Improving Population Health

Can Our Environmental Stressors be Inherited by Our Children?

By David A. Kindig, MD, PhD

A while ago I presented a cautious population health perspective on the potential impact of modern genomics, ending with the observation that:

It is not anti-scientific to worry that our American belief in technology and venture capitalism could result in much waste, while less expensive investments we already know to be effective are ignored.  The problem is that it is hard to predict the future, and decades from now there will certainly be important benefits from genomic research, including both treatments and preventive interventions.  We can only insist that the most careful evidence on population health cost-effectiveness be used to guide investments, rather than the potential for profit from very expensive therapies that benefit few.

But what to make of this quote I came upon the other day from Duke University geneticist Randy Jirtle?

Do You Really Mean "Health" Expenditures?

This post originally appeared on the Health Affairs Blog:

Kindig DA, Do You Really Mean "Health Expenditures?" Health Affairs Blog, 8/7/12, http://healthaffairs.org/blog/2012/08/07/do-you-really-mean-health-expenditures/, Copyright ©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

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By David A. Kindig, MD, PhD

Using the term health expenditures yields a narrow and seriously misleading view of what it will really cost to improve population health.

I’ve been worried about this for some time, but most recently while reading the excellent and important new report on For the Public’s Health: Investing in a Healthier Future from the Institute of Medicine Committee on Public Health Strategies to Improve Health. This is the third of three reports in a series; it addresses the critical issue, in a time of budgetary austerity, of resource needs and realistic approaches to addressing them in a “predictable and sustainable manner to ensure a robust population health system.”

In their first Recommendation, the report authors advise that the

Secretary of the Department of Health and Human Services should adopt an interim explicit life expectancy target, establish data systems for a permanent health-adjusted life expectancy target, and establish a specific per capita health expenditure target to be achieved by 2030. Reaching these targets should engage all health system stakeholders in actions intended to achieve parity with averages among comparable nations on healthy life expectancy and per capita health expenditures.

More Perspectives on “Population Medicine”

By David A. Kindig, MD, PhD

My previous post on population medicine prompted a number of thoughtful responses which I’d like to share. This is not simply a terminology discussion. The breadth of the population health view we espouse here can be undermined if it is confused with chronic disease management of enrolled patients.

Emma Eggleston, MD, MPH Instructor, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA

Population medicine…takes a population perspective from a healthcare system base. It encompasses the intersection between the health care system and other determinants of (and partners in) populationhealth e.g. public health, communities, the built and social environments,etc.  In other words, it is the sum of 1) the population- specific activities of the health care system itself and 2) the intersection ofthe health care system with other determinants of population health. While the population-specific activities of the health care system are important and arguably easier to delineate and act upon, the exciting potential for long-term innovation and impact is in the intersection.

Are Male Genetic Health Differences Disparities or Inequities?

By David A. Kindig, MD, PhD

A year ago I discussed health disparities in several posts, including one on Rates and Burden, where I noted that “rates are very useful measures, because they allow comparison across populations of different sizes. But from a population health perspective, rates alone are not enough, because large disparities in very small populations have a different impact than similar disparities in larger populations. Burden refers to the impact of a health problem in a population, combining both the rate and the number of people affected.” I went on to observe that in comparing male and female mortality, there is a surprisingly high male mortality rate, but it is the size of this population (155 million) that transforms the rate into a significant population health burden, equal or more important than those by race or socioeconomic status.

This old post came immediately to mind several months ago when I saw the New York Times headline “Male Genes May Explain Higher Health Disease Risk,” which focuses on work by Fadi Charchar and colleagues that appeared in The Lancet. Findings reveal that British men have one of two variants of a cluster of genes on their Y chromosome – one of which carries a 50% increased risk of heart disease, even after controlling for smoking, diabetes, and cholesterol.

Is Population Medicine Population Health?

By David A. Kindig, MD, PhD

Terminology can be tricky; a word or phrase can sometimes mean different things to different people. This is currently the case with both population medicine and population health.

On this blog we have been explicit in our definition of population health, from the 2003 article I wrote with Greg Stoddart: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.“ Population health also encompasses the multiple determinants of health that produce these outcomes.

Really?? A Free Population Health Textbook from Preventing Chronic Disease??

By David A. Kindig, MD, PhD

Yes, the online CDC journal Preventing Chronic Disease (PCD) has just released a compilation of 23 essays on current population health practice and scholarship relating broadly to population health metrics, incentives, and partnerships.

