Public Health
Call for Papers
Public Health Risks, Costs & Prevention Strategies
Chair: Linda McKibben, Ph.D.
Sunday, June 6 • 9:30 a.m.-11:00 a.m.
● Health Care Costs of Moderate and Severe Obesity
Tatiana Andreyeva, M.A., Roland Sturm, Ph.D.
Presented by: Tatiana Andreyeva, M.A., Doctoral Fellow,
RAND Graduate School, 1700 Main Street, Santa Monica, CA
90401; Tel: 310.393.0411 Ext. 6047; Fax: 310.451.7040; Email: tatiana@rand.org
Research Objective: Estimate the excess health care costs
associated with moderate and severe obesity among
individuals ages 50-69. Despite the sound evidence that
obesity increases health care costs by more than a third, there
is no data distinguishing how severe obesity differs from
moderate obesity. As severe obesity increases at a much faster
rate than moderate obesity, using average cost effects is
unlikely to provide a good estimate to predict future health
care costs.
Study Design: This study uses the Health and Retirement
Study, a nationally representative biennial longitudinal survey
of 9,825 Americans in their 50’s at baseline in 1992, to
analyze differential impacts of severity of obesity on health
care utilization and costs. Dependent variables are total
medical spending and three measures of health care utilization
(number of ambulatory visits, hospital stays and the
probability of hospitalization). We subset the analysis to
individuals whose weight does not change by more than 10%
between two adjacent waves to obtain a better measure of
long-term weight. The results are adjusted for
sociodemographic changes to isolate the unique effect of
obesity category. Regressors include: age, educational
achievement, racial minority, family income, insurance and
marital status. We estimate models separately for men and
women. Individuals are classified into weight categories based
on the body mass index (BMI) calculated from self-reported
weight and height. In addition to the standard obese category,
defined as a BMI >= to 30 kg/m2, the groups of interest are
more extreme categories: BMI: 35-40 and BMI>=40. The
statistical analysis of medical expenditures uses a two-part
model. We estimate probit and linear models for service
utilization variables.
Population Studied: Nationally representative adults ages 5069.
Principal Findings: Among individuals ages 50-69, moderate
obesity (BMI: 30-35) is associated with a 32% increase in
annual health care costs among women and 16% among men,
a BMI of 35-40 with an increase of 62% and 42%, a BMI of
40 or more with an increase of 98% and 74% respectively. In
absolute terms, overweight implies an average increase of
$447 per year in health care costs for men and $397 for
women. Moderate obesity increases medical spending by $635
for men and - twice as much - $1,255 for women. The effects
trend up as severity of obesity grows. Severe obesity increases
medical spending by $2,433 per year for men and $1,814 for
women. The largest effect is for the most obese segment,
which is extra annual medical spending of $2,888 for men and
$3,833 for women. There are also significant disparities in
service utilization by weight category.
Conclusions: The prevalence of severe obesity is increasing at
a double-fold rate among US adults than obesity. As
comorbidities and resulting service use are much higher
among severely obese individuals, the widely published trends
for overweight/obesity, including health care costs,
underestimate the consequences for physician practices,
hospitals, and health plans.
We show that severe obesity increases average health care
costs twice as much as moderate obesity and almost four times
more in the very severe cases.
Implications for Policy, Delivery or Practice: Average
estimates hide all of the effects on health care system from the
“obesity epidemic” in the US and underestimate future costs
associated with obesity. Accurate estimates of obesity costs,
however, have major implications for future outlays from
Social Security programs and Medicare that already pay for
almost a half of expenditures attributable to overweight and
obesity.
● Is Some Physician Advice on Smoking Cessation Better
than No Advice? An Instrumental Variable Analysis of the
2001 National Health Interview Survey
Yuhua Bao, Ph.D., Naihua Duan, Ph.D., Sarah Fox, Ed.D.
Presented by: Yuhua Bao, Ph.D., Health Economist,
Department of Medicine, UCLA, 1100 Glendon Avenue, Suite
2010, Los Angeles, CA 90024; Tel: 310.794.3081; E-mail:
yuhuabao@mednet.ucla.edu
Research Objective: Of the more than thirty-three million
smoking adults who visited their health providers during one
year (2000-2001), about 65% received some advice to quit
smoking. Health providers do not consistently advise smoking
cessation partly because they lack confidence in the
effectiveness of their advice and partly because the “best
practice” identified by randomized controlled trials is usually
too time and resource intensive for community practice. This
study estimates the effect of provider advice as practiced in
day-to-day clinical contacts on patients’ cessation outcome
using non-experimental data.
Study Design: We use the sample adult file from the 2001
National Health Interview Survey. We estimate a joint model
of self-reported smoking cessation and ever having received
advice in the past twelve months during medical visits to
providers. Because providers tend to advise mostly heavier
smokers and/or patients already diagnosed with smokingrelated conditions, we use provider advice for diet/nutrition
and for physical activity reported by the same patient as
instrumental variables for smoking cessation advice. A similar
analysis is conducted on the sample without any smokingrelated conditions. We also exclude patients who reported
receiving additional help to quit smoking such as counseling
and medication (about 37% of those who received some
advice) to estimate the effect of advice alone on the cessation
of lighter smokers.
Population Studied: Adult patients who either are current
smokers (every day and some days) or quit during the last
twelve months and who had some contact with the health care
providers or facilities they most often go to for acute or
preventive care.
Principal Findings: We find that provider advice doubles the
chances of success in (self-reported) smoking cessation by
their patients. The probability of quitting by the end of the
twelve-month reference period averaged across all smoking
patients is increased from 8% to 16%, which is both
statistically and practically significant (p<0.001). The effect
size is similar when we restrict the analysis to patients without
any smoking-related conditions. The effect of providing
advice alone to patients who are lighter smokers and/or who
have fewer smoking-related conditions is even larger (from
8% to 23%, p<0.001).
Conclusions: Provider advice delivered in routine practice
settings has a sizable effect on the success rate of smoking
cessation among smoking patients. The effect size is larger
than that of almost all other tobacco control policies made so
far such as tax on tobacco products and clean in-door air laws.
Implications for Policy, Delivery or Practice: Current rate
of smoking cessation advice during clinical contacts is far
below optimal, given the large effect of some provider advice
found in this study. While it is not feasible or effective to
adopt the “best practice” identified in clinical trials in every
clinical context, providers can make a big difference by
consistently providing advice and other help to all their
smoking patients.
Primary Funding Source: NCI
● The Impact of Obtaining Documented Informed Consent
for Population-Based Voluntary Supplemental Newborn
Screening in California
Lisa Faulkner, Ph.D., Maura Hanlon, M.P.H., CHES, Lisa
Feuchtbaum, Dr.PH, Fred Lorey, Ph.D., Kathleen Velazquez,
M.P.D., M.A., George Cunningham, M.D., M.P.H.
Presented by: Lisa Faulkner, Ph.D., Research Scientist,
Genetic Disease Branch, Public Health Institute c/o California
Department of Health Services, 850 Marina Bay Parkway,
Room F175, Richmond, CA 94804; Tel: 510.412.1453; Fax:
510.412.1560; E-mail: lfaulkne@dhs.ca.gov
Research Objective: To assess the impact of obtaining
documented informed consent during an 18-month populationbased supplemental newborn screening research project using
tandem mass spectrometry in California.
Study Design: Using a prospective cohort study, we
compared participation in voluntary supplemental newborn
screening (which required written consent) to participation in
mandatory newborn screening (which allows opt out for
religious reasons only) in a prospective cohort.
Population Studied: To assess the impact of the informed
consent process on decision-making we conducted 5 focus
groups with 31 pregnant women, a mail survey of prenatal
care providers and a telephone survey with MS/MS program
participants.
Principal Findings: Less than half (354,000 or 47%) of the
756,000 California babies who received mandatory newborn
screening also received supplemental screening for metabolic
disorders. While 42,000 (6%) of parents refused supplemental
screening; the remaining 360,000 (47%) had no documented
consent or refusal. Only half the hospitals in the State
submitted samples with documented consent for 50% or more
of the babies born at their facilities. Only 17% of prenatal
care providers handed out the educational materials and
offered to answer questions while another 29% didn’t hand it
out at all. The focus group discussions revealed the benefits
and risks were not well understood.
Conclusions: Population-based informed consent for newborn
screening places a burden on hospitals and significantly
reduces the population screened and the number of disorders
detected in the newborn period. Informed consent does not
appear to be feasible for population based screening and it
didn’t achieve its presumed benefits of protecting subjects by
enabling them to make informed decisions about participation
in population-based research.
Implications for Policy, Delivery or Practice: If applicable,
obtain a waiver of written informed consent for population
based newborn screening research or pilot projects with
minimal risk. Investigate barriers to why prenatal care
providers do not discuss with patients and try to increase their
participation since most pregnant women appear to rely on
them for advice about newborn screening. Improve
educational materials to better convey risks and benefits.
Primary Funding Source: HRSA
● Impact of Low Health Literacy on Medical Costs
David Howard, Ph.D., Julie Gazmararian, Ph.D., Ruth Parker,
M.D.
Presented by: David Howard, Ph.D., Assistant Professor,
Department of Health Policy and Management, Emory
University, 1518 Clifton Road, N.E., Atlanta, GA 30322; Tel:
404.727.3907; Fax: 404.727.9198; E-mail:
dhhowar@emory.edu
Research Objective: Despite the prevalence of low health
literacy and the number of studies documenting its impact on
health outcomes, there is a paucity of information on the
implications for medical costs. The objective of this study was
to examine the impact of low health literacy on medical costs
and resource use.
Study Design: Costs incurred over a one year period were
compared between persons with low and adequate health
literacy using propensity scores. Propensity scores were based
on age, race, income, education, and chronic conditions.
Population Studied: A total of 3,260 non-institutionalized
elderly persons enrolling in one of four Medicare managed
health care plans (Cleveland, Ohio; Houston, Texas; South
Florida; Tampa, Florida) in 1997.
Principal Findings: Controlling for observed covariates,
persons with low health literacy incur expenditures for
emergency room care that are $86 (66% of the sample average
emergency room expenditures) higher (1997 U.S. dollars)
(P<0.01) than persons with adequate health literacy. Costs for
outpatient care and prescription drugs are $137 (7%) lower (P
= 0.42) and $27 (4%) higher (P = 0.60), respectively. The cost
of inpatient care was $979 (18%) higher (P = 0.25) but
statistically insignificant, possibly due to the extreme
skewness of the inpatient spending distribution. When persons
incurring inpatient expenditures above the 99th percentile
were excluded, the difference was $1,017 (19%) and
significant at the 5% level.
Conclusions: Persons with low health literacy incur higher
expenditures for emergency room care. Comparisons of the
likelihood of using inpatient care, inpatient admissions, and
costs with outliers excluded indicate that persons with low
health literacy use more inpatient resources as well. Future
research should seek data sources with larger sample sizes,
examine the sensitivity of results to alternative models for
comparing health spending, and determine whether results are
consistent across different demographic groups.
Implications for Policy, Delivery or Practice: Programs to
improve health literacy and simplify communication of health
information have the potential to reduce health care costs.
Primary Funding Source: Pfizer Foundation
● Maternal Smoking and the 1998 Master Settlement
Agreement
Douglas Levy, M.P.H., Ellen Meara, Ph.D.
Presented by: Douglas Levy, M.P.H., Ph.D. Candidate,
Department of Health Care Policy / HMS, Harvard University,
180 Longwood Avenue, Boston, MA 02115; Tel:
617.432.4356; Fax: 617.432.0173; E-mail:
delevy@fas.harvard.edu
Research Objective: Immediately following the November
1998 Master Settlement Agreement (MSA) between the states'
attorneys general and several large tobacco companies there
was a large (45 cent) increase in the price of cigarettes that
took effect nationally. Prior literature suggested that such a
large price increase would reduce smoking among pregnant
women by as much as 14% and would improve birth weight
outcomes, preventing as many as 6,600 low birth weight
outcomes (<2500g) per year. We sought to determine how the
MSA affected smoking among pregnant women and whether
the MSA affected birth weight outcomes.
Study Design: We performed interrupted time-series analyses
on data from the national Natality Detail Files, examining
smoking participation, smoking intensity, birth weight, and
low birth weight status (LBW) immediately before and after
the MSA. Subgroup analyses were conducted by maternal age,
race, and educational attainment.
Population Studied: We included all singleton births
conceived from March 1996 to February 1998 and from
December 1998 to February 2000 to mothers 15 to 44 years
old in the 47 states reporting maternal smoking and the
District of Columbia. Pregnancies overlapping the
announcement of the MSA were excluded. In total, our study
population comprised 9,012,048 births.
Principal Findings: The large increase in cigarette prices
following the MSA had no substantive effect on smoking
prevalence (log-odds post- vs. pre-MSA=0.000071, p=0.99) or
smoking intensity (among smokers, 0.22 fewer cigarettes
smoked per day post-MSA, p<.0001) reported by pregnant
women. Furthermore, we found the MSA had no significant
effect on birth weight outcomes (birth weights down an
average of 1.6g post-MSA, p=0.125). Findings were similar
across all subgroups we analyzed.
Conclusions: Our analyses indicate most pregnant women are
unlikely to change their smoking habits in response to price
changes. It is possible that as public awareness of the dangers
of smoking during pregnancy continues to increase and as
prices have increased over the past fifteen years, the remaining
core of women willing to smoke during pregnancy is
particularly intransigent. Alternatively, it is possible that
previous studies in this area, using state tobacco excise taxes
as a proxy for price, captured state-level changes in policy
and/or attitudes towards smoking coincident with the excise
tax changes rather than a true price effect.
Implications for Policy, Delivery or Practice: Efforts to
reduce smoking and improve health outcomes by increasing
cigarette excise taxes will not affect all populations
identically. Targeted interventions may be necessary to
prevent low birth weight morbidity associated with cigarette
smoking. More rigorous studies using other outcomes and
populations are needed to verify the health benefits of this
popular tobacco control measure.
Primary Funding Source: AHRQ
Call for Papers
Public Health Infrastructure:
Identifying & Closing the Gaps
Chair: Glen Mays, Ph.D., M.P.H.
Monday, June 7 • 4:00 p.m.-5:30 p.m.
● Optimizing Use of Resources for Conducting Practicebased Immunization Assessments
Margaret Coleman, Ph.D., Noelle-Angelique Molinari, Ph.D.,
Shannon Stokley, M.P.H., Hussain Yusuf, M.B.B.S., M.P.H.,
Mark Messonnier, Ph.D.
Presented by: Margaret Coleman, Ph.D., Economist, HSREB,
CDC/NIP, 1600 Clifton Road, N.E., MS-E52, Atlanta, GA
30333; Tel: 404.639.8801; Fax: 404.639.8614; E-mail:
zby5@cdc.gov
Research Objective: Assessment, feedback, information, and
exchange (AFIX) is a practice-based strategy that promotes
childhood immunizations and has been shown to improve
medical provider vaccination coverage rates. The Centers for
Disease Control and Prevention (CDC) recommends that
federally funded immunization programs conduct annual
AFIX site visits in at least 25% of provider offices. This
project seeks to understand how grantees use funds to
administer AFIX and determine what factors influence
completion of AFIX assessments.
Study Design: 2000 and 2001 CDC program funding records
were compared with immunization program self-reported data
of completed AFIX assessments. A Poisson model was
estimated with maximum likelihood to determine what factors
influenced the dependent variable, completed AFIX
assessments. The independent variables were grantee vaccine
purchase policies, full time equivalent employees (FTEs), perchild funding, and population of children.
Population Studied: State and urban programs receiving
grant monies to administer AFIX.
Principal Findings: There was an extremely wide spread in
per-assessment spending, i.e. 2000 federal spending ranged
from $81 to $174,926. Median funding for AFIX programs
was $106,551 in 2000 and $266, 387 in 2001, far less than
average funding which was $240,056 and $501,629,
respectively. The model results showed that numbers of
completed AFIX assessments increased 30% with a 10%
increase in FTEs and 8% when there was a 10% increase in
AFIX site-visits combined with other required site visits for
the Vaccines for Children (VFC) program. The funding perchild variable was significant in explaining numbers of
completions.
