Midterm Flashcards
(188 cards)
1
Q
Population Health
A
the health outcomes of a group of individuals, including DISTRIBUTION of such outcomes
2
Q
Studying Population Health
A
look at patterns of determinants
look at outcomes and quality
direct policy and research agendas
3
Q
Who is responsible for overall health improvement
A
No on in the public or private sector currently has responsibility for overall health improvement
4
Q
Factors that impact individual patients
A
location
insurance coverage
rare disease
language barriers
5
Q
Examples of Population Health
A
rural vs urban
age
race
education levels
levels of health literacy
employees
6
Q
Parts of the Care Continuum
A
Health Promotion, Wellness
Health Risk MGMT
Care Coordination/Advocacy
Disease/Case MGMT
7
Q
Program Outcomes: Care Continuum
A
Psychosocial Outcomes
Behavior Change
Clinical and Health Status
Productivity
Financial Outcomes
8
Q
Goals of Pop Health
A
set targets for overall population
maintain and improve health of entire population
eliminate or significantly reduce deficiencies and disparities between subgroups
9
Q
Healthy People 2020 Findings
A
Poor or Near Poor families did not meet target objectives, however improved or no detectable change
Middle-High income met target, but had statuses that got worse
10
Q
Healthy People 2030 includes _____ core or measurable objectives as well as developmental and research
A
355
11
Q
Healthy People 2030 Objectives
A
health conditions
health behaviors
populations
SDOH
12
Q
Relevance of Health Outcomes
A
relevance to policy makers and payers in both the private sector due to cost (of healthcare) an productivity (healthier people = more productivity)
13
Q
Types of Groups in Healthy People 2030
A
Adolescents/Children/Infants/Older People
LGBTQ
Parents and Care givers
Men/Women
People with Disabilities
Workforce
14
Q
Definition of Health
A
the capacity of people to adapt to, respond to, or control life’s challenges and changes
15
Q
What is the greater focus of improving pop health?
A
SDOH
no amount of medical attention will help decrease the likelihood of someone developing T1DM or RA, yet both are more common in lower socioeconomic groups
16
Q
Source of Potential Conflict within Pop Health
A
self interest of the individual vs the common good
ex: PAs, what is best for the pop isn’t what is best for the individual patient
17
Q
Foundations of Pop Health: Descriptive Epidemiology
A
burden, course, and distribution of disease/injury
18
Q
Foundations of Pop Health: Health Research Evaluation
A
Comparative Effectiveness Research (CER)
aims to produce the type of evidence that will assist all parties to make informed decisions to improve heath care at both the individual and population levels
19
Q
Foundations of Pop Health: Evidence Based Practice
A
assessing the evidence using nationally recognized gu8idelines
20
Q
Foundations of Pop Health: Implementation of Health Promotion and Disease Prevention Interventions
A
Target Audience for Direct Interventions
21
Q
Foundations of Pop Health: Determinants of Health
A
impact of social factors on individual behaviors
income, education, employment
22
Q
Foundations of Pop Health: Pop Health Informatics
A
collection of pop health data to assess population health, guide the provision of healthcare services and analyze health outcomes
23
Q
Foundations of Pop Health: Evaluation
A
process, quality, and outcomes assessments
decision analysis
quality improvement processes
24
Q
Claims Data
A
easy to obtain, standardized, diagnosis codes
25
Electronic Health Record Data
provides clinical clues; ease of grouping patients
26
Socioeconomic Data
Not frequently linked with EHR data
27
Patient Generated Health Data
satisfaction surveys; patient reported outcomes
28
prescription and medication adherence data
EHR and claims data
29
Examples of Pop Health Outcomes
life expectancy
mortality
premature death
cost burden
access to care
QOL indicators
quality of care indicators
unhealthy days
% reporting fair to poor health
% reporting mentally unhealthy
30
US life expectancy comparision
Ranked 45 with LE of 77 yoa
infant mortality is 5.8%
maternal mortality is 10%
31
Costs and Life Expectancy in the US
The US has a lower life expectancy than the comparable country average and pays double for health care
32
Drops in life expectancy causes
covid (3rd most common cause of death in 2020)
opioid overdose
33
Cause of Child Mortality in the US
Firearms
34
Population Health Mangement
optimizes health outcomes for a specific segment of a population (location, age, income, illness)
35
