Richard K. Riegelman

Clinical prevention and population health: Curriculum framework for health professions

Abstract The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services–health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title “Clinical Prevention and Population Health” has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.

Statistical first aid : interpretation of health research data

Understanding basic principles understanding univariable analysis understanding bivariable analysis understanding multivariable analysis.

Evidence-based public health education as preparation for medical school.

The Institute of Medicine has recommended that all undergraduates have access to public health education. An evidence-based public health framework including curricula such as “Public Health 101” and “Epidemiology 101” was recommended for all colleges and universities by arts and sciences, public health, and clinical health professions educators as part of the Consensus Conference on Undergraduate Public Health Education. These courses should foster critical thinking whereby students learn to broadly frame options, critically analyze data, and understand the uncertainties that remain. College-level competencies or learning outcomes in research literature reading, determinants of health, basic understanding of health care systems, and the synergies between health care and public health can provide preparation for medical education. Formally tested competencies could substitute for a growing list of prerequisite courses. Grounded in principles similar to those of evidence-based medicine, evidence-based public health includes problem description, causation, evidence-based recommendations for intervention, and implementation considering key issues of when, who, and how to intervene. Curriculum frameworks for structuring “Public Health 101” and “Epidemiology 101” are provided by the Consensus Conference that lay the foundation for teaching evidence-based public health as well as evidence-based medicine. Medical school preparation based on this foundation should enable the Clinical Prevention and Population Health Curriculum Framework, including the evidence base for practice and health systems and health policy, to be fully integrated into the four years of medical school. A faculty development program, curriculum guide, interest group, and clear student interest are facilitating rapid acceptance of the need for these curricula.

Healthy People 2020 and Education for Health: What Are the Objectives?

The Education for Health framework is designed as an educational roadmap for Healthy People 2020. It aims to connect the educational phases and suggests overall educational strategies needed to educate health professionals and the public to achieve a healthier America. The framework seeks to develop a seamless approach to prevention and population health education from Pre-K through graduate school. The framework is built on national movements in health literacy, undergraduate public health education and evidence-based thinking. It envisions a coordinated set of learning objectives divided into Pre-K through Grade 12, 2-year and 4-year colleges, and graduate education in the health professions as well as for health education for the community-at-large. The Healthy People Curriculum Task Force, a consortium of eight health professions education associations, has developed the framework and connected the framework with new and revised educational objectives of Healthy People 2020. The Task Force envisions a decade-long process to define and implement specific learning outcomes that can be integrated across the educational continuum. Interprofessional prevention education, in which health professionals learn and practice together, is seen by the Task Force as a key method for implementation. Understanding the roles played by a range of clinical health professions is also essential to communication and understanding. Healthy People 2020 and its new and revised educational objectives provide a vehicle for promoting the discussion and experimentation that will be needed to achieve an integrated and seamless approach to education for health for the American public as well as for health professionals.

Health Information Systems and Health Communications: Narrowband and Broadband Technologies as Core Public Health Competencies

THE INFORMATION REVOLUTION is affecting every aspect of health and medicine. The race to master the Web-based tools of distance education is just the beginning. We are being challenged to reexamine what we teach and how we organize what we teach in public health and health services education.

Community colleges and public health: making the connections.

Community colleges, in collaboration with public health agencies, can advance public health education by reaching a diverse student body, integrating public health into general education, and providing specialized associate degrees that serve workforce needs. Career ladders that include transferability of coursework to 4-year institutions and continuing education, including certificate programs, are key to success of these efforts. Community, or 2-year, colleges are well positioned to connect components of the Healthy People Curriculum Task Forces Education for Health framework by providing general education core courses in public health, epidemiology, and global health compatible with the educated citizen and public health movement. To serve specific workforce needs, associate degree programs are proposed, including environmental health, public health preparedness, public health informatics, and pre-health education. A generalist option designed for transfer to public health and related majors at 4-year institutions is also recommended.

The effect of birth month on the risk of respiratory syncytial virus hospitalization in the first year of life in the United States

Background: Respiratory syncytial virus (RSV) is the most common cause of severe respiratory illness in infants. To help direct targeted interventions and future RSV vaccine programs, we examined risk of RSV-related hospitalization by infant age and birth month. Methods: We conducted Poisson regression analyses to evaluate birth month as a risk factor for RSV-related pediatric hospitalizations (identified by any mention of ICD-9-CM diagnosis codes: 466.11, 480.1 or 079.6) from State Inpatient Data in Arizona, Iowa, New York, Oregon and Wisconsin between July 1996 and June 2006. We used an age cohort approach to compute total relative risk of RSV during the first year of life. Results: We identified 82,296 RSV-related infant hospital admissions, corresponding to 13.9 per 1000 person-years among infants <12 months of age. Of these, 42% of the patients were female and 73% were <6 months old. One-month-old infants born in January were ~10 times more at risk for RSV-related hospitalization than 1-month-old infants born in October [relative risk: 9.8 (7.8–12.4)]. Across the first year of life, infants born in December and January had a 2- and 3-fold higher risk, respectively, of an RSV-related hospitalization event than infants born in July. Conclusions: Birth month and age at admission impacted the risk of RSV-related hospitalization within the first year of life in 5 states we investigated. As RSV vaccine candidates are currently under investigation in clinical trials, our findings help identify ideal RSV vaccine schedules to prevent early and severe events while improving the use of expensive prophylactic drugs.

