109 terms

PH200 Final Exam

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6 Dimensions of Quality of Care
1. Effective
2. Efficient
3. Safe
4. Timely
5. Patient-Centered
6. Equitable
5 A's of Access to Healthcare
1. Affordability
2. Accessibility
3. Availability
5. Accommodation
6. Acceptability
Where are there work force shortages in Health Community?
Primary Care Physicians - High cost of med school, most students choose to specialize in order to pay off debts, Increasing demand for primary care physicians due to aging baby boomers

Nurses - Nursing workforce is older now (Baby boomers), Aging population
Who does Medicare Cover?
Elderly population (over 65), Any people who have kidney disease, Disabled individuals
Who does Medicaid Cover?
Low income populations
Health Status Disparities vs Health Care Disparities
Health Status - Higher burden of illness, mortality experienced by 1 population relative to another

Health Care - differences between groups in health insurance coverage, quality of care

Health Care + other factors = Health Status
Structural Flaws in US HC System
Fee-for-service

Paradox of "excess and deprivation" - some receive excess, costly care; others receive too little care and are uninsured

Insurance is still connected to employment, not available to everyone
Health Care Reform Triple Aim
Improve Health
Maintain or improve quality
Reduce costs
Health Care Industry Reforms
Guranteed Issue - cannot exclude already sick people
No rescission - cannot remove people from plans
No annual/lifetime caps
Dependents up to 26 y/o
Individual Mandate
Everyone must have insurance
Some exemptions: Financial hardship, religious reasons, indian tribes, unauthorized immigrants
Health Insurance Marketplace
Can purchase private insurance with subsidies (tax credits) from government
Role of Public Programs
Community Health Centers
Medicaid Expansion
Children's Health Insurance Plan (CHIP)
Indian Health Care Improvement Act
Major Features of ACA
Improving Quality and Efficiency of Health Care
Prevention of Chronic Disease and Improving Health
Health Care Workforce
ACA and Public Health
Coverage for Clinical Preventive Services
Prevention and Public Health Fund
Hospital Community Benefit Regulations
Progress from ACA
Uninsurance dropped by 43% (2010-2015)
Improved access to care
Improved quality of care
Improved affordability of care
Slowed growth in health care costs
ACA Challenges
Coverage gap in states that haven't expanded Medicaid
More competition needed in Marketplace
Takes time to see benefits, and many aspects need tweaking
Exposure Disease Model
Source - Movement of Pollutants - Human Exposure - Adverse Health Effect - Dose
What is the difference between Dose and Exposure?
Dose is amount of pollutant that ends up in body

(Exposure leads to dose)
Public and Occupational Health Hierarchy of Controls
Elimination/Substitution
Engineering Controls
Warnings
Training and Procedures
Personal Protective Equipment
Environmental Justice
Fair treatment and meaningful involvement of all people (law, policy, regulations)
Where did burden of Flint water crisis fall?
Lower income groups, minorities
How many americans develop foodborne illness/year?
1 in 6
How much does foodborne illness cost/year?
$15.6 billion
Top Pathogens in foodborne illness
Norovirus (virus), Salmonella (bacteria), Clodistrium perfringens (bacteria), Listeria (bacteria)
Top foods associated with foodborne illness
Raw meats (meat, poultry, seafood), eggs, milk, contaminated fruits and vegetables
USDA regulation
Meat, poultry, eggs
20% of regulated foods
17% of illnesses
Daily inspection of plants
$1.03 billion budget
FDA regulation
Regulates all other foods (besides meat, poultry, eggs)
80% of regulated foods
67% of foodborne illnesses
Plant inspections every 10 years
$1.5 billion budget
HACCP
Food safety protocol for food processors/manufacturers based upon the principles of hazard analysis and risk assessment
Food, Drug and Cosmetic Act of 1938
FDA has authority over food and ingredients
Truthful labeling
Food Additives Amendment (1958)
Requires FDA approval for any proposed food additive
Delaney Clause
Prohibits the use of any food additives found to cause cancer in animals or humans
Dietary Supplement Health and Education Act of 1994
Prohibits FDA from regulating herbs and supplements
FDA has basically no regulation over supplements
Food Safety Modernization Act of 2011
Emphasizes prevention rather than responding to contamination
More frequent plant inspections
Mental Illness vs Mental Health
Illness - Characterized by alterations in thinking, mood, and/or behavior

