MPH 600 MPH 600 Introduction Public HealthIntroduction Public Health

Planning and Goal Setting in Planning and Goal Setting in Public HealthPublic Health

William R. Nelson, M.D., M.P.H. Past Director Chesterfield County HDWilliam R. Nelson, M.D., M.P.H. Past Director Chesterfield County HD, VDH, VDH

Kim Buttery, Past Commissioner VDH.Kim Buttery, Past Commissioner VDH.

Core Functions of Public Core Functions of Public HealthHealth

►AssessmentAssessment

►Policy DevelopmentPolicy Development

►AssuranceAssurance

From The Future of Public Health :Institute of Medicine 1988From The Future of Public Health :Institute of Medicine 1988

GOALS & ObjectivesGOALS & Objectives

► Use of Use of datadata to formulate and make to formulate and make decisions: to establish “Policy”decisions: to establish “Policy”

► What is PolicyWhat is Policy►   How health policies are formulatedHow health policies are formulated►   Forces that shape development of Forces that shape development of

policypolicy

"Policy""Policy"

A definite course of action adopted as A definite course of action adopted as expedient, or from considerations:expedient, or from considerations:

e.g. "a business policy"e.g. "a business policy"

  Definition from the American Heritage Definition from the American Heritage

DictionaryDictionary

Evolution of Health PolicyEvolution of Health Policy

►Common Wisdom- Learned from direct Common Wisdom- Learned from direct observationobservation

►Age of Discovery- Application of the Age of Discovery- Application of the scientific methodscientific method

►Prospective Age – Population based Prospective Age – Population based analysisanalysis

Policy Development Policy Development

"Policy development is the means by "Policy development is the means by which problem identification, technical which problem identification, technical knowledge of possible solutions, and knowledge of possible solutions, and societal values join to set a course of societal values join to set a course of action."action."

Institute of Medicine Report.Institute of Medicine Report.

‘‘The Future of Public Health’ – 1988’ – 1988

Review summary and Pages 44 and 45Review summary and Pages 44 and 45  

Policy DevelopmentPolicy Development

Problem Identification Technical Knowledge

Societal Values

Problem IdentificationProblem Identification

►    AnecdotesAnecdotes►    MediaMedia►    Public Health DataPublic Health Data►    EpidemiologyEpidemiology

In the News

Data tells a story

Epidemiology points to the answers

Technical Knowledge of Technical Knowledge of SolutionsSolutions

►   Basic ScienceBasic Science►    Clinical StudiesClinical Studies►    EconomicsEconomics►    LawLaw► Health Behavioral theory- Health Behavioral theory-

PyschologyPyschology

Societal ValuesSocietal Values

►Political ProcessPolitical Process►Legislative, Judicial & Legislative, Judicial &

Executive expressionExecutive expression►Social & Political SciencesSocial & Political Sciences► Interest GroupsInterest Groups►Town Hall MeetingsTown Hall Meetings►Blogs, Web PagesBlogs, Web Pages

Setting a Course of ActionSetting a Course of Action

►   Easier Easier Said;Said; Having a visionHaving a vision Setting goalsSetting goals Picking objectivesPicking objectives Designing action stepsDesigning action steps

   Than Than DoneDone Legal and regulatory frameworkLegal and regulatory framework FundingFunding Organizational structure to accomplishOrganizational structure to accomplish Work plan: staffing, equipmentWork plan: staffing, equipment Cooperation or interest of those affectedCooperation or interest of those affected Patient/provider, customer/provider, community/leader Patient/provider, customer/provider, community/leader

relationshipsrelationships  

Framework for AnalysisFramework for Analysis

► Establish the contract: desired result of the effortEstablish the contract: desired result of the effort ► Layout the Alternatives: options to considerLayout the Alternatives: options to consider ► Predict the consequences: use of data and modelsPredict the consequences: use of data and models ► Value the outcome: numerous valuation strategiesValue the outcome: numerous valuation strategies ► Make a choice: legal, ethical, societal, moral, Make a choice: legal, ethical, societal, moral,

financial and practical parametersfinancial and practical parameters  

Making the ChoiceMaking the Choice

►The Decision Maker; Role of “the The Decision Maker; Role of “the Decider”Decider” A personA person A group of peopleA group of people

