Risk Management

1
Risk Management Population HealthCase Study
of Canada

• Prepared By- Mohammad Abu Mahfouze
• Master Security of Information System
• AABFS
• Supervised By- Dr. Loai Tawalbeh

2
Introduction

• Health policy development has focused on
  individuals and the role of medical care in
  preventing and treating disease and injury .
• Recent attention to health inequities and social
  determinants of health has raised the profile of
  population health and evidence-based strategies
  for improving the health of whole populations
• This presentation reviews a historical
  developments in the fields of risk management and
  population, health and proposes a joint
  population health risk management framework that
  integrates the key elements of both fields

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Introduction

• Risk science has started at the 1970s, and since
  that time it has been developed into powerful
  tool for managing technological change.
• Modern risk analysis took shape with the
  application of probabilistic risk assessment
  methods in the evaluation of reactor safety.
• As a result of the air pollution in urban areas
  in Canada associated with motor vehicle and
  industrial emissions has been linked to adverse
  health effects, which raised the important of the
  policy questions about pollution management .We
  still know little about the potential risks from
  genetically modified organisms, including foods,
  therapeutic products, and best control products.

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Introduction

• The evolution in thinking about how to manage
  health and environmental risks associated with
  modern technology and technological change. In
  1983, the U.S. National Research Council (NRC)
  issued a pioneering report on Risk Assessment in
  the Federal Government Managing the Process
• This work proposed a comprehensive framework for
  assessing and managing health and environmental
  risks that has influenced the development of risk
  management policy. This and subsequent frameworks
  provide guidance both on scientific approaches to
  characterize risks, and on policy options for
  managing them.

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Introduction

• The concept of population health has also emerged
  over the past 30 years, during which it became
  accepted that changes in lifestyle or social and
  physical environments may have a greater impact
  on population health than the health system.
• Although risk management and population health
  evolved largely independently, both approaches
  offer firm bases for guiding evidence-based
  health policy

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An Integrated Framework for Risk Management and
Population Health (1983)
Figure 1. U.S. National Research Council
framework for risk assessment(1983).
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EVOLUTION OF RISK MANAGEMENT

• The NRC (1983) report, commonly referred to as
  the Red Book, gave the first structured
  description of the health risk assessment and
  management process, and has been widely endorsed
  throughout the world. The framework consists of
  three components Research, Risk assessment, and
  Risk management (Figure 1).
• Risk assessment is defined as characterization
  of the potential adverse health effects of human
  exposures to environmental hazards.

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Risk assessment involves four steps

1. Hazard identification is the process of
   determining whether exposure to an agent can
   increase the incidence of a health condition
2. Dose-response assessment is the process of
   characterizing the relation between the dose of
   an agent administered or received and the
   incidence of an adverse health effect in exposed
   populations it expresses incidence as a function
   of exposure to the agent.

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Risk assessment involves four steps

• Exposure assessment is the process of measuring
  or estimating the intensity, frequency, and
  duration of human exposures to an existing agent
  or of estimating hypothetical exposures that
  might arise from the release of new chemicals
  into the environment .
• Risk characterization is the process of
  estimating the incidence of a health effect under
  the various conditions of human exposure
  described in the exposure assessment

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Risk Management

• Risk management refers to the process of
  evaluating alternative regulatory options and
  selecting among them. The results of risk
  characterization are used to identify potential
  options that are then evaluated in terms of
  expected public health, economic, social, and
  political consequences.
• The responsible agency then makes a decision and
  implements the selected option.

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Risk Determination Diagram

• The limitations of the NRC framework are that it
  is better suited to dealing with environmental
  agents than other health hazards it only
  considers regulatory options it contains no
  provision for monitoring, evaluating, or revising
  the risk management strategy nor is stakeholder
  involvement explicitly addressed .
• So it was not the best framework .

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Health and Welfare Canada 1990 Framework

• In 1990, Health Canada developed a risk
  management framework that defined and described
  the general process used to assess and deal with
  health risks, then it was updated at 1993(Health
  and Welfare Canada 1993).
• The Risk Determination Framework consists of two
  major components Risk assessment and Risk
  management .

