The collaboration between family medicine and public health is a crucial link in efforts to bring the benefits of health care to all Americans. Healthy People 2010,1 recently released by the U.S. Surgeon General and the U.S. Department of Health and Human Services, provides an action plan for such collaboration. The plan follows Promoting Health/Preventing Disease2 published in 1980 and Healthy People 2000,3 released in 1990 as the national public health blueprint. Healthy People 2010 represents the collective work of 250 state and federal health agencies and 350 national organizations. It has two overarching goals: to increase the quality and years of healthy life and to eliminate health disparities. The successful implementation of this important document rests largely on the actions of front-line physicians. What follows is a brief description of its underlying principles and specific recommendations for ways physicians may implement aspects of this national initiative in their offices.
Healthy People 2010 presents 10 leading health indicators that read like a list of core competencies for family medicine (Table 1). Twenty-eight focus areas are introduced, forming the core of the document, and they are elaborated into 467 objectives (Table 2). The objectives are specific and measurable, covering a sweeping range of prevention strategies. The full document may be accessed at the following Web site: http://www.health.gov/healthypeople.
The first goal, to increase life expectancy and years of healthy life, is based on the fact that at least 18 countries rank ahead of the United States in life expectancy. The second goal, to eliminate health disparities, recognizes the fact that gender, race and ethnicity, income and education, disability, sexual orientation and rural location are major factors that affect access to health care services and underlie many health disparities in the United States. Understanding the need to address health disparities is one of the greatest contributions of Healthy People 2010.
Biologic and genetic determinants of health have been unable to explain differences in health outcomes among different racial and ethnic groups. Healthy People 2010 describes numerous health disparities (ethnic/racial labels are borrowed from the language of the document). For example, African-Americans have double the infant mortality rate, a 40 percent higher death rate from heart disease, a 30 percent higher death rate from cancer, a seven times higher death rate from acquired immunodeficiency syndrome (AIDS) and a six times higher rate of homicide when compared with whites. The Hispanic population in the United States has high rates of obesity and hypertension, and members of this group are twice as likely to die of diabetes as the non-Hispanic white population. American Indians have an infant mortality rate that is twice that of whites. Persons from Asian/Pacific Islander populations differ widely, but also endure disproportionate health disparities when compared to white Americans. For example, women of Vietnamese heritage have nearly five times the rate of cervical cancer as white women.
Education and income are closely tied to health disparities, and income inequality has increased since the 1960s.1 While regional and demographic differences in poverty and educational attainment do exist, overall death rates are almost double in persons with less than 12 years of education compared with persons who have 13 or more years of education. Similarly, infants born to mothers with less than 12 years of education have nearly twice the risk of dying within the first year of life.1
The Role of Family Physicians
When addressing health disparities, family physicians must remain sensitive to the importance of education as a lever toward improved health outcomes. Success in school remains an important focus of a well-child visit. Physicians should encourage children, adolescents and their parents in this endeavor. Early intervention for persons experiencing academic or personal problems, in particular those at risk of dropping out of school, may provide significant future health benefits.
In addition to education, Healthy People 2010 focuses on increasing access to health care. A critical part of improving this aspect of health care is to increase the number of health professionals who are members of underserved minority groups, specifically African-American, Hispanic and American Indian populations. Family physicians, in talking to children and adolescents about their school performances and aspirations, may open the door for minority youth to consider health careers.
Family physicians are playing a greater role in population-based health care. The implementation of the National Commission for Quality Assurance (NCQA) Health Plan Employee Data and Information Set (HEDIS)4 makes health plans and medical groups accountable for the health of large populations. Like the HEDIS criteria, Healthy People 2010 provides the parameters for measuring the success of population-based, disease-management programs.
Family physicians can use the measurable targets in Healthy People 2010 to develop practice-based, disease-management programs. For example, the national asthma hospitalization rate in 1997 was 60 of 10,000 for all children less than five years of age; the rate for white children in this age group was 33 of 10,000 compared with 125 of 10,000 for African-American children in the same age group. The Healthy People 2010 asthma hospitalization target rate is 25 of 10,000 children less than five years of age. Between 1995 and 1997, the hospital emergency department visit rate for asthma for African-American children was 407 of 10,000—more than four times the rate in white children. The Healthy People 2010 emergency department goal for asthma visits is 80 of 10,000 children less than five years of age.
The childhood asthma statistics demonstrate a significant health disparity that can be addressed in your practice through four steps5:
Choose common conditions that lend themselves to a systems' approach to care—in this case, childhood asthma.
Identify the patients in your practice with these conditions—in this case, children less than five years of age.
Choose measurable outcomes that reflect the best evidence-based medical practice. For example, measuring emergency department visits or clinical outcomes such as the prescribing and use of inhaled anti-inflammatory medications, the immunization rate of children with asthma in your practice or the use of patient education programs based on the National Heart, Lung, and Blood Institute (NHLBI) guidelines.6
Regularly measure and try to improve these outcomes (e.g., enhanced monitoring, follow-up and reminder systems for families of children with asthma).
Much of the implementation of Healthy People 2010 will occur within the communities in which family physicians practice. Key to the success of this local work is the collaboration of family physicians with public health and community organizations. Such collaboration will occur through the following7:
Development of a shared vision of quality of health and quality of life for all communities.
Linkage with community organizations such as the American Heart Association, American Cancer Society, American Lung Association and the local county health department.
Increased involvement of family physicians in community-based health improvement projects.
Development of community outreach models that link the community with family physicians.
Two important resources are available to assist in the implementation of Healthy People 2010. The Centers for Disease Control and Prevention (CDC) Community Prevention Services Task Force is gradually releasing the Guide to Community Preventive Services,8 which describes the scientific basis for community interventions. Most recently, the task force released guidelines for community-based adult and childhood immunization programs. In addition, the Public Health Foundation released the Healthy People 2010 Tool Kit: A Field Guide to Health Planning.9
Healthy People 2010 is a valuable compass for all who are dedicated to improving the health of individuals and communities. Family physicians are critical participants in the process of making the targets of Healthy People 2010 a reality.