Goals of population health mgmt
preventative health
manage chronic diseases
reduce healthcare costs
36
Population Health Framework
strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with, and targeted interventions for the population
37
Goal of Pop Health Framework
maintain or improve the physical and psychosocial well-being of individuals through cost-effective tailored health solutions
38
States with the Highest Drug Overdose Deaths Rates
OH
PA
KY
WV
DE
MD
DC
Ct
MA
NH
39
Which opioid is involved with the highest percentage of deaths in the last 10 years
synthetic opioids other than methadone
40
Difference Between Pop Health and Public Health
public health has been understood by many to be the critical function of state and local health departments such as preventing epidemics, containing environmental hazards, and encouraging healthy behaviors
major pop health determinants like healthcare, education, and income remain outside of public health authority
41
Pharmacoeconomics
description and analysis of the cost and consequences of pharmaceuticals and related services
process of identifying, measuring, and comparing the costs, risks, and benefits of programs, services, or therapies
determining the outcomes from the perspective of the patients, the healthcare system, or society
42
Why is pharmacoeconomics important?
healthcare costs increasing
healthcare outcomes are declining in the US
drugs are (and will continue to be) expensive
trade off considerations on how to spend resources
43
Four Types of Costs
direct medical costs
direct non-medical costs
indirect costs
intangible costs
44
direct medical costs
medical costs for providing treatment
ex: cost of medication, physician visits, hospitalizations
45
direct non medical costs
costs to the patient/family directly associated with treatment, but not medical in nature
cost: cost of transportation to clinic, babysitter, food/lodging if out of town
46
indirect costs
costs that result from loss of productivity because of illness or death
do not involve a transfer of money
ex: missed work or school days, decreased productivity
47
intangible costs
costs of pain, suffering, anxiety, or fatigue due to an illness or treatment of an illness
difficult to measure and assign value
48
Perspective in Pharmacoeconomics
Describes whose costs are relevant based on the purpose of the pharmacoeconomic study
49
Four Types of Pharmcoeconomic Analyses
Cost Minimization Analysis (CMA)
Cost Benefit Analysis (CBA)
Cost Effectiveness Analysis (CEA)
Cost Utility Analysis (CUA)
50
Cost Minimization Analysis
used to compare costs of interventions with equivalent clinical outcomes
generic vs brand name
drug a vs drug b assuming equal efficacy and safety
51
CMA Measurement Unit
dollars
52
CMA outcome measurement
not measured, assumed to be equivalent
53
CMA advantages
simplicity
no assessment of outcome
54
CMA disadvantages
only useful when outcomes are equal
55
Cost Benefit Analysis
measures costs of interventions and outcomes in monetary units
determines which intervention provides best monetary benefit (can be used to compare different drugs or services for different outcomes)
must assign monetary outcome to clinical endpoint (how much does it cost to lower BP by _____ mmHg)
56
CBA cost measurement unit
dollars
57
CBA outcome measurement unit
dollars
58
CBA advantages
allows comparisons of interventions with different outcomes
59
CBA disadvantages
requires assigning monetary value to pain, suffering, life
60
Cost Effectiveness Analysis
measures outcomes in natural health units (infections cured, lives saved, number of life years saved)
Determines which intervention achieves a given object at the lowest cost
most common type of analysis
61
CEA Comparisons
Want: Equal cost, more effective, lower cost equally effective, or lower cost more effective therapies
62
Incremental Effectiveness Ratio
additional cost required to obtain the additional effect gained by switching from Drug A to Drug B
ICER = (total cost of drug a - total cost of drug b)/(outcome of drug a - outcome of drug b)
63
CEA cost measurement unit
dollars
64
CEA outcome measurement
natural health unit
65
CEA advantages
outcomes measured in unit that are understandable to many clinicians
no need to convert outcomes into dollar amount
66
CEA disadvantages
outcomes must be measured in same units
length of life is not the same as quality of life
67
Cost Utility Analysis
measures outcomes in terms of the quality of the outcome produced
Examines cost of an intervention and the value of the outcome (Value= Cost + Quality)