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Health and Welfare Canada 1990-1993 Framework
Figure 2. Health Canada health risk determination
framework (1990, 1993).
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A- Risk assessment consists of four steps

1. Hazard Identification is the process of
   determining whether exposure to an agent can
   increase the incidence of a health condition .
2. Risk Estimation is the process of characterizing
   the relation between the dose of an agent
   administered or received and the incidence of an
   adverse health effect in exposed populations it
   expresses incidence as a function of exposure to
   the agent.

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Risk assessment consists of four steps

• Exposure Assessment is the process of measuring
  or estimating the intensity, frequency, and
  duration of human exposures to an existing agent
  or of estimating hypothetical exposures that
  might arise from the release of new chemicals
  into the environment
• Risk Characterization is the process of
  estimating the incidence of a health effect under
  the various conditions of human exposure
  described in the exposure assessment.

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B- Risk management

• Risk management Refers to the process of
  evaluating alternative regulatory options and
  selecting among them. The results of risk
  characterization are used to identify potential
  options that are then evaluated in terms of
  expected public health, economic, social, and
  political consequences. The responsible agency
  then makes a decision and implements the selected
  option.

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Risk Management consist of four steps

1. Decision Is the process of choosing between the
   options .
2. Implementation Is the process of creating the
   option that we had choose .
3. Monitoring and Evaluation Is the process of
   controlling the option to be sure that we
   achieved our aim .
4. Review Is the process of choosing other option
   in case we didnt have the best results.

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Canadian Public Health Association (CPHA)

• In 1989, a National Advisory Panel on the
  Risk/Benefit Management of Drugs was appointed by
  the Canadian Public Health Association (CPHA), to
  review risk/benefit methodology applied to the
  field of prescription drug use and to develop a
  framework for use in risk management. The panel
  built on the 1993 Health Canada Risk
  Determination Framework as a starting point to
  develop its Benefit/Risk/Cost Determination
  Framework (CPHA 1993).
• This added the assessment and management of
  benefits and costs within the risk determination
  paradigm

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Canadian Public Health Association (CPHA)

• The intent of this expanded framework was to
  examine benefits, risks, and costs in a formal
  manner, and to use standard procedures to
  calculate a net benefit/risk/cost value for the
  drug under examination. Changes in
  quality-adjusted life expectancy was proposed as
  a utility based measure of health benefit
  associated with therapeutic intervention
  however, this refined measure of risk has limited
  the broader applicability of the framework.

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The Framework for Environmental Health Risk
Management

• The Framework for Environmental Health Risk
  Management developed by the U.S.
  Presidential/Congressional Commission on Risk
  Assessment and Risk Management (1997) is designed
  to assist risk managers, such as government
  officials, private sector businesses, and
  individual members of the public in making good
  risk management decisions about environmental
  health risks (Figure 3). The framework is
  sufficiently general to encompass a wide variety
  of environmental health risk issues, with the
  level and effort invested being scaled to the
  importance of the problem, the potential severity
  and economic impact of the risk, level of
  controversy surrounding it,

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Figure 3. U.S. Presidential/Congressional
Commission Framework for Environmental Health
Risk Management (1997).
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The Framework for Environmental Health Risk
Management

• The framework is intended primarily for risk
  decisions related to setting standards,
  controlling pollution, protecting health, and
  cleaning up the environment. The framework
  consists of Six Steps Define the problem and put
  it into context Analyze the risks associated
  with the problem in context Examine options for
  addressing the risks Make decisions about which
  options to implement Take actions to implement
  the decisions and Conduct an evaluation of the
  results of the action

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The Framework for Environmental Health Risk
Management

• These steps are implemented in collaboration with
  stakeholders. In this framework, risk management
  is used both to encompass the process of
  analyzing, selecting, implementing, and
  evaluating actions to reduce risk, and to
  describe the entire process. The framework
  emphasizes the importance of considering health
  and environmental problems in a broad context
  rather than evaluating individual risks
  associated with single agents in specific
  environmental media, ensuring stakeholder
  involvement to the extent appropriate and
  feasible during all stages of the risk management
  process, and adopting an iterative approach that
  affords the flexibility to revisit early stages
  of the process as new information becomes
  available.

