Urban Health: Public Health Lessons from Los Angeles .


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Urban Health: Public Health Lessons from Los Angeles. Wharton School of Business October 18, 2007. Jonathan E. Fielding, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. County Department of Public Health. Los Angeles County – Background. 4,300 square miles
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Urban Health: Public Health Lessons from Los Angeles Wharton School of Business October 18, 2007 Jonathan E. Handling, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. Region Department of Public Health

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Los Angeles County – Background 4,300 square miles 89 consolidated urban communities and 2 islands 9.9 million inhabitants (more than 42 States) 46% Latino, 32% White, 13% Asian/Pacific Islander, 10% African American, 0.3% American Indian Over 100 distinct dialects talked by huge size populaces 15% living in destitution (14% of families & 24% <18) 22% of grown-ups & 8% of youngsters have no medical coverage

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Why Should We Care About Urban Health? Urbanization speaks to a noteworthy demographic move in mankind\'s history At start of 19 th century 5% of individuals lived in urban zones At end of 19 th century 45% of individuals were living in urban zones Today right around 400 urban areas have pops. > 1 million Studying urban wellbeing obliges us to explore the connection between the urban setting and the dissemination of wellbeing and ailment inside a urban populace Source: Galea & Vlahov. "Urban Health: Evidence, Challenges, and Directions." Annual Review of PH, 2005 (26).

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Determinants of Health in Urban Areas Characteristics of the urban environment that influence populace wellbeing Access to wellbeing and social administrations Physical environment Land utilize and group plan Pollution Housing Water Social environment Poverty Social attachment Education openings Source: Galea & Vlahov. "Urban Health: Evidence, Challenges, and Directions." Annual Review of PH, 2005 (26).

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South Los Angeles: Poor inhabitants Crowded however much lower thickness than mid-West and every drift urban areas Fewer people group assets, (for example, greenspace, nourishment outlets, ERs/injury focuses) Los Angeles rural areas: Higher wage occupants Housing thickness lower than internal city More people group assets (parks, supermarkets & eateries, clinics) What Is Urban Health? Urban zone is regularly described by thick internal city encompassed by less thick rural areas

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Leading Causes of Death Based on Crude Mortality, Los Angeles County, 2004

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Leading Causes of Premature Death (Before age 75) - Los Angeles County, 2004

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Leading Causes of Disability-Adjusted Life Years (DALYs) in Los Angeles County, 1998

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Leading Causes of Death & Premature Death For Males in LA County, 2004

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Leading Causes of Death & Premature Death For Females in LA County, 2004

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How We Can Approach Disease Level 1 – Treating ailment condition e.g. improving illness administration for diabetes Level 2 – Reducing hazard elements for ailment e.g. enhance sustenance and increment physical action to counteract diabetes Level 3 – Focus on fundamental determinants of sickness e.g. guarantee open doors for individuals to accomplish ideal wellbeing by Supporting hostile to destitution programs so individuals can stand to eat refreshingly Supporting the improvement of greenspaces and stops so individuals can be physically dynamic

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How We Can Reduce the Overall Disease and Injury Burden Level 1 – Treating ailment conditions Pros: not a viable replacement for non-preventable conditions Applying great malady administration can decrease weight of numerous illnesses New therapeutic advances can encourage lessen load Cons: Usually expensive and less practical than dealing with different levels For individuals without standard access to mind, the advantages of restorative advances are minimized

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Effectiveness of Chronic Disease Self-Management Programs Of 780 studies screened, 53 examines contributed information to the arbitrary impacts meta-investigation Data on diabetes, osteoarthritis and hypertension: Self-administration intercessions prompted a measurably and clinically huge pooled impact size of: 1) - 0.36 (95% CI, - 0.52 to - 0.21) for hemoglobin A1c, identical to a diminishment in HgbA1c level of around 0.81%. 2) Decreased systolic circulatory strain by 5 mm Hg (impact measure, - 0.39 [CI, - 0.51 to - 0.28]). 3) Decreased diastolic circulatory strain by 4.3 mm Hg (impact measure, - 0.51 [CI, - 0.73 to - 0.30]). 4) Data on osteoarthritis measurably critical however clinically unimportant for agony and capacity results. Chodosh et al. Meta-investigation: ceaseless ailment self-administration programs for more seasoned grown-ups. Ann Intern Med. 2005;143:427-438.

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ROI From Changes in Employee Health Risks on A Company\'s Health Care Costs Estimate of the effect of corporate wellbeing administration and hazard lessening programs for The Dow Chemical Company utilizing an imminent quantifiable profit (ROI) show Methods: hazard and consumption gauges got from numerous relapse examinations Results: "Earn back the original investment" situation would require organization o diminish each of 10 populace wellbeing dangers by 0.17% focuses every year over course of 10 years Conclusion: comes about bolster proceeded with interests in wellbeing change projects to accomplish chance decrease and cost reserve funds Goetzel et al. Evaluating the Return-on-Investment from changes in representative wellbeing dangers on the Dow Chemical Company\'s Health Care Costs. J Occup Environ Med. 2005;47:759-768.