Conclusions: The wide range in per-assessment spending
indicates that assessment process work practices need to be
standardized. A standardized funding formula may need to be
developed to more systematically distribute grant monies.
Grantees should administer AFIX in conjunction with VFC
site visits to the extent possible. Funding increases to grantees
that support hiring and training more FTEs may result in
increased numbers of completed assessments.
Implications for Policy, Delivery or Practice: Standardizing
assessment work practices and distributing grant monies more
systematically will improve the quality of AFIX and assure
policy makers that government funds are being appropriately
spent.
Primary Funding Source: CDC
● Racial/Ethnic Differences in Trust of Public Health to
Respond Fairly After Bioterrorism
David Eisenman, M.D., M.S.H.S., Cheryl Wold, M.P.H.,
Anna Long, Ph.D, M.P.H., Claude Setodji, Ph.D.
Presented by: David Eisenman, M.D., M.S.H.S., Associate
Natural Scientist, Behavioral Health, RAND Corporation,
1700 Main Street, Santa Monica, CA 90407; Tel:
310.393.0411 Ext. 6429; E-mail: david_eisenman@rand.org
Research Objective: Public health departments’ effectiveness
in the response phases of catastrophic terrorism will require
diverse communities’ trust in their institutions and actions.
This study describes variations in “trust”—perceptions about
whether the public health system would respond fairly to one’s
needs regardless of race/ethnicity, income, or other personal
characteristics—by racial/ethnic and other demographic,
household/neighborhood, and healthcare-related factors, in a
large U.S. metropolitan population.
Study Design: We analyzed data from the Los Angeles
County Health Survey, a periodic, random-digit-dialed
telephone population survey in Los Angeles County (LAC).
The outcome variable (trust) was an affirmative response to
the item: “If there is a bioterrorist attack in LA, do you think
the County’s public health system will respond fairly to your
health needs regardless of race, ethnicity, income or other
personal characteristics?” Mantel-Haenszel chi-square tests
were conducted to assess the prevalence of trust by variables
that were selected because they were predictors of trust in
previous studies or due to a priori reasoning: demographic
(race/ethnicity, age, gender, education, income, interview
language), household/neighborhood (household dependents,
perceived neighborhood safety), healthcare-related (health
status, insurance, perceived access to healthcare), and
perceived risk of a terrorist attack. To examine the effect of
race/ethnicity on trust we performed simple and multivariate
logistic regression, adjusting for demographic and other
variables associated with trust (perceived access to healthcare
and perceived neighborhood safety.)
Population Studied: Eligible participants were noninstitutionalized adults; spoke English, Spanish, or one of four
Asian languages; and lived in LAC from October 2002—
January 2003. A random sub-sample (n=1,041) of the 8,127
participants answered 12 additional items regarding terrorism.
Principal Findings: Trust was associated with race/ethnicity
(white 77%, Latino 73%, Asian/Pacific Islander 68%, African
American (AA) 63%, p=0.001); advancing age (18-39 years
77%, 40-64 years 83%, 65 and older 85%, p=.03); language
(English 80%, Spanish 86%, Asian languages 62%, p=0.01);
perceived access to healthcare (more difficult over past year
76%, less difficult 89%, no change 82%, p=0.09); and
perceived neighborhood safety (very unsafe 63%, somewhat
unsafe 78%, somewhat safe 81%, very safe 84%, p=0.01).
Compared to whites, AA’s were less likely to report trust (OR
0.4; 95% CI 0.2—0.7). Multivariate predictors of trust were
AA race (aOR 0.5; 95% CI 0.3—0.9), age 18-39 (aOR 0.5;
95% CI 0.2—0.9), Asian language (aOR 0.3; 95% CI 0.1—
0.7) and greater perceived neighborhood safety (aOR 1.4; 95%
CI 1.1—1.7).
Conclusions: In this population-based study, trust in public
health to respond fairly to bioterrorism was lower among
African Americans, Asian language groups, younger adults,
and residents of unsafe neighborhoods.
Implications for Policy, Delivery or Practice: Public health
officials charged with preparing and responding to a
bioterrorist event must continue to develop institutional trust
with African American and Asian/Pacific Islander
communities. Addressing variations in trust by age, language,
and perceived neighborhood safety also are important for
designing and implementing strategies to improve trust and
confidence in the public health system.
Primary Funding Source: RAND
● Public Health Finance: An Investigation of Jurisdiction
Funding Patterns and Performance Capacity
Peggy Honore, D.H.A., M.H.A., Eduardo Simoes, M.D.,
M.Sc., M.P.H., Walter Jones, Ph.D., Ramal Moonesinghe,
Ph.D., M.A., M.S.
Presented by: Peggy Honore, D.H.A., M.H.A., Instructor,
Rollins School of Public Health, Emory University, 3113-L
Flowers Road, South, Atlanta, GA 30341; Tel: 770.234.9599;
Fax: 770.220.1835; E-mail: PAHONORE@aol.com
Research Objective: A field of study for public health
finance has never been developed. Consequently, very little is
known about the relationships, types, and amount of finances
that fund the public health system in America. Research and
analysis of the health care delivery system financial structures
are studied in great detail; however, a comparable degree of
routine analysis in public health simply does not exist. This
research was an effort to illustrate practices for public health
financial analysis that could serve as instruments to strengthen
the financial foundation of the public health system while also
aiding with defining a field of public health finance by
building on the sparse knowledge available. Specific
objectives were to investigate if different levels and types of
revenues, expenditures, and other demographic variables in a
public health jurisdiction are associated with performance of
the 10 Essential Public Health Services.
Study Design: The research utilized local public health
system performance scores in each of the 10 Essential Public
Health Services as calculated through the Local Public Health
System Performance Assessment Instrument. In this
correlational study, each of the participating local health
systems are data points with a bivariate relationship between a
specific financial or demographic indicator and an essential
public health performance score.
Population Studied: The population consisted of 50 local
health agencies in a mid-west state.
Principal Findings: One of the study’s most significant
findings was the degree of synergism between public health
jurisdiction taxes per capita and local public health system
capacity. Statistically significant correlations were found in 6
of the 10 essential services performance scores. Analysis of
the financial data also revealed that, on average, high scoring
local public health systems had taxes per capita 38% greater
than the lower scoring systems. However, an association
between jurisdiction revenues per capita to higher
performance was not observed. This suggests that flexible
funding streams such as those under the direct control of
jurisdictions like taxes are more effective with improving
system performance.
Conclusions: A vital component to performance improvement
is the ability to collect, analyze and transform data into
information. While this research was an attempt to illustrate
the usefulness of such analysis, replication of it in other
jurisdictions across the nation is hindered by the lack of
available financial data such as public health jurisdiction tax
rates, revenues, and expenditures.
The significance of this research on strengthening the public
health systems is supported by an IOM (2002)
recommendation to experiment with increasing local funding
flexibility.
Implications for Policy, Delivery or Practice: Analysis to
determine the adequacy and effectiveness of financial
resources to sustain appropriate standards within the public
health system should be routine, anticipated, and
institutionalized as a collective responsibility throughout the
system. If results showing increased performance capacity to
be associated with higher taxes per capita are replicated
nationally, it would provide a powerful analytical tool to
policymakers for determining how to increase investments for
the delivery of essential public health services.
● Competency of Public Health Nurses and Faculty in the
Essential Public Health Services
Michele Issel, Ph.D., Kathleen Baldwin, Ph.D.
Presented by: Michele Issel, Ph.D., Clinical Associate
Professor, School of Public Health, UIC, 1603 W. Taylor
Street (MC 923), Chicago, IL 60612; Tel: 312.355.1137; Fax:
312.996.3551; E-mail: issel@uic.edu
Research Objective: For public health nurses to contribute
substantively to the health of the public, they need to be
competent at performing the ten essential public health
services. Their competence begins with their public health
nursing education and, hence, public health nursing faculty
also need to be competent in the ten essential public health
services. Little information exists regarding the level of
competency of either public health nursing staff or faculty,
despite federal priorities and interest in advancing the
education of nurses for population-based practice.
This research sought to assess the self-reported level of
competency of the public health nursing workforce in Illinois.
Study Design: A questionnaire based on the ACHNE
standards for public health nursing was developed and
reviewed by an expert panel for readability and applicability to
public health nurses. Competency in each essential public
health service was scored on a 1 (need to be taught this) to 5
(do and teach this to others) Lickert scale, with 3 (do or can do
this) or higher as being competent in the essential service.
Alpha reliability for the essential public health services ranged
from .89 to .97.
Population Studied: Two independent samples in Illinois
were used. For the public health nursing staff survey, a
purposive sample was 50 local health departments in which
the director of public health nursing and three of their public
health nurses responded to the questionnaire. For the faculty
survey, a purposive sample of 124 nurses who were deans and
faculty currently overseeing or providing PHN education were
surveyed.
Principal Findings: Staff respondents (n=168) were mostly
48 year old, white females with a baccalaureate degree.
Faculty respondents (n=47) were 50 years old, most had a
doctorate, and annually teach community/public health for 8
semester hours. Both staff and faculty felt most competent in
linking people to services (mean 3.4 and 4.2, respectively).
This was the only essential service in which staff rated
themselves as competent. Faculty rated themselves as
competent in researching innovative strategies (mean 4.0), and
monitoring population health (mean 4.0), and marginally
competent in policy and planning skills (mean 3.1). Among
the staff, higher education was correlated with higher
competency scores in ensuring a competent workforce,
developing polices and mobilizing community partnerships.
Faculty with an educational background in public health
nursing had higher competence in teaching about ensuring a
competent workforce, mobilizing community partners, and
policy and planning than did faculty without a public health
nursing degree.
Conclusions: Overall, competency in the essential public
health services is low. The essential service of highest
competency is individual focused and a uniquely nursing task.
Higher education and work experience increase self-reported
competency
Implications for Policy, Delivery or Practice: The results
suggest the need for broad state-wide educational offerings to
increase the competency of public health nurses and faculty.
Curriculum could be tailored to address the competencies
rated lowest. Greater emphasis is needed in local health
agencies and nursing programs on requiring and assisting
public health nursing staff to acquire minimum competency in
all ten essential public health services.
● Rural Hospitals’ Health Promotion and Disease
Prevention Services: Relationships with External Forces
and Hospital Characteristics
Mei Zhao, M.S., Peter Olden, Ph.D., Henry Carretta, M.P.H.
Presented by: Mei Zhao, M.S., Research Associate, Health
Administration, Virginia Commonwealth University, P.O. Box
980203, Richmond, VA 23298; Tel: 804.827.1811; Fax:
804.828.1894; E-mail: mzhao@hsc.vcu.edu
Research Objective: Examine organizational and
environmental factors associated with provision of Health
Promotion / Disease Prevention (HPDP) services by U.S. rural
acute care hospitals in 2000, using Oliver’s strategic response
theoretical framework.
Study Design: Oliver’s framework identifies 5 internal and
external constructs that may influence organizational response
to external factors. Oliver’s constructs (and our variables) are
cause (for-profit status); constituents (sum of dummy variables
for HMO, PPO, Blue Cross, JCAHO, medical school,
Medicare, hospital system, network, and alliance); content
(sum of dummy variables for hospital mission and long-term
plan for community health); control (ratio of HPDP services
offered by all other hospitals in county to maximum number
of such services that could be offered by them); and, context
(sum of three dummy variables for hospital works with others
to conduct community assessments, to assess appropriate
capacity, and, to share clinical and health information). Total
margin, total hospital staff per bed, volunteer department, per
capita county income, number of staffed beds, and Medicare
case mix index were included as control variables. The
dependent variable (DV) was defined as number (0-18) of
HPDP services offered by each hospital. Cross-sectional data
from 2000 AHA Annual Survey of Hospitals, 1999 Medicare
Cost Reports, February 2000 Area Resource File, and 2000
Center for Medicare and Medicaid Service Case Mix Index
files were concatenated for the study population. After
multicollinearity tests, two models were tested with both OLS
and Poisson multivariate regressions. An un-weighted model
used a simple count of the number of HPDP services as the
DV. A second model weighted the number of HPDP services
by the number of hospitals that do not offer the service in the
entire study population. This gave more weight to services
offered by fewer hospitals.
Population Studied: 1,513 non-federal, rural, acute care
general hospitals that responded to the AHA 2000 Annual
Survey.
Principal Findings: Mean percentage of hospitals offering an
individual HPDP service ranged from 7.0% to 78.4%. Forprofit (cause) hospitals provided significantly less HPDP
services than not-for-profit hospitals. The number of
constituents, hospital goals (content), and their
interconnectedness with external partners were all positively
associated with more HPDP services (p<.05). HPDP
penetration (control) was less significant (p=.09). All control
variables, except total margin, were significant (p<.05). The
OLS (weighted) and Poisson (un-weighted) analyses were
similar except that for-profit status (cause) was not significant
in the Poisson analysis, perhaps reflecting the importance of
weighting HPDP services.
Conclusions: Four of Oliver’s five constructs were useful
predictors of organizational and environmental factors
influencing rural hospital adoption of HPDP services. Market
HPDP penetration (control) may be less important. Hospital
total margin, staffing, volunteer department, staffed beds, and
CMI, and, local per capita income are important to consider in
models.
Implications for Policy, Delivery or Practice: Rural health
stakeholders have called for improved rural health, noting that
it lags non-rural health. This study extends knowledge of
factors influencing rural hospitals’ provision of HPDP, which
could help improve rural health. Future studies should
consider using weighted HDPD measures and the six control
variables.
Related Posters
Poster Session A
Sunday, June 6 • 6:45 p.m.-8:00 p.m.
● Predicting the Costs and Allocation of Public Health
Nursing Services
Kaye Bender, R.N., Ph.D., FAAN
Presented by: Kaye Bender, R.N., Ph.D., FAAN, Dean and
Professor, University of MS School of Nursing, 2500 North
State Street, Jackson, MS 39216-4505; Tel: 601.984.6220;
Fax: 601.815.5958; E-mail: KBender@son.umsmed.edu
Research Objective: To design a probablility model for
anticipating the allocation and costs of public health nursing
services within a public health jursidiction.
Study Design: The design for this study is a prospective
modeling design which includes relative capability, ranked
scoring, and predictive numerical estimations for public health
nurse staffing for a given population. Modeling allows a
public health jurisdiction to utilize a formula by which to
predict and allocate staffing levels and costs of public health
nursing services.
Population Studied: A statistically significant sample of
public health nurses from selected states and local
jurisdictions across the United States is being developed. The
final sample size will be determined by the anticipated power
level for the study.
Principal Findings: This research is currently underway, but
will be concluded by May 2004. Findings are anticipated to
lead to the testing of the predictive model, with adjustments
based on a variety of jurisdictional sizes and public health
needs.
Conclusions: Conclusions will be developed as the final
results of the study are analyzed. However, it is anticipated
that the model will move public health administration forward
in its approach to planning staffing levels and finances for the
largest public health professional workforce, public health
nurses, at a time when the national nursing shortage has been
predcited to create workforce gaps for the already vulnerable
public health infrastructure.
Implications for Policy, Delivery or Practice: National
organizations such as APHA, ASTHO, NACCHO, ANA, and
others are predciting the most significant nursing shortage to
occur between now and the year 2020. The potential impact of
that shortage on the public health infrastrcuture is notable,
given the fact that public health nurses constitute the single
largest component of the governmental public health
workforce. Historically, nursing shortages have also impacted
the public health budgets, as salary increases have
accompanied the quest for recruiting and retaining qualified
public health nurses. The anticipated nursing shortage,
coupled with the current concerns over state finances and
budgets, create the potential for a crisis situation. The
development and testing of a predictive model for forecasting
staffing levels and costs of public health nursing services has
the potential to guide state and local public health jursidictions
toward sound workforce and financial planning.
Primary Funding Source: State funds
● Developing Statewide Public Health Department
Capacity for Response to Chemical Incidents
Lisa Benton, M.D., M.P.H., Erica Weis, M.P.H, Kevin Chao,
Ph.D., Robert Melton, M.D., M.P.H., Sharon Lee, Ph.D.,
Raymond Neutra, M.D., Dr.P.H.