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The Framework for Environmental Health Risk
Management

• Health Canada has recently revised its approach
  for dealing with health risks (Risk Management
  Framework Project Team, Health Protection Branch
  Transition and Health Canada, 2000). The proposed
  Decision-Making Framework consists of a series of
  inter-connected steps that may be grouped into
  three phases Issue Identification (identify the
  issue and put it into context) Risk Assessment
  (assess potential risks and benefitswhere
  appropriate) and Risk Management (identify and
  analyze regulatory and non-regulatory options
  select a strategy implement the strategy and
  monitor and evaluate the results).

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The Framework for Environmental Health Risk
Management

• The framework portrays the involvement of
  interested and affected parties throughout the
  process, including partners, the public, and
  other stakeholders. The framework is similar in
  structure to that developed by the U.S.
  Presidential/Congressional Commission, although
  many aspects of the framework have been developed
  in more detail.
• The Health Canada framework focuses on examining
  and integrating other types of information
  (social, cultural, ethical, and economic factors
  as well as perceived risk) into the risk
  assessment process when there is a demonstrated
  influence on the level of risk for specific
  populations.

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EVOLUTION OF POPULATION HEALTH

• Public health addresses environmental conditions
  that exert widespread effects on the health of
  populations. The U.S. Institute of Medicine (IOM
  1988, p. 7) has defined public health as
  fulfilling societys interest in assuring
  conditions in which people can be healthy.
  Public health interventions include sanitation,
  the protection of drinking water mass
  immunization against vaccine-preventable diseases
  and the control of microbiological, radiological,
  and chemical hazards. The IOM views the
  application of scientific knowledge to disease
  prevention and health promotion in an organized
  community effort as the aim of public health
  services.

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EVOLUTION OF POPULATION HEALTH

• Health promotion was defined by the World Health
  Organization (WHO) as the process of enabling
  people to increase control over, and to improve
  their health (WHO 1986, p. 1). Arising out of
  the health education movement, it focused less on
  physical factors that cause specific diseases
  than did public health, and more on changing
  broad aspects of lifestyles .
• Population health has been defined as a
  conceptual framework for thinking about why some
  populations are healthier than others, as well as
  the policy development, research agenda, and
  resource allocation that flow from it (Young
  1998,p. 4).

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EVOLUTION OF POPULATION HEALTH

• The distinction between population and public
  health continues to be a point of discussion
  ,Whereas public health focused traditionally on
  environmental factors that influence disease,
  including sanitation and infectious disease
  control, population health takes into account all
  of the factors affecting the health of
  populations. The IOM (2002) foresees closer
  linkages between the fields of public and
  population health, suggesting that public health
  can be enriched by the incorporation of
  population health principles.

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EVOLUTION OF POPULATION HEALTH

• In an article entitled Achieving Health For All
  A Framework for Health Promotion, Epp (1986)
  proposed a new approach to health that would meet
  emerging health challenges. The report first
  emphasized the importance of inequities in health
  and of reducing inequities in the health of low
  versus high income groups. Epp cited the
  disturbing evidence that, despite Canadas
  equitable health services delivery system,
  peoples health remained directly related to
  their economic status. Epps second health
  promotion challenge was to increase prevention
  efforts by finding new and more effective ways of
  preventing injuries, illnesses, chronic
  conditions, and disabilities .

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Figure 5. Federal, Provincial, and Territorial
Advisory Committee on Population Health Framework
for Population Health (1994).
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Conclusion

• Although it is now widely recognized that a
  variety of determinants can influence our health,
  the conceptualization of health and the
  determination of how health can be achieved and
  how health inequalities and inequities can be
  reduced remains complex.
• An integrated approach provides a stronger
  foundation for evidence-based population health
  risk management decision-making by encouraging a
  more consistent, systematic and comprehensive
  evaluation of population health issues.