referred to as utility units (patient preferences or functional status)
68
QALY
takes into account both the quantity and the quality of life generated by healthcare interventions
Drug A: 4 years in health state 75% = 3 QALYs
Drug B: 4 years in health state 50% = 2 QALYs
Perfect Health: 1 Utility Score
Breast Cancer: 0.80 Utility Score
Death: 0.0 Utility Score
69
CUA Measurement Unit
dollars
70
CUA outcome measurement
QALY or other utility measure
71
CUA advantage
accounts for quality and quantity
72
CUA disadvantage
not a precise measure
viewpoint may bias outcome measures
73
Role of a Pharmacist
evaluating pharmacoeconomic literature
applying results to clinical decision
assist in the design and implementation of research studies
74
Evaluating Studies
evaluate the question (should be clearly stated)
determine the perspective (should be clearly stated)
alternatives (treatments should be comparable
study design (explicit details need to be provided)
types of analysis conducted (is the title consistent with the methods)
all important and relevant costs and outcomes included
any important costs or consequences not included
was discounting utilized appropriately
are all assumptions stated
summary/conclusion
75
Pharmacoepidemiology
study of the use, risks, and benefits of drugs in populations
the study of utilization and effects of drugs in large numbers of people
76
pharmacovigilance
continual monitoring for unwanted effects and other safety-related aspects of marketed drugs
77
comparative effectiveness research (CER)
determining what therapeutic intervention (not just drug products) works best for a given disorder in a patients likely to be seen in clinical practice
78
pragmatic research
studies (often using randomization) that often test small practical changes that could have an impact on health outcomes
79
experimental
RCTs (active treatment, usual care, pragmatic)
80
non-experimental (observational)
case control
cohort
others
81
Pharmacoepidemiologic and pharmacovigilance studies are primarily what?
observational
82
examples of pharmacoepi studies
studies to provide estimate of probability of beneficial effects in populations, or probability of adverse effects in populations
83
Pharmacoepi and premarketing studies
supplements information from premarketing studies
better quantify ADRs and beneficial effects
higher precision
can include populations not well represented
can study effects of other drugs/disease states
can study effects relative to other drugs for same indication
84
Identifying New Info using Pharmepi
new info not available from premarketing studies
previously undetected ADRs/beneficial effects
patterns of drug utilization
effects of varied doses
economic impact of drug use
reassurance of drug safety
ethical and legal obligations
85
data sources for pharmepi
adverse drug reaction reports
medical claims data (private, government, insurance providers, third party vendors, diagnostic, procedure, lab, rx codes with basic patient information)
EMR
86
____ data sources and ______ computational abilities have more rigorous pharm epi studies possible
richer, more robust
increased
87
Indiana Network for Patient Care (INPC)
> 100 separate healthcare entities providing data including:
major hospitals, health networks, and insurance providers
data on > 18 million pts
clinical observation
encounter records
mineable text
prescription drug data
percent of residents who have touched the INPCR has grown to 2/3 or indiana's pop
88
Bias
systematic deviation from the truth that distorts the results of research
89
confounding
relationship between treatment and response (or exposure and disease) is actually attributable to another variable (the confounder)
90
Information Bias
bias related to information regarding exposure or outcome
includes measurement and/or classification error
91
Detection Bias
specific outcome is diagnosed preferentially in subjects exposed to the agent
may be more likely to look for an AE in someone who is exposed to a drug
92
Confounding by Indication
indication for a drug or severity of disease predicts the use of the drug
occurs when the risk of an event is related to the indication for medication use but not the use of the medication itself
appears when the reason of prescription is associated with the outcome of interest
COXIBs and GI Bleeds
ACEis in preventing MI in pts with HTN (pts with comorbidities may be more likely to get ACEi)
93
Selection Bias
bias related to procedures used to select subjects/influence study participation
due to systematic differences in characteristics btwn those who are selected for the sutdy and those who are not
