Improving patient and community well-being.
Two points are important to understand:
* Well-being is influenced by multiple factors, with evaluation and treatment less important than preventive health care, government, socioeconomic factors, environment, and genetic make-up.
* Use of health care is determined more by social factors, education, income, social status, and insurance coverage than by disease factors.
One may consider well-being a pyramid (see figure on page 42). At the base are genetic make-up and environmental factors: preconceptual, pre-natal, and post-natal. Next in importance are government factors, such as rights, education, utilities, and laws. Socioeconomic factors, such as housing, food, education, income, employment, family, religion, insurance, and life-style, are strong predictors of health and well-being. These four factors - genetic, environmental, government, and socioeconomic - are important to well-being and health status but are overlooked or minimized by health professionals, the public, and government. If these infrastructure areas are addressed and supported with resources comparable to those expended on health care, the well-being and health of patients and the public will be substantially improved. The model shows that preventive health care, immunizations, periodic health examinations, counseling, and education have a greater impact on well-being than do evaluation and treatment, which are highly visible and expensive.
Recent literature increasingly indicates that the use of health care is determined more by the social factors of education, income, social status, and insurance coverage, than by disease factors.
There are significant gaps in well-being and preventive health care. We will look at three representative age groups: infants 0-12 months, adolescents 12-17 years; and adults 45-64 years. The leading causes of death, injury, and illness for these age groups are shown in table 1, page 42. Motor vehicle crashes are the leading cause of spinal cord injuries, brain injuries, pelvic fractures and facial injuries in this country. Tobacco causes 30+ percent and diet 35+ percent of cancer deaths. Substance use by adolescents increases dramatically from the 6th grade to the 10th grade, as shown in the Wisconsin data in table 2, page 43. At the same time, in Wisconsin, of young adults 18-24 years of age, 21.6 percent are uninsured, and nationally, 12.5 percent of teens, ages 12-18, from low-income households are uninsured. In all age groups, more than 37 million people are uninsured and millions more underinsured.
There are many individual practice opportunities for the physician and health care professional to address the gap in well-being and preventive health care. Seventy percent of all adults see their physicians once a year, and 90 percent once in 5 years. The average adult sees a physician more than 4 times per year. Adolescents see their physicians frequently for injuries, minor illnesses, well-visits, and mental health. Infants and children are seen frequently for periodic well-visits and episodic illnesses.
There are many community opportunities for the physician to address the gap in preventive health care. State and federal governments are looking to expand health care accessibility. These levels of government frequently consider laws and regulations on tobacco, alcohol, education, and seat belt and helmet usage. Physician and health care workers are leaders, have respect, and are a highly knowledgeable community resource that government leaders and planners can access.
At the practice level, health education, in the form of one-on-one, physician-to-patient encounters using educational materials, including foreign language, classes, mailings, patient participation, feedback reminders, and follow-up, are effective tools to promote health and to prevent disease. This results in improved well-being. Periodic health examination guidelines; data, such as clinical practice profiles and highrisk patient identification and profiles; traditional quality measures; surveys; and outcomes and health status measures are also effective tools.
At the community level, the media; the legislative and regulatory processes; the school system and other educational forums; and clinics, hospitals, and medical societies are tools that can be used to improve well-being.
Does patient education work? Yes! Physicians do influence their patients' behavior patterns: There can be a 20-25 percent success rate in changing behavior for tobacco, alcohol, and seat belt usage.
Does community action work? Yes! In Wisconsin and other states, there are smokefree schools, restaurants, and work places; seat belt and helmet laws; effective alcohol and tobacco age limits; drug education programs; and improved health insurance coverage. Seat belt usage was up from 35 percent to 75 percent from 1984 to 1988. Cardiovascular and cancer mortality per 100,000 population are down. (However, the rate for lung cancer has gone up significantly.) The Institute of Medicine estimates that $3.34 is saved in initial hospitalization expenses for every dollar spent on comprehensive prenatal services for high-risk, low-income women.
Be active and visible in the community! Patient education and community action do favorably change patient and public life-styles! Health care professionals, with their knowledge, leadership, respect, and action in the community, can favorably affect the environmental, government, and socioeconomic infrastructure of well-being. Action by health are professionals at the practice and community levels are synergistic: Action at the practice level + Action at community level = Improved well-being.
[TABULAR DATA OMITTED]
Table 2. Change in Level of Adolescent Substance Abuse, Wisconsin 6th Grade 10th Grade Alcohol 11% 52% Cigarettes 5% 31% Marijuana 0% 12% Smokeless tobacco 1% 8%
Nicholas E. Mischler, MD, MS, is Medical Director, Physicians Plus Insurance Corp., Madison, Wis. He is Vice Chair of the College's Society on Insurance and a member of its Society on Managed Health Care Organizations and Forum on Cost Management.
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|Author:||Mischler, Nicholas E.|
|Date:||Oct 1, 1994|
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