Assessing local public health
capacity and performance in
diabetes prevention and control
Deborah Porterfield, MD MPH
University of North Carolina-Chapel Hill
and RTI International
AcademyHealth PHSR Interest Group
6.07
Measuring diabetes prevention and control
in North Carolina LHDs
„
Diabetes as a model chronic disease for study
„
State Diabetes Prevention and Control Program
‰
Problem statement: Local public health
and chronic disease
„
Available evidence suggests that chronic disease
activities in local health departments (LHDs) lag
behind the historically important issues of control of
infectious diseases, maternal and child health, and
environmental health.
(NACCHO, 2006)
„
In order to improve LHD performance in chronic
disease, we must first describe current practice, and
develop valid measures of performance
Objectives
1.
Measure capacity of NC LHDs to conduct
diabetes prevention and control activities.
2.
Measure levels of performance in diabetes
related prevention and control services and
programs in NC LHDs.
3.
Assess characteristics of local health
departments and their jurisdictions
(communities) that may be associated with
higher performance.
Provides technical assistance and funding to LHDs
(Diabetes Today)
Survey administration
4.
Examine differences in capacity and
performance between LHDs that have
received training and funds through a specific
federal and state program, Diabetes Today,
and those who have not, in order to assess if
participation has increased capacity and
performance.
„
„
„
Mailed survey
Participants: All local health departments in
North Carolina (n=85)
Instrument adapted from the Local Public
Health System Performance Assessment
‰
‰
10 Essential Services
Additional diabetes-specific questions
1
Measuring “capacity” and “performance”
„
Capacity defined as FTEs in diabetes
prevention or control
„
„
„
Performance defined as self-reported
provision of program or service
‰
„
33 yes/no questions combined into a 10 point
index, one point for each Essential Service
Based on model of public health performance
by Handler, et al (2001)
Other characteristics of LHD and community
under categories of “Macro Context”,
“Structural Capacity”, and “LHD Mission”
Main predictors of interest: History of
Diabetes Today (or Project IDEAL) funding;
Mission statement; estimates of need
‰
‰
Secondary data sources
„
County-specific sociodemographic and
medical care data
‰
‰
‰
‰
Diabetes Prevention and Control Program, DPH
NC Health Professions Data system
US Census
NC Community Health Center Association
Data Analysis
„
„
Profile survey of the National Association of
City and County Health Officers (NACCHO)
Results
„
100% response
‰
Univariate descriptions
Bivariate analyses to examine relationship
between performance and LHD or jurisdiction
characteristics
‰
„
„
Size of LHD considered to be a confounder
Accreditation status not considered as confounder
T-tests and Spearman correlation coefficients
Limited multiple linear regression modeling
‰
the effect of confounding assessed one variable
at a time
LHD characteristics
Number of FTEs (median)
80
(IQR 51-128)
2 mailings, reminder postcards, phone follow up
Expenditures, million (median)
$ 4.81
(IQR 2.95-8.0)
Accredited
Diabetes Today funding
Project IDEAL funding
Full time medical director
DM or chronic disease in mission
31%
35%
4%
20%
18.9%
2
Characteristics of LHD jurisdictions
Single-county
Population >100k
Urban
% population below poverty (mean)
Any C/MHC or free clinic
Physician/100k ratio (median)
93%
31%
47%
14% (sd 4.2)
71%
62.0
Capacity: FTEs
„
„
Prevention FTEs (median) 0.05 (IQR 0-0.5)
Control FTEs (median)
0.1 (IQR 0-0.5)
‰
40% have no FTEs devoted to prevention or
control
(IQR 47.8-89.0)
9.1% (sd 0.93)
Performance by Essential Service
Performance index
No.
questions
Median (IQR)
ES1 Monitor health
6
0.5 (0.33-0.83)
ES2 Diagnose, investigate
3
0.33 (0.33-0.67)
ES3 Inform, educate
4
0.75 (0.5-1)
ES4 Mobilize partnerships
2
0.5 (0-1)
ES5 Develop policies, plans
3
0 (0-0.33)
ES6 Enforce laws
1
0 (0-0)
ES7 Link persons
7
0.43 (0.14-0.71)
ES8 Assure competent workforce
3
0.33 (0-0.33)
ES9 Evaluate
2
0 (0-0)
ES10 Conduct research
2
0.5 (0-0.5)
.2
Density
.15
.1
0
Associations between index and LHD
characteristics
Number of FTEs
Expenditures, in millions
Accredited
Yes
No
Diabetes Today funding
Yes
No
Project Ideal funding
Yes
No
Mean 3.5 (range 0-9.2; sd 1.9)
.25
„
.05
Est. diabetes prevalence (mean)
R* or Mean index
P
0.349
0.003
0.363
0.002
4.30
3.23
0.025
4.08
3.15
0.030
6.70
3.36
0.002
0
2
4
6
Total essential services
8
10
Associations between index and
jurisdiction characteristics
R* or Mean index
Population>100k
Yes
No
4.26
3.13
P
0.010
3
Regression models
„
„
To understand the association between
Diabetes Today funding and performance
index
Conclusions
„
Limited capacity (FTEs)
„
Variation in performance of Essential Services
‰ Surveillance, health education, linking to
services HIGH
‰ Research, evaluation, policy LOW
‰ Specific questions with notable results:
Controlling for population size did not change
the association between DT funding and the
performance index.
„
„
Assessment of availability of clinical care or
diabetes education LOW
Community based screening HIGH
Limitations
„
Total performance not higher in areas with
greater need (prevalence of diabetes,
availability of primary care)
„
Self-report
‰
„
‰
„
Funding from state health department or
foundation and the size of the LHD are
associated with performance
„
„
„
Implications
„
„
Although some NC LHDs are able to provide
diabetes services and programs with limited
resources, the findings suggest the
opportunity to enhance local public health
practice through targeted funding
Specific findings can influence technical
assistance provided by the state DPCP to
LHDs
Types, numbers of respondents
Item validity and reliability
Measuring capacity and performance
Cross-sectional design
Generalizability
Other characteristics of LHD not measured
Acknowledgments
„
The NC Association of Local Health Directors Health Promotion
Committee: Curtis Dickson and Beth Lovette
„
NC Division of Public Health: Janet Reaves, RN, MPH; Marcus
Plescia, MD, MPH
„
UNC School of Public Health and the NC Institute for Public Health:
Ed Baker, MD, MPH; Mary Davis, DrPH, MSPH; Bob Konrad, PhD;
Bryan Weiner, PhD
„
Data for this study were obtained from the 2005 National Profile of
Local Health Departments, a project supported through a
cooperative agreement between the National Association of County
and City Health Officials and the Centers for Disease Control and
Prevention (U50/CCU302718).
„
Work funded by the Pfizer Scholars Grants in Public Health
4
Deborah Porterfield, MD, MPH
Department of Social Medicine
UNC Chapel Hill School of Medicine
porterfi@email.unc.edu
919/843-6596
5