94
referral bias
reason for encounter is related to drug treatment
95
protopathic bias
exposure of interest is used unknowingly to treat adverse event related to outcome/agent is used for early manifestation of a drug of a disease that has not been diagnosed yet
antipsychotic may be started to treat delirium, but the drug may have effects that contribute to delirium
96
prevalance bias
prevalent cases rather than new (incident) cases are selected
97
Protopathic bias reverse causality
occurs if a particular treatment was started, stopped, or otherwise changed because of the baseline manifestation caused by a disease or other outcome event
drug is initiated in response to first symptom of disease which at this point is undiagnosed
98
lag time bias
proton pump inhibitors and fracture risk
outcome reported by pts and confirmed by medical reports after enrollment
99
immortal time bias
period of follow-up when, due to exposure definition, the outcome being studied could never occur
survival time, transplant studies, hospital stays and mortality
100
Pharmacovigilance
continual monitoring for unwanted effects and other safety related aspects of marketed drugs
historically has involved collection of spontaneous reports of drug related morbidity or mortality
101
Type of Data used in Pharmacovigilance
wider use of observational data conducted across multiple databases, development of large networks of observational databases
post marketing surveillance, single detection, surveillance, data mining
often involves regulatory authorities, industry
102
Pharmacovigilance Examples
V-safe after vaccination
fluoroquinolone (peripheral neuropathy, indications of uncomplicated UTI, sinusitis, bronchitis, cystitis, outcome reported as disability)
103
Types of CER
multiple study designs
- rcts with active treatment arms
- observational studies
patient-centered health research
104
efficacy of CER
whether a drug or treatment ha the ability to bring about a given intended effect in a controlled setting
105
effectiveness of cer
whether in a real-world pts and settings, a treatment in fact achieves its desired effect
106
Goals of CER
to inform decisions on interventions or approaches to healthcare in a real-world setting with regard to their intended and unintended outcomes that are relevant to pts
to put new treatment into proper perspective in relation to older treatment
identify pts who are more/less likely to respond to a given intervention than others
overcome external validity problems with traditional RCTs
107
Pragmatic research
studies (often using randomization) that often test practical changes that could have a big impact on health outcomes
108
pragmatic RCT
a randomized clinical trial with one or more pragmatic elements
include real world pts from diverse background
aspects of care controlled by clinician
include providers from diverse settings
comparators are those used in clinical practice
outcomes matter to clinician and patients
aims to help clinician decide between new intervention and current standard of care
109
What is wrong with our healthcare system?
Too expensive
$13,000 year/person
17% of GNP
110
Average Annual Expenditures Growth Rates for Selected Services
In 2020-2022, retail drug costs made up most of health expenditures compared to hospitals and physicians/clinics
111
Most total national health expenditures are spent on what service?
hospitals (30.4%)
112
Disconnect between ______ , _________, and ______.
What we pay, what we value, and outcomes achieved
pay more for doing more
incentives to produce better health and lacking
life expectancy, infant mortality, maternal mortality, does not measure up
113
US compares ______ to other industrialized countries
poorly
114
Top preforming countries
- provide universal coverage and remove cost barriers
- invest in primary care systems to ensure high value services are equitably available in all communities to all people
- reduce admin burdens that divert time, efforts, and spending on HC improvements
- invest in social services, especially for children and working age adults (access the HCS the least, where we can improve the most)
115
Too much is spent for __________ and at __________ without clear benefit
older patients, end-of-life
116
Those age 18 and younger are the _______ of the total population and utilize the ________ amount of total health spending
majority, least
117
A _______ percentage of the population consume the _______ resources
small, most
118
Why do drug companies charge higher prices?
