intersection of clinical care and public health
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Intersection of Clinical Care and Public Health. AcademyHealth 2007 Annual Research Meeting June 4, 2007 / Orlando. Ron Davis, MD President-elect American Medical Association. 1847 – Founding of the AMA and Publication of the Code of Medical Ethics. - PowerPoint PPT PresentationTRANSCRIPT
Intersection of Clinical Care and Public Health
AcademyHealth 2007 Annual Research Meeting
June 4, 2007 / Orlando
Ron Davis, MDPresident-elect
American Medical Association
“Physicians, as conservators of the public health, are bound to bear emphatic testimony against quackery in all its forms.…”
1847 – Founding of the AMA and Publication of the Code of Medical Ethics
AMA mission
• To promote the science and art of medicine and the betterment of public health
• Unchanged since 1920
AMA’s health care advocacy agenda for 2007
• Expand medical coverage for the uninsured
• Reform the Medicare physician payment system
• Reform the medical liability system• Improve the quality and safety of
health care• Improve public health through …
• Healthy lifestyles • Reducing health disparities• Disaster preparedness
Topics
• Medicine and Public Health Initiative
• Clinical preventive services
• Health promotion & disease prevention in managed care
• Examples• Prevention activities in the medical sector
• Collaboration between medicine and public health
• Tobacco, alcohol, and obesity
Medicine and Public Health Initiative (MPHI)
Hippocrates urged physicians to recognize the environmental, social, and behavioral determinants of disease:
• the airs “peculiar to each particular region”
• the “properties of the waters” inhabitants consume
• their “mode of life … whether they are heavy drinkers, taking lunch, and inactive; or athletic, industrious, eating much and drinking little”
Medicine and Public Health Initiative (MPHI) – continued
Rudolf Virchow (1821–1902), founder of cellular pathology:
“Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of all.”
Medicine and Public Health Initiative (MPHI) – continued
• Formed in 1994 by the AMA and APHA to bridge the gulf between medicine and public health
• National Congress in March 1996 (> 400 delegates from both disciplines)
• RWJF and AHCPR formed the “Cooperative Actions for Health” Program, which funded 19 state MPHI projects
• NPO: UT-Houston Health Science Center
Medicine and Public Health Initiative (MPHI) – continued
• NY Academy of Medicine examined the history of collaboration between medicine and public health
• Identified 414 discrete examples• Medicine & Public Health: The Power of
Collaboration monograph sent to all medical schools in the U.S.
• Pocket Guide to Cases of Medicine & Public Health Collaboration
www.cacsh.org/mphguide.html
Medicine and Public Health Initiative (MPHI) – continued
• “Although (the) MPHI was embraced in some states and localities, it was unable to bridge the cultural and institutional divide in others.”
• There has been “difficulty in sustaining the momentum of (the) MPHI.”
LM Beitsch et al, AJPM 2005; 29: 149-53“The Medicine & Public Health Initiative: 10 Years Later”
Medicine and Public Health Initiative (MPHI) – continued
• Visible renewal of the shared commitment to partnership among AMA, APHA, ACPM, APTR, CDC, and others
• Professional education to integrate elements of public health and medicine into each other’s curriculum
• Research into effective strategies to overcome barriers across the medicine-public health chasm
• Leadership by local medical and public health communities to translate the MPHI into action
To reinvigorate the MPHI, Beitsch et al recommend:
Medicine and Public Health Initiative (MPHI) – continued
• State and local medical societies should establish public health committees
• Organized medicine should be represented on public health advisory committees and boards of health
• Medical societies should form foundations to expand their work in public health
RM Davis, AJPM 2005; 29: 154-157“Marriage Counseling for Medicine & Public Health”
Medicine and Public Health Initiative (MPHI) – continued
• Leaders in medicine and public health should offer speaking opportunities to their counterparts at meetings and conferences
• Public health and preventive medicine physicians need to join their county and state medical associations and the AMA
RM Davis, AJPM 2005; 29: 154-157“Marriage Counseling for Medicine & Public Health”
Medicine and Public Health Initiative (MPHI) – continued
“An Issue to Rally Around” – work together to bolster the funding of each sector
• Tobacco taxes
• Tobacco settlement funds
• Alcohol taxes
• Taxes on non-diet soft drinks
RM Davis, AJPM 2005; 29: 154-157“Marriage Counseling for Medicine & Public Health”
Clinical Preventive Services
• Guidelines for clinical preventive services issued by the U.S. Preventive Services Task Force
• Administered by the Agency for Healthcare Research & Quality (AHRQ)
• Based on a rigorous review of evidence
• Services are divided into categories of screening, counseling, immunization, and chemoprophylaxis
Clinical Preventive Services– continued
• Recommendations have been issued for ~ 75 services
• Guidelines are updated and new guidelines are released on an ongoing basis
• www.ahrq.gov/clinic/uspstfix.htm
• AHRQ website includes “Put Prevention Into Practice” program – tools and information aimed at improving implementation of clinical preventive services guidelines
• www.ahrq.gov/clinic/ppipix.htm
Clinical Preventive Services– continued
• Yarnall et al estimated that primary care physicians, in order to fully satisfy the USPSTF recommendations, would need to spend 7.4 hours per working day (Am J Public Health 2003; 93: 635-641)
• National Commission on Prevention Priorities prioritized clinical preventive services based on the clinically preventable burden and cost-effectiveness (Am J Prev Med 2006; 31: 52-61)
2006 Prevention Priorities
Short Name CPB CE Total
Aspirin Chemoprophylaxis – “high risk” 5 5 10
Childhood Vaccination Series 5 5 10
Tobacco-Use Screening & Intervention 5 5
10
Short Name CPB CE Total
Colorectal Cancer Screening 4 4 8
Hypertension Screening 5 3 8
Influenza Immunization – adults 4 4 8
Pneumococcal Immunization – adults 3 5 8
Problem Drinking Screening & Brief Counseling 4 4 8
Vision Screening – adults 3 5 8
2006 Prevention Priorities
2006 Prevention Priorities
Short Name CPB CE Total
Cervical Cancer Screening 4 3 7
Cholesterol Screening 5 2 7
Breast Cancer Screening 4 2 6
Chlamydia Screening 2 4 6
Calcium Chemoprophylaxis 3 3 6
Vision Screening – children 2 4 6
High-Priority, Low-Use ServicesShort Name Total Score National Delivery
RateTobacco Cessation Counseling 10 35%
Colorectal Cancer Screening 8 25%
Pneumococcal Immunization – adults 8 56%
Chlamydia Screening 6 40%
Aspirin Chemoprophylaxis 10 ?