►The AnalystThe Analyst►The StaffThe Staff►Significant InfluencesSignificant Influences

Private SectorPrivate Sector

►Easier when only the bottom line is Easier when only the bottom line is considered: not always the only considered: not always the only questionquestion

► Increasingly complexIncreasingly complex►Conventional wisdom = always more Conventional wisdom = always more

efficientefficient►Rise of public-private sectorRise of public-private sector

Public sector; more difficultPublic sector; more difficult

► All the following want a hand in the decision All the following want a hand in the decision making:making:

CongressCongress Federal CourtsFederal Courts Executive BranchExecutive Branch State LegislatureState Legislature Governor & Executive BranchGovernor & Executive Branch State CourtsState Courts ActivistsActivists Local Councils/SupervisorsLocal Councils/Supervisors City/County Execs City/County Execs

► Here is the local health department!Here is the local health department!  

Activists and concerned individuals at every level

Comparison of Clinical Medicine and Comparison of Clinical Medicine and Public Health PracticePublic Health Practice

Clinical MedicineClinical Medicine Public Health- Population MedicinePublic Health- Population Medicine

Take a history of the current illnessTake a history of the current illness Ask directed questionsAsk directed questions

Problem identification; anecdotes, focus Problem identification; anecdotes, focus groups, basic population health indicators,groups, basic population health indicators,

Review of symptomsReview of symptoms Surveillance statistics, Disease registriesSurveillance statistics, Disease registries

Physical examination of the patientPhysical examination of the patient Behavioral risk studies, NHANES, Behavioral risk studies, NHANES, observational studies; cross sectional studies, observational studies; cross sectional studies, case controlcase control

Develop a single or differential diagnosisDevelop a single or differential diagnosis Develop a hypothesisDevelop a hypothesis

Conduct tests to confirm the diagnosis or Conduct tests to confirm the diagnosis or reduce the number in the differentialreduce the number in the differential

Case control studies, prospective cohort Case control studies, prospective cohort studies, studies,

Evaluates possible modes of treatment-Evaluates possible modes of treatment- Clinical studiesClinical studies

Evaluates modes of treatment-Evaluates modes of treatment- Outcome evaluationOutcome evaluation Cost-benefit analysisCost-benefit analysis

Treat the problemTreat the problem Select, modify and implement programsSelect, modify and implement programs

Monitor resultsMonitor results Monitor outcome indicatorsMonitor outcome indicators

Adjust treatment plan as necessaryAdjust treatment plan as necessary Revise programs as necessaryRevise programs as necessary

Chief Complaint – Problem Chief Complaint – Problem IdentificationIdentification

Review of Symptoms- Community Health Review of Symptoms- Community Health Status IndicatorsStatus Indicators

0

5

10

15

20

25

30

1 4 7 10 1 4 7 10 1 4 7 10

1995 1996 1997

E. Coli 0157:H7 in Virginia

Examine the patientExamine the patient

► Death rates by Death rates by causecause(See Vital (See Vital Statistics)Statistics)

► Hospital Hospital admissionsadmissions

► NHANESNHANES► BRFSBRFS► Reportable Reportable

DiseasesDiseases► RegistriesRegistries

CancerCancer Birth DefectsBirth Defects AlzheimersAlzheimers

Differential diagnosis - Develop a Differential diagnosis - Develop a hypothesishypothesis

Congestive Heart Failure

Pulmonary Embolism

Chronic Obstructive Lung Disease

Rates of cancer in this neighborhood are NOT elevated

Rates of cancer in this neighborhood are elevated, but this is a random effect.