Presented by: Lisa Benton, M.D., M.P.H., Public Health
Medical Officer, Division of Enviromental & Occupational
Disease Control, California Department of Health Services,
1515 Clay Street, Suite 1700, Oakland, CA 94612; Tel:
510.622.4453; Fax: 510.622.4902; E-mail:
lbenton@dhs.ca.gov
Research Objective: Given the greater likelihood of their
occurrences compared to a biological terrorist event, response
to chemical terrorism or hazardous materials incidents
demands coordination of health department capabilities with
those of non-traditional partners. To strengthen capabilities of
public health departments to respond to chemical emergencies,
contemplation of contamination scenarios provides useful
guidance for identifying needs, assets, and agency partners for
preparedness.
Study Design: To strengthen the California Department of
Health Services’ (CDHS) capacity to respond to a chemical
threat or disaster resulting in contamination, the Division of
Environmental and Occupational Disease Control (DEODC)
designed, implemented, and assessed practical processes
focused on the unique immediate and long-term challenges
presented by chemical emergencies and incidents. From
December 2002 until now, the DEODC prioritized eight (8)
public health response activities for chemical emergencies.
Based on the state health department’s distinct expertise for
acute and long-term environmental laboratory, toxicology,
epidemiology, surveillance, risk communication, and guidance
for worker health and safety, DEODC created a template --a
public health functional working group, to facilitate health
effects assessment and support interagency response. To
integrate these functions: DEODC implemented a 24-hour oncall intra-agency response protocol operating within an
interagency emergency notification algorithm; conducted key
informant interviews with potential stakeholders at the local
and county level to assess knowledge and needs; provided
guidance, recommendations and technical assistance for public
health laboratory directors; assessed worker health and safety
information needs during a chemical incident; identified gaps
in communication and offered solutions; developed modules
for immediate and long-term community risk surveillance and
studies; and created pathways to quickly produce toxicology
and chemical fact sheets.
Population Studied: Key informant individuals having
distinct roles for emergency response to chemical incidents at
the 62 local and county health departments, and state level in
CA: first responders, health providers, environmental health
scientists, industrial hygienist, toxicologists, law enforcement
personnel, epidemiologists, community based organizations.
Principal Findings: The need to evaluate methods for public
health department response to chemical emergencies is
essential. Many public health personnel often need to better
define, plan, and implement concerns about long-term
consequences to human and environmental health as well as
contamination cleanup. Many agencies perceived by health
departments to be stakeholders do not initially consider public
health agencies as part of their integrated response plans.
Because of the frequency of spills requiring hazardous
materials teams to intervene, public health agencies should
consider these models in planning and emergency response.
Throughout California, many local health departments are
requesting guidance and assistance for mitigation and recovery
of spills involving chemicals and hazardous materials and do
not have resources to address these threats.
Conclusions: Compared to preparedness and response
activities for biological events where public health
departments have clear mandates and authorities for
leadership, the roles for public health departments responding
to chemical emergencies often appear to overlap with first
responder entities and can often be unclear. Key informant
interviews and regional workshops addressing management of
chemical incidents are effective tools to prepare local health
departments and laboratories to handle assessment of chemical
contamination.
Implications for Policy, Delivery or Practice: The resources
dedicated for terrorism response should be evaluated in the
context of creating added capacity to prepare for and respond
to chemical threats. Since hazardous materials incidents occur
frequently, they can serve as models for testing public health
response capabilities and integrating intermediate and longterm interventions and coordination pertaining to
contamination clean up and human health effects.
Primary Funding Source: CDC
● Are Birth Outcomes Linked to Public Health System
Performance?
Michelyn Bhandari, M.P.H., F. Douglas Scutchfield, M.D.,
Evelyn Knight, Ph.D., Ann Kelly, M.H.A., I. Puiu Vasilescu,
Ph.D.
Presented by: Michelyn Bhandari, M.P.H., Research
Associate, School of Public Health, University of Kentucky,
121 Washington Avenue, Room 105, Lexington, KY 405360003; Tel: 859.257.2821; Fax: 859.257.6644; E-mail:
mwbhan2@uky.edu
Research Objective: Much of published public health
research has focused on evaluation of specific public health
interventions, and very few studies have tested the relationship
between public health system performance and health
outcomes. This study examines the relationship of birth
outcomes to public health system performance on the 10
essential public health services (EPHS) and to health
departments’ offering certain maternal and child health
programs. Answers to these questions will contribute to a
better understanding of the particular contribution of public
health functions to health status changes beyond what an
individual program evaluation contributes.
Study Design: This study uses data from three states that
participated in the National Public Health Performance
Standards Program test of the local assessment instrument
(version 5b) in 2000. The performance data was matched by
county to three additional databases: 1) the 1997 National
Association of County and City Health Officials (NACHHO)
profile of health departments, 2) Area Resource File (ARF)
published by Health Resources and Services Administration’s
(HRSA) Bureau of Health Professions in 2001, and 3) and the
Community Health Status Indicators (CHSI) Project published
by HRSA in 2000. Maternal child health program variables
were obtained from the NACCHO profile, and birth outcome
variables were obtained from the CHSI project. We explored
the bivariate relationships between system performance on the
10 EPHS and maternal child health programs offered by the
health departments, and between system performance and
birth outcomes. This study also used multiple linear regression
to assess the relationship between birth outcomes and system
performance while controlling for other variables such as
percent of persons below the poverty level and percent
nonwhite population. Control variables were obtained from
the ARF.
Population Studied: This study use cross-sectional data from
152 county or city/county health department jurisdictions
located within three states.
Principal Findings: The mean public health system
performance score on seven out of 10 of the essential services
was higher among those jurisdictions offering childhood
immunization programs than among those which did not offer
such programs. However, system performance was inversely
associated with five other maternal and child health programs
provided by the HDs. Bivariate results indicated that both the
infant mortality rate and percentage of low birth weight babies
in our study population was statistically significantly related to
public health system performance. However, after controlling
for poverty and percent nonwhite, public health performance
was not a significant contributor to these birth outcomes.
Conclusions: Results indicate that performance of the system
on the 10 EPHS is not related to birth outcomes when
contextual factors are taken into account. Clearly, more
research is required to determine the mechanism through
which public health systems processes influence community
health status. Further study using multilevel analysis will be
done to explore alternative pathways of getting from system
performance to community health status outcomes.
Implications for Policy, Delivery or Practice: Clarification
of relationships within the conceptual model of public health
practice is warranted. Evidence that clearly demonstrates a
pathway between public health performance and outcomes
would likely generate support for performance management
and quality improvement efforts in the practice sector.
Primary Funding Source: CDC, ATPM
● Patterns of Alcohol Consumption within the Context of
Hepatitis C
Eleanor Stoller, Ph.D., Carol Blixen, Ph.D., Adam Perzynski,
M.S., Joshua Terchek, BS, Stephanie Kanuck, M.S., Richard
McCormack, Ph.D.
Presented by: Carol Blixen, Ph.D., Associate Director for
Research Program Development, Division of Clinical
Research-NA-10, Cleveland Clinic Foundation, 9500 Euclid
Avenue, Cleveland, OH 44195; Tel: 216.444.6254; Fax:
216.444.9275; E-mail: blixenc@ccf.org
Research Objective: Research Objective: Alcohol use is
discouraged or contraindicated for patients with a variety of
medical illnesses. However, little is known about why patients
continue to consume alcohol in the face of diagnoses that
warrant a reduction in use or abstinence. The objective of this
research was to explore the patterns of alcohol consumption
among patients diagnosed with the Hepatitis C Virus (HCV).
Study Design: Study Design: Cross sectional research design
employing thematic analysis using N*Vivo, a software
program for managing and coding qualitative data.
Population Studied: Population Studied: Two sources of
qualitative (textual) data were used: (1) 30 semi-structured
interviews with currently nonproblematic drinkers (determined
by the Alcohol Use Disorders Identification Test [AUDIT]
scores) diagnosed with HCV at a metropolitan teaching
hospital and (2) 307 illness narratives posted on Hepatitis Crelated sites on the Internet.
Principal Findings: Principle Findings: We categorized
decisions regarding alcohol consumption within the context of
HCV into three categories: Compliance, Tailoring, and
Noncompliance. Some compliant subjects quit immediately
after diagnosis, whereas others quit drinking only after a delay
(until they experienced disease symptoms and complications;
because of negative reactions to alcohol; or for reasons not
related to the diagnosis). Tailoring involved some change in
drinking behavior following HCV diagnosis, most often
decreases in the frequency or amount or a change in the type
of alcohol consumed. Some individuals drank only on special
occasions or in response to stress. Others tried to monitor
their bodies for evidence of disease progression or employed
strategies they believed would lessen the negative impact of
alcohol. Finally, a number of individuals disregarded medical
advice and continued to drink at pre-diagnosis levels
(noncompliance). While some challenged recommendations
of medical providers, others discounted the likelihood that
alcohol-related risks applied to them. Others saw little reason
to stop drinking, either because they believed there was no
“cure” for HCV or because the perceived benefits of drinking
outweighed the costs.
Conclusions: Conclusions: Almost all of these informants
were aware that alcohol consumption was contraindicated
among people with a diagnosis of HCV and most could
describe the negative impact of alcohol on liver function. Yet
we found a proportion of HCV patients, even among these
nonproblematic drinkers, who continued to consume alcohol,
either at reduced or pre-diagnosis levels. Some people
classified as Tailoring reported that they had “quit drinking,”
but later described situations in which they still drank.
Individuals often exhibited more than one pattern indicating
that “adherence” may be a series of contextualized decisions
that unfolded over time. Further analyses will determine the
prevalence of these patterns among these respondents.
Implications for Policy, Delivery or Practice: Implications
for Policy, Delivery, and Practice: Abstinence from alcohol
use represents a major opportunity to prevent a decline in the
health and quality of life of patients with HCV and similar
diseases. Information generated by this research will be
incorporated into a tool designed to enhance the effectiveness
of primary care providers in discouraging alcohol
consumption among non-abusing/nondependent drinkers
diagnosed with HCV.
Primary Funding Source: NIAAA,
● The Association of Violence Perpetration and
Victimization with Risky Sexual Behavior
Laura Bogart, Ph.D., Rebecca Collins, Ph.D., William
Cunningham, M.D., M.P.H., Robin Beckman, M.P.H., Daniela
Golinelli, Ph.D., David Eisenman, M.D., Chloe Bird, Ph.D.
Presented by: Laura Bogart, Ph.D., Social/Behavioral
Scientist, Health, RAND Corporation, 1700 Main Street, P.O.
Box 2138, Santa Monica, CA 90407; Tel: 310.393.0411Ext.
7109; Fax: 310.451.6930; E-mail: lbogart@rand.org
Research Objective: Prior research has found that violence
perpetration and victimization are related to greater
engagement in high risk sexual behavior. However, the
majority of studies have assessed overall perpetration,
victimization, and risk behavior, rather than within the context
of intimate or sexual relationships. Furthermore, research in
this area has primarily focused on women and HIV-negative
individuals. In the present study, we examined whether
people with HIV who experience or perpetrate abuse within a
close relationship are more likely to engage in unprotected
intercourse with that same partner. We also assessed whether
this association holds across women, men who have sex with
men (MSM), and heterosexual men.
Study Design: Data are from the Risk and Prevention (R&P)
survey of the HIV Cost and Services Utilization Study
(HCSUS). HCSUS used multistage national probability
sampling to select a random sample of adults with known HIV
infection who had at least one health care visit at a facility
other than a military, prison, or emergency department from
January 1996 to February 1996. The R&P sample was
selected from the second HCSUS follow-up (September
through December 1998); analyses were weighted to represent
the entire surviving sample at second follow-up. Eight items
assessed specific abusive behaviors within spousal or primary
relationships (threaten to hit or throw something; push, grab,
or shove; kick, bite or hit with fist; force to have vaginal or
anal sex), separately for perpetration and victimization; these
variables were combined and dichotomized into “any
perpetration” or “any victimization” vs. none. Unprotected sex
was defined as any anal or vaginal sex without a condom.
Both had a “past six months” reference period. Logistic
regressions were conducted predicting any unprotected sex
with any perpetration or victimization, gender/orientation
group (women, heterosexual men, MSM) and the
gender/orientation group by perpetration/victimization
interactions. Control variables included age, race, income,
education, geographic region, and CD4 count.
Population Studied: A total of 1421 people with HIV were
surveyed. The present analyses focused on those in a close
relationship (288 women, 148 heterosexual men, and 292
MSM).
Principal Findings: Respondents who had perpetrated abuse
within their close relationships were more likely than those
who had not to report engaging in any unprotected intercourse
in the past 6 months (OR = 2.54, 95%CI = 1.32-4.87, p < .01).
Similarly, respondents who had been victims of abuse within
their close relationships were more likely than those who had
not to report engaging in any unprotected intercourse (OR =
3.01, 95%CI = 1.78-5.10, p < .001). Gender/orientation group
did not moderate these effects (all ps > .10).
Conclusions: Across all three gender/orientation groups,
perpetrating violence and experiencing victimization within a
close relationship was strongly and significantly associated
with ever having unprotected sexual intercourse within that
relationship.
Implications for Policy, Delivery or Practice: Interventions
for HIV positive individuals designed to prevent sexual
transmission of HIV to close relationship partners need to take
into account the sometimes abusive contexts in which sexual
activity may occur, regardless of the gender/orientation group
targeted.
Primary Funding Source: NHLBI
● Community Social Capital, Individual Social Capital
and Obesity
Timothy Brown, Ph.D.
Presented by: Timothy Brown, Ph.D., Assistant Director,
Petris Center - School of Public Health, University of
California at Berkeley, 2150 Shattuck Avenue, Suite 525,
Berkeley, CA 94720-7380; Tel: 510.643.4103; Fax:
510.643.4281; E-mail: timbrownphd@yahoo.com
Research Objective: This research seeks to determine the
possible association between community-level social capital,
individual-level social capital and an intermediate health state,
obesity, in US metropolitan areas.
Study Design: I examine the effects of lagged communitylevel social capital on body mass index both independently
and interacted with all other variables in the model including
individual-level social capital using multivariate regression
analysis. I control for sex, race/ethnicity, age, marital status,
education, physician office visits, smoking status, and aerobic
exercise status. I test for the endogeneity of physician office
visits, smoking status, aerobic exercise status, and individuallevel social capital by estimating two-stage least squares and
using a Hausman-type test of endogeneity. The strength of the
identifying variables in the first-stage regressions is tested
using the Staiger-Stock criteria. The exogeneity of the
identifying instruments in the first-stage regressions is tested
using an overidentification test. Finally, the exogeneity of the
social capital variables is tested using a new approach that
does not require instruments: the De Luna-Johansson test.
Population Studied: I study adults aged 18 years and older
who live in US metropolitan areas using data from the 2000,
2001 National Health Interview Surveys and the 2000 County
Business Patterns survey.
Principal Findings: Individual body mass index (BMI) and
community-level social capital are found to be negatively
associated. Individual-level social capital is found to be
positively related to BMI, but this association is attenuated in
areas with higher levels of community-level social capital.
Conclusions: Both community-level social capital and
individual-level social capital may be important influences on
individual BMI independent of sex, race/ethnicity, age, marital
status, exercise, medical care, smoking, and education.
Implications for Policy, Delivery or Practice: Public health
professionals should further investigate possible mechanisms
by which community-level social capital may affect health
before making policy changes so that changes may be
appropriately targeted and their effects appropriately
measured.
● Systems Assessment of HIV Service Delivery in Chicago
Title I EMA
Douglas Bruce, M.S.W., Nathan Linsk, Ph.D., Linda
Lesondak, Ph.D., Barbara Schechtman, M.P.H., Michael Bass,
M.S.W., Chuck Bright, M.S.W.
