PM 424
health inequalities
***Definition: differences in health status or in the distribution of health determinants between different population groups. **EX: differences in mobility between elderly people and younger populations or differences in mortality rates between people from different social classes. -health behaviors do not account for all differences in mortality and disease risk •health inequalities across the lifespan are important in disease and mortality risk •social structure= disadvantages (or advantages) cluster in sub-populations and accumulate longitudinally
EX of PIECOT
**Do high levels of workplace stress increase the one-year incidence of acute MI compared to low levels of workplace stress? **Patients taking platelet inhibitors have increased need for TBI-related trauma center services in the 72 hours post-injury compared to patient's not taking those meds
stages of epidemiologic transition
**proposed in 1971 by Omran -age of pestilence and famine -age of receding pandemics -age of man-made and degenerative diseases -age of delayed degenerative diseases -debatable 5th stage
cardiovascular disease definition/ clinical presentation
*congestive heart failure definition: The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return *atherosclerosis: diseased arteries
enabling factors
-"environmental" factors that affect health in a positive or negative way • living situations • occupational settings • societal support • resources • lack of public health/ medical care
reinforcing factors
-Factors that have the ability to support the production/ transmission or the prevention of a disease -negative reinforcing factors perpetuate disease -positive reinforcing factors assist with disease prevention
secondary prevention
-action which halts the progress of a disease at its incident stage and prevents complications
accumulation
-advantages or disadvantages tend to cluster within sub-populations: occupational, neighborhood -advantages and disadvantages also tend to cluster and accumulate over time (in utero, infancy, childhood, adulthood, old age) -accumulation of many relatively minor exposures over time may have significant influence on health
selecting a prevention target
-burden of suffering caused by the condition: 5 D's include death, disease, disability, discomfort, dissatisfaction, destitution -frequency of condition
primordial prevention
-consists of actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social and behavioral conditions and cultural patterns of living **goal is to reduce the occurrence of risk factors/ exposures
cardio sub-diseases
-coronary heart disease -stroke -ischemic heart disease -peripheral vascular disease -hypertension
neuro challenges to conduct research
-cost-effectiveness studies
3 models of life course epidemiology
-critical periods -accumulation -pathways
origins of life course epidemiology
-developed due to increased research in: biology/ genetics, epidemiologic methods/ birth cohort studies, health inequalities
neuro challenges to diagnose
-diagnostic variation/ definitions
Neurodevelopmental disease definition/ clinical presentation
-federal definition: -AAIDD definition: -NY definition
stage 2: age of receding pandemics
-fewer epidemics: infectious disease less common due to improved hygiene/ sanitation/ nutrition/ medicine during the industrial revolution -time of industrial revolution -slow rise in man-made and degenerative disease -characterized by: decrease in mortality rate, little change in fertility rates, increase in life expectancy, population growth occurs -poor people who crowded into Industrial cities had high death rates due to Cholera -discovery of penicillin
neuro prevention measures
-health care -prenatal vitamins/ healthy lifestyle
chronic disease in developing country
-historically chronic disease due to infection and nutrition
cancer epidemiology
-in terms of cancer incidence, male incidence prostate, lung/ bronchus, colon/ rectum -in terms of cancer incidence for females, breast, lung/ brochus, colon/ rectum, uterine corpus -in terms of mortality, highest death rate due to lung cancer in both males and females
osteo prevention measures
-increase bone mass density via diet, weight bearing exercise, lifestyle (avoid alcohol and smoking) -hip protectors -decrease risk of falls -meds if necessary
stage 3: age of man-made diseases
-infectious disease well controlled and have minimal burden on the population -chronic diseases are responsible for most deaths characterized: decrease in mortality rates to decline to a minimal level, decline in birth rates, increase in life expectancy, population growth continues -heart disease and cancer
causal inference
-is a social process -what we regard as causes depends on our conceptual framework
mortality
-is the fundamental factor in the dynamics of population growth and causes of death -mortality has no fixed upper limit. if fertility approached its upper max, depopulation would still occur
survival curve shape
-it is becoming increasingly rectangular. There is much lower premature morbidity. Trauma is now the dominant cause of death in early life.
