8/1/2019 Items to be covered in today’s 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 moving forward ● 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 Bonita Stanton, MD I have nothing to disclose Dean, Hackensack Meridian School of ● Why do these differences exist? Medicine at Seton Hall University July 26, 2019 ● What are we doing to address these issues? 1
8/1/2019 Decline in US health relative to peer nations o 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 o Life expectancy at birth in the US in late 1960s was 71 years— Decline in Health of U.S. Over Time one year longer than average of all OECD nations; in 2015, life Status of health in the USA expectancy in the US was only 78 years, two years shorter than that of the OECD nations (80 years) o From 1960’s to 2015, US life expectancy increased by only 7 years —compared to increase among OECD nations of 10 years . 2
8/1/2019 Decline in US health relative to peer nations, con. Decline in health of USA compared Life expectancy decreased in USA in 2015, 2016 and to other nations 2017. Not happened since Great Flu Epidemic in 1916 to 1918. 3
8/1/2019 Select Population Health Outcomes and Risk Factors Life Expectancy Inf Infant m mortality, per per Percent ent o of pop. age e 65+ Obesity rat Obe ate Pe Percent o of pop. (age Pe Percent Life Life exp exp. at at 1,00 1, 000 l live births, with th tw two or mo more ch chronic (B (BMI>30), 15+) who are 15+ who are dail daily of of pop pop. birth, 201 2013 a 201 2013 a cond nditions, 201 2014 b 2013 a, 201 a,c smok sm okers, 201 2013 a ag age 65+ 65+ Australia ralia 54 82.2 3.6 28.3 e 12.8 14.4 Canada ada 56 81.5 e 4.8 e 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 14.5 d 24.1 d 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 Data Source: WHO. Infant mortality rate (probability of dying in the first year after New New Z Zealand 81.4 5.2 e 37 30.6 15.5 14.2 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 Nor Norway 81.8 2.4 43 10.0 d 15.0 15.6 Swe Sweden 82.0 2.7 42 11.7 10.7 19.0 Swi Switzerland 82.9 3.9 44 10.3 d 20.4 d 17.3 Unit United King Kingdom 81.1 3.8 33 24.9 20.0 d 17.1 Unit United S Stat ates 68 78.8 6.1 e 35.3 d 13.7 14.1 OE OECD medi dian — 81.2 3.5 28.3 18.9 17.0 4
8/1/2019 Expenditures are not appropriately Increased health cost compared to targeted to need or related to outcomes peer nations 5
8/1/2019 Impact of Different Factors on Risk of Health and Social Care Spending as a Percentage of GDP Health care spending and Life Expectancy Premature Death Percent 6
8/1/2019 Inequities in health by race and ethnicity Racial gaps exist in the USA ● 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. Inequities in health by race and ethnicity ● 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) (Williams et al. J Health Soc Behav 2013 53: 279‐295) 7
8/1/2019 Income and Life Expectancy at Age 25, United States ● Genetic? Group White Black W/B (W) (B) ● Environment? All 1 53.4 48.4 5.0 ● Income? By Income 2 Why do these differences exist? ● Insurance? Poor 49.0 45.5 3.5 Near Poor 51.4 48.0 3.4 ● Physician‐population racial/ethnic Middle Income 53.8 50.7 3.1 mismatch? 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. J Health Soc Behav. Author manuscript; available in PMC 2013 July 16. 1National Vital Statistics (Murphy 2000);2 National Longitudinal Mortality Study (Braveman et al. 2010) 8
8/1/2019 Race and Genetics: Not An Hypertension in Blacks by Country of Residence: Explanation for Health Disparities. Advantaged Environment matters Cumulative probability of group death, by country, TRUE : Allele‐based diseases (hemoglobinopathies, degenerative by socioeconomic group disorders, etc.) more frequent in in‐bred populations. FALSE : “Race Genetics” explains pandemic differences in ● infant and childhood mortality Disadvantaged ● maternal mortality group ● life expectancy and ● survival or functional outcome from range of diverse diseases (myocardial infarction, asthma, diabetes, etc.) Chen et al. 2015 http://economics.mit.edu/files/9922 Catecholamine response to the stress of disadvantage? Am J Pub Health 1997;87:160‐8. 9
8/1/2019 Under‐represented minorities in medical school Current composition of U.S. population (2016) Percent applying: Percent matriculating: 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/ 10
8/1/2019 If you could build a new medical school… Estimated speed of doubling time of new medical knowledge over time since 1950 ● 1950: Doubling time ~50 years What are we doing to address these issues? ● 1980: Doubling time~ 7 years ● 2010: Doubling time~ 3.5 years Changing the approach to medical education and the health ● 2020: Estimated that doubling time will be 73 days of our population and globe Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011; 122: 48–58. 11
8/1/2019 Current and near‐future advances in technology Mission VISION The physicians we train, in their delivery of the highest quality care to all Telemedicine: Undermine or fortify patient‐doctor relationship? patients, will: Artificial Intelligence : Will not replace human physicians but will change our roles Each person in New Jersey and in the USA, • Act on their understanding that context, community, and behavior Virtual and Augmented Reality : Greatly augment teaching platform for students, drive wellbeing; regardless of race or socioeconomic status, will continuing education, research and patients • Embrace and model our professional and our university’s Catholic roots enjoy the highest levels of wellness in an Health trackers : Empowering patients and augment patient‐provider dialogue of reverence for the human condition, empathy toward suffering, excellence in medical care, and humility in service; economically and behaviorally sustainable fashion. Genome sequencing : Leading to meaningful personalization of medicine • Continue to serve and learn from the engagement of underrepresented Expediting drug development : Alternatives to the randomized, controlled trial minority populations among students, faculty, staff, and community; and explorations of the possibility of simulated trials • Integrate lifelong learning and inquiry into their practice; and Robotics : Great advances in helping the disabled to regain many lost abilities • Work in communion with scholars and practitioners of other disciplines Nanotechnology : Advances in drug and therapy targeted delivery and detection to integrate their perspectives, experiences, and tools . https://medicalfuturist.com/ten‐ways‐technology‐changing‐healthcare 36 35 12
8/1/2019 Our approach Individual Learning Plan Meetings Our approach cont’d Underlying structure A curriculum that respects our students dollars and time ● No distinction between basic science and clinical curriculum; basic science content ● Three‐year core curriculum , meeting rigorous, standardized will be presented in its clinical context with clear medical relevance. ● Learn within an integrated curriculum in a team‐oriented, collaborative environment. learning outcomes. ● Utilize the best components of different evidence‐based teaching methods for adult ● Complemented in the fourth year by a self‐directed, learners (competency‐based, TBL, PBL) personalized, individualization of the SOM experience. ● Structure curriculum to thrive in modern, technically demanding, clinical settings ● Choose from a variety of options including dual degrees, The importance of community research‐intensive concentrations, clinical immersion, global ● Health and wellness occur in the community, not in the hospital health concentration, community‐based projects, innovation ● Through immersive and longitudinal experiences, students understand roles of programs or early entry into residence. individual, community and the clinical context in determining health and wellbeing and disease treatment and prevention. 13
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