Presented by: Douglas Bruce, M.S.W., Jane Addams College
of Social Work, Univ. of Illinois at Chicago, Midwest AIDS
Training and Education Center, 1640 W. Roosevelt Road,
Suite 511, Chicago, IL 60608; Tel: 312.996.0514; E-mail:
dbruce@uic.edu
Research Objective: To describe degree to which the primary
care, mental health, and substance abuse treatment systems
interact and collaborate in delivering services to persons living
with HIV/AIDS;
To identify obstacles to effective systems interaction; and
To recommend modifications to improve systems interactions
and collaborations.
Study Design: Mixed methods study using semi-structured
interviews of key informants from multiple service systems.
Principal domains of inquiry in interview were: existing
services in the systems described; gaps in services; systems
linkages and interactions; existing and emerging patterns;
development needs; and recommendations. First-level and
second-level coding of qualitative data used to analyze
responses and describe themes that emerged.
Population Studied: Publicly funded systems of care
providing services to persons living with HIV/AIDS,
including medical care, mental health, substance abuse, case
management, housing, child welfare, and corrections. Key
informants included providers, administrators and consumers
within these care systems.
Principal Findings: There is a lack of coordination and
collaboration among systems due to structural factors and
different treatment paradigms. Structural factors include
inconsistent eligibility criteria for clients, data reporting
requirements that preculde effective collaboration among
providers, and "turf battles." Divergent care models often
results in a lack of knowledge among providers regarding the
treatment delivered by other professional disciplines, as well
as conflicting approaches to treatment. The HIV/AIDS
service delivery model has shifted in recent years to a medical
care model, while co-locating services in a single location is
thought to improve patient access to care and present
opportunities for improving coordination of care. Emerging
policy changes affecting the systems of care include faithbased initiatives, decreased access to medications, and rapid
testing mandates.
Conclusions: Services for persons living with HIV/AIDS
should be located within single locations as well as combined
at the administrative level.
Housing, mental health, and substance aubse services need to
be expanded.
A continuum of services including prevention, case finding,
testing, and behavioral health services needs to be developed
further.
Improved collaboration, planning, and data systems are
viewed as important mechanisms for eliminating duplication
of services and maximizing resources.
There is a need for the development of vision and leadership
commitments among stakeholders to effect constructive
change.
Policy changes are needed at the local, state, and national
level.
Implications for Policy, Delivery or Practice: Developing
integrated systems of care should be a priority.
There is a need for coordinated data systems to better plan,
coordinate, and evaluate care services.
Policy issues that need to be addressed include lobbying for
increased AIDS Drug Assistance Program (ADAP) funds,
closer examination of disclosure issues regarding rapid testing,
lobbying for expanding the maximum length of stay in
residential substance abuse treatment. Providers from
different disciplines and practice settings need to be crosstrained in order to overcome barriers to effective treatment
coordination.
Leadership from different disciplines need to have focal point
discussions on how to examine HIV/AIDS care within larger
care systems, and not as a free-standing system developed
from dedicated federal and state funding.
Primary Funding Source: HRSA, Local Title I Grantee
● Relationship of Attitudes towards Doctors and the
Receipt of Preventative Services
Andrea Cherrington, M.D., Donald Pathman, M.D., Giselle
Corbie-Smith, M.D.
Presented by: Andrea Cherrington, M.D., Research Fellow,
Medicine, UNC/RWJ Clinical Scholars Program, 1004 West
Trinity Avenue, Durham, NC 27701; Tel: 919.530.1164; Email: andrea_cherrington@med.unc.edu
Research Objective: To examine whether an association
exists between attitudes towards doctors and the receipt of
preventative services.
Study Design: We used data from a 2002-2003 telephone
survey of adults living in 150 rural counties in 8 states of the
U.S. southeast that queried respondents on their use of health
services, their barriers to care and their opinions on access
issues. For this study, primary independent variables were
measured through four questions that were combined into two
2-item scales that assessed agreement with statements that one
should (1) see doctors early and regularly and (2) avoid seeing
doctors in preference of self-treatment. Chi-square analyses
were used to look for associations between attitudes towards
doctors and the receipt of preventative services. Findings were
weighted to sampling and response probabilities.
Population Studied: Individuals living in rural counties in the
southeast. Minorities were oversampled.
Principal Findings: Of the 4, 879 adult respondents, 54%
were female, 70% were white and 27% were African
American. Only half had graduated high school and 43% had
an annual household income of less than $25,000. A total of
13.5% (n=656) didn´t believe in seeing doctors early and
regularly and 18% (n=877) believed that one should delay or
avoid seeing doctors. Persons who indicated that they don´t
believe in seeing doctors early and regularly were less likely
than those who do to have had a routine doctor visit in the
previous year (66.1% vs 83.2%, p< 0.001), had a flu shot in
the previous year (50% vs 69.9%, p=0.004), had a
mammogram in the previous year (37.4% vs 60.4%, p<0.001),
had a pap smear in last 3 years (81.2% vs 89.2%, p<0.001),
had a cholesterol check in the last 5 years (61% vs 76.5%,
p<0.00.1) or ever had endoscopic screening (34.9% vs 48.4%,
p<0.001). Persons who agreed that they believe in
avoiding/delaying seeing doctors also received fewer
preventive services when compared with those who didn´t
agree.
Conclusions: Attitudes and beliefs about seeing doctors
versus self-treatment are associated with the likelihood that a
person will have received recommended preventative services.
Implications for Policy, Delivery or Practice:
Understanding individuals´ beliefs about health and the role of
physicians in disease prevention will facilitate targeted
interventions aimed at increasing uptake of preventative
services
Primary Funding Source: RWJF
● Geographic Variation in the Prescription of Schedule II
Opioid Analgesics Among Outpatients in the United States
Lesley Curtis, Ph.D., Jennifer Stoddard, B.A., B.S., Jasmina
Radeva, M.A., Steve Hutchison, Ph.D., Raymond Woosley,
Ph.D., Kevin Schulman, M.D.
Presented by: Lesley Curtis, Ph.D., Assistant Research
Professor, Center for Clinical and Genetic Economics, Duke
Clinical Research Institute, Duke University Medical Center,
PO Box 17969, Durham, NC 27715; Tel: 919.668.8101; Fax:
919.668.7124; E-mail: lesley.curtis@duke.edu
Research Objective: Previous reports have examined the use
of opioid analgesics, including oxycodone. However, no study
has explored geographic variations in the use of these drugs
systematically. We sought to measure geographic variations in
opioid use in a large outpatient population.
Study Design: We conducted a retrospective cohort study
using the administrative claims database of a large
pharmaceutical benefit manager. Main outcome measures
were number of claims per 1000 total claims for opioid
analgesics and oxycodone at state and county levels. We
measured state-level variation using the weighted coefficient
of variation and the systematic component of variation. We
calculated county-level rates by dividing the number of claims
for all opioid analgesics and for oxycodone by the total
number of claims by zip code, which we mapped to counties
to obtain aggregate figures. In univariate and multivariable
analyses of county-level rates, we explored associations with
explanatory variables, including sociodemographic
characteristics, hospital admissions and surgeons per 1000,
urban influence, and presence of state-level prescription
monitoring programs.
Population Studied: Subjects were included if their insurance
carriers required the benefit manager to track claims at the
subject level, excluding those whose plans used a single
identifier for multiple family members. The data set consisted
of 7,873,337 outpatients enrolled continuously from January
through December 2000 and who filed at least 1 prescription
drug claim during that period. Each subject's claims were
linked using a unique identifier encrypted to ensure
confidentiality. A total of 1171 insurers were represented,
covering all 50 states, the District of Columbia, and US
territories.
Principal Findings: A total of 391,299 subjects (5.0%) filled
a prescription for an opioid analgesic. Of almost 9 million
claims, 567,778 (64.2 per 1000) were for an opioid analgesic.
Claim rates varied by state from <20 to >100 claims per 1000.
States with long-standing prescription monitoring programs
had among the lowest rates for both opioid analgesics and
oxycodone. In multivariable regression analysis of countylevel data, statewide prescription monitoring programs,
number of surgeons per 1000, location in a metropolitan area,
and poverty rate were independently associated with claim
rates for all opioid analgesics. Monitoring programs, number
of surgeons per 1000, location in a metropolitan area, and
median age were independently associated with claim rates for
oxycodone.
Conclusions: Although there are important geographic
variations in claim rates for oxycodone, they are consistent
with variations in the use of other opioid analgesics.
Prescription monitoring programs, number of surgical
specialists, location in a metropolitan area, and poverty rate
are associated with claims for oral opioid analgesics, including
oxycodone.
Implications for Policy, Delivery or Practice: Although
prescription monitoring programs have been shown to reduce
the use of opioid analgesics, some believe that physicians may
under-prescribe these drugs in states with monitoring
programs. Alternatively, monitoring programs may have a
Hawthorne effect, whereby physicians prescribe more
appropriately because their behavior is being observed. Better
understanding of geographic variations will require detailed
analyses of the costs, risks, and benefits of therapies and the
circumstances in which they are used.
Primary Funding Source: AHRQ
● The Effect of Income Question Design in Health Surveys
on Family Income, Poverty and Eligibility Estimates
Michael Davern, Ph.D., Holly Rodin, MPA, Timothy Beebe,
Ph.D., Kathleen Thiede Call, Ph.D., Lynn Blewett, Ph.D.
Presented by: Michael Davern, Ph.D., Research Associate,
SHADAC, University of Minnesota, 2221 University Avenue,
S.E., Suite 345, Minneapolis, MN 55414; Tel: 612.625.4835;
E-mail: daver004@umn.edu
Research Objective: To evaluate the differences between two
methods of collecting family income information. The first
method, termed “the omnibus approach,” asks for the total
family income amounts with one central survey item and is
used in health surveys such as the National Health Interview
Survey (NHIS) and the Behavioral Risk Factor Surveillance
System (BRFSS). The second method, used in the Current
Population Survey Demographic Supplement (CPS-DS), sums
specific amounts of income obtained from multiple income
sources over everyone in the family. We call this the
“summed income amounts” approach. We also assess whether
there is a bias resulting from using the omnibus income item
to estimate the number of people below a certain level of
poverty or eligible for a public program.
Study Design: We utilize the 2001 CPS-DS data because it
contains both an “omnibus” and “summed income amounts”
measure. First we compare the summed amount to the
omnibus amount of family income. Second, we use the
various sources of summed income to predict whether there is
a mismatch between the omnibus and summed income
amounts. Finally, if the summed amount is not within the
omnibus amount range, we assign a new summed amount of
income to the family that is restricted to be within the range of
the omnibus amount. We compare tabulations based on the
new restricted summed amounts to the previous summed
income values and observe differences.
Population Studied: The 2001 CPS-DS covers the noninstitutionalized US population.
Principal Findings: We find a great deal of variation between
the omnibus family income question and the summed income
amounts from every source and every member within a
family. These differences derive from predictable sources.
For example, having children under 24 in the household with
earned income is related to the mismatch. Furthermore, the
percent of people estimated to be in poverty is higher using the
omnibus income item relative to the estimates derived from
the aggregated items.
Conclusions: Income is often collected in health surveys as
both a correlate of health insurance coverage and as a means
to model public program eligibility. There are realistic
constraints to including more than an omnibus income
question in health surveys, such as survey administration
costs, length of time per interview, and concerns about
respondent sensitivity to lengthy segments of the survey
focusing on income questions. However, analysts should be
aware that the income data derived from such a survey is
limited with respect to eligibility estimation because it tends to
produce lower family income estimates and does not allow an
analyst to adjust for various income disregards associated with
many public programs.
Implications for Policy, Delivery or Practice: The
methodologies employed in this paper could be generalized to
enhance health survey income data by statistically matching
respondents from a survey with detailed income data to health
survey data in order to have better estimates of income and the
sources of income. This is important in order to develop more
realistic program eligibility estimates using health survey data.
Primary Funding Source: RWJF
● An Evaluation of Hazardous Materials Emergency
Response Planning: Implications for Policy Improvement
at the County Level in California
Muntu Davis, M.D., M.P.H.
Presented by: Muntu Davis, M.D., M.P.H., The California
Endowment Scholars in Health Policy at Harvard University,
The California Endowment, 10620 De Haven Avenue, Hansen
Hills, CA 91331; Tel: 310.776.0406; E-mail:
muntu_davis@post.harvard.edu
Research Objective: 1. To evaluate the implementation of
current federal and state hazardous materials emergency
response planning policies at the county level
2. To determine the responsibilities of the different agencies
involved in hazardous materials emergency response planning
3. To identify areas for improvement
Study Design: Federal laws, California legislation, and
emergency response planning guidelines were analyzed for
legal precedence and current practice pertaining to hazardous
materials emergency response planning. Data were obtained
from the Department of Pesticide Regulation for pesticide
incidents from the years of 1999 to 2001. Census data was
obtained from the US Census Bureau for 2000. Structured
interviews with State, County and Local government agencies
responsible for planning and responding to hazardous
materials accidents were conducted, as well as interviews with
residents of Earlimart, Tulare county, California.
Population Studied: Not applicable.
Principal Findings: 1. California's budget cuts have limited
the ability of emergency response agencies to prepare for
hazardous materials accidents.
2. At minimum, emergency response plans are conducted
undergo yearly reviews, which may simply include updating
phone numbers.
3. Some agencies are able to conduct tabletop exercises with a
limited number of their staff. These exercises do not test all
skills required for an actual response effort.
4. No interagency drills are performed.
5. The public and its needs, e.g. linguistic, are not included in
the planning process.
6. Bio-terrorism has a) increased funding for pre-hazard
mitigation planning and b) heightened the awareness of the
need to improve communication among different emergency
response agencies at and between different levels of
government.
7. Hazardous materials emergency response planning is not
viewed the same as bio-terrorism preparedness despite the fact
that the protocols are the same for both.
Conclusions: The legislation and guidelines reviewed are
theoretically very comprehensive and sound in terms of
outlining the process of hazmat planning and response.
However, as the number of agencies responding to a
hazardous materials accident increases, the chance of an
ineffective response increases. Considering this, a few
recommendations can be made to improve the current
hazardous materials emergency response system.
Implications for Policy, Delivery or Practice: The key to
effective emergency management is rapid, well planned
responses. And as first responders, county and local agencies
need to plan and to practice working together to ensure an
effective response to any type of emergency. Therefore, I
recommend the following:
1. Consolidate grant programs for emergency response efforts
into larger partnership grants given to local governments with
accountability provisions based on objective measures of
outcomes or effectiveness.
2. More state or regional oversight over county planning and
preparation, recognizing that local responders begin the
process and activation of the emergency response system in
the state.
3. Interagency drills every 2 or 3 years for improved
interagency coordination and communication.
4. Ensure that resources used for bio-terrorism preparedness
coincide with the needs for hazardous materials response
planning and preparation.
5. Pesticide-related disasters are different in nature and risks
compared with other emergencies, like a fire, flood or civil
unrest. Yet, all can be very dangerous and involve a large
number of people.
6. Inclusion of the public would enable emergency responders
to assess needs, e.g. language needs, prior to an emergency.
Primary Funding Source: The California Endowment
● UNC Certificate Program: Are We Training the Public
Health Workforce?
Mary Davis, Dr.PH, MSPH
Presented by: Mary Davis, Dr.PH, MSPH, Program Planner
and Evaluator, North Carolina Institute for Public Health,
UNC School of Public Health, CB 8165, Chapel Hill, NC
27599; Tel: 919.843.5558; E-mail: mary_davis@unc.edu
Research Objective: Public health workers need to be trained
in the latest approaches of the core public health sciences.
Developing distance-learning methods that use a lifelong
learning framework to train the public health workforce has
been identified as an essential strategy for improving the
public health system infrastructure and meeting the public
health needs of the nation. A number of schools and programs
in public health have created public health worker training
programs. The University of North Carolina at Chapel Hill
School of Public Health (UNC SPH) created the on-line
Certificate in Core Public Health Concepts with public health
workers as the primary target audience. Public health worker
participation in these programs, however, has yet to be
examined. Additionally, there has been considerable debate as
to who should be counted as a public health worker. The
purpose of this research was to define and examine public
health worker participation in the UNC SPH Certificate
Program.
Study Design: The National Public Health Performance
Standards Program defines the public health systems as public,
private, and voluntary entities that contribute to delivery of
essential public health services within a jurisdiction. Using
this definition, all Certificate programs applicants were
assigned a job code by place of employment.