life expectancy trends
-life expectancy at birth has increased by 26 years in this century -expectancy [at age of 75] has only increased 3 years -projections show that life expectancies will converge to the ideal age of 85 in 2045
stage 4: delayed degenerative
-life expectancy of older people extended through medical advances -cancer medicines, bypass surgery, better diet, reduced use of tobacco, and alcohol -consumption bad food= obesity increase
life course epidemiology
-linking effects across different points of an individual life history
the US preventive services task force
-makes recommendations on clinical preventive services to primary care clinicians -makes recommendations based on rigorous review of existing peer-reviewed evidence
tyranny of the urgent
-manage acute illness and hopefully chronic issues fix themselves -Physicians are trained and programmed to focus on management of patients' acute illnesses with the hope that patients' chronic diseases will subsequently work themselves out. That is, there is a conflict within the medical field between things that are important and things that are urgent. More often than not, urgent matters will be prioritized when it comes to areas where research, time and money must be allocated. The "tyranny of the urgent" concept can be applied to heart disease in multiple cases. For example, the system will prioritize treatment of myocardial infarctions (an acute event) rather than allocating funding to prevent the onset of heart disease in the first place (public health education about healthy eating, exercise, behavioral pattern changes, etc). Education and empowerment of individuals' health-seeking behavioral patterns is more difficult to set in motion when compared to simply prescribing medications or conducting a routine stent placement, angioplasty after an MI.
components of epidemiology
-measure disease frequency -assess distribution of disease -identify determinants of disease
neuro risk factors
-neural tube defects -prenatal vitamin deficiencies -down syndrome/ rett syndrome -environment: lead, PCB's, methyl mercury
Passive vs. active surveillance
-passive: reports received from physicians, hospitals, labs, individual patients -active: requires regularly contacting reporting sources
cancer challenges to conducting research
-patients may spend years in treatment -comorbidities -some cancers are incurable -cancer and its treatment can have lasting effects that result in chronic morbidity
osteo challenges to diagnosis
-patients only find out that they have it after a fracture/ fall (may already be too late)
cancer sub-diseases
-sarcoma -leukemia/ lymphoma -carcinoma
quaternary prevention
-set of health activities to mitigate or avoid the consequences of unnecessary or excessive intervention of the health system
osteo sub-diseases
-spinal compression fractures, hip, wrist, pelvic, rib -primary versus secondary osteoporosis --> primary is seen in people over the age of 70; secondary is the disease process unrelated to aging
James Fries
-studied compression of morbidity hypothesis
Abdel Omran
-studied the evolution of disease -came up with a theory to characterize population change--> epidemiologic transition
AHRQ
-support task force -mission: to improve the quality, safety, efficiency, effectiveness of health care for all Americans
frailty definition
-syndrome of decreased reserve and resistance to stressors that result in cumulative declines across multiple physiological systems, causing vulnerability to adverse outcomes -an age-associated decline in physiologic reserve and function across multiple systems
demography
-the study of populations and sub-populations -population dynamics: studies changes in population structure over time
cancer definition/ clinical presentation
-unregulated growth of cells
tertiary prevention
-used when disease process has advanced beyond its early stages -reduce or limit impairments and disabilities -goal is to reduce the number of complications/ deaths
Omran's theory
1971 •Omran argued that we cannot view diseases in isolation •It is critical to look at the pattern of diseases, not a single disease •The epidemiologic transition is a stage of development characterized by a shift in population growth, life expectancy and disease patterns
osteo epidemiology
8 million women, 2 million men 34 million men and women have osteopenia
25 X 25 Target
Achieving a 25% relative reduction in overall mortality from cardiovascular disease, cancer, diabetes, or chronic respiratory diseases by 2025.