These essays were an early part of our Robert Wood Johnson Foundation funded project called Mobilizing Action Toward Community Health (MATCH) at the University of Wisconsin Population Health Institute, which many readers know has evolved into County Health Rankings & Roadmaps efforts. In 2009, we commissioned essays to critique underlying assumptions about metrics, incentives, and partnerships and to suggest approaches for overcoming potential barriers to population health improvement.

The Link Between Income and Health

By David A. Kindig, MD, PhD

Listening to the national conference call for the release of the 2012 County Heath Rankings last week, I was struck by the number of questions regarding the socioeconomic factors in the model. It made me recall the early morning call from a small town reporter when we released the first Wisconsin County Rankings in 2003, saying “do you mean that county income levels might be as important as the number of uninsured or the smoking rates?”

This concept is better understood today than it was in 2003, but it is still hard to communicate. We accept the health-compromising effects of smoking and lack of health care access, but how education and income ‘get under the skin” to produce disease and death is less obvious. Yet a growing body of literature supports this finding, and is the reason why we give social factors a weighting of 40% in the County Health Rankings model.

This week we’re calling attention to a study I co-authored with one of our PhD candidates, Erika Cheng. The article, Disparities in premature mortality between high and low income U.S. counties, appears in the April 2012 issue of Preventing Chronic Disease.

IPH Reader Craig Mosbaek Weighs in on 2012

We were delighted to have a few takers for our recent call for readers' ideas for what's on the population health radar in 2012. We thought many would appreciate reader Craig Mosbaek's perspective:

By Craig Mosbaek, MPH

Here are six trends I think will have big impacts on public health in the coming year.

The policy approach to public health. The understanding of how policies and environments shape health behaviors and health outcomes will continue to develop.  Elected officials are beginning to appreciate this more, as well as public health professionals and others. You can see this institutionalized in initiatives such as CDC’s Community Transformation Grants, APHA’s new policy contest, and the Public Health Accreditation standards.

Funding for public health departments.  There have already been big budget cuts at many local and state health departments.  With the poor economy, these cuts will persist and there may be major reductions in federal spending on the horizon.  With limited resources, health departments should focus their efforts on the most important public health issues.

Healthcare costs saved by public health efforts. Public health advocates are increasingly using the argument that policies to improve population health will reduce long-term healthcare costs.  More research will focus on the return on investment (ROI) of public health approaches. Effective use of this argument could help alleviate the upcoming budget cuts for health departments.

Broadening the definition of public health. When expanding the definition of public health, some people use terms such as the social determinants of health or health in all policies. We are still working on how to talk about this broadened definition in ways that engage the public and encourage collaboration with other sectors.

Health impact assessments.  A corollary to the above (broadening the definition of public health) is the growing use of health impact assessments  (HIAs).  The PEW site shows about 80 completed HIAs nationwide right now. I wouldn’t be surprised to see 80 more HIAs completed in 2012 alone.

New communications technology. New media (blogs, Facebook, Twitter, video over the Internet) will continue to transform the ways we communicate. This impacts how public health professionals collaborate with each other, as well as how we interact with the public.  

Craig Mosbaek, MPH, President of Mosbaek Consulting, focuses on improving public health policy through communications, research/evaluation, and strategic planning. In 2010, he worked for Congress as the American Public Health Association’s Public Health Fellow in Government.

Population Health Outlook for 2012

By David A. Kindig, MD, PhD

Last week I reflected on Improving Population Health in 2011; today I’m looking forward to the year ahead. So what are the opportunities and challenges that 2012 presents for us?

The fall elections. On the one hand this is a challenge, since health outcomes and health disparities rarely directly enter into the political discussion and debate. Health care costs do, from both political parties, but in a relatively confined way. Rarely do ideas extend beyond the cost savings to examine, for example, how waste could be directed towards non-health care investments. The overwhelming task of implementing the Affordable Care Act (ACA) and defending its legal challenges requires much time and energy and has led some to believe that the current situation necessitates focusing efforts. Perhaps we should work now to consolidate and strengthen health care access and cost issues and – at least for now – have other determinants take a back seat.

Given what we know produces health, such an approach may be appropriate and opportunistic. Access to affordable health care is an important determinant of health, but even with full ACA implementation will not reach everyone. Jobs and economic development are at the top of the political agenda, and many candidates appreciate the role of education in increasing opportunity and economic productivity. Many leading Republicans support such goals. In an unexpected twist the Occupy Wall Street movement has moved the issue of income inequality onto the front page. Influencing candidates of both parties to campaign on strong economic development and education agendas could be the most important thing population health advocates could do this year.

