use 14. Immunization levels

16. TOBACCO LIST There are 25 entries in Tobacco List. Among them: ICD Code Lip, oral cavity, pharynx (140-149) Esophagus (150) Pancreas (157) Larynx (161) Trachea, lung, bronchus (162) more...

17. TOBACCO: RPI Each year in Pierce County:: l 1,072 deaths are associated with tobacco smoking l The equivalent of 3,275 person-years are lost prematurely due to the causes associated with tobacco smoking

18. TOBACCO: RPI (contd) l One third of all hospital bed days can be attributed to the effects of tobacco use l Residents spend the equivalent of 53 years in Pierce County hospitals due to illnesses related to tobacco l About 53,000 outpatient visits are associated with cigarette smoking effects

19. DIETARY FACTORS AND ACTIVITY PATTERNS (DFAP) LIST Heart diseases Cerebrovascular diseases Cancers Diabetes

20. DIETARY FACTORS AND ACTIVITY PATTERNS: RPI Each year in Pierce County: 889 deaths are associated with dietary factors and activity patterns (DFAP) l 2,615 years of potential life are lost due to diseases associated with DFAP Approximately 11,680 bed-days and 3,300 outpatient visits are associated with illnesses related to DFAP

21. ALCOHOL LIST There are 36 entries in Alcohol List. Among them: ICD Code Lip/oral cav/pharynx (140-149) Esophagus (150) Stomach (151) Liver (155) Larynx (161) Alcoholic psychoses (291) more...

22. ALCOHOL MISUSE: RPI Each year in Pierce County: 275 deaths are associated with alcohol misuse l 3,793 years of potential life are lost in association with alcohol misuse Approximately 13,400 bed-days and 48,700 outpatient visits are associated with illnesses related to alcohol misuse

23. FIREARMS LIST l ICD Code l Unintentional firearms E922 l Suicide by firearmsE955.0 - E955.4 l Assault by firearmsE965.0 - E965.4 l Legal, other firearms E970, E985.0 - E985.4

24. VIOLENCE WITH FIREARMS: RPI Each year in Pierce County: l 95 people die from a firearm wound l 2,679 years of potential life are lost l Equivalent of 2 years are spent in hospitals

25. UNPROTECTED SEX LIST ICD Code HIV, sexually acquired(042) Hepatitis B infection, sexually acquired(070.2, 070.3) Syphilis and other venereal diseases(090 - 099) Trichomoniasis (131) Cervical cancer (fem) (180)

26. UNPROTECTED SEX: RPI Each year in Pierce County: l 54 people die from diseases associated with unprotected sex l 1,512 years of potential life are lost l The equivalent of 8 years are spent in hospitals

27. RISK PRIORITY INDEX: CALCULATION RESULTS l Tobacco DFAP Alcohol Firearms Sex ___________________________________________________________________________________________________________________________________________________________ Deaths 1,072 889 275 95 54 __________________________________________________________________________________________________________________________________________________________ YPLL/Mort. 3,275 2,615 3,800 2,680 1,500 ___________________________________________________________________________________________________________________________________________________________ Bed-days 19,000 11,680 13,400 760 2,900 __________________________________________________________________________________________________________________________________________________________ Outp.vsts 53,000 3,300 48,700 N/A 200 Losses pertaining to risk behaviors (per one year, Pierce County population)

28. RISK PRIORITY INDEX Deaths and YPLL/Morbidity Tobacco Alcohol DFAP Microbial Firearms Unprotected sex Years of Potential Life Lost / Morbidity Deaths

29. RISK PRIORITY INDEX Firearms YPLL/Mortality and YPLL/Morbidity Years of Potential Life Lost/Morbidity Years of Potential Life Lost/Mortality Unprotected sex Microbial Dietary Factors/ Activity Patterns Alcohol Tobacco

30. FROM THE RISK PRIORITY INDEX TO THE HEALTH INTERVENTION PRIORITY INDEX l The RPI cannot be used for establishing priorities of health interventions l The Health Intervention Priority Index accounts for the partial reduction of the health risks

31. HEALTH INTERVENTION PRIORITY INDEX: DEFINITION The Health Intervention Priority Index (HIPI) is the quantitative measure of improvement of the population health caused by implementation of the health intervention The improvement is measured in person-years of life saved

32. TOBACCO: HIPI It was assumed in this study that the relative reduction of smokers in Pierce County by 40% (from about 25% down to 15%) is an achievable goal. As a result: l 240 deaths would be prevented l 858 person-years of life would be saved

33. DIETARY FACTORS AND ACTIVITY PATTERNS: HIPI It was assumed in this study that relative reduction of the aggregated risk factor associated with dietary factors and activity patterns by 15% is an achievable goal. As a result: l 134 deaths would be prevented l 253 person-years of life would be saved

34. ALCOHOL: HIPI It was assumed in this study that the relative reduction of the aggregated risk factor associated with alcohol misuse by 20% is an achievable goal. As a result: l 55 deaths would be prevented l 775 person-years of life would be saved

35. FIREARMS: HIPI A 15% relative reduction of the aggregated risk factor associated with firearms was assumed in this study as an achievable goal. As a result: l 14 deaths would be prevented l 402 person-years of life would be saved

36. UNPROTECTED SEX: HIPI A 10% relative reduction of the aggregated risk factor associated with unprotected sex was assumed in this study as an achievable goal. As the result: l 5 deaths would be prevented l 160 person-years of life would be saved

37. ANTICIPATED REDUCTION OF DEATHS AND YPLL l Tobacco DFAP Alcohol Firearms Sex l ___________________________________________________________________________________________________________________________________________________ l Risk Reduction 40% 15% 20% 15% 10% ___________________________________________________________________________________________________________________________________________________ l Deaths 240 134 55 14 5 __________________________________________________________________________________________________________________________________________________ l YPLL/Mortality 832 248 759 402 151 ___________________________________________________________________________________________________________________________________________________ YPLL/Morbidity l (Inpatient) 14 5 7 0.3 0.8 ___________________________________________________________________________________________________________________________________________________ l YPLL/Morbidity l (Outpatient) 12 0.5 9 - -

38. HEALTH INTERVENTION PRIORITY INDEX: DEATHS VS. YPLS/TOTAL S Years of Potential Life Saved (Total) Deaths 150300450600750900 125 250 Tobacco Alcohol DFAP Firearms Unprotected Sex

39. HEALTH INTERVENTION PRIORITY INDEX: YPLS/MORTALITY VS. YPLS/MORBIDITY Years of Potential Life Saved (Morbidity) Years of Potential Life Saved (Mortality) 150300450600750900 Tobacco Alcohol DFAP Firearms Unprotected Sex 6 24 18 12

40. CONCLUSION The 3 leading behavioral risks to health in Pierce County are: l Tobacco l Alcohol l Firearms Reduction in the burden of preventable illness and death is estimated.