Health - Ability to cope with the normal stresses of life
How are symptoms of mental disorders diagnosed?
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Barriers to Treatment of Mental Health Conditions
Low perceived need for treatment
Financial
Availability
Transportation
Inconvenient
Wanted to handle on own
Stigma
Which populations have a high prevalence of Mental Health Conditions?
Homeless
Incarcerated
Youth in Juvenile justice systems
How is mental health linked to chronic disease?
Mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer
How is mental health linked to usage of medical care?
Mental illness is associated with lower use of medical care, reduced adherence to treatment therapies for chronic diseases, and higher risks of adverse health outcomes
What are the domains of mental health indicators?
Emotional
Psychological
Social
Social Determinants of Mental Health
Adequate housing
Safe neighborhoods
Equitable jobs and wages
Quality education
Equitable access to quality health care
Why is adolescent and young adult mental health important from a public health perspective?
High prevalence
High burden of disease, measured by disability adjusted life years (DALYs)
Early age of onset compared with other chronic diseases
How many college students have some type of mental health issue?
1/3
What are some major Global Population Growth trends?
95% of births in the next 25-50 years will be in world's poorest countries
Urban migration
Some countries face negative population growth (AIDS, famine, war, fertility)
What are reasons for rapidly declining death rates in the world?
Vaccination
Reduction in infectious diseases
Sanitation, water
Disease treatment
Reduction in warfare
What are reasons for rapidly declining birth rates in the world?
Policies (China 1-child policy)
Higher infant & child survival rates → less births needed to have the same # of children
Determinants of Carrying Capacity
Nature (weather, fertility of land, water)
Humans (urbanization, pollution, population density, technology)
Kyoto Protocol (1997)
1st international agreement to call for mandatory (country-specific) reductions in greenhouse emissions

Not very successful (US has not ratified)
Measures used for population control
Family size restrictions
Family planning programs
Address conditions to improve infant chances of survival
What are some LGBT disparities in violence?
Sexual minority youth more likely to experience fights, sexual coercion, and dating violence
Sexual minority youth more likely to miss school because of safety concerns
What are some LGBT disparities in HIV?
~60% of HIV diagnoses 2010-2014 were due to male-to-male sexual contact
~25% of HIV cases in southeast Michigan are among young MSM (13-29 yrs)
WHO recommendation for breastfeeding duration
2 years
Who is least likely to breastfeed?
Rural, under 20 y/o, low education, poverty
Benefits of spacing birth at least 18 months
Decreased risk of premature birth
Decreased risk of perinatal and infant mortality
Decreased Pregnancy complications
Most effective type of contraception
Implanon (birth control implant)
Least effective form of contraception
Withdrawal and Condoms
Barriers to LARCs (Long-acting reversible contraceptives)
Provider education
Information
Access (currently covered in ACA)
Inequity vs Inequality
Inequality - quantifiable difference related to health
Inequity - involved contextual judgement about health inequality

Ex: Infant mortality in African American Women - stress during pregnancy (infant mortality rate is higher)
Upstream determinants of PH
Social Inequalities, Institutional Power
Midstream determinants of PH
Neighborhood conditions, Risk behaviors
Downstream determinants of PH
Disease and Injury, Mortality
Community Based Participatory Research (CBPR) CORE principles?
a commitment to build on community strengths and resources

to foster co-learning and capacity building

to balance research and action for mutual benefit of all partners
How did population of Detroit change from 2000 to 2010?
Dropped by 25%
What were redlining issues in Detroit?
Segregation by race
Blacks viewed as undesirable
Black bottom neighborhood
4 causes of death expected to rise in next 15 years?
1. Cancer
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Road Traffic Accidents
Big 3 Infectious Diseases
Malaria, Tuberculosis, HIV/AIDS
What is the Gini coefficient?
Represents the income or wealth distribution of a nation's residents

Higher number = more inequality

Inequality more common in low income countries
What has spread from high-income countries to LMICs?
Smoking, alcohol use, obesity
How many global deaths are smoking and high-fat diets responsible for?
2/3 of all global deaths
How many cases of polio are asymptomatic?
90%
How many cases of polio lead to irreversible paralysis?
1 in 200
How has polio decreased from 1988 to 2016?
~350,000 to 33

3 countries: Nigeria, Afghanistan, Pakistan
Global Polio Eradication Initiative (GPEI)
1988 World Health Assembly: established a public-private partnership for public health
How much money has been spent on polio eradication for last 25 years?
$10 billion

3 billion children have been immunized
Complexities and Challenges of eradication programs
Difficult to reach rural populations
Competing priorities
Elderly Dependence Ratio
Elderly in Labor Force / Total Labor Force
Means-Test
Providing people with more or less benefits from a public program depending on their current income or wealth
How is the elderly population in US changing?
It is INCREASING
What is the compression of mortality and morbidity?
Diseases are starting LATER in life (rather than over prolonged period)
What is the "Perfect Storm" of Medicare?
1. High and Rising costs of care
2. Aging Population
3. Increasing Elderly Dependency Ratio