The science of early intervention. Nicholas Kristoff’s recent op-ed, A Poverty Solution that Starts with a Hug summarizes the findings from an American Academy of Pediatrics policy statement in this way: “Cues of a hostile or indifferent environment flood an infant, or even a fetus, with stress hormones like cortisol in ways that can disrupt the body’s metabolism or the architecture of the brains. The upshot is that children are sometimes permanently undermined. Even many years later, as adults, they are more likely to suffer heart disease, diabetes or other physical ailments. They are also more likely to struggle in school, have short tempers, and tangle with the law.” This science is not unknown to scholars, but it is beginning to diffuse into the policy arena (and Kristoff is hardly a science/policy columnist). We need to keep developing more robust findings and facilitate their understanding at all levels of private and public policy.

The Best of 2011 – and an Invitation to Help Shape IPH in 2012

By David A. Kindig, MD, PhD

I don’t usually make formal New Year’s resolutions, but I do think about the passing of the old year and the opportunities and responsibilities in the new one. In that spirit, I’m devoting this week’s post to some key pieces from our 2011 archives.  Next week, we’ll be looking forward to give a preview of possible topics for 2012. We welcome any and all ideas from readers – this is your chance to help shape Improving Population Health in the coming year! Please just use the comment box below or email me directly.

So whether it’s for the first time -- or for a second look -- I invite you to take a look at some of my favorite posts from 2011.

Have You Heard of "Primordial Prevention"?

By David A. Kindig, MD, PhD

I never had, until I started thinking about a post on prevention and went to John Last’s Dictionary of Epidemiology to get started. His basic definition is “actions aimed at eradicating, eliminating, or minimizing the impact of disease or disability,” and includes primary, secondary and tertiary prevention. Last defines primary prevention as “protection of health by personal and communal efforts such as enhancing nutritional status, immunizing against communicable diseases, and eliminating environmental risks such as contaminated water supplies.”

I’ve given a lot of thought to the issue of prevention this spring, especially since writing about the National Prevention Council’s Strategy Framework. In that post, I applauded the Framework’s call for Healthy Environments (such as affordable housing, employment opportunities, efficient transportation, good schools, and effective policing) but cautioned against interest group sidelining of these “Cross-cutting Priorities” in favor of the seven behavior-related “Priority Areas” which are more closely related to the primary prevention definition shown above.

A Year in the Blogosphere

By David A. Kindig, MD, PhD

This week, we’re celebrating the first anniversary of Improving Population Health. We began last May with a post on population health advocacy that asked, “Is Population Health Finally Coming into Its Own?” That post outlined the blog’s purpose:

Why am I starting a blog on issues and perspectives in the field of population health? It is because I believe we are at a "tipping point" in which a convergence of scholarship, policy, and practice initiatives seem poised to bring an overdue population health perspective to thinking about and acting on health and health improvement. The challenge of the next decade will be to find practical ways in which new approaches to financial and non-financial incentives and multi-sectoral partnerships can be applied to improve population health outcomes here and elsewhere.

Improving Population Health...in 2011

By David A. Kindig, MD, PhD

I spent some time last week musing about potential blog topics for 2011, which brought me back to the population health model that underpins this blog.

 

Last year I touched on many parts of this model. I wrote about and offered opinions on the social determinants of health, how savings in healthcare could enhance the population health agenda, and the extent to which health-related behaviors are beyond individual control. I also addressed  policy-related topics such as the IRS consideration of Community Benefit policy and whether a cross-sectoral integrator is necessary or possible. I’ll revisit these topics in 2011 but will also cover other important population health issues, such as:

1. Which outcome measures are most useful in guiding population health policy?
2. How do improvement metrics differ from achievement metrics?
3. Will raising average health reduce disparities?
4. Are racial health disparities the most important ones?
5. Are genetics a modifiable determinant of population health?
6. Will climate change increase the importance of the physical determinants of health?
7. What is prevention?
8. Top down vs. bottom up approaches to population health policy
9. Why can’t historical patterns of investment in healthy and unhealthy communities show the optimal path for others?
10. What are population health incentives?
11. Is there a business model for population health improvement?
12. What is the health impact of non-healthcare programs and policies?