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Level 1 – Treating the Disease: Healthcare Spending Financial expense: 16% (~$2 trillion) of U.S. Gross domestic product spent on social insurance in 2005 1 Projected to increment to 20% by 2015 2 U.S. has most noteworthy social insurance spending per capita ($6,700 in 2005), more than twice as high as the middle OECD nation 3 ROI: U.S. medicinal services framework execution positioned #37 in world (out of 191 nations) 4 U.S. positioned #38 th in world in future 5 1 (Catlin et al. 2007, Health Affairs); 2 (Borger et al. 2006, Health Affairs); 3 (Anderson et al. 2007, Health Affairs), (OECD) Organization for Economic Cooperation and Development; 4 (World Health Report 2000); 5 (United Nations: World Population Prospects: 2006 modification)

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Level 1 – Treating the Disease: U.S. Social insurance Expenditures, 1970-2004 Source: Smith, et.al., Health Affairs, 2006

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Level 1 – Treating the Disease: Efficacy of Disease Management 23% of grown-ups in LAC report being determined to have hypertension (2005) percent of grown-ups taking pharmaceutical to lower circulatory strain has expanded from 65% in 1999 to 73% in 2005 24% of grown-ups in LAC report being determined to have elevated cholesterol (2005) just 52% taking prescription to lower cholesterol

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PFP Report – High Impact, Low Cost Clinical Preventive Services Source: Dr. Eduardo Sanchez, PFP (2007)

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PFP Report – High Impact, Low Cost Clinical Preventive Services Source: Dr. Eduardo Sanchez, PFP (2007)

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Actual Causes of Death in the United States in 2000 Deaths Estimated Percentage of Cause No. Total Deaths Tobacco 435,000 18 Diet/action patterns 365,000 15 Alcohol 85,000 4 Microbial agents 75,000 3 Toxic agents 55,000 2 Motor vehicles 43,000 2 Firearms 29,000 1 Sexual behavior 20,000 1 Illicit utilization of drugs 17,000 <1 Total 1,124,000 47 Sources: Mokdad, Marks, Stroup & Gerberding, JAMA 2004 Mokdad, Marks, Stroup & Gerberding, JAMA 2005

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How We Can Approach Disease Level 2 – Addressing the behavioral hazard components for infections Pros: Relatively few hazard figures intensely affect frequency of different ailments Each hazard consider influences numerous sicknesses Preventing illness frequently has much preferable ROI over treating and overseeing malady Cons: Must address both anticipation (to decrease rate) and hazard diminishment (to lessen commonness) Variable proof of viability of mediations by conduct Very huge abberations still exist between different demographic gatherings even after successful intervetions

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Percent of Adults who Smoke Cigarettes by Gender - LA County, 1997-2005

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Level 2 – Addressing Risk Factors: Effect of Smoking Reduction Efforts About half of decrease in coronary illness mortality because of therapeutic medicines, other half because of diminishments in hazard elements 1 NY state prohibition on smoking at worksites connected with 8% drop in healing facility confirmations for heart assaults 2 Similar decays found in urban communities that have executed smoking bans (e.g. Knocking down some pins Green, OH, Pueblo, CO, Helena, MO) One study gauges around 40% of the decrease in male passing rate from lung CA between 1991-2003 because of diminishments in tobacco smoking 3 1 (Ford et al, 2007 NEJM) 2 (Juster et al, 2007 AJPH) 3 (Thun and Jemal, 2006, Tobacco Control)

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Percent of Adults who Smoke Cigarettes by Race - LA County, 1997-2005 Large differences still exist!

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Level 2 – Addressing Risk Factors: Benefits of Regular Physical Activity Life traverse increment: 2 years Risk of Cardiovascular Disease: 40% less Rates of High Blood Pressure and Diabetes: Reduced Risk of bosom & colon malignancy: Reduced Mood and emotional well-being status: Improved Body Mass Index (BMI): Reduced Health mind costs: $300-$400 less every year for grown-ups Cost: low to direct; significant cost can be singular open door cost however fetched changes incredibly Source: Surgeon General\'s Report, 1996

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One Way to Increase PA

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What Are the Combined Effects Of Treatment & Risk Factor Reduction? The best news you never heard Gradual enhancements are not newsworthy Not cutting edge No single intercession to highlight No snappy alter

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Trends in the Leading Causes of Death, Los Angeles County, 1993-2004 * age-acclimated to year 2000 U.S. standard populace

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Behavioral Causes of Death - 2000 Source: Schroeder, NEJM, 9/20/07

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Life Expectancy at Birth by Sex & Race/Ethnicity - LA County, 2000 Life hope in LA County expanded by approx 2.6 years from 1991 to 2000 Source: 1991 PEPS and Census 200

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