prevention definition
Actions aimed at eradicating, eliminating or minimizing the impact of disease and disability or if none of these are feasible, retarding the progress of the disease and disability
cardio risk factors
Age, male gender, smoking, elevated low density lipoprotein cholesterol, low high density lipoprotein, hypertension
cardio epidemiology
Coronary heart disease is number 1 killer and stroke is 4
FINER
F: feasible I: Interesting N: Novel E: Ethical R: Relevant
predisposing factors
Factors or conditions that are already present in the host that produce a susceptibility or disposition to a disease without actually causing that disease
biological programming
Genetic factors and organ development in utero and during infancy determines maximum function during adulthood
PIECOT
P: population or problem I (or E): intervention or exposure C: comparison... unexposed O: outcome T: Time of experiment/ duration of exposure
goals of PH
The goals of public health and medicine are to promote health, to preserve heath, to restore health when it is impaired, and to minimize suffering and distress
morbidity curve
The morbidity curve is made rectangular, and the period of morbidity compressed between the point of the end of adult vigor and the point of natural death.
Health Surveillance
The tracking and forecasting of any health event or health department
web of causation
The web of causation is a paradigm that posits that there are several factors that contribute to the occurrence of chronic disease. This theory is important in studying the etiology of chronic disease in that researchers and clinicians must consider that there are multiple components that will together cause the increased risk and subsequent development of the disease. This certainly creates a sense of complexity, as factors may be connected on a similar pathway. No one behavior or factor will cause disease X. Rather, the dynamics and synergy of multiple factors may cause disease X onset. Researchers studying the cause of chronic diseases must be cognizant of this in order to not overlook potential connections in the web.
primary prevention
action taken prior to the onset of disease, which removes the possibility that the disease will ever occur
compression of morbidity hypothesis
compress the number of years that you have to suffer until as late as possible; The concept behind the Compression of Morbidity Theory is that public health interventions and treatments should strive to squeeze or compress the time between onset of chronic disease and death. That is, it is in an individual's best interest to increase their healthspan (or years of healthy living) and push back the onset of chronic disease as late into life as possible so as to minimize the number of years of suffering and poor health. The theory is not implicating that we can completely eliminate chronic disease. Rather, it posits that work can be done to delay the age in which an individual must begin to suffer from these arguably inevitable diseases. Not only does the field of chronic disease prevention want to limit the incidence of chronic disease, but researchers also want to recognize that, in some cases, onset is inevitable. In such cases, it is optimal to limit the amount of time individuals have to live with the diseases. This is true not only in regards to limiting human suffering, but also in terms of financial efficiency and resource allocation.
osteoporosis disease definition/ clinical presentation
loss in total mineralized bone [disruption of normal balance of bone breakdown and build up] *NIH definition: Skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture
challenges to study chronic disease
measuring comorbidities
5th stage
more infectious disease
the chronic care model
o A guide to high quality chronic illness management within primary care Goal: The overarching purpose of this model is to serve as a guide to the proper management of chronic illness care and practice improvement within primary care. o Components: •Community resources and policies •Health care organization •Self-management support •Delivery system design •Decision support •Clinical information systems
descriptive epidemiology
o Describe the burden of diseases o Surveillance efforts o Describe according to person, place, time •Person-level characteristics •Geography? •Time-trends?
