8/1/2019 Items to be covered in todays lecture Status of health and - - PowerPoint PPT Presentation

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8/1/2019 Items to be covered in todays lecture Status of health and - - PowerPoint PPT Presentation

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8/1/2019 Items to be covered in todays lecture Status of health and healthcare in Status of health in the USA DISCLOSURES the USA and globally: Decline in health overall over time Decline in health compared to other nations

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Bonita Stanton, MD Dean, Hackensack Meridian School of Medicine at Seton Hall University July 26, 2019

Status of health and healthcare in the USA and globally: moving forward

DISCLOSURES I have nothing to disclose

  • Status of health in the USA
  • Decline in health overall over time
  • Decline in health compared to other nations
  • Increased health cost in US: overall and compared to peers
  • Expenditures not appropriately targeted to need or related to outcomes
  • Inequities in health by race and ethnicity
  • Why do these differences exist?
  • What are we doing to address these issues?

Items to be covered in today’s lecture

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8/1/2019 2 Status of health in the USA

Decline in Health of U.S. Over Time

 Decline in US health relative to peer nations

  • Life expectancy at birth in the OECD nations in late 1960’s was 70

years; in 2015 had increased to 80 years—gain of 10 years

  • Life expectancy at birth in the US in late 1960s was 71 years—
  • ne year longer than average of all OECD nations; in 2015, life

expectancy in the US was only 78 years, two years shorter than that of the OECD nations (80 years)

  • From 1960’s to 2015, US life expectancy increased by only 7

years—compared to increase among OECD nations of 10 years.

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Decline in US health relative to peer nations, con.

 Life expectancy decreased in USA in 2015, 2016 and

2017.

 Not happened since Great Flu Epidemic in 1916 to 1918.

Decline in health of USA compared to other nations

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Life Expectancy

Data Source: WHO. Infant mortality rate (probability of dying in the first year after birth per 1,000 live births) Mortality and global health estimates. 2015. http://apps.who.int/gho/data/view.main.182 Updated: September 11, 2015. Accessed: October 25, 2016

Life Life exp

  • exp. at

at birth, 201 2013a Inf Infant m mortality, per per 1, 1,00 000 l live births, 201 2013a Percent ent o

  • f pop. age

e 65+ with th tw two or mo more ch chronic cond nditions, 201 2014b Obe Obesity rat ate (B (BMI>30), 201 2013a,

a,c

Pe Percent o

  • f pop. (age

15+ 15+) who are who are dail daily sm smok

  • kers, 201

2013a Pe Percent

  • f
  • f pop

pop. ag age 65+ 65+ Australia ralia 82.2 3.6 54 28.3e 12.8 14.4 Canada ada 81.5e 4.8e 56 25.8 14.9 15.2 De Denmark 80.4 3.5 — 14.2 17.0 17.8 Fr France 82.3 3.6 43 14.5d 24.1d 17.7 Germ Germany 80.9 3.3 49 23.6 20.9 21.1 Ja Japan 83.4 2.1 — 3.7 19.3 25.1 Net Netherlands 81.4 3.8 46 11.8 18.5 16.8 New New Z Zealand 81.4 5.2e 37 30.6 15.5 14.2 Nor Norway 81.8 2.4 43 10.0d 15.0 15.6 Swe Sweden 82.0 2.7 42 11.7 10.7 19.0 Swi Switzerland 82.9 3.9 44 10.3d 20.4d 17.3 Unit United King Kingdom 81.1 3.8 33 24.9 20.0d 17.1 Unit United S Stat ates 78.8 6.1e 68 35.3d 13.7 14.1 OE OECD medi dian 81.2 3.5 — 28.3 18.9 17.0

Select Population Health Outcomes and Risk Factors

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Increased health cost compared to peer nations Expenditures are not appropriately targeted to need or related to outcomes

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Impact of Different Factors on Risk of Premature Death

Health and Social Care Spending as a Percentage of GDP

Percent

Health care spending and Life Expectancy

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Inequities in health by race and ethnicity

Inequities in health by race and ethnicity

  • AA overall death rate 30% higher than whites while all other racial

groups lower than whites.

  • AA death rates higher for 10 of 15 leading causes of death.
  • Overall age‐adjusted death rates hide some significant differences;

(for example, American Indians higher age‐specific death rates than whites ages birth through 54 years, but then evens out)

Racial gaps exist in the USA

(Williams et al. J Health Soc Behav 2013 53: 279‐295)

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Income and Life Expectancy at Age 25, United States

Group White (W) Black (B) W/B

All 1

By Income 2

53.4 48.4 5.0 Poor 49.0 45.5 3.5 Near Poor 51.4 48.0 3.4 Middle Income 53.8 50.7 3.1 High Income 55.8 52.6 3.2 Income Difference 6.8 7.1

Poor = below federal poverty level (FPL); Near Poor =above the FPL but less than twice the FPL; Middle Income = more than twice but less than four times the FPL; High Income = four times the FPL or more. 1National Vital Statistics (Murphy 2000);2 National Longitudinal Mortality Study (Braveman et al. 2010) J Health Soc Behav. Author manuscript; available in PMC 2013 July 16.

Why do these differences exist?

  • Genetic?
  • Environment?
  • Income?
  • Insurance?
  • Physician‐population racial/ethnic

mismatch?

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TRUE: Allele‐based diseases (hemoglobinopathies, degenerative disorders, etc.) more frequent in in‐bred populations. FALSE: “Race Genetics” explains pandemic differences in

  • infant and childhood mortality
  • maternal mortality
  • life expectancy and
  • survival or functional outcome from range of diverse

diseases (myocardial infarction, asthma, diabetes, etc.)