I’d love to know what you think of this list and I welcome suggestions for additional topics anytime. This week, I’m hoping for 10 new ideas from readers on questions or issues this blog should address as we head into 2011. Thanks in advance for your contributions!

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

New Year’s Resolutions and Population Health Improvement: Anything in Common?

By Kirstin Siemering, DrPH and David Kindig, MD, PhD

The U.S. government’s official web portal lists ten ever-popular New Year’s resolutions (actually, it lists 11 but we left off “take a trip” since it’s a good idea but not relevant to this discussion!):

1. Drink less alcohol
2. Get a better education
3. Get a better job
4. Get fit
5. Lose weight
6.  Manage debt
7. Manage stress
8. Quit smoking now
9. Save money
10. Volunteer to help others

From an individual perspective, the list is basically what we might expect. As a society, our default frame for New Year’s resolutions is that they require tremendous willpower and against-the-odds discipline to accomplish. Not surprisingly, the majority of us fail in our behavior change endeavors. Time magazine reported at the start of this year that 35% of those who resolve to make changes don’t even make it “out of the gate.”

But, we were somewhat surprised to realize that these individual priorities are also population health priorities (although a balanced agenda would also have to include attention to healthcare and the physical environment). Since experts always offer advice this time of year for how to keep resolutions, we thought it would be interesting to assess if their advice also has population health relevance.

As it turns out, tips for success for New Year’s resolutions have a familiar ring. Wall Street Journal Work and Family Columnist Sue Shellenbarger’s suggestions are fairly typical (and actually align quite well with content from our work from the County Health Rankings and this blog):

1. Get a little help from your friends (Work together)
2. Take one step at a time (Pick priorities) 
3. Figure out your attachment to bad habits (Assess needs and resources)
4. Change your environment (Find programs and policies that work)
5. Announce your intentions (Set ambitious but realistic goals)
6. Expect setbacks (Evaluate efforts)

So, as you’re contemplating your own resolutions for 2011 (such as what approaches to adopt for losing weight and getting fit), don’t forget to think about resolutions for your neighborhood, community, or even state. Mobilizing Action Toward Community Health will happen one step at a time, as we figure out our attachment to bad habits and announce our intentions. And with a little help from our friends, we’ll overcome setbacks and ultimately change our environment.

Happy New Year from Improving Population Health!

Population Health: If It's Everything, Is It Nothing?

By David A. Kindig, MD, PhD

As you know, I’m new to blogging, and still getting used to it from a career of more academic writing. Several of you, as well as our MATCH staff, have observed that the topics seem to be a bit random and “out of the blue” from week to week. In addition, a respected colleague emailed a response to the post on advance directives that “it could imply that everything is about population health (which, as you and I agree, I hope) doesn’t do much to advance the cause of purchasing population health.”

Hmmm…if it’s everything, is it nothing? A look at the population health model underpinning this blog and all I work on in population health, suggests that indeed it is perhaps everything: a broad set of outcomes produced by a comprehensive set of determinants which are influenced or activated by programs and policies in the public and private sectors.

You will not, however, find me blogging on each and every micro-determinant or program/policy that theoretically and actually has some detectable impact on population health outcomes. What is then the decision rule that makes a topic of program or policy of importance not only for this blog but for public and private policy makers?

In this resource-limited world, I believe the criterion should be largely based on economics, and in particular, the relative effectiveness and cost-effectiveness of the determinant or the program and policy on health outcomes. I have previously noted that we do not yet have adequate evidence to make this an easy exercise. Research is needed to explore the effectiveness and cost effectiveness of broad policies and programs designed to effect health improvement at the population level. Some investments have an evidence base, like smoking cessation and immunization and early childhood programs. Other investments, such as removing the LAST microgram of a toxic substance in a Superfund site, would probably have some marginal effectiveness but extremely low cost-effectiveness.

Of course, determining what action to take toward health improvement is hardly straightforward. Decision makers must weigh not only on available evidence on effectiveness and cost-effectiveness but must also take into account many other factors, especially resource (financial and nonfinancial) and political supports and constraints.

As we try to cover topics that address all parts of our population health model, I would welcome feedback as to whether you either KNOW or SUSPECT that any program or policy we discuss is of such low cost-effectiveness as to not meet my criterion above.

Your feedback and suggestions are always welcome and appreciated!

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Is Population Health Finally Coming into Its Own?