epidemiologic "assumptions"`
o Disease doesn't occur in a vacuum o Disease is not randomly distributed throughout a population o Epidemiology uses systematic approach to study the differences in disease distribution in subgroups o Allows for study of causal and preventive factors
goals of US Preventive Services
o Improve understanding of the U.S. Preventive Services Task Force (USPSTF or Task Force) o Explain the connection between the USPSTF and the Agency for healthcare research and quality (AHRQ) o Describe how the task force develops recommendations o Highlight opportunities for public input
component causes
o Individual exposures which are necessary for the completion of a sufficient cause o One piece of the causal pie o Chronic diseases are multifactorial in nature • Combined they will constitute a sufficient cause
sufficient causes
o Inevitably initiates or produces the disease o Individual exposures are very rarely sufficient causes • Rabies virus and death • Measles virus and measles o More commonly sufficient causes are thought of as a combination of component causes without any one of which the disease would not have occurred
necessary causes
o a component cause that is a member of every sufficient cause o must always precede the disease o this effect need not be the sole result of the one exposure o EX: Tubercle bacillus necessary for development of tuberculosis
osteo risk factors
o age, estrogen deficiency, family history, female, race, low calcium/ vit D, smoking, alcohol, hyperthyroidism, liver and renal • women 5X more likely → lose bone mass rapidly after menopause
infectious + nutritional etiology of chronic disease
o macronodular cirrhosis o hetaocellular carcinoma o rheumatic heart disease o iron deficiency anemia •related to nutritional deficiency o goiter o diabetes
key messages of life course epidemiology
o there are social processes which drive trajectories o there are critical periods o exposures tend to cluster in sub-populations o exposures accumulate over time o all of the above influence the biological processes of disease causation (risk)
causal framework
o what exposure if removed, reduced, and/ or controlled would reduce the frequency of the outcome and/ or the burden of disease o induction period: the period required for a specific cause to produce the disease • usually longer with chronic diseases • relevant period of exposure
population mass strategy vs. high-risk strategy
oPopulation mass strategy •Directed at the whole population irrespective of individual risk levels → studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease •Population approach is directed towards socio-economic, behavioral and lifestyle changes oHigh-risk strategy •Aims to bring preventive care to individuals at special risk •This requires detection of individuals at high risk by the optimum use of clinical methods
levels of prevention
pre-primordial, primary, secondary, tertiary, primordial, quarternary
UPSTF scope for clinical preventive services include:
screening test counseling preventive medications
critical periods
there are key times in human development that are vital and can influence risk of disease: biologic development, behavioral patterns, social development
health as a continuum
throughout the life course, health may fluctuate between states of health and states of disease
when does epidemiologic transition occur for a country
when it undergoes modernization from developing nation to developed nation status
stage 1: age of pestilence and famine
•Characterized by: o High birth rates o High mortality rates; large swings in mortality due to epidemics o Very low and variable life expectancy o Little population growth o stage I diseases: black plague, TB, malaria, dysentery, leprosy, puerperal fever, small pox, typhoid fever
birth cohort studies
•Cohort of subject born at a similar time •Repeated surveys of large numbers of individuals from birth and throughout their lives •Measurement of multiple exposures, life events, health metrics, outcomes •1946 British birth cohort: National Survey of Health and Development
key principles of Omran's theory
•Mortality is a fundamental factor in population dynamics •A long-term shift occurs in mortality and disease patterns •The most profound changes in health and disease patterns were among children and young women •The shifts in health and disease are closely associated with the demographic and socioeconomic transition that constituted modernization •There are variations in the transition
what are the barriers to risk factor control?
•Societal transformations •Macroeconomic intervention •Primary care systems for chronic illness •Medical management of chronic illness
determinants of prevention
•Successful prevention depends upon: •Knowledge of causation •Dynamics of transmission •Identification of risk factors and risk groups •Availability of prophylactic or early detection and treatment measures •An organization for applying these measures to appropriate persons or groups •Continuous evaluation of and development of procedures applied
the epidemiologic transition
•a shift occurred in population dynamics related to mortality and disease patterns •Epidemics of infection were replaced by epidemics of man-made diseases and degenerative diseases •SES, mortality, and morbidity are tied together in a system of disease and population dynamics •We cannot view diseases in isolation. It is critical to look at the pattern of disease, not a single disease. •During the epidemiologic transition, a long-term shift occurs in mortality and disease patterns whereby pandemics of infection are replaced by degenerative and man-made diseases
key determinants
•mortality is the key determinant in population growth and population dynamics •mortality has no fixed upper limit •no matter what the birth rate is, people will still die
dependency ratio
•the ratio of the sum of the very young and elderly to the working-age population •DR is now low because fertility rates are down and the elderly population remains small in much of the developing world •This trend will continue for another decade or so •But as increases in life expectancy occur, the proportion of elderly individuals in the population will rise substantially •DR will increase resulting in expenses related to the complications of stroke, diabetes, and myocardial infarction
pathways
•there are pathways or early life events that influence the health trajectory •early life advantages or disadvantages set a person on a trajectory to an important etiologic event or disease exposure which then leads to an increase or decreased risk of disease
