ESTABLISHING HEALTH INTERVENTION PRIORITIES FOR LOCAL PUBLIC

HEALTH AGENCIES

Alexandre Klementievaklementiev@tpchd.org

Tacoma-Pierce County Health Department, WA

GOAL 2

“To identify three broad-based, behavioral risks to health which, if reduced, will offer a tangible reduction in the burden of preventable illness and death in the Pierce County population*.”

j* Tacoma - Pierce County Health Department Strategic Plan, 1996-2000 (Tacoma, WA)

This presentation demonstrates the method designed for identification of the leading behavioral risks to health.

If these risks were reduced, the method would allow to estimate the resulting reduction in the burden of preventable illness and death.

GOAL 2 (contd)

RISK FACTOR

If a disease/cause of death (D) is more common among those with a certain characteristic (C) than among those without it, then there is an association between C and D.

If C occurs, or is present, prior to D, the characteristic C is a risk factor for the disease (cause of death) D.

C

is

present

C

is not

present

D

D

D

D

D

D

D

D

D

BURDEN OF HEALTH RISK

The burden of a health risk is composed of:

Disabled years lived with preventable

illnesses (morbidity component)

Deaths associated with specific risk

behaviors (mortality component)

FROM ROUTINELY COLLECTED HEALTH DATA TO MILLER’S INDEX

In 1970, J.E.Miller offered the Q-index which allows integrating of morbidity and mortality data, so that a fairly consistent ranking of the classes of disease could be made.

Q-INDEX: DEFINITION

Qk = (MTk/MRk)*Pk*Dk

+ 100,000*Ak /365 /N

+ 100,000*Bk /(3*365)/N

Q-INDEX: DEFINITION (contd)

MTk (MRk) : age-/sex- adjusted mortality ratein target (reference) population;

Pk : years of life lost due to premature death,average per one death;

Dk : crude mortality rate;Ak : number of inpatient days, per year;Bk : number of outpatient visits, per year; N : size of the target population.___________________________________________________________________________________________________________________________

k indicates disease/cause of death.

Q-INDEX: DISCUSSION

Q-index provides a rationale for combining mortality and morbidity components in a single index number which is used for ranking

This rank pertains to a given class of disease/cause of death

In reality, the risk factor is associated with more than one class of disease/cause of death

FROM Q-INDEX TO THE RISK PRIORITY INDEX

The Q-index cannot be used for prioritizing health programs when those programs pertain to the behavioral health risks associated with multiple classes of diseases

VISUALIZING HEALTH RISK

Mor

bid

ity

Eff

ect

Mortality Effect

A

B

D

C

F

JDIS

JDTH

RISK PRIORITY INDEX: DEFINITION

The Risk Priority Index (RPI) is defined as the sum of all partial impacts of the health risk of interest on the population health.

Partial impacts of diseases and deaths in RPI are measured with the use of the Q-index.

CALCULATING RPI

The method of calculating the RPI components depends on the availability of relevant data

The direct method is based upon data collected on relative risks and prevalence pertaining to the risk factor of interest, along with mortality, bed-days, and the outpatient visits

If some of the data for the direct method is unavailable, experts best estimate can be used for the lacking data

CANDIDATE RISK FACTORS

1. Violence/Firearms 8. Alcohol misuse 2. Physical inactivity 9. Air quality

3. Food quality 10. Tobacco use

4. Water quality 11. Dietary habits

5. Unsafe sexual behavior 12. Hazardous waste

6. Seat belt use 13. Workplace hazards

7. Cycle helmet use 14. Immunization levels

TOBACCO LIST

There are 25 entries in Tobacco List. Among them:

ICD CodeLip, oral cavity, pharynx (140-149)Esophagus (150)Pancreas (157)Larynx (161)Trachea, lung, bronchus (162)more ...

TOBACCO: RPI

Each year in Pierce County::

1,072 deaths are associated with tobacco smoking

The equivalent of 3,275 person-years are lost prematurely due to the causes associated with tobacco smoking

TOBACCO: RPI (contd)

One third of all hospital bed days can be attributed to the effects of tobacco use

Residents spend the equivalent of 53 years in Pierce County hospitals due to illnesses related to tobacco

About 53,000 outpatient visits are associated with cigarette smoking

effects

DIETARY FACTORS AND ACTIVITY PATTERNS (DFAP) LIST

Heart diseases

Cerebrovascular diseases

Cancers

Diabetes

DIETARY FACTORS AND ACTIVITY PATTERNS: RPI

Each year in Pierce County:

889 deaths are associated with dietary factors and activity patterns (DFAP)

2,615 years of potential life are lost due to diseases associated with DFAP

Approximately 11,680 bed-days and 3,300 outpatient visits are associated with illnesses related to DFAP

ALCOHOL LIST

There are 36 entries in Alcohol List. Among them:

ICD Code Lip/oral cav/pharynx (140-149)Esophagus (150)Stomach (151)Liver (155)Larynx (161)Alcoholic psychoses (291)more ...