Race and Genetics: Not An Explanation for Health Disparities. Hypertension in Blacks by Country of Residence: Environment matters

Catecholamine response to the stress of disadvantage? Am J Pub Health 1997;87:160‐8.

Advantaged group Disadvantaged group

Cumulative probability of death, by country, by socioeconomic group

Chen et al. 2015 http://economics.mit.edu/files/9922

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Current composition of U.S. population (2016)

  • White Americans are racial majority: ~ 61% population
  • African Americans are largest racial minority: ~ 13%

population

  • Hispanic and Latino Americans are largest ethnic

minority: ~ 18% population

  • Asians are: ~ 5% of the population

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156603/

Under‐represented minorities in medical school

Percent applying: Percent matriculating:

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  • 1950: Doubling time ~50 years
  • 1980: Doubling time~ 7 years
  • 2010: Doubling time~ 3.5 years
  • 2020: Estimated that doubling time will be 73 days

Estimated speed of doubling time of new medical knowledge over time since 1950

Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011; 122: 48–58.

If you could build a new medical school…

What are we doing to address these issues?

Changing the approach to medical education and the health

  • f our population and globe
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VISION

Each person in New Jersey and in the USA, regardless of race or socioeconomic status, will enjoy the highest levels of wellness in an economically and behaviorally sustainable fashion.

Mission

The physicians we train, in their delivery of the highest quality care to all patients, will:

  • Act on their understanding that context, community, and behavior

drive wellbeing;

  • Embrace and model our professional and our university’s Catholic roots
  • f reverence for the human condition, empathy toward suffering,

excellence in medical care, and humility in service;

  • Continue to serve and learn from the engagement of underrepresented

minority populations among students, faculty, staff, and community;

  • Integrate lifelong learning and inquiry into their practice; and
  • Work in communion with scholars and practitioners of other disciplines

to integrate their perspectives, experiences, and tools.

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 Telemedicine: Undermine or fortify patient‐doctor relationship?  Artificial Intelligence: Will not replace human physicians but will change our roles  Virtual and Augmented Reality: Greatly augment teaching platform for students, continuing education, research and patients  Health trackers: Empowering patients and augment patient‐provider dialogue  Genome sequencing: Leading to meaningful personalization of medicine  Expediting drug development: Alternatives to the randomized, controlled trial and explorations of the possibility of simulated trials  Robotics: Great advances in helping the disabled to regain many lost abilities  Nanotechnology: Advances in drug and therapy targeted delivery and detection

Current and near‐future advances in technology

https://medicalfuturist.com/ten‐ways‐technology‐changing‐healthcare

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Our approach

Underlying structure

  • No distinction between basic science and clinical curriculum; basic science content

will be presented in its clinical context with clear medical relevance.

  • Learn within an integrated curriculum in a team‐oriented, collaborative environment.
  • Utilize the best components of different evidence‐based teaching methods for adult

learners (competency‐based, TBL, PBL)

  • Structure curriculum to thrive in modern, technically demanding, clinical settings

The importance of community

  • Health and wellness occur in the community, not in the hospital
  • Through immersive and longitudinal experiences, students understand roles of

individual, community and the clinical context in determining health and wellbeing and disease treatment and prevention.

A curriculum that respects our students dollars and time

  • Three‐year core curriculum, meeting rigorous, standardized

learning outcomes.

  • Complemented in the fourth year by a self‐directed,

personalized, individualization of the SOM experience.

  • Choose from a variety of options including dual degrees,

research‐intensive concentrations, clinical immersion, global health concentration, community‐based projects, innovation programs or early entry into residence.

Our approach cont’d

Individual Learning Plan Meetings

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The Human Dimension: Structure

  • Initial immersive experience
  • Longitudinal 3 year course
  • Pairs of students matched to a panel of ~3 families
  • Groups of 6‐8 students supervised by 1 faculty
  • 1st and 3rd year students will follow the same panel, providing

vertical continuity

The Human Dimension: Goals

Students will

  • Understand context in which individuals, families, and communities living

and making decisions

  • Help families navigate healthcare system
  • Understand critical impact of community and context on wellness and

disease

  • Provide benefit to families and communities
  • Recognize the enormous gift they are receiving from these families and

communities

Homeostasis and Allostasis

  • Cardiac
  • Pulmonary
  • Renal

Immunity and Infection

  • Immunology, ID, Rheumatology
  • Cancer
  • Hematology
  • Dermatology (but also

longitudinal) Neurosciences and Psychiatry

  • Integrated

Nutrition, GI, Metabolism

  • Significant inclusion of

biochemistry

  • Nutrition as a longitudinal thread

The Developing Human

  • Endocrine, Reproduction
  • Reintegration of genetic

mechanisms

  • Life stages‐ Pediatrics & Geriatrics

Sciences/Skills/Reasoning Phase 1b Course Modules

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Health Systems Content: Factors impacting health

  • utcomes beyond basic and clinical sciences (“3rd Pillar”)

Part 1: Structure and Function of Health Systems

How healthcare systems and systems that affect health are structured; how they work; what are the drivers in a system.

Part 2: Information and Data

How to understand, use, and generate information and data

Part 3: Systems‐based Practice

The practice of medicine and the promotion of health (or disease) occur within a

  • system. What are those systems, and how can they be created to promote health

(or disease) for all.

Phase 2

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Phase 3 ‐ Individualization

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QUESTIONS?