Population Studied: Applicants were classified as: 1) Public
Health Agency workers work for a state or local health
department, only, 2) Public Health System workers work for
healthcare providers such as hospitals or laboratories, human
services and charity organizations, and 3) “Other” category
work for organizations that are not among those listed above,
e.g. temporary agencies. Applicants were also categorized by
participation in the program: 1) Participants were current
students or graduates of the program, 2) Nonparticipants
enrolled in a course but subsequently withdrew from the
program and those accepted who never enrolled in any
courses.
Principal Findings: Among 273 applicants examined, 147
(54%) were classified as Nonparticipants and 126 (46%) were
classified as Participants. Of the total applicants, 36 (13%)
have completed the program. Fifty three (19 %) of the
applicants were classified as Public Health Agency Workers,
174 (64%) were classified as Public Health System Workers,
and 46 (17%) were classified as being employed in the Other
category. Among Nonparticipants, 31 (21%) were Public
Health Agency Workers, 89 (61%) were Public Health System
Workers, and 27 (18%) were classified in the Other category.
Among Participants, 22 (17.5%) were Public Health Agency
Workers, 85 (67.5 %) were Public Health System Workers,
and 19 (15%) were classified in the Other category. Among
graduates, 8 (22%) were Public Health Agency Workers, 22
(61%) were Public System Workers, and 6 (17%) were
classified in the Other category. This paper will also present
Participation satisfaction with the program and student
performance.
Conclusions: The Certificate applicants and enrollees include
a number of government public health agency employees as
well as public health system workers from more direct care
settings.
Implications for Policy, Delivery or Practice: While online
programs reach the public health workforce, no specific
benchmarks for participation have been established. This
research provides insight into the participation of public health
agency workers in training.
● Preparedness for Bioterrorist Events and Other Public
Health Emergencies in Rural Florida
Aram Dobalian, Ph.D., M.P.H., J.D., Jennie Tsao, Ph.D.
Presented by: Aram Dobalian, Ph.D., M.P.H., J.D., Assistant
Professor, Health Services Administration, University of
Florida, P.O. Box 100195, Gainesville, FL 32610-0195; Tel:
352.273.6081; Fax: 352.273.6075; E-mail:
adobalia@phhp.ufl.edu
Research Objective: Approximately 80% of U.S. land is
classified as rural. Rural communities are found in all states,
and 65 million Americans live in these communities. Because
of their remote locations and limited resources, rural
communities have specific concerns that vary from urban
communities when it comes to recovery from mass casualty
events. Whereas existing studies have addressed medical
needs such as injury or physical trauma, little is known about
how rural health care providers will respond to the
intermediate and longer-term health needs, particularly mental
health needs, of rural communities following bioterrorist and
other public health emergencies.
Study Design: This study used key informant interviews to
assess existing preparedness based on the structure, process
and outcomes of care, as well as knowledge/awareness of
preparedness among primary care providers. We evaluated
which models are working with regard to quality of care, and
which models promoted greater provider awareness of what to
look for and who to ask for assistance following bioterrorist
and other public health emergency events. We also examined
special concerns of certain vulnerable, priority populations
including women, children and families, and frail elders.
Population Studied: To date, we have examined a mix of
various organizations within rural communities in Northern
Florida: community health centers and the public health
system, primary care clinics, hospitals, individual providers,
and a long-term care provider.
Principal Findings: Bioterrorism was not perceived to be a
significant threat to rural communities, and some interviewees
expressed concern that resources are being diverted from what
they perceived to be higher priority health needs. Providers
did indicate some heightened interest from patients around the
time of major news events (e.g., anthrax, SARS). Many
interviewees were aware of the existence of bioterrorism
preparedness plans, but few expressed familiarity with the
details of those plans. Existing resources were viewed as
inadequate to meet current mental health needs. Few providers
identified PTSD as a likely consequence of bioterrorism.
Conclusions: Public health emergencies were generally
viewed as less important than the common chronic conditions
that confront providers in rural communities. Existing
resources may be inadequate to meet current health needs
given comments by interviewees who stressed the need to
address inadequate access to providers, especially specialty
care (e.g., mental health, dental health), and patient-level
barriers to care such as a lack of insurance, the cost and
distance involved in transportation, and a lack of financial
resources to pay for care. These issues would be exacerbated
by a mass casualty event.
Implications for Policy, Delivery or Practice: Greater
education and training regarding mental health conditions that
may result from or be exacerbated by major public health
emergencies is necessary for primary care providers. This
training may have the added benefit of assisting providers in
decreasing unmet need for mental health care in rural
communities.
Primary Funding Source: AHRQ, Health Resources and
Services Administration
● Adopting and Adapting Small Area Variation to
Improve Clinical Quality of Care in Health Plans
Huda Fadel, M.P.H., Ph.D.
Presented by: Huda Fadel, M.P.H., Ph.D., Manager, Health
Services Research, Center for Health Care Quality and
Evaluative Studies, Blue Cross Blue Shield of Michigan, 600
East Lafayette, Mailcode J418, Detroit, MI 48226; Tel:
313.225.7175; Fax: 313.225.5993; E-mail:
hfadel@bcbsm.com
Research Objective: Small area variation (SAV) analysis in
health care has been in use since the 1970s, and its findings of
variation have spurred improvement in quality of care through
evidence based medicine. Most SAV work has come from
academia, relying on large Medicare or other national files and
reporting findings with system-wide implications. Health
plans can play an important role in reducing variation,
however, it is only recently that they have begun to adopt
SAV to diagnose problems, establish priorities and target
resources in their health management programs. Although
SAV has great potential, turning research into practical
solutions has been a challenge
Study Design: Blue Cross Blue Shield of Michigan
(BCBSM), the state’s largest commercial health insurer, has
adopted this approach to understanding utilization and
improving quality of care for its population. Its atlases show
extensive practice variation, in some health topics more than
others.
1. In 2000, BCBSM, in conjunction with the Center for
Evaluative Clinical Sciences, produced the Dartmouth Atlas of
Health Care in Michigan, one of the first examinations of its
kind in commercially-insured populations. The Atlas
addressed variation in several medical conditions, surgical
procedures, end-of-life care and pharmacy utilization and is
published on the company’s website.
2. One of the Atlas’ most interesting findings was the wide
variation in pediatric ADHD prescribing. In 2003, BCBSM
collaborated with researchers at the University of Michigan
Medical School to study quality of care for ADHD. A parallel
investigation into the Michigan Medicaid population was
included for comparison purposes.
3. In 2004, four BCBS plans will collaborate to produce an
Atlas of pharmacy utilization and quality measures. This
Atlas will provide empirical benchmarks and a national
platform for sharing and discussion best practices in pharmacy
programs
Principal Findings: The empirical findings from these atlases
have been excellent vehicles for educating consumers and
providers. Corporate quality studies now include an SAV
analysis and atlas in their plan; all results are published in the
company’s newsletters and on its website. Over time, it is
anticipated that variation will decrease for these topics.
Similar efforts are being investigated for provider profiles and
customer reports.
Community coalitions use atlas findings to improve quality in
their areas. This helps target resources and efforts in the areas
where they are needed. BCBSM works closely with these
groups.
Another area under development is focused provider networks
and centers of excellence, based on the practice of evidencebased medicine.
Most progress to date has been on health issues for which
medical science is clear (and variation is “unwarranted”). The
issues for which guidelines are not available are problematic,
though we know there is variation. Health plans struggle with
the question of “which rate is right?” and appropriate actions.
Meanwhile, variation continues to entails high cost.
Conclusions: Most progress to date has been on health issues
for which medical science is clear (and variation is
“unwarranted”). The issues for which guidelines are not
available are problematic, though we know there is variation.
Health plans struggle with the question of “which rate is
right?” and appropriate actions. Meanwhile, variation
continues to entails high cost.
Implications for Policy, Delivery or Practice: Large health
plans have immense data assets that are well-suited for SAV
studies. These activities are resource intensive, and are
undertaken to improve health care. Although the method has
generated a great deal of interest, turning research into
practical solutions remains a challenge
● Proactive Recruitment of Health Plan Members into
Smoking Cessation Counseling
Jodi Summers Holtrop, Ph.D., Huda Fadel, M.P.H., Ph.D, Sam
Vansen, MHSA, David Weismantel, M.D., M.S., William
Wadland, M.D., M.S.
Presented by: Huda Fadel, M.P.H., Ph.D, Manager, Health
Services Research, Center for Health Care Quality and
Evaluative Studies, Blue Cross Blue Shield of Michigan, 600
East Lafayette, Mailcode J418, , MI 48226; Tel:
313.225.7175; Fax: 313.225.5993; E-mail:
hfadel@bcbsm.com
Research Objective: The purpose of the study is to determine
if delivery of proactive phone calls or postcards to health plan
members currently using pharmacotherapy alone increases
participation in smoking cessation counseling services and to
assess the resource costs to the program of doing so
Study Design: Health plan members filling pharmacotherapy
claims were identified weekly from health plan pharmacy
claims data and randomized into one of three groups: control,
recruitment postcard, or recruitment phone call by a nurse
counselor. Enrollment of study members to the smoking
cessation program was tracked for one month
Population Studied: Adult members of a large health insurer
in Michigan. Subjects were enrolled in the PPO or indemnity
product and had pharmacy coverage
Principal Findings: Over a 5-month time period, 625 total
individuals were identified for participation in the study with
the following respective enrollments to the program: 0/157
control; 2/156 postcard; 66/312 phone call recruitment
(p<0.0001). Over 50% of the prescriptions were for
bupropion. Most of the members (53%) had quit by the time
of the call. Members with lower confidence (p=0.02) and
experiencing episodes of relapse (p<0.0001) were significantly
more likely to enroll in the counseling services. The 2-month
quit rates for the phone call participants were similar to other
participants spontaneously calling to enroll during the same
time period. Total costs for each intervention were: $3389
(phone) and $4766 (call). Incremental cost per intervention
type shows $73.25 per participant receiving postcards and
$24.56 per telephone participant
Conclusions: Query of a pharmacy database to identify
smokers filing claims for pharmacotherapy and proactive
telephone recruitment by smoking cessation counselors of a
health plan may be an effective way to reach smokers
attempting cessation in a non-HMO environment. Although
the total investment of personally contacting individuals by
telephone is high, the resulting enrollment makes it the most
cost-effective way of encouraging participation in quitlines
Implications for Policy, Delivery or Practice: Compared to
the use of pharmacotherapy alone, smoking cessation
counseling provided to those making a quit attempt increases
the likelihood of successfully quitting over no additional
assistance. Many smokers attempting cessation do not access
methods available to them that would increase their chances of
successful cessation. Methods for encouraging participation
in effective programs are needed and proactively contacting
smokers may be one of them.
Primary Funding Source: RWJF
● Combining the Benefits of Decision Science and
Financial Analysis in Public Health Management: A
County-Specific Budgeting and Planning Model
Peter Fos, Ph.D., M.P.H., Danny Miller, M.B.A., CB.A., Brian
Amy, M.D., MHA, M.P.H., Miguel Zuniga, M.D., DrPH
Presented by: Peter Fos, Ph.D., M.P.H., Chief Science
Officer, Mississippi State Department of Health, 570 E.
Woodrow Wilson, Jackson, MS 39216; Tel: 601.942.8367; Email: Peter.Fos@msdh.state.ms.us
Research Objective: Determine the benefit of combining the
use of decision and financial analysis by developing a countyspecific budgeting and planning model, using multi-attribute
utility methodology.
Study Design: A modified Delphi technique was used to
develop a decision support system to assist in budgeting and
planning. The decision support system variables were based
on three national sets of indicators:the CDC Health Objectives
for the Nation Consensus Set of Health Status Indicators for
the General Assessment of Community Health Status -United States; the UnitedHealth Group State Health Rankings,
and the newly released Institute of Medicine 20 Key Areas to
Transform Health Care System. An additive multi-attribute
utility method is employed to develop a scoring system to rank
statewide health status objectives according to a weighted
numerical score. Four objectives related to health risks, health
outcomes, health resources, and healthcare quality are used to
measure each board's member’s perceptions of importance in
each indicator. The four objectives were subdivided into 20
sub-objectives representing detailed health status data. A
county-specific interactive computer based model was
developed to determine the impact of changes in budgeting
and planning on each county’s capability to achieve services
delivery objectives. These services delivery objectives were
determined following the Agency mission and vision,
associated with financing issues and considerations.
Population Studied: The state of Mississippi population was
the target population for the study. Specifically, since the
decision support system is a county-specific budgeting and
planning model, each of the 82 counties in the State
represented the unit of analysis. Group meetings of board
members, district health officers and administrators were held
to assess valuations and trade-offs across a set of objectives
for health status assessment.
Principal Findings: The county-specific budgeting and
planning model is a reasonable decision support system for
use in a public health agency. The model illustrates the
impact on a county health department’s capability to deliver
public health services, as well as indicates the expected
change in health measures. One benefit is that the model
allows for planning and budgeting, and the analysis or the
associated effects, without the restrictions of categorical
funding and financing. The decision support system can be
used for real-time budgeting and planning, as well as
simulations that can assist in strategic financial decision
making.
Conclusions: The county-specific budgeting and planning
model allowed for better alignment of available resources to
existing needs, which enhances individual county capacity.
This promotes the highest utility decision making process for
the Agency. In addition, local monies can be used to enhance
local capacity, whereas Federal, State must be spread across
the state evenly. The flexible use of discretionary monies
allow the Agency, through the use of the county-specific
budgeting and planning model, to identify achievable
improvement in county capacity rather than expending scarce
resources into unachievable, no matter how worthy or noble,
pursuits. Deciding which partnerships and collaborations will
be most successful for the State, and where these initiatives
should occur, results in better outcomes and avoids those
situations in which money is spent with less than favorable
outcomes.
Implications for Policy, Delivery or Practice: This
information can be used to redesign processes of care, design
quality improvement initiatives, and to guide policy
formulation and implementation.
Primary Funding Source: Mississippi State Department of
Health.
● Local Preparedness Drills: Establishing Criteria
Kristine Gebbie, Dr.PH, R.N., Patricia Hegadorn, M.P.H.,
R.N., Kristine Qureshi, DNSc, RN, Jacqueline Merrill,
M.P.H., R.N.
Presented by: Kristine Gebbie, Dr.PH, R.N., Associate
Professor and Director, Center for Health Policy, Columbia
University School of Nursing, 630 West 168th Street, M.B. 6,
New York, NY 10032; Tel: 212.305.1794; Fax: 212.305.0722;
E-mail: kmg24@columbia.edu
Research Objective: As a part of a large project to establish
criteria for evaluating local public health agency emergency
preparedness drills and exercises, develop and validate an
evaluation framework and methodology.
Study Design: A qualitative method combining extensive
literature review, expert panel assessment and response from
the practice field.
Population Studied: The ultimate population is the 2600
local public health agencies in the US; the population for the
framework establishment is a deliberate panel of experts in
emergency response and public health emergency response.
Principal Findings: The initial framework developed from
earlier studies of emergency preparedness is too general and
non-quantifiable; combining the framework with key quality
elements (structure, process, outcome) allows for
identification of key points for quantifiable data.
Conclusions: The expert draft framework is sufficient for a
first round of testing with the 12 Project Public Health Ready
pilot sites, adjustment based on findings, and testing with a
larger sample of 60 sites.
Implications for Policy, Delivery or Practice: Current
assessment of emergency response exercises is generally
impressionistic, done immediately after the drill (the FEMA
'hot wash') and does not allow for measurement of
improvement over time or comparative research on
components or methods of improvement
Primary Funding Source: CDC
● Counting Public Health Workers: A Comparison of
Data Sources
Kristine Gebbie, Dr.PH, R.N., Jacqueline Merrill, M.P.H.,
R.N., Lorraine Sanders, M.S., RN, Eric Gebbie, M.A., MIA
Presented by: Kristine Gebbie, Dr.PH, R.N., Associate
Professor and Director, Center for Health Policy, Columbia
University School of Nursing, 630 West 168th Street, M.B. 6,
New York, NY 10032; Tel: 212.305.1794; Fax: 212.305.0722;
E-mail: kmg24@columbia.edu
Research Objective: Identify differences in reported numbers
of key public health professionals in two widely used data
bases, both of which have been criticized, and develop
hypotheses that might be explanatory of the differences
Study Design: Comparative display of data on key public
health professions from the HRSA-sponsored Public Health
workforce 2000 and the Department of Labor Bureau of Labor
Statistics.