By David A. Kindig, MD, PhD

Why am I starting a blog on issues and perspectives in the field of population health?  It is because I believe we are at a "tipping point" in which a convergence of scholarship, policy, and practice initiatives seem poised to bring an overdue population health perspective to thinking about and acting on health and health improvement. The challenge of the next decade will be to find practical ways in which new approaches to financial and non-financial incentives and multi-sectoral partnerships can be applied to improve population health outcomes here and elsewhere.

Although the roots of broad population health thinking go back for centuries, in the United States, the second half of the 20th century was dominated by the rise of biomedical science and clinical medicine. Many in public and population health (how are these different?) have been critics of the dominance of health care emphasis and investment, but these advances have been critical and will continue to be so. The end of the century has seen additional growing understanding and support that such behaviors as tobacco use, diet, and exercise also make substantial contributions to the health of individuals and populations. My own population health epiphany came with my exposure in the early 1990s to the thinking of Bob Evans and Greg Stoddart and their population health "field model" from the Canadian Institutes of Advanced Research (1). At once simple and profound, it captured the basic population health principles:

• that health outcomes were more than the absence of disease;
• that these outcomes were produced by complex interactions of multiple determinants (health care, behaviors, genetics, the social environment, the physical environment); and
• that in a resource-limited world, the relative cost effectiveness of these determinants was critical for policymakers.

While this Canadian work has provided an important framework for international population health scholarship and policy development, the last 15 years in the U.S. have been dominated by such issues as health care access and costs and pressing immediate public health issues like emerging communicable diseases (e.g., HIV-AIDS and H1N1). Periodic activity and reports from government agencies and foundations have addressed parts of the broad issue of outcomes and determinants, but not in visible and sustainable ways. Notable exceptions have been (A) the Institute of Medicine (IOM) and Centers for Disease Control and Prevention’s (CDC) emphasis on a broad public health “system,” (B) the creation of the Robert Wood Johnson Foundation's (RWJF) Health and Society Scholars Program to grow a new generation of multidisciplinary scholars for this emerging field, (C) the RWJF Commission to Build a Healthier America, and (D) the WHO Europe’s 2003 report on the social determinants of health. (I will return in a future post to the challenge the social determinants of health pose for policymakers.) In 2010, however, this emerging field has still not matured in either scholarship or policy. However, the last several years have seen growing attention from a policy perspective. Here are some examples:

• Decades of work from the Dartmouth group demonstrated how communities that spend the most on health care may not have the highest quality or outcomes.
• The groundbreaking documentary Unnatural Causes provided wide exposure to the multiple determinants of health.
• The California Endowment is making a major long term investment in the broad health of 10 communities in California.
• The State of Minnesota has invested $43M in its State Health Improvement Plan to create "accountable health communities" that address obesity and tobacco through policy, systems, and environmental changes.
• The Institute for Health Improvement has endorsed population health improvement as one of the three legs of its Triple Aim strategy and is considering moving to a regional strategy
• CDC has funded a cooperative agreement with the National Business Coalition on Health to work with business-led health coalitions and the business sector on building the capacity of members to be leaders of health reform and advance value based health and health care.
• Concerns about obesity have underscored the complexity of addressing this critical issue (look for a future post on the tension between free will and the social context with regard to behavior choices).
• Obama administration officials have been discussing a “place-based” approach for social investments as well as a major Community Health Data Initiative.
• The National Quality Forum and the National Priorities Partnership are discussing the need for new broad measurement tools such as a national index of health.
• Our own Robert Wood Johnson Foundation MATCH project in February released the first ever National County Health Rankings of 3,014 counties in all 50 states according to a broad population health model that has been used in Wisconsin since 2003. 

When I published Purchasing Population Health: Paying for Results in 1996, this list of activities was much shorter. Now every day we learn of some new policy, practice, or research finding that is aimed at population health improvement. Keeping track of and commenting on these exciting developments is the purpose of this blog. We plan to post on a weekly basis, with content from our own team as well as guest posts from prominent policy and practice leaders.The University of Wisconsin Robert Wood Johnson Health and Society Scholars Program will each month identify several recently published papers that make important contributions to policy, practice, or scholarship. All posts will in some way relate to our underlying population health model, including key concepts of outcomes and factors.

My hope is for this blog to prompt lively and provocative dialogue--and even action--toward improving population health.I welcome comments on this first post and all contributions to follow. I look forward to hearing from you!

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Reference:

 1. Evans R. Stoddart G. (1990). Producing health, consuming health care. Social Science and Medicine, 31(12), 1347-63.