because they can
119
Lack of ______ with respect to cost in the US
transparency
120
Access issues to healthcare in specific populations
# PCP per 10k patients
poor and rural
geography
average costs of annual health insurance premiums
southeast
121
Equity issues
adults with below average income have poorer access to healthcare, less timely care, and less engagement with providers
122
______ people spend more on healthcare
white
123
population with the highest % of adults who delayed or did not get health or dental care due to cost
Uninsured
hispanic
worse health status
urban (by 1%)
124
too ______ PCPs. _________ distributed, __________ reimbursed
few, poorly, poorly
125
_____ of care coordination in the US
lack
126
Healthcare ________ is very powerful
lobby
127
public health has been historically _______ and thought to be a _______ responsibility
underfunded, local
128
Individualism in the US
most individualistic country on earth
high on indulgence, short term thinking, masculinity
129
most patients are ________ or _________ about their healthcare and associated costs
misinformed, poorly informed
130
Managed Care Organizations
often focus on decreasing utilization of healthcare services and certain medications across the board vs target use
decision makers are not associated with the patient's care
131
Health care costs for employers and employees
increasing costs for both
employers have been shifting more costs to employees (deductibles and co-pays)
132
Waste in the US
unnecessary care
care outside of standards and guidelines
fraud
providers' time due to administrative duties (prior authorizations)
133
How should we measure healthcare?
quality
access
efficiency
equity
healthy lives
134
Who is uninsured?
young, latinx/hispanic, poor, sicker, living in the south
135
Health Insurance: 1920s
some hospitals offered services on pre-paid plan
136
Health Insurance: 1929
first employer-sponsored plan was created by teachers in dallas, TX
137
Health Insurance: 1935
social security act: no health coverage
138
WWII impact on insurance
employer sponsored plans as benefit dramatically expanded as a direct result of wage control
139
Health Insurance: 1946
Hill Burton Act: hospital construction
140
Health Insurance: 1948
president truman proposes national health insurance
141
Health Insurance: 1954
tax deduction for employers in the revenue act
142
Health Insurance: 1965
Medicare, Medicaid, self employed who had to buy their own insurance through exchanges (ACA)
143
Goals of the ACA
improve accessibility to coverage
decrease the number of uninsured
improve efficiency of providing care
improve quality of care
decrease cost of care
144
30 day readmission penalties
review of the data indicates 75% of readmission are preventable
ACA penalizes hospitals for excessive readmission rates
(AMI, CHF, pneumonia, knee/hip, COPD)
145
Lyndon B Johnson's Impact on Healthcare
Medicare and Medicaid
7/30, 1965
146
Medicare
health insurance for the elderly (≥65 yo), disabled, ESRD, ALS
No dental or eye benefits
No drug benefits for outpatient
147
Medicare Part A
covers hospital costs
no premium costs
SNF care (max 100 days)
some home health care, hospice
148
Medicare Part B
-premium costs deducted from SS
covers physician costs, not required
medical supplies
drugs admin in MD offices
149
Medicare Part C (Medicare Advantage)
parts A + B+D (may cover broader list of services
managed care (private insurance companies)
150
Medicare Part D
drug benefit
premium costs deducted from SS
151
Enrolling in Part A
begins 3 months before 65th birthday (do not need to be retired)
do not have to enroll as long as you have a comparable insurance plan
starts when you start receiving SS benefits
most people receive Part A for free
penalty for late enrollment, impact on part B
152
What is not covered by Part B?
long term care
dental care
cosmetic surgery
eye exams for prescribing glasses
routine foot care
hearing aids and exams
acupuncture
153
Billing Medicare: Where will medications be used?
A: in hospital
B: doctors office
D: at home
154
Billing Medicare: What will the medications be used for?
D: po methotrexate for arthritis
B: immunosuppressive/cancer treatment
155
Billing Medicare: How will it be used?