Population Studied: Data reported on key public health
professional groups in Public Health Workers Enumeration
2000 and 2002 Bureau of Labor Statistics report.
Principal Findings: The numbers reported in Enumeration
2000 are consistently smaller than those included in the
Bureau of Labor Statistics; the proportion of professionals
within any one class reported as being federal, state or local
varies widely as well.
Conclusions: The reporting sources used for the two reports
can account for much of the difference, but is not adequate to
allow a choice between the two.
Implications for Policy, Delivery or Practice: The public
health policy-making community must make decisions about
needed data and establish a routine for data collection and
analysis that can be viewed as sufficiently reliable for policy
use.
● Hepatitis C among Homeless Adults in Los Angeles
Lillian Gelberg, M.D., MSPH, Marjorie Robertson, Ph.D.,
Lisa Arangua, M.P.P., Ronald Andersen, Ph.D., Barbara
Leake, Ph.D., Hal Morgenstern, Ph.D.
Presented by: Lillian Gelberg, M.D., MSPH, George F.
Kneller Professor, Department of Family Medicine, David
Geffen School of Medicine at UCLA, 50-071 CHS Box
951683, Los Angeles, CA 90095-1683; Tel: 310.794.6092;
Fax: 310.794.6097; E-mail: lgelberg@mednet.ucla.edu
Research Objective: Persons infected with the hepatitis C
virus (HCV) are at high risk for serious long-term health
problems, and they are potentially infectious to others. NIH’s
national agenda for preventing the spread and consequences of
hepatitis C includes early detection, treatment, and prevention
efforts for high-risk and infected persons. Recent research by
our team and others suggests that homeless adults in urban
areas are at particularly high risk for HCV infection due to
their high rates of risky drug use. Despite their apparent high
risk, however, there are no population–based studies of
hepatitis C in this group. For emerging infectious diseases,
protecting the health of the community as a whole will depend
on protecting the health of those most at risk. The objective of
this study was to document the prevalence and correlates of
hepatitis C infection among homeless adults, and to identify
high-risk sub-groups that should be targeted for screening and
subsequent treatment or prevention efforts.
Study Design: We conducted a community-based probability
survey of 500 homeless adults in 41 shelters and meal
programs in the Skid Row area of Los Angeles, using a 2-hour
face-to-face interview and blood testing for HCV, HBV, and
HIV.
Population Studied: 500 homeless adults.
Principal Findings: Rates of lifetime infection were as
follows: HCV (28.7%), HBV (ever infected 32.7%, currently
infected 2.2%), HIV (3.7%); 47% had ever been infected with
either of these three infections. Most adults with lifetime
HCV infection (59%) also had been infected in their lifetime
with HBV. HCV rates were higher among: lifetime IDUs
(85%, but only 52% of HCV+s reported IDU), lifetime
intranasal drug users (37%), sex workers for cash, but not for
drugs) (46%), 3+ tattoos in lifetime (48%), transfusion before
1990 (41%), older adults (18-29 yrs 0%, 30-49 yrs 26%, 50+
yrs 37%), former prison inmates (52%), and among men who
had sex with men (28%) (all p < .001). There was no
significant variation in HCV by gender (men marginally
higher), ethnicity (black, white, Latino), chronic
homelessness, recruitment site (shelters vs. meal programs),
blood transfusion history, or psychiatric hospitalization
history. Despite their high HCV rates, only 37% of the overall
sample had ever been tested for HCV. Among HCV+s, 50%
had never been tested for HCV, only 24% knew they had
HCV, and only 24% had ever been counseled about HCV.
Conclusions: As expected, hepatitis C rates were high among
the Los Angeles homeless population relative to the general
population (28.7% vs. 1.8%). Persons infected with HCV
were at high risk for being infected with HBV, suggesting the
need for HBV vaccination programs for this high risk
population of homeless adults. Consistent with the literature
in other populations, injection drug use was the strongest risk
factor for HCV infection. However, since only half of those
infected reported IDU, other risk factors for HCV infection
might also be important among homeless adults.
Implications for Policy, Delivery or Practice: The findings
from this study will be used to inform clinicians, health
planners, and health policymakers regarding HCV screening,
prevention, and treatment for homeless persons.
Primary Funding Source: NIDA
● Factors Associated with Receipt and Adherence to
Lifestyle Recommendations and Impact on Hypertension
Control
Mark Horng, M.D., LeRoi Hicks, M.D., M.P.H., Earl Francis
Cook, SD
Presented by: Mark Horng, M.D., General Medicine Fellow,
Division of General Medicine, Brigham and Women's
Hospital, 1620 Tremont Street, Boston, MA 02120-1613; Tel:
617.732.4815; Fax: 617.732.7072; E-mail:
mhorng@partners.org
Research Objective: To examine rates of adherence to
suggested lifestyle modifications for HTN management and of
associated blood pressure control
Study Design: Nationally representative, cross-sectional
survey using a stratified multistage probability sample of
noninstitutionalized, civillian population of the US.
Population Studied: The NHANES 1999-2000 survey
participants aged 20 or older who were told they had HTN at
least twice by a doctor or other health professional were
included in logistic regression model to determine factors
associated with adherence to therapies and rates of
hypertension control.
Principal Findings: Of aware hypertensive individuals
(n=1244), 146 (13.1%) were only advised to take medications
and 81 (7.3%) to alter lifestyles, while 846 (76.0%) were
advised to do both. Patients advised to take medication only
had higher adherence rates (84.2%), than those advised to
modify their lifestyle only (54.3%), or advised to do both
(53.9%). Hypertension is controlled in 36.6% of those taking
medications, 56.8% of those following lifestyle changes, and
46.1% doing both. Individuals are less likely to receive
lifestyle recommendations if they are aged 60 or greater (OR
0.25; CI 0.13-0.48), are white (OR 0.46; CI [0.23-0.89]), or
have completed high school (OR 0.39; CI [0.19-0.81).
Individuals who are obese (BMI>30) (OR 0.25; CI [0.150.42]), diabetic (OR 0.42; CI [0.20-0.89]), or
hypercholesterolemic (OR 0.49; CI [0.30-0.80]), have lower
odds of adhering to lifestyle recommendations, while higher
odds of adhering to lifestyle recommendations were associated
with being white (OR 1.76; CI [1.04-2.96]) or age 60 or older
(OR 2.29; CI [1.33-3.96]).
Conclusions: Despite higher adherence rates, prescribing
medications alone has lower rates of hypertension control
combined to prescribing both medications and lifestyle
modification.
Implications for Policy, Delivery or Practice: Clinicians
should recommend and encourage adherence to both
medications and lifestyle changes for optimal management of
hypertension, and future research examining patterns of care
for hypertension should examine rates of advising lifestyle
modification as well as medication prescribing.
Primary Funding Source: HRSA
● Bioterrorism-Related ED Utilization: NYC 2001
Nathaniel Hupert, M.D., M.P.H., Mary Koshy, MPA, Jason
Cuomo, M.P.H., Neal Flomenbaum, M.D.
Presented by: Nathaniel Hupert, M.D., M.P.H., Assistant
Professor of Public Health and Medicine, Departments of
Public Health and Medicine, Weill Medical College of Cornell
University, 411 E. 69th Street, New York, NY 10021; Tel:
212.746.3049; Fax: 212.746.8544; E-mail:
nah2005@med.cornell.edu
Research Objective: To quantify surge emergency
department (ED) admissions temporally and geographically
related to the 2001 New York City anthrax attacks.
Study Design: We examined ED admissions data from
9/01/01 to 12/31/01 as well as comparison data from the same
time frame in years 2000 and 2002 from three hospitals in
New York City located near midtown Manhattan (Hospital A),
the Bronx (Hospital B), and Brooklyn/Queens (Hospital C).
We compared ED admissions per day for all visits and for
selected individual primary ICD-9 codes, including those for
respiratory symptoms, chest pain, gastrointestinal symptoms,
and malaise and fatigue. In addition, we pooled ED
admissions by patient zip code to study geographic trends in
admissions. We hypothesized that ED admissions for
respiratory complaints would be higher at the study hospitals
in October 2001 (the month of peak anthrax-related activity)
than in other study months.
Population Studied: Urban population in metropolitan area
targeted by 2001 anthrax attacks.
Principal Findings: The average daily ED census in 2001 at
Hospital A was 119.9 (2000=114.4, 2002=114.2), at Hospital
B was 363.4 (2000: 343.8, 2002: 372.6), and at Hospital C
was 166.7 (2000=160.0, 2002=147.1). Hospital A
experienced a significant rise in ED admissions during
October 2001 compared to other months in 2001 as well as
2000 and 2002 (average daily census October 2001=129.3;
other months in 2001=116.7, 2-tailed Student’s t-test
p=0.0007; October ‘00/02=112.8, p<0.0001). Hospitals B and
C did not experience a statistically significant rise in ED
admissions in October 2001 compared to other months in
2001. The increase in ED admissions at Hospital A was not
attributable to cases with primary ICD-9 codes for chest pain,
respiratory ailments, gastrointestinal disturbance, or malaise
and fatigue. However, there was a significant rise in cases
coded as “V01.9, communicable disease contact NOS”
(October, 2001=93, all other study months of 2001=70,
Chi2=12.09, p value=0.0005). Hospitals B and C had
insignificant numbers of V01.9 diagnoses (<10 for entire study
period). Hospital A also had significantly more admissions
arising from its local zip code during October 2001 compared
to other months in 2001 (t-test p=0.02) and to October of
‘00/’02 (p<0.0001).
Conclusions: The study hospital closest to the epicenter of the
2001 NYC anthrax attacks (i.e., midtown Manhattan)
experienced a significant increase in ED admissions during
October 2001. At least part of this surge appears to have been
local attack-related admissions that were coded as
“communicable disease contact.” In contrast, the two more
distant study hospitals did not experience any significant surge
in ED admissions during this time period.
Implications for Policy, Delivery or Practice: This study
provides the first quantitative assessment of potential
overloading of hospital-based emergency services in the
aftermath of the first lethal bioterrorist attack on U.S. soil.
Our results do not support the notion of a generalized increase
in ED utilization during the 2001 anthrax attacks. Rather, the
impact of the attacks on ED utilization appears local even
within an affected metropolitan area. This finding has
important implications for planning of emergency response
and health care resource allocation in the aftermath of future
bioterrorist attacks or natural epidemics.
Primary Funding Source: AHRQ
● Policy Implications of Dual Healthcare Use Across
Medicare and VA
Denise Hynes, Ph.D., R.N., Min-Woong Sohn, Ph.D., Kristin
Koelling, M.P.H., Noreen Arnold, M.S., Larry Manheim,
Ph.D., Fran Weaver, Ph.D.
Presented by: Denise Hynes, Ph.D., R.N., Director, VA
Information Resource Center, Edward Hines Jr. VA Hospital,
5th Avenue and Roosevelt Road, Building 1, Room C303,
Hines, IL 60141; Tel: 708.202.2413; Fax: 708.202.2415; Email: hynes@research.hines.med.va.gov
Research Objective: The Medicare and Department of
Veterans Affairs healthcare systems represent the largest
healthcare systems in the U.S. An increasing number of
elderly use both systems of care. Such dual use has significant
implications for coordination of care, quality of care, and
economic impacts at the patient, provider and societal level.
We linked data from the VA and the Centers for Medicare and
Medicaid Services (CMS) to examine patterns of healthcare
utilization and costs across systems.
Study Design: We combined data from CMS and VA for
calendar year 1999 to identify a cohort of dually eligible
elderly. Using linked demographic, health care utilization and
claims data across the two systems of care, we examined
factors predictive of the healthcare system used. For risk
adjustment, we used the Hierarchical Condition Categories
(HCC) risk scores that will be used to adjust for differences in
risks for Medicare reimbursement in 2004. Hierarchical
categories in HCC are designed to allow for coding variations
due to different financial incentives under the VA and
Medicare. We compared VA-only use, Medicare-only use or
dual usage patterns using multinomial logistic regression on a
5% random sample (N = 86,140).
Population Studied: A cohort of 2.6 million elderly who
were dually eligible for VA and Medicare in 1999.
Principal Findings: Of all dually eligible veterans, 83.7%
were enrolled in Medicare fee-for-service. Of these, 21.9%
used only VA services, 30.3% used only Medicare services;
42.6% used both VA and Medicare services. Compared with
Medicare-only users, VA-only users tended to have a high VA
priority level (Odds Ratio [OR] = 20.85; P < 0.001) or lived
less than 10 miles from a VA inpatient facility (OR = 2.09; P
< 0.001), while dual users tended to be older (85 or older, OR
= 2.23; P < 0.001; 75 – 84, OR = 1.40; P < 0.001). AfricanAmericans were more likely to be VA-only users, but, when
their Medicare premiums were paid through state Medicaid
programs, they tended to use both systems of care more than
non African-Americans. Patients with high-risk scores
(indicating poorer health status) were more likely to be dual
users and those with the lowest risk scores were more likely to
use VA alone.
Conclusions: Adjusting for patient age, race, and other
demographic factors, older and sicker elderly tended to use
both systems of care more, while the least sick were more
often users of VA services exclusively. Eligibility (e.g., VA
priority score and Medicare state buy-in status) and access
(e.g., distance to the nearest VA inpatient facility) were
important determinants of dual use patterns.
Implications for Policy, Delivery or Practice: Dually
eligible may use heath care services from both VA and
Medicare, creating the potential for fragmentation and
duplication of care. Understanding how the elderly manage
their health care is important for both systems of care. For
example, low-income elderly with poor health status may
benefit from improvements in continuity of care across the
two systems of care. Future research should examine whether
coordination of care between VA and Medicare providers can
improve patient outcomes.
Primary Funding Source: VA
● VA and Medicare Dual Use by Veterans with Colorectal
Cancer
Denise Hynes, Ph.D., R.N., Min-Woong Sohn, Ph.D., Ruth
Perrin, M.A., Kristin Koelling, M.P.H., M. Rosario Ferreira,
Ph.D., Charles Bennett, Ph.D.
Presented by: Denise Hynes, Ph.D., R.N., Director, VA
Information Resource Center, Edward Hines Jr. VA Hospital,
5th Avenue and Roosevelt Road, Building 1, Room C303,
Hines, IL 60141; Tel: 708.202.2413; Fax: 708.202.2415; Email: hynes@research.hines.med.va.gov
Research Objective: Veterans with colorectal cancer (CRC)
require combination therapy including surgery, chemotherapy
and/or radiation therapy, and long-term follow-up. To ensure
CRC patients’ extensive healthcare needs are being met,
understanding patterns of healthcare use between VA and
Medicare-covered systems is important.
Study Design: Of 2.6 million VA and Medicare dually
eligible beneficiaries in CY1999, we identified CRC patients
based on diagnosis coding. Using linked demographic, health
care utilization and claims data across the two systems of care,
we examined factors predictive of the healthcare system
patients used. We performed multivariable regression
analyses, including disease severity/risk category determined
by Hierarchical Condition Categories (HCC). We compared
VA-only use, Medicare-only use or dual usage patterns using
multinomial logistic regression.
Population Studied: We identified 33,001 patients with CRC
who were age 65 or older and were dually eligible.
Principal Findings: There were 33,001 veterans age 65 or
older with CRC. VA only use, rather than dual use was more
likely among CRC patients who had higher VA priority levels
(Odds Ratio [OR] = 3.1, p < 0.001), were African American
(OR = 2.8, p < 0.001), and lived <10 miles from VA hospitals
(OR = 2.3, p < 0.001). Those who used only VA services,
compared to those who used only Medicare services, were
more likely to have poorer health (OR = 2.0, p < 0.001), be
older (OR = 2.3, p < 0.001, for 85 and older compared to 65 to
74 years old), and African American with low incomes (OR =
2.6, p < 0.001).