ALCOHOL MISUSE: RPI

Each year in Pierce County:

275 deaths are associated with alcohol misuse

3,793 years of potential life are lost inassociation with alcohol misuse

Approximately 13,400 bed-days and 48,700 outpatient visits are associated with illnesses related to alcohol misuse

FIREARMS LIST

ICD CodeUnintentional firearms E922Suicide by firearms E955.0 - E955.4Assault by firearms E965.0 - E965.4Legal, other firearms E970, E985.0 - E985.4

VIOLENCE WITH FIREARMS: RPI

Each year in Pierce County:

95 people die from a firearm wound 2,679 years of potential life are lost Equivalent of 2 years are spent in

hospitals

UNPROTECTED SEX LIST

ICD CodeHIV, sexually acquired (042)

Hepatitis B infection, sexually acquired (070.2, 070.3)

Syphilis and other venereal diseases (090 - 099)

Trichomoniasis (131)

Cervical cancer (fem) (180)

UNPROTECTED SEX: RPI

Each year in Pierce County:

54 people die from diseases associated with unprotected sex

1,512 years of potential life are lost The equivalent of 8 years are spent

in hospitals

RISK PRIORITY INDEX:CALCULATION RESULTS

Tobacco DFAP Alcohol Firearms Sex

_________________________________________________________________________________________________________________________________________________________

__ Deaths 1,072 889 275 95 54

_________________________________________________________________________________________________________________________________________________________

_ YPLL/Mort. 3,275 2,615 3,800 2,680 1,500

_________________________________________________________________________________________________________________________________________________________

__ Bed-days 19,000 11,680 13,400 760 2,900 _________________________________________________________________________________________________________________________________________________________

_ Outp.vsts 53,000 3,300 48,700 N/A 200

Losses pertaining to risk behaviors(per one year, Pierce County population)

RISK PRIORITY INDEX

0

200

400

600

800

1,000

1,200

0 20 40 60 80 100 120

Deaths and YPLL/Morbidity

Tobacco

Alcohol

DFAP

Microbial

Firearms

Unprotected sex

Years of Potential Life Lost / Morbidity

Dea

ths

RISK PRIORITY INDEX

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

0 20 40 60 80 100 120

Firearms

YPLL/Mortality and YPLL/Morbidity

Years of Potential Life Lost/Morbidity

Yea

rs o

f P

oten

tial

Lif

e L

ost/

Mor

talit

y

Unprotected sex

Microbial

Dietary Factors/Activity Patterns

Alcohol

Tobacco

FROM THE RISK PRIORITY INDEX TO THE HEALTH INTERVENTION

PRIORITY INDEX

The RPI cannot be used for establishing priorities of health interventions

The Health Intervention Priority Index accounts for the partial reduction of the health risks

HEALTH INTERVENTION PRIORITY INDEX: DEFINITION

The Health Intervention Priority Index (HIPI) is the quantitative measure of improvement of the population health caused by implementation of the health intervention

The improvement is measured in person-years of life saved

TOBACCO: HIPI

It was assumed in this study that the relative reduction of smokers in Pierce County by 40% (from about 25% down to 15%) is an achievable goal.

As a result: 240 deaths would be prevented 858 person-years of life would be

saved

DIETARY FACTORS AND ACTIVITY PATTERNS: HIPI

It was assumed in this study that relative reduction of the aggregated risk factor associated with dietary factors and activity patterns by 15% is an achievable goal.

As a result: 134 deaths would be prevented 253 person-years of life would be saved

ALCOHOL: HIPI

It was assumed in this study that the relative reduction of the aggregated risk factor associated with alcohol misuse by 20% is an achievable goal.

As a result: 55 deaths would be prevented 775 person-years of life would be saved

FIREARMS: HIPI

A 15% relative reduction of the aggregated risk factor associated with firearms was assumed in this study as an achievable goal.

As a result: 14 deaths would be prevented 402 person-years of life would be saved

UNPROTECTED SEX: HIPI

A 10% relative reduction of the aggregated risk factor associated with unprotected sex was assumed in this study as an achievable goal.

As the result: 5 deaths would be prevented 160 person-years of life would be saved

ANTICIPATED REDUCTION OF DEATHS AND YPLL

Tobacco DFAP Alcohol Firearms Sex ___________________________________________________________________________________________________________________________________________________

Risk Reduction 40% 15% 20% 15% 10%

___________________________________________________________________________________________________________________________________________________ Deaths 240 134 55 14 5

__________________________________________________________________________________________________________________________________________________ YPLL/Mortality 832 248 759 402 151

___________________________________________________________________________________________________________________________________________________ YPLL/Morbidity(Inpatient) 14 5 7 0.3 0.8 ___________________________________________________________________________________________________________________________________________________ YPLL/Morbidity(Outpatient) 12 0.5 9 - -

HEALTH INTERVENTION PRIORITY INDEX: DEATHS VS. YPLS/TOTAL

S

Years of Potential Life Saved (Total)

Dea

ths

150 300 450 600 750 900

125

250Tobacco

Alcohol

DFAP

Firearms

Unprotected Sex

HEALTH INTERVENTION PRIORITY INDEX: YPLS/MORTALITY VS. YPLS/MORBIDITYY

ears

of

Pot

enti

al L

ife

Sav

ed (

Mor

bid

ity)

Years of Potential Life Saved (Mortality)

150 300 450 600 750 900

Tobacco

Alcohol

DFAPFirearms

Unprotected Sex

6

24

18

12

CONCLUSION

The 3 leading behavioral risks to health in Pierce County are: TobaccoAlcoholFirearms

Reduction in the burden of preventable illness and death is estimated.