Vision Screening – adults 8 ?
Problem Drinking Screening 8 ?
Health promotion & disease prevention in managed care
Several forces are pushing prevention in managed care
• National Committee for Quality Assurance (NCQA) accreditation
• Health Plan Employer Data and Information Set (HEDIS) “report card”
• Pressure from purchasers — public (eg, Medicaid) and private
Preventive Services in HEDIS
• Pap tests (21-64 years old)
• Mammograms (52-69 y/o)
• Colorectal cancer screening (50-80 y/o)
• Childhood immunization• DTP (4), polio (3), MMR (1)
• Hib (2), hep B (3), varicella (1)
• Adolescent immunization (13 y/o)• MMR (2), hep B (3), varicella (1)
• Influenza immunization (> 50 y/o)
• Smoking cessation advice/assistance
• Initiation/engagement of alcohol & other drug treatment (> 18 y/o)
• Chlamydia screening (women 16-26 y/o)
• LDL cholesterol after acute CV event
• Diabetes care (HbA1c, LDL cholesterol, screening for eye and kidney disease)
• Prenatal and postpartum care
• Glaucoma screening (> 65 y/o)
Preventive Services in HEDIS – continued
Parallels between Public Health and Managed Care
Public Health Managed Care
• Primary prevention
• Secondary prevention
• Tertiary prevention
• Demand management
• HEDIS measures (mammogram, Pap)
• Disease management
The language of managed care
• Risk management
• Utilization management
• Quality management
• Disease management
• Demand management
• Physician management?
Tobacco Control – AMA
• AMA SmokeLess States program (funded by RWJF) gave grants to state coalitions for advocacy for tobacco control policies
• > $90M provided to > 40 state coalitions during 1994-2004
• AMA worked with “Partnership for Prevention” and CTFK to successfully petition CMS to provide Medicare coverage for tobacco cessation counseling
• AMA has joined amicus briefs in support of tobacco control litigation in many states
Tobacco Counteradvertising Contest for Schoolchildren in Michigan
• Sponsored by Wayne County Medical Society Foundation and Henry Ford Health System
• Funded by the Community Foundation of Southeastern Michigan and other sources
• Conducted contests in 2002 and 2005
• A third contest is now underway
• www.counteradvertising.com
Omar PaulkGrade 8:
“In the neighborhood, the phrase ‘to smoke’ means to kill someone. ‘He got smoked’ means he got killed. When smokers finish a cigarette, they say they are killing the cigarette. My drawing asks the question, Who’s Smoking Who? It means the cigarette is killing the smoker.”
Alcohol Control – AMA
• Two AMA programs funded by RWJF• Reducing Underage Drinking through
Coalitions: Youth and Adults United for a Change
• A Matter of Degree: The National Effort to Reduce High-Risk Drinking Among College Students
• www.ama-assn.org/go/alcohol
Alcohol Taxation
• AMA Resolution 438 (A-05)
• RESOLVED, That our American Medical Association support increases in federal taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the prevention of alcohol abuse and drunk driving, treatment of persons with alcohol dependence or at-risk drinking patterns, and public health and medical programs that serve vulnerable populations; and be it further
RESOLVED, That our AMA encourage state and local medical societies to support increases in state and local taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the purposes noted above …
• Chronicle of Higher Education
• College newspapers
DePaul Univ
Univ of WI (Madison)
Univ of Iowa
Georgia Tech
Indiana University
Ole Miss
AMA Primer on Assessment and Management of Adult Obesity
• Available in 3-ring binder, on CD-ROM, and the web
• 10 booklets• Assessment
• Dietary management
• Physical activity mgmt
• Pharmacologic mgmt
• Surgical mgmt
• Office environment
• Communication/counseling
“Coming together is a beginning;keeping together is progress; working together is success.”
Henry Ford – on partnership