Conclusions: CRC patients with higher risk scores tended to
use Medicare services more, but the sickest, poorest and
minority CRC patients were most likely to use both Medicare
and VA services.
Implications for Policy, Delivery or Practice: Minority CRC
patients in the VA with the poorest health status may benefit
most from improvements in coordination of care throughout
the continuum of care across systems. Coordination of
prevention, early identification, and treatment improvements
across health care systems are needed to benefit those most in
need.
Primary Funding Source: VA
● What Do Local Public Health Departments Do?
Evelyn Knight, Ph.D., F. Douglas Scutchfield, M.D.,
Michelyn Bhandari, M.P.H., Ann Kelly, M.H.A., Mary Kay
Rayens, Ph.D.
Presented by: Evelyn Knight, Ph.D., Project Director, School
of Public Health, University of Kentucky, 121 Washington
Avenue, Room 107C, Lexington, KY 40536-0003; Tel:
859.257.9168; Fax: 859.257.6644; E-mail: eknig0@uky.edu
Research Objective: Characterizing local public health
departments and their programs in a standardized manner has
become a national policy concern due to the lack of
standardization. Programs to accredit local agencies are being
discussed and the National Association of County and City
Health Officials (NACCHO) is developing an “operational
definition” of local public health agencies that would define
the minimum requirements. This study sought to determine if
patterns exist in the groups of programs offered by local health
departments.
Study Design: Using data from NACCHO’s 1997 National
Profile of Local Health Departments, the programs offered by
local agencies were studied. Factor analysis based on a
tetrachoric correlation matrix was applied to create groups of
programs that tended to be offered together. Programs
selected for inclusion in the analysis were the 34 general
programs included in the profile plus nine more specific
chronic disease programs.
Population Studied: A group of 152 health departments in
three states were studied. These health departments had
completed the 1997 NACCHO Profile as well as a test version
of the NPHPSP performance assessment, indicating their
interest (or that of their state public health agency) in
performance improvement.
Principal Findings: Since the factor analysis required
variation in the programs offered, 13 programs were removed
that were provided by 80% or more of the health departments.
Four other programs were removed because they were offered
by 20% or fewer health departments, and one was removed
because a correlation was not calculable. For the remaining
25 programs three factor groups were identified: (1) ten
“basic” programs, (2) seven “expanded clinical” programs,
and (3) eight “outreach” programs.
Conclusions: Public health programs offered in this sample of
local health departments clustered into groups that seem to
indicate specific policy direction. Further analysis on other,
larger numbers of health departments, with more specific
qualitative and quantitative information on the programs, may
classify different types of local health departments based on
their program offerings.
Implications for Policy, Delivery or Practice: Development
of a typology describing local health agencies based on their
program offerings would enable more directed planning to
enhance and standardize public health services available to all
populations. This typology would assist decision makers
assessing state and national initiatives to augment public
health services provided locally. In addition, relationships of
public health infrastructure and high performing agencies to
the types of services offered by local agencies could be
evaluated.
Primary Funding Source: CDC, ATPM
● Preventing Unnecessary Hospitalizations: How is the
U.S. Doing?
Denise Kruzikas, Ph.D., H. Joanna Jiang, Ph.D., Denise
Remus, Ph.D., R.N., Marguerite Barrett, M.S., Rosanna
Coffey, Ph.D., Roxanne Andrews, Ph.D.
Presented by: Denise Kruzikas, Ph.D., Health Researcher,
Research and Pharma, Medstat, 4301 Connecticut Avenue,
N.W., Suite 330, Washington, DC 20008; Tel: 202.719.7869;
Fax: 202.719.7801; E-mail: Denise.Kruzikas@thomson.com
Research Objective: To identify U.S. hospitalizations that
may be avoided through high quality primary and preventive
care and to investigate trends over time, by region and among
priority populations, including children, older Americans,
women, low-income individuals, and rural residents.
Study Design: This project examines potentially avoidable
hospitalizations across the U.S. using the AHRQ Prevention
Quality Indicators (PQIs), which focus on 10 chronic and five
acute conditions, as well as one obstetric outcome. The
primary data source is the Healthcare Cost and Utilization
Project (HCUP) Nationwide Inpatient Sample (NIS) hospital
discharge database. Population-based hospitalization rates are
calculated using data from the NIS, U.S. Census, Current
Population Survey, and Claritas Census projections. Rates are
adjusted for age and sex using direct standardization. Standard
error calculations and bivariate significance tests account for
sampling strategies of each database.
Population Studied: U.S. population for 1994, 1997, and
2000.
Principal Findings: Between 1994 and 2000, admission rates
declined 71% for angina without procedure; 30% for
uncontrolled, uncomplicated diabetes; and 30% for adult
asthma. Rates rose 20% for chronic obstructive pulmonary
disease and 13% for hypertension. Hospitalization rates vary
by geographic region; the West has the lowest rates for 15
PQIs, while the Midwest has the highest rates for 11 PQIs.
Admission rates are highest among very young children (0-4
years) and individuals 85 years and older. Compared with
men, women are 2.5 times more likely to be admitted for adult
asthma and 50% more likely to be admitted for hypertension,
but are 50% less likely to experience diabetes-related lower
extremity amputations. Girls are 35% less likely than boys to
be hospitalized for pediatric asthma. Low-income residents
have the highest admission rates for all PQIs. Rates vary 6278% between the lowest and highest income groups;
differences are most pronounced among chronic conditions.
Rural residents have higher hospitalization rates for nine PQIs.
Conclusions: The U.S. health care system has reduced
potentially unnecessary hospitalizations in a number of areas.
During the study period, admission rates decreased
significantly for specific health conditions including angina
without procedure; uncontrolled, uncomplicated diabetes; and
adult asthma. Western states consistently have the lowest
hospitalization rates in the nation. These results suggest the
potential for improvement in other areas. Higher rates among
select conditions and regions need to be explored to determine
which hospitalizations may be avoidable. Variations among
sub-populations must be investigated further, particularly
among low-income and rural residents, to understand why
priority populations experience higher rates of hospitalization.
Implications for Policy, Delivery or Practice: These results
provide insight into the quality of primary and preventive care
at national and regional levels. Policy makers may use these
results to evaluate priority areas (e.g., diabetes and
hypertension) and identify targets for health care system
improvement or more extensive study. State and local leaders
can incorporate the national and regional benchmarks into
their quality improvement initiatives. These efforts may
ultimately improve the quality of outpatient care and further
prevent unnecessary hospitalizations. Because hospitalizations
constitute the largest component of health care costs, reducing
admissions through better quality primary and preventive care
can result in substantial cost savings for the U.S. heath care
system.
Primary Funding Source: AHRQ
● Examining Public Health Financing in New York State:
A Methodology for Evaluating Local and National Public
Health Data
Perri Leviss, MPM, Lloyd Novick, M.D., M.P.H.
Presented by: Perri Leviss, MPM, Consultant, 40 Branford
Road, Hastings-on-Hudson, NY 10706; Tel: 914.478.3468;
Fax: 914.478.4876; E-mail: pleviss@earthlink.net
Research Objective: This study uses data collected from
local health departments in New York State for the period
2000- 2002 with the purpose of developing improved methods
of collecting and analyzing this type of information. This
study follows an initial investigation of trends in local public
health funding in New York State. Information from this study
was successfully used in support of policy recommendations
made to the New York State Legislature by the New York
State Association of County Health Officials (NYSACHO).
However, differences in data collection and the array of
services offered by individual local health departments, has
led to the further examination of methodology and results
reported here.
Study Design: In an effort to understand fiscal trends for local
health departments in New York State, the New York State
Association of County Health Officials (NYSACHO)
developed and administered a survey in December 2002 that
collected data on spending and funding sources from CY 2000
– CY 2002. Of the 58 surveys distributed, NYSACHO had a
response rate of over 75%. Findings from the survey included
significant changes in public health programs and revenue
streams across New York State during the 3 year period.
Of the 51 responding counties, 6 counties’ data could not be
used in any of the data analyses because it was too incomplete
based on the screening criteria that was developed. Therefore
the data below includes 45 of the 58 counties in New York
State. In some cases, the actual N<45 because some counties
may not have expended funds for specific public health
programs, and therefore a portion of the data analyses was not
performed. The responding counties included a relatively
even distribution of small and large counties as well as
urban/suburban/rural counties. All the State’s largest counties
participated in the survey with the exception of New York
City who could not participate due to data conversion issues.
However, initial analysis of this data encountered problems of
comparing “apples and oranges” because of a variation in the
services offered by local health departments particularly in the
areas of primary care, home health care and early intervention.
A future follow-up study will examine basic public health
funding and compare select groups of counties according to
the pattern of services rendered.
Principal Findings: Many of the findings noted below were
difficult to interpret because the data collection and array of
services between counties was not truly comparable.
Reanalysis of the data and recommendations for a revised data
collection instrument will be made as part of the follow-up
study.
The highest per capita expenditures were among smaller
county health departments.
The range in per capita expenditures among LHDs was
relatively large, but smaller if you look at LHDs which are
similar in size and scope.
Some county health departments had similar total expense
budgets, but varying per capita expenditures.
The increase in Early Intervention (EI) expenditures may be
limiting the availability of resources for other core public
health services.
Some LHDs spend a large percentage of their total
expenditures on Early Intervention programs.
The counties with the smallest total EI expenditures also had
the smallest EI percentages of total budgets in 2001.
Some counties had similar total EI expenditures, but very
different percentages of the total budget.
Many LHDs maintain large home health/home care programs.
In some cases, LHDs in NYS may have supported other core
public health functions through home care revenues, limiting
the need for local tax levy.
Some of the largest home care programs reside in both large
and small LHDs.
The small counties rely most heavily on State Aid as a
percentage of total revenues and these LHDs are most
vulnerable to budget reductions. Population is one factor in
determining the reliance on State Aid as a revenue source, but
it appears that there are other factors influencing the data as
well.
The analysis may underestimate the true impact of a reduction
in State Aid upon core public health services because the
denominator includes revenues from EI and Home Care
Services. Therefore, some small LHDs are even more reliant
on State Aid for the provision of core public health services.
Those counties with the largest per capita State Aid funding
were not the counties most reliant on State Aid as revenue
source (as a percentage of LHD revenue).
Conclusions: There are distinct differences in the mix and
levels of public health services that are provided by LHDs
across New York State. In the NYSACHO survey, this was
demonstrated by the lack of consistency in what counties call
their public health services and the fact that almost no two
LHDs provided the same array of services. This variability
contributes to the differences in impact of proposed budget
reductions on LHDs. In New York State, there is a loose
definition of the minimum set of public health services that are
required in order to be considered a LHD. In a time of
constrained budgets, states must clearly define and enforce the
range of required services and provide guidelines about the
distribution of funds among these public health programs,
leaving some room for individual modifications. Finally,
returns from the NYSACHO survey demonstrate that
reductions in local support/local tax levy are increasing
concern and compounds issues of State Aid losses. Further
examination of this issue as well as some of the others listed
above is required.
Implications for Policy, Delivery or Practice: The survey
instrument developed and then subsequently revised by
NYSACHO, presents a national model for States and local
public health departments to evaluate their own
resources/needs and to promote information exchange within
and between localities. With limited resources, local public
health officials must make difficult choices about their
programs and activities. By encouraging localities to collect
uniform financial data sets, public health will be better suited
to support its case for stable and sufficient funding.
LHD’s across the country must come together to address the
issues of state financing for core public health functions and to
ensure that the basic infrastructure of public health is not
destroyed at a time when the demands on public health are
greater than they ever have been before. Budget deficits at
both state and local levels are sharply reducing public health
support at a time of unprecedented challenge. The Sudden
Acute Respiratory Syndrome, bioterrorism preparedness,
smallpox vaccination, and other emerging diseases including
West Nile Virus calls for increased public health capacity, not
a lessoning of this vital function. Diseases do not know of
boundaries and the assurance of one’s health requires many
states and localities to work together. National organizations
that represent local public health have an obligation to assist
LHDs in this long and uphill battle. The small amount of
funds spent on public health activities across the country now
will provide for a lifetime of good health.
● The Public Health Workforce: A Six State Case Study
Jean Moore, B.S.N., M.S.N., Peter House, MHA, Robert
Wood, M.P.H., Elizabeth Mertz, M.P.A.
Presented by: Jean Moore, B.S.N., M.S.N., Deputy Director,
SUNY School of Public Health, Center for Health Workforce
Studies, One University Place, Rensselaer, NY 12144; Tel:
518.402.0250; Fax: 518.402.0252; E-mail:
jmm04@health.state.ny.us
Research Objective: The research objective was to conduct a
study of the public health workforce. The study focused on
governmental public health agencies at the state and local
levels and particularly on public health physicians, dentists
and nurses as well as workers with formal public health
training. The study also assessed the role that schools of public
health play in assisting these public health agencies to recruit,
retain or provide continuing education to their workforce.
Major goals of this study included:
1)assessing the adequacy of the supply of these workers in
relation to the demand for them;
2)quantifying differences in staffing in light of organizational
responsibilities and relationships as well as the size of the
population served by the agency; and
3)understanding the role that schools of public health play in
addressing public health workforce needs of these agencies.
Study Design: The study had three main components:
1. A six state case study that included surveys and interviews
with staff of state and local public health agencies in those
states on their most pressing health workforce issues.
2. Identification and analysis of available data on the
workforce of public health agencies in the six states studied.
3. Convening a Project Advisory Committee to provide
guidance on the overall study methodology, the issues to be
discussed and the questions to be asked of state and local
public health agencies, and to assist with the interpretation of
findings.
The six states selected for study were New Mexico; Montana;
Georgia; California;
Texas; and New York. The states were selected to assure
representation of the four organizational models described in
Local Public Health Practice: Trends and Models, (APHA,
2000) which represent different relationships between the state
and local public health agencies. The four models are
1)Centralized - a state operated public health system (New
Mexico);
2)Decentralized – a public health system operated by local
government (Montana);
3)Shared – a public health system jointly operated by state and
local government (Georgia); and
4)Mixed - a public health system with differing levels of state
and local involvement (California, Texas, New York).
Population Studied: Using the case study methodology, five
local public health agencies and/or district offices in each of
the case study states were selected to participate in the study,
including at least one urban, one rural, one suburban, and
where appropriate, one local agency on an international
border. A survey of district/local public health agencies was
conducted, with topics including: general workforce issues;
staffing and function; recruitment and retention issues for
public health nurses, public health physicians; the oral health
workforce; supply of and demand for workers with formal
public health training; training and continuing education
needs; and collaborations with educational institutions,
including Schools of Public Health. Interviews were
conducted with key public health stakeholders in the six case
study states, including state, district and local public health
leaders and managers. Interviews focused on the topics
included in the survey.
Principal Findings: Public Health Nurses (PHNs)
o Public health agencies in all six case study states reported
difficulty recruiting PHNs, especially in rural areas, but less
difficulty retaining them.
o Reasons for the recruitment difficulties included: budget
constraints, a general shortage of RNs, non-competitive
salaries and lengthy processing time for new hires.
o A wide range of PHN training needs were identified; the
greatest unmet need was for public health oriented training
o Lack of access to baccalaureate nursing, masters of public
health, and other advanced training programs is a significant
barrier to upgrading existing staff, particularly in rural areas.
Public Health Physicians (PHPs)
o PHPs play different roles in public health agencies,
depending upon the size of the agency.
o Formal public health education for PHPs is often a
preference rather than a requirement.
o Rural public health agencies in all six case study states
reported difficulty recruiting PHPs.
o Barriers to recruiting PHPs include non-competitive salaries
and rural locations.
Oral Health Staff
o There are very few dentists and dental assistants, and even
fewer hygienists in the public health workforce.
o Many dental public health programs are run by PHNs or
other dental staff (dental hygienists or dental assistants) and
utilize volunteer or contract dentists only for services
requiring their expertise.
o Recruitment of dentists into public health is difficult, but
those who choose it tend to stay.
o The lack of oral health services in most LDHs is more often
a function of lack of funding for services than a lack of staff,
although staffing can be problematic as well.