A history of undergraduate education for public health: from behind the scenes to center stage

Education for Public Health traces its roots to the Welch–Rose report of 1915. The Welch–Rose report defined education for public health as applied graduate education primarily for professionals such as physicians, nurses, and engineers who needed academic education and the latest research to help them take on leadership roles in governmental public health (1). The graduate and research focus of academic public health dominated the landscape for the better part of the twentieth century. Yet behind the scenes, changes were occurring that have led in the twenty-first century to new approaches to undergraduate public health education. The Society for Public Health Education (SOPHE) was founded in 1950. As was the practice of the era, membership required a graduate degree. A decade later, SOPHE began admitting members with an undergraduate degree and practice experience (2). Undergraduate programs supported by SOPHE have included community health and school health. The emergence of environmental health as a distinct field led to the development of environmental health programs at the bachelor’s degree level with a strong science emphasis. In 1967, the National Environmental Health Science & Protection Accreditation Council (EHAC) was established. East Tennessee State’s undergraduate environmental health program became the first accredited undergraduate program (3). When the Association of University Programs in Health Administration (AUPHA) was founded in the late 1940s, graduate degree programs formed the basis of eligibility for membership. Undergraduate programs were gradually added. By the late part of the century, AUPHA was offering a certification process for undergraduate health administration programs (4). During the last half of the twentieth century, undergraduate programs in public health and related fields were developed that either did not qualify for membership in SOPHE, EHAC, or AUPHA, or chose not to pursue such membership. According to the Association of Schools and Programs of Public Health (ASPPH), by 1992, there were 45 institutions that were offering one or more undergraduate degrees in a public health related field. By 2000, this number had risen to 76 (5). These early efforts to develop specialty degrees for undergraduates not only survived but have grown over the years. At the turn of the twenty-first century, they represented the major source of undergraduate education for public health.

Commentary: Health systems and health policy: a curriculum for all medical students.

A companion article in this issue of Academic Medicine provides an example of a method for electively integrating health systems and health policy issues into medical education. However, a curriculum in health systems and health policy is crucial to the education of all future physicians and other health professionals. The Clinical Prevention and Population Health Curriculum Framework of the Healthy People Curriculum Task Force has recently recommended a health systems and health policy curriculum that includes the domains of organization of clinical and public health systems; health services financing; health workforce; and health policy process. The curriculum should commence prior to year three and continue in years three and four so that students have a framework for integrating and subsequently sharing their experiences. Current Liaison Committee on Medical Education data indicate that on average less than 70% of medical schools require any curriculum in these four domains and only 40% of medical schools include all four of these domains in their required curriculum. Incorporation all of these domains into well-defined, required curricula that are broad in scope has the potential to change the attitudes of future clinicians toward efforts to control costs, collaborate with other health professions, and influence health policies.

Interaction and intervention modeling: predicting and extrapolating the impact of multiple interventions.

PURPOSE Methods called interaction and intervention modeling are presented. Interaction modeling examines the interactions between variables as the basis for predicting the impact of multiple variables on a target population and on populations with difference distributions of risk factors. Intervention modeling incorporates these interactions and aims to extrapolate the impact of multiple interventions to new populations. The aim is to develop methods that will be useful for modeling and comparing intervention strategies using existing data and standard statistical methods. METHODS Traditional hypothesis testing methods used for randomized clinical trials and cohort studies and extrapolating the results to new populations are compared with interaction and intervention modeling methods. Interaction and intervention modeling utilizes the same data as the traditional approach but examines the impact of multiple simultaneous interactions and allows extrapolation of the results to populations with different prevalences and distributions of risk factors. An example using real data demonstrates the potential of interaction and intervention modeling to predict the impact of multiple interacting variables and to compare the impact of alternative interventions. RESULTS The methods outlined take into account the impact of the magnitude of the relative risks, prevalence of risk factors, and interaction of risk variables when predicting the impact on a new population or extrapolating the results of one or more interventions on a new population. Traditional methods that do not take into account interactions are shown to produce different conclusions from the intervention modeling approach that incorporates interactions. The impact of the intervention modeling approach compared with the traditional approach will be quite variable depending on the prevalence of the risk factors and their extent of interaction. CONCLUSIONS Studies designed to test a hypothesis treat most variables as potential confounding variables adjusting for their impact and their interactions as part of the analysis using traditional regression methods. Interaction and intervention modeling focuses on the interactions themselves and allows comparison of the effectiveness of alternative interventions.