B: insulin B for pump
D: syringe
156
Medigap-Medicare Supplement
not administered through CMS but standardized by Federal law
picks up deductibles for part A
picks up deductibles and copays for part B
standard options in each state
purchased through private companies
157
Medicare Part C: Managed Care
also called medicare advantage plans
PAs very common
recently aggressively advertised with greatly expanded list of services
premiums, deductibles, networks , optional services
increasing amount of enrollees over the years
158
Features of Advantage Plans
administered by private companies but the beneficiary is still considered enrolled in Medicare
premiums or the costs of services (co-pays and deductibles) can be lower than they are in original medicare or original medicare with a medigap policy
they may offer extra benefits including vision and dental
coordinate your care, fewer choices
159
Medicare STAR Rating System
used by CMS to measure how well Medicare Advantage and Part D plans perform
plans reviewed annually
1 to 5
rated on how well plans perform in certain categories
160
Medicare Part D Impact
largest change in insurance processing in retail pharmacy history
run by private insurance companies, but CMS sets minimum standard
not a single entity, beneficiaries need to voluntarily enroll and select a plan
formularies for each plan are different
program never funded
161
History of Medicaid
health insurance for the poor and medically indigent of all ages
not required by states
managed by state government
wide variation in the quality and range of services in various states
162
Medicaid Milestones
2014: allows people with income up to 138% of FPL to qualify, expansion due to ACA
163
Nationally, Medicare is _________ to private insurance for access to care
comparable
164
Medicaid per enrollee spending is significantly greater for which populations
elderly and individuals with disabilities (long term care> acute care)
165
Medicaid drug spending and rebates
more money coming back as rebates than what is spent
166
Medicaid in Indiana
Adopted
children and pregnant women mostly enrolled
167
Medicaid not adopted in what region?
southeast mostly
168
Who qualifies for medicaid?
low income families who meat certain state requirements (<138% of FPL in IN)
infants born to medicaid eligible pregnant women
children < 6yo and pregnant women with incomes < 138% FPL (IN, <158%)
pregnant mothers are covered for 12 months after pregnancy ends
certain medicare beneficiaries
169
True/False: Most Women Covered by Medicaid Work Outside of Home
true
170
Hoosier Healthwise
children and pregnant women
171
Hoosier Care Connect
> 65 yo not eligible for Medicare;blind;disabled
172
Traditional Medicaid
> 65 eligible for Medicare LTC; home ore community-based waiver services
173
Healthy Indiana Plan (HIP)
low income adults 19-64 with income <138% FPL
174
Mandatory Services of Medicaid
LTC, hospital, physician, home health, prenatal care, family planning services
175
Optional Services of Medicaid
pharmacy, dental, ICF for mentally retarded, mental health rehab
176
Eligibility of Medicaid
1/3 of all children are insured through medicaid
while children are eligible for dental coverage, few dentists participate
aca provides eligibility for most low-income adults <65 with incomes <138% FPL
177
Medicaid Reimbursement
100%
178
Importance of non-clinical factors
40% of non clinical factors are socioeconomic factorsP
179
Distribution of US Population by Race/Ethnicity
By 2050, white, non hispanic population % is projected to drop, while asian, hispanic, and other population % projected to increase
180
Coverage, access and use of care among people of color compared to white people
mostly worse
181
Uninsured rates among the non-elderly population by race/ethnicity
higher rates in AIAN and hispanic populations
182
Life expectancy in years by race/ethnicity
lowest in AIAN
183
Infant mortality and maternal mortality worse in which population
black
184
highest death rates for diabetes by race/ethnicity
NHOPI (native Hawaiian or other pacific islander)
AIAN
Black
185
SDOH among people of color
worse for black and hispanic people compared to white people
186
Educational Attainment by race/ethnicity
worse in AIAN and NHOPI
187
True/False: nearly half of health care workers have witnessed discrimination against patients
True
especially black HCWs, HCWs age 18-29
188
Insurance model most insured Americans have
employer-based insurance
