1. Population Health-Past, Present and Future A Clinician’s Perspective Clyde Wesp, Jr., MD, MAOM Pediatrician Executive Clinical Strategist- Jacobus Consulting Adjunct Professor USC Price School of Public Policy

2. SCOPE OF POPULATION HEALTH

4. LEARNING FROM HISTORY ■What happened over the past 100 years? ■Why did it happen? ■Where did change occur? ■What can we do now?

5. 1900-1998

6. SOME FACTS ■In 1900, >3 in 100 children died between their first and 20th birthday ■Today <2 in 1000 die. ■Maternal Mortality Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. ■Infant Mortality In 1915, approximately 100 white infants per 1000 live births died in the first year of life; In 1998, the IMR was 7.2 deaths per 1000 live births (6.0 for white infants, and 14.3 for black infants), a figure more than twice the rate for white infants. The rate for black infants was almost twice as high Between the years 1915 and 1998, the overall IMR decreased by 93%, the neonatal mortality rate, (deaths in the first 28 days of life) by 89% and the post- neonatal mortality rate (deaths from 29 days through 11 months) by 96%.

7. AT THE BEGINNING OF THE 20TH CENTURY ■The leading causes of child mortality were infectious diseases Between 1900 and 1998, the death rate from the major infectious diseases declined 99.7%, from 466 to 0.7 deaths per 100,000 Diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. ■Between 1900 and 1998, The percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents declined two-thirds, from 47.5 to 15.9 deaths per 100,000.

8. INTERVENTIONS State and local health departments implemented public health measures including water treatment, food safety, organized solid waste disposal, and public education about hygienic practices. These improvements in water and food safety and purity are linked to the major decline in diarrheal diseases seen in the early years of the century

9. THE VACCINE EFFECT The reductions in vaccine-preventable diseases, however, are impressive. In the early 1920s, diphtheria accounted for about 175 000 cases annually and pertussis for nearly 150 000 cases; measles accounted for about half a million annual cases before the introduction of vaccine in the 1960s. Deaths from these diseases have been virtually eliminated, as have deaths from Haemophilus influenzae, tetanus, and poliomyelitis.

10. SCIENTIFIC-SOCIO-POLITICAL MODEL OF POPULATION HEALTH

11. SCIENTIFIC INFORMATION AND KNOWLEDGE SOCIAL KNOWLEDGE AND TRANSFORMATION POLITICAL RESPONSE

13. SOCIO-POLITICAL MODEL 1970- President Richard Nixon signs legislation officially banning cigarette ads on television and radio. Nixon supported the legislation at the increasing insistence of public health advocates. 1990- San Luis Obispo, California, became the first city in the world to ban indoor smoking at all public places, including bars and restaurants. 1998- it became illegal to smoke in bars, restaurants and public places in California.

14. THE CURRENT STATE The Big Reason for Change The Challenge The Momentum

15. U.S. Health Costs Rising More Steeply, 1970- 2008

20. DETERMINANTS OF HEALTH AND THEIR CONTRIBUTION TO PREMATURE DEATH Adapted from: McGinnis JM, Williams‐Russo P, Knickman JR. “ The case for more active policy attention to health promotion” Health Affairs (Millwood) 2002;21(2):78‐93.

23. “We have learned that more and more health care does not explicitly improve health.” “Health can’t be defined in one dimension alone- it is in the context of a person’s life.”

24. COMPONENTS OF POPULATION HEALTH ■Population Identification ■Comprehensive needs assessment ■Health promotion programs ■Self-management interventions ■Reporting ■Feedback loops the involve the healthcare consumer ■On-going evaluation of outcomes

25. NON-COMMUNICABLE DISEASE ■Common, preventable risk factors underlie most non- communicable diseases. ■Most non-communicable diseases are the result of four particular behaviors (tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol) ■They lead to four key metabolic/physiological changes (raised blood pressure, overweight/obesity, raised blood glucose and raised cholesterol).

26. CHANGE THEORY

29. POPULATION HEALTH OUTCOMES ■ Health care professionals partner with populations to improve the health of populations by promoting health, preventing disease, and addressing health inequities. Outcomes include: Advocacy to decrease health disparities Policy making to address health disparities Improving health outcomes of populations in need Implementing cost effective strategies to address health disparities Leadership strategies to impact safety, cost, and clinical outcomes Executing educational approaches to improve clinical decision making and evidence-based practice Developing practice guidelines

30. THE WELLNESS PICTURE

31. WHO IS RESPONSIBLE FOR POPULATION HEALTH ANYWAY? ■The community ■Providers ■Insurers ■Individuals ■The government ■All of us!!!