Why is Population Health Important to Academic Medicine? Paul R. Marantz, MD, MPH Professor, Department of Epidemiology and Population Health Co-Director,

Why is Population Health Why is Population Health Important to Academic Important to Academic

Medicine?Medicine?

Paul R. Marantz, MD, MPHPaul R. Marantz, MD, MPHProfessor, Department of Epidemiology and Population Professor, Department of Epidemiology and Population

HealthHealth

Co-Director, Institute for Public Health Sciences of Yeshiva Co-Director, Institute for Public Health Sciences of Yeshiva UniversityUniversity

Associate Dean for Clinical Research EducationAssociate Dean for Clinical Research Education

Albert Einstein College of Medicine, Bronx, NYAlbert Einstein College of Medicine, Bronx, NY

What is population health?What is population health?

Consider Dr. Nash’s definitionConsider Dr. Nash’s definition A focus on the denominator instead of, A focus on the denominator instead of,

or in addition to, the individual patientor in addition to, the individual patient

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What is “academic medicine”?What is “academic medicine”?

Education/trainingEducation/training ResearchResearch

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What is “important”?What is “important”?

Sometimes in academic medicine, Sometimes in academic medicine, “important” means interesting“important” means interesting

In this context, “important” means In this context, “important” means relevant, and leading to improved health relevant, and leading to improved health outcomesoutcomes

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Teaching and research in Teaching and research in population health is important population health is important

in several ways:in several ways:

Research provides the knowledge base that Research provides the knowledge base that informs public health policy and preventive informs public health policy and preventive medical practicemedical practice

Education and training provides trainees with Education and training provides trainees with the requisite knowledge, skills, and attitudes the requisite knowledge, skills, and attitudes to effectively perform their roles, includingto effectively perform their roles, including- cliniciansclinicians- policy makerspolicy makers- researchersresearchers- educatorseducators- administratorsadministrators 5

Population health researchPopulation health research

Informs clinical decision making, Informs clinical decision making, especially in preventionespecially in prevention

Informs public health policyInforms public health policy

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Preventive medicinePreventive medicine

Applies the results of population-based Applies the results of population-based data and rigorous clinical studies to data and rigorous clinical studies to individual patientsindividual patients

Clinical experience is Clinical experience is notnot sufficient – or sufficient – or in many cases, not even relevantin many cases, not even relevant- Example: if a patient is found to have a Example: if a patient is found to have a

high PSA, has a resection of a localized high PSA, has a resection of a localized prostate Ca, and survives: did screening prostate Ca, and survives: did screening save his life?save his life?

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Beta-carotene supplementationBeta-carotene supplementation

Was thought to lead to reduced risk of Was thought to lead to reduced risk of cancer (anti-oxidant)cancer (anti-oxidant)

Was found in 2 randomized trials to Was found in 2 randomized trials to increaseincrease lung cancer rate by 20% in lung cancer rate by 20% in smokerssmokers

33rdrd trial in non-smokers showed no trial in non-smokers showed no effecteffect

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Public health policyPublic health policy

The best available evidence is used to The best available evidence is used to develop approaches to improving health develop approaches to improving health and preventing diseaseand preventing disease- Smoking restrictionsSmoking restrictions- Seat belt useSeat belt use- Dietary guidelinesDietary guidelines

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Reducing dietary fat consumptionReducing dietary fat consumption

Consistent dietary recommendation Consistent dietary recommendation (since about 1980): reduce % calories (since about 1980): reduce % calories from fatfrom fat

““Goal” achieved over time: significant Goal” achieved over time: significant reduction in % total calories from fatreduction in % total calories from fat

How was this achieved? What was the How was this achieved? What was the consequence?consequence?

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ORIGINAL ‘FOOD PYRAMID’

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Fat intake and overweight in womenFat intake and overweight in women

61.7

51.2

41.1 42

32.833.43636.1

0

20

40

60

80

100

1971 1976 1981 1986 1991 1996 2001

Y ear

Percent

% overweight or obese % total calories from fat

Marantz PR, Bird ED, Alderman MH. Marantz PR, Bird ED, Alderman MH. Am J Prev MedAm J Prev Med 2008 Mar;34(3):234-40. 2008 Mar;34(3):234-40. 12

Dietary changes in women (%)Dietary changes in women (%)

32.8

51.650.645.4 46

36.1 36 33.4

0

20

40

60

80

100

1971 1976 1981 1986 1991 1996 2001Year

% calories from carbohydrates % calories from fat

Marantz PR, Bird ED, Alderman MH. Marantz PR, Bird ED, Alderman MH. Am J Prev MedAm J Prev Med 2008 Mar;34(3):234-40. 2008 Mar;34(3):234-40. 13

Dietary changes in women (absolute)Dietary changes in women (absolute)1877

1798

1542 1522

969910

700 700

616601548557

0

500

1000

1500

2000

1971 1976 1981 1986 1991 1996 2001Year

Age-adjusted caloric intakeAbsolute carbohydrate intake

Absolute fat intake

Marantz PR, Bird ED, Alderman MH. Marantz PR, Bird ED, Alderman MH. Am J Prev MedAm J Prev Med 2008 Mar;34(3):234-40. 2008 Mar;34(3):234-40. 14

How good is the evidence base How good is the evidence base for dietary guidelines?for dietary guidelines?

Largely based on indirect evidence and Largely based on indirect evidence and inferenceinference

New research, and perhaps novel New research, and perhaps novel research methods, neededresearch methods, needed

For now, new guidelines issued and For now, new guidelines issued and food pyramid revisedfood pyramid revised

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ORIGINAL ‘FOOD PYRAMID’

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Education/training in population Education/training in population healthhealth

Clearly important for those practicing Clearly important for those practicing population health (e.g., public health population health (e.g., public health officials, health plan administrators)officials, health plan administrators)

Also important for “personal encounter Also important for “personal encounter physicians,” since population health physicians,” since population health concepts translate to clinical decision concepts translate to clinical decision making and patient counselingmaking and patient counseling

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POPULATION HEALTH CONCEPTS CAN BE UNDERSTOOD BY PATIENTS

AND PHYSICIANS

Published 9.16.2007

Article by Gary Taubes

(excellent overview of research methods in population health)

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What did Dr. Thompson mean?What did Dr. Thompson mean?

Was asked in an unscientific survey, N Was asked in an unscientific survey, N of 5: 2 practicing physicians, 2 of 5: 2 practicing physicians, 2 professors of medicine, 1 administratorprofessors of medicine, 1 administrator

All said: “early detection saves lives”All said: “early detection saves lives” Same question posed to a professor of Same question posed to a professor of

epidemiology and a medical studentepidemiology and a medical student Both said: “lead time bias”Both said: “lead time bias”

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The importance of population The importance of population health (academic context)health (academic context)

Research needed to inform policy and Research needed to inform policy and practicepractice

Practitioners need to be able to apply Practitioners need to be able to apply denominator-based thinking to patient denominator-based thinking to patient carecare

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