Medicare is not sustainable
How have Medicare, Medicaid, and Social Security changed spending over time?
Medicare: Increased (more people live longer)
Medicaid: Possible Decrease (little nursing home care)
SS: Increased (more people living longer)
ACA Titles
1. Quality, Affordable HC for All Americans
2. Role of Public Programs
3. Improving Quality and Efficiency
4. Prevention of Chronic Disease and Improving Health
5. Health Care Workforce
6. Transparency and Program Integrity
7. Improving Access to Innovative Therapy
9. Revenue Provisions
10. Strengthening Quality Affordable Health Care for All Americans
What features of ACA were meant to avoid adverse selection?
Guaranteed issue— cannot exclude people with pre-existing conditions
No rescission - cannot kick sick people off of their plans
No annual or lifetime caps
Can cover dependents up to 26 years old
Effective clinical preventive services must be offered at no charge to patients
Out of Pocket spending allowed by ACA
Individual: $6,600
Family: $13,200
How much of premiums should be spent on healthcare?
Health insurance companies must spend 80-85% of premiums on health care (medical loss ratio)
Uncompensated Care Trends in 2015
Uncompensated care costs fell from 5.2% in FY13 to 2.9% in FY15

Average annual uncompensated care fell from $7.2 million to $3.8 million

Large Detroit hospital fell from $35.8 to $19.5 million
Medicaid Expansion under ACA
Mandated Expansion: Medicaid will cover everyone under 133% of FPL, including childless adults (12-20 million people)

Feds cover 100% of costs for newly eligible (2014-17), then 95% (2018-19), then 90% of costs after 2020

Reauthorized Children's Health Insurance Plan (CHIP) until 2019
Of 3,000 HPV, what % have basic risk information?
Only 7% of HPV chemicals have all six basic screening tests
Globally, rivers that serve X million (or billion) people are plagued by chemical, biological, and physical hazards?
5 Billion
How many Americans live in areas that > NAAQS?
127 million people in US live in counties that exceed national air quality standard
What % of global death/disease is due to environmental hazards?
¼ global disease burden due to modifiable environmental factors

1 billion lack safe water, 2.5 billion sanitation
How many premature deaths caused by pollution in 2015?
9 million (16% of deaths worldwide)
Infant Mortality disparity between Detroit and Michigan
Detroit Black babies - 14.5/1000
Michigan - 6.9/1000

Black babies also more likely to be born premature or low birth weight
Elderly population (over 65) change from now to 2030
Now - 14%
2030 - 20%
Which countries have negative population growth?
Ukraine (-0.8%/yr)
Russia and Belarus (-0.6%/yr)
Japan (21% population loss by 2030)
Medicare beneficiary estimate in 2030?
expected to rise by 50%
How much of federal budget does Medicare use?
15% ($670 billion/year)
Solutions to Medicare to solve unsustainability
Increase age of eligibility (same as SS)
Increase premiums for high-income people
Decrease benefits
Means-test
6 Building Blocks of Health System
1. Service Delivery
2. Health Workplace
3. Information
4. Medical Products, vaccines, tech
5. Financing
6. Leadership/Governance
10 Essential PH Services
1. Monitor population health status
2. Diagnose and investigate
3. Inform and educate
4. Mobilize community partnerships
5. Develop policies and plans
6. Enforce laws and regulations
7. Link people to needed personal health services.
8. Assure competent public and personal health care workforce
9. Evaluate effectiveness, accessibility, and quality of health services
10. Conduct research
Basic Components of U.S Health Care System
Patients
Services
Providers
Administrators/Other Staff
Facilities (clinics, hospitals, pharmacies, etc.)
Assurance/Oversight
Governance
Key Dimensions of Public Policy
Access to Care
Coverage/Financing
Quality of Care/Safety
How many people are covered by Medicare?
55 million people
Life Expectancy Statistics of 2015
US - 78.8
Males - 76.3
Females - 81.2

US Ranked 53rd worldwide

White - 79.0
Blacks - 75.5
1,4 - dioxane
Organic solvent discovered in Ann Arbor surface water (1984-85)
Water usage statistics
North America - 1,630 m^3
Why has arable land per capita declined?
47% decline

Green Revolution - dramatically increased food production but also damaged land

Urban Sprawl, Erosion from overgrowing
UN Paris Climate Change Conference
Legally binding universal agreement to limit greenhouse emissions
Barriers to population control
Political
Economic value of children (as workers and caretakers)
Cultural/religious
Personal
Restrictions on individual liberty