A specific type of cancer is appearing more often than it should.

The increased rate of cancer is related to an exposure to a certain chemical in the drinking water.

Clinical tests Clinical tests ---- Case Control Case Control Studies Studies Prospective studies Prospective studies

Environmental testingEnvironmental testing

Hemoglobin 12 gm/dL

WBC 18,000/mm

Treat the Treat the Treat the Treat the disease disease problem problem

► MedicationMedication► SurgerySurgery► DietDiet► Physical, emotional, Physical, emotional,

or behavioral or behavioral therapytherapy

► Lifestyle changesLifestyle changes

► Stop the exposureStop the exposure► Screening programsScreening programs► Prevention programsPrevention programs► Promote diet and Promote diet and

lifestyle changeslifestyle changes► EngineeringEngineering► Changes in Changes in

community structurecommunity structure

Treating a Societal ConditionTreating a Societal ConditionRx = Policy DevelopmentRx = Policy Development

Problem Identification Technical Knowledge

Societal Values

Monitor Patient -- Monitor Monitor Patient -- Monitor Health Results Health Results IndicatorsIndicators

► Re-interview Re-interview regarding regarding symptomssymptoms

► Re-examine Re-examine periodicallyperiodically

► Repeat lab tests Repeat lab tests when helpfulwhen helpful

► Death rates by causeDeath rates by cause(See Vital Statistics)(See Vital Statistics)

► Hospital admissionsHospital admissions► NHANESNHANES► BRFSBRFS► Reportable DiseasesReportable Diseases► RegistriesRegistries► Parameters set up Parameters set up

specifically for thisspecifically for this► Example: Healthy Example: Healthy

People 2010 People 2010 Healthy People 2010 Home Page

Evolution of Health Care Evolution of Health Care

► 800 AD – 1900’s hospitals = poor houses 800 AD – 1900’s hospitals = poor houses ► 1800’s – bacteriology becomes a science1800’s – bacteriology becomes a science► 1870-1910 Hygiene Movement: rise of science1870-1910 Hygiene Movement: rise of science► 1945 Specialization following vast improvement of 1945 Specialization following vast improvement of

surgery and use of antibiotics associated with WW surgery and use of antibiotics associated with WW II.II.

► 1980s Identification of limited and competing 1980s Identification of limited and competing resources, movement to primary care, ambulatory resources, movement to primary care, ambulatory care cost reductioncare cost reduction

► 2121stst century- continued explosive growth of costs century- continued explosive growth of costs creates a financial and political crisiscreates a financial and political crisis

Great Health Policy MomentsGreat Health Policy Moments

► 1600s Bill of mortality – London1600s Bill of mortality – London► 1918- Flexner Report; use of the science and 1918- Flexner Report; use of the science and

standards vs. apprenticeshipstandards vs. apprenticeship► 1935 Social Security Act1935 Social Security Act► 1946 Hill Burton Act1946 Hill Burton Act► 1965 Medicaid/Medicare 1965 Medicaid/Medicare ► 1980s Medicare implements capitation: DRGs1980s Medicare implements capitation: DRGs► 1990s Health Care Reform- managed care1990s Health Care Reform- managed care► 2121stst Century- struggle over health care system Century- struggle over health care system► Emergence of chemical and biologic weapons: Emergence of chemical and biologic weapons: ► Public Health Security and Bioterrorism Public Health Security and Bioterrorism

Preparedness and Preparedness and Response Act Response Act

An Example of a An Example of a recent problem that recent problem that

lead to an urgent lead to an urgent program goal using program goal using

the previously the previously described actions.described actions.

Anthrax as a Weapon: Anthrax as a Weapon: United StatesUnited States

► An urgent program goal to “assess the An urgent program goal to “assess the danger to Virginians”danger to Virginians”

Quickly determined despite media hype that the dangers were to selected political figures and postal workers.