1. Health and Preventive Medicine Paul Dassow, MD, MSPH MD 815 November 10, 2006

2. 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

3. Health – what is it?

5. What is “Health” World Health Organization –Health is a complete state of physical, emotional, and social well-being, not just the absence of disease

6. What makes someone healthy? Who’s dying, who’s getting sick, and why? –Money? (Access to care, SES) –Behavior? –Genetics? –Luck?

7. Life Expectancy – 20 th Century

8. A Historical Perspective Deaths 1900

9. Infant Mortality – 20 th Century

10. Life Expectancy – 20 th Century

11. 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

12. Life Expectancy – 20 th Century

13. Cause of Death - 2004

14. A Historical Perspective Deaths 1900

15. The Fall in Infectious Diseases Immunization Antibiotics Organism identified

16. The Fall in Infectious Diseases BCG vaccination Chenotherapy Organism identified

17. 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

18. Cause of Death - 2004

19. Deaths, by age group 2004 Age under 1Age 15-24 - birth defects- Unintentional injuries - premature births- Homicide - SIDS- Suicide Age 1-4Age 25-44- Unintentional injuries - Birth defects- Cancer - Cancer- Heart disease Age 5-14Age 45-64 - Unintentional injuries- Cancer - Cancer- Heart disease - Birth defects- Unintentional injuries

20. 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

21. Summary - Determinants

22. 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

23. Preventive Medicine The core components of Preventive Medicine: –Vaccinations –Screening –Counseling Future components? –Genetic screening

24. 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)

25. 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

26. 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

27. 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

28. 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.B recommendation

29. 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

30. Counseling Typical topics of counseling include: –Use of recreational substances (tobacco, Etoh) –Nutrition –Weight loss strategies –Maintaining sexual health –Cancer avoidance –Exercise

31. Counseling For the parents of children, counseling would include: –Safety, safety, safety –Accepted parenting techniques –Age appropriate nutrition –Basics of virus care –Basics of newborn care

32. 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

33. 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)

34. Questions?