Workers with Master’s of Public Health (MPHs)/Schools of
Public Health (SPHs)
o MPHs most commonly worked in state health departments
or as top managers in large public health agencies; they were
needed, but rare in smaller public health agencies.
o MPHs who worked in LHDs often had clinical skills and
duties.
o LHD staff who got MPHs often left the LHD to work in
larger organizations that offered better opportunities.
o Public health agencies in the six case study states reported
greater need for training in core public health concepts than
for MPHs.
o SPHs, in general, have done a poor job collaborating with
public health agencies; however, there are models of
successful collaborations.
o More opportunities for public health training and education
should be accessible to senior staff of public health agencies,
particularly those in leadership positions.
Additional
o Budget constraints is the single biggest barrier to adequate
staffing of governmental public health agencies.
o Public health agencies in the case study states reported
workforce shortages across a variety occupations, including:
health educators, nutritionists, social workers, clerical staff,
epidemiologists, dental hygienists, dental assistants, laboratory
personnel and home health aides.
o Rural public health agencies in most states reported drawing
their staff from the local labor market and had more difficulty
recruiting more educated, skilled public health workers.
o Public health agencies in border counties identified a need
for public health workers who are bi-lingual; are culturally
competent; and have up-to-date knowledge of tropical
diseases, such as dengue, murine typhus.
o Some public health agencies are concerned about losing
senior staff to retirement in the next five years and reported a
need for succession planning.
Conclusions: This study documents the difficulty experienced
by the public health system in recruiting the workers it needs.
In addition, many of these workers lack formal public health
training and in many instances, this training is either not
affordable or accessible to them.
The public health system is undergoing many changes, faced
with declining resources, emerging diseases, new roles and
new technology. There is a need to develop strategies that
assure an adequate supply of well-prepared public health
professionals in order to maintain an effective public health
system in America.
Implications for Policy, Delivery or Practice: There is a
need continue to study trends in the public health workforce,
to better understand the issues that impact on the recruitment
and retention of an adequately trained workforce. It may also
be helpful to conduct a functional enumeration of public
health workers, to develop benchmarks based on job
functions, which include direct patient services, populationbased services and program management. In addition, there is
a need to develop strategies to address some of the finding of
this study, including the use of scholarships and career
ladders, among others. Schools of public health and other
educational programs must find avenues to create accessible
and affordable educational opportunities to the existing public
health workforce.
Primary Funding Source: HRSA
● Bridging the Chasm: How Hospitals are Taking on
Public Health Responsibilities
Peter Weil, Ph.D., Reed Morton, Ph.D., Richard Bogue, Ph.D.,
Paul Halverson, Dr.P.H.
Presented by: Reed Morton, Ph.D., Associate Director,
Research & Development, American College of Healthcare
Executives, 1 N. Franklin, Suite 1700, Chicago, IL 60606;
Tel: 312.424.2800; Fax: 312.424.0023; E-mail:
RMorton@ache.org
Research Objective: In the U.S., community hospitals have
traditionally had very little to do with improving the health
status of their communities. Instead, they provided the
structure for the provision of acute care, delivered by privately
employed physicians to patients many of whom had private
insurance and lived near the hospital.
But beginning in the mid 80s, hospitals began to reach out to
their community for either marketing purposes or to satisfy
their requirement to provide "community benefit" that allowed
them to maintain their favored tax status.
From the public side, the Institute of Medicine noted that a
public health system neither can nor should be achieved by
public helath professionals alone. It urged public health
agencies to cultivate relationships with physicians and other
private sector groups.
We conducted this study to assess what kinds of activities
hospitals were undertaking to build relationships with public
health agencies in their communities. A useful structure to
examine the relationship is provided by the "essential services
of public health" issued in 1994. These ten services were
developed by a number of public health groups to show how
public health agencies carry out their role to promote physicial
and mental health and prevent disease, injury and disability.
Thus, the purpose of the study was to examine what types of
essential public health services leading hospitals are providng
either alone or in concert with public health agencies.
Study Design: Seven "leading hospitals" were identified by
reviewing the literature, contacting professional associations,
obtaining data from a mailed survey and validating these
through follow-up fax surveys and 30 minute telephone
interviews with hospital CEOs. A national advisory committee
selected those hospitals that appeared to have initiated novel
management practices that promoted community health. Twoday site visits were then scheduled by two researchers.
Each visit consisted of semi-structured interviews with
between 10 and 14 individuals, including the CEO, the current
board chair, the board secretary, the senior vice president or
chief operating officer, the medical staff president, the head of
fundraising or the foundation and the vice president with
responsiblity for community health. Interviews were also
conducted with the executives of two ro three community
organizaitons involved in community health partnerships with
the hospital or health system and others based on the
initiatives and corporate structure of the leading practice sites.
Through 63 detailed on-site interviews, we identified 24
distinct practices some of which contribute to the ten essential
public health services.
Population Studied: This was a qualitative study designed to
elicit best practices in providing public health services by
hospitals. Eligible were any general, medical surgical, short
term hospitals in the U.S. Using the methods described above,
seven leading hospitals were studied on site.
Principal Findings: None of the hospitals appear to
participate in the essential service related to enforcement and
regulation. All leading hospitals participate in essential public
health service 1 (Monitor health status to identify and solve
community health problems), 3 (Inform, educate and empower
people about health issues) and 4 (Mobilize community
partnerships and action to identify and solve health
problems). We illustrate how the leading hospitals contribute
to achieving nine of the ten essential public health services.
Conclusions: Our findings show that only those essential
public health functions that are specifically regulatory are
excluded from the agenda of leading hospitals. Hospitals
under both public and not-for-profit auspices are collaborating
with public health agencies and other community groups.
They fulfill in whole or in part, essential public health
services.
Implications for Policy, Delivery or Practice: The paper
contributes to our understanidng of the blurring of lines
between the public and private health sectors and shows that
managers of certain hospitals promote a broader view of the
hospital's role in the community. The problem today is to find
ways to ensure that not just leading hospital executives, but all
hospital executives take responsibility to provide or ensure
that their community has each essential public health service.
Suggested are:(1) providing education to hospital executives
and aspiring executives about methods to achieve public
health services; (2) evaluating executives' performance based
in part, on their public health achievements; (3) giving award
to hospital leaders accomplish the public health services alone
or who collaborate with public health agents in their
community; and (4) including the ten essential public health
services in protocols that evaluate communities as desirable
places to in which to live.
Primary Funding Source: WKK
● Evolving Relationships between Turning Point
Partnerships and Public Health Institutes
Bud Nicola, M.D., M.H.S.A, Joseph Kimbrell, MA, LCSW,
Chris Kinabrew, M.S.W., M.P.H., Stephen M. Padgett, R.N.,
M.S., Betty Bekemeier, M.S.N., M.P.H.
Presented by: Bud Nicola, M.D., M.H.S.A, Senior
Consultant, Turning Point National Program Office, 6
Nickerson Street, Suite 300, Seattle, WA 98109; Tel:
206.616.8410; Fax: 206.616.8466; E-mail:
bnicola@u.washington.edu
Research Objective: (1) Describe the relationships between
state-level Turning Point partnerships and Public Health
Institutes in states which have both, and (2) develop models
that represent the variety of those relationships.
Study Design: Turning Point is a program funded by The
Robert Wood Johnson Foundation, involving 21 state-wide
initiatives and 2 ‘linked’ states which formed multi-sector
collaborative partnerships for public health systems change.
In 18 of those states, there are also free-standing Public Health
Institutes, which either preceded or resulted from Turning
Point. Key participants in those state partnerships and
institutes, and staff at the National Network of Public Health
Institutes and the National Program Office of Turning Point,
were interviewed to elicit perspectives on the relationship
between the two structures. These interviews were analyzed to
identify and illustrate the historical and continuing
relationships among state health agencies, Public Health
Institutes, and Turning Point partnerships.
Population Studied: 18 states with both a Turning Point
partnership and a Public Health Institute, either emerging or
established.
Principal Findings: Both Turning Point and Public Health
Institutes represent efforts to reform and modernize public
health systems, and to institutionalize those changes. The
relationships of Turning Point state partnerships with their
respective Public Health Institutes have taken many shapes.
In some cases the state health agency developed the Turning
Point partnership, which in turn led to the establishment of a
Public Health Institute. In other cases, the Public Health
Institute preceded the Turning Point initiative, and may or
may not have been involved with Turning Point activities. In
still other cases, state health agencies were less involved in the
formation of either the Turning Point partnership or the Public
Health Institute. Participants reported more administrative
flexibility with Public Health Institutes, and greater
opportunities for policy development and advocacy, than is
usually possible within state government. Along with this
flexibility, however, free-standing institutes also have greater
uncertainty about funding streams, and in some cases, are
perceived as more distant from policy implementation.
Participants generally recommended complementary, rather
than competitive, roles for Public Health Institutes in relation
to state health agencies and other organizations.
Conclusions: Turning Point state partnerships and Public
Health Institutes share a number of goals regarding public
health systems change, and often involve alliances with
similar partners. Public Health Institutes represent a more
flexible administrative structure, with a greater ability to
pursue independent funding and advocacy work. Factors that
influence the choices and sequencing of these options are
largely related to local contexts, and political and economic
resources. Many of the Turning Point participants perceived
Public Health Institutes to be a useful ‘successor’
organizational form for the process of public health systems
change. While the establishment of Public Health Institutes
was generally considered beneficial, there are many viable
paths toward this goal.
Implications for Policy, Delivery or Practice: Successful
and sustainable public health systems change requires
continuing relationships with multiple partners, and careful
assessment of needs and resources. Decisions about
appropriate administrative structures and governance models
should reflect local histories, build on existing relationships
when possible, and extend these when necessary. States
considering the development of a public health institute may
look to the experiences of Turning Point partnerships for
useful lessons on the opportunities and challenges posed by
public health institutes.
Primary Funding Source: RWJF
● Cost-Effectiveness Comparison between a Free Nicotine
Replacement Therapy Program and a Smoke-Free
Workplace Policy Campaign for the State of Minnesota
Michael Ong, M.D., Ph.D., Stanton Glantz, Ph.D.
Presented by: Michael Ong, M.D., Ph.D., VA Ambulatory
Care Fellow, Medicine, Stanford University, 117 Encina
Commons, CHP/PCOR, Stanford University, Stanford, CA
94305-6019; Tel: 650.723.1503; Fax: 650.723.1919; E-mail:
mikeong@stanford.edu
Research Objective: Public health tobacco control programs
are increasingly being asked to consider individual-based
smoking cessation programs beyond quitlines, particularly free
nicotine replacement therapy (NRT) programs. Budget
limitations force public health tobacco control programs to
choose between individual-based programs and more
traditional population-based programs, such as smoke-free
workplace campaigns. This analysis compares the benefits
and costs of a free NRT program with a smoke-free workplace
campaign.
Study Design: We simulated the benefits and costs of both
programs generated after one year. Benefits are calculated in
number of quitters generated and in quality-adjusted life years
(QALYs). We estimated the number of smokers interested in
quitting and in using NRT from a 1999 survey conducted by
the Minnesota Partnership for Action Against Tobacco. Key
assumptions of our free NRT program model include the
chance of cessation success with each NRT attempt is 7.1%,
that individuals will have a maximum of 2 cessation attempts
in one year, that NRT equally assists both heavy and light
smokers (<15 cigarettes/day), and there is a 35% relapse rate.
Costs of free NRT programs are based on costs of patch and
gum NRT therapy used in quit attempts, and we assume
minimal distribution costs. Key assumptions of our statewide
smoke-free workplace policy include an absolute smoking
prevalence reduction of 3.7%, a 35% relapse rate, and that
these policies are 90% effective. Costs of our smoke-free
workplace policy include enactment campaign costs and
media enforcement costs.
Population Studied: For our free NRT program model, we
use a hypothetical cohort of all smokers for the state of
Minnesota based on 2001 Census Bureau population estimates
and 2001 smoking prevalence data from the Centers for
Disease Control (CDC). For our smoke-free workplace policy
model, we use a hypothetical cohort of indoor workers from
Minnesota who smoke based on the 2001 Occupational
Employment Survey and 2001 smoking prevalence from the
CDC.
Principal Findings: After one year, a smoke-free workplace
policy induces 10,400 quitters at a cost of $8.3 million. This
ratio of $798 per quitter translates into a cost-effectiveness
ratio of $505 per QALY. After one year, a free NRT program
induces 30,900 quitters at a cost of $121 million. This ratio of
$3,900 per quitter translates into a cost-effectiveness ratio of
$2,470 per QALY.
Conclusions: A free NRT program produces more quitters
than a smoke-free workplace policy. However, it does so at
nearly fifteen times the overall cost and with a nearly five
times higher cost-effectiveness ratio. As it is unclear whether
light smokers actually benefit from NRT, a free NRT program
may generate fewer quitters than our estimation.
Implications for Policy, Delivery or Practice: While free
NRT programs are cost-effective, smoke-free workplace
policies are more cost-effective and cost less overall. Given
budget limitations, smoke-free workplace policies should be a
funding priority for public health programs.
● Understanding the Financing and Functions of
Metropolitan Health Departments: A Key to Improved
Public Health Response
Alonzo Plough, Ph.D., M.P.H.
Presented by: Alonzo Plough, Ph.D., M.P.H., Professor,
Health Services, School of Public Health and Community
Medicine, University of Washington, 999 3rd Avenue, Suite
1200, Seattle, WA 98104; Tel: 206.296.1480; E-mail:
Alonzo.Plough@METROKC.GOV
Research Objective: To describe and better understand the
specific financing issues facing large Metropolitan Health
Departments. Such departments are not well described in
previous studies but play a major role in the provision of local
public health services to nearly 50% of the U.S. population.
Study Design: The study design is a descriptive, case study
drawing on data collected by the National Association of City
and County Health Officials and in-depth financial
information from a representative Metropolitan Health
Department
Population Studied: This study focuses on the organizational
and financial characteristics of an estimated 50 MHD’s out of
the 3000 local health departments in the country.
Principal Findings: An analysis of the large metropolitan
health departments suggest that current assumptions about
local health department capacities and financing challenges
mistakenly equate the characteristics of the average LHD with
the financial and organization characteristics of the health
departments which serve most of the US population; the
MHD.
Conclusions: Large metropolitan health departments play a
very significant role in public health service delivery and have
financial, and organization capacities and challenges which
are not well understood or reflected in federal public health
financing strategies.
Implications for Policy, Delivery or Practice: Health
disparity reduction, chronic disease prevention and public
health preparedness efforts must better understand and more
appropriately fund Metropolitan Health Departments to have
significant impacts on urban populations. The traditional statecentric approach to funding may not appropriately fund to a
scale to achieve measurable outcomes or clear replicable
models of prevention.
● Evaluation of Strategic Workforce Development in a
Local Public Health Agency
Margaret Potter, J.D., M.S., Molly Eggleston, M.P.H., CHES,
Gerald Barron, M.P.H., G. Daniel Bednarz, Ph.D., Christine E.
Ley, Ph.D., M.P.H., M.S.W., Carl I. Fertman, Ph.D., M.B.A.,
CHES
Presented by: Margaret Potter, J.D., M.S., Associate Dean
and Director, Center for Public Health Practice, University of
Pittsburgh, 3109 Forbes Avenue, Pittsburgh, PA 15260; Tel:
412.383.2400; Fax: 412.383.2228; E-mail: mapotter@pitt.edu
Research Objective: Measure the impact of a strategicallydesigned training program on participating workers and on
their organizational employer.
Study Design: Through a strategic assessment process, a local
public-health agency identified for performance improvement
a prioritized list of essential services. Trainers designed a 30hour program to improve competencies of the agency’s
employees in three domains (analytic, cultural, and
communications), which were related to those essential
services with the highest priority for strategic improvement.
Outcome evaluation of this training program included both
organizational and individual-trainee indicators. The primary
organizational indicator was application of appropriate
evaluation methods in the agency’s annual program plans.
The individual-trainee indicators were: 1) change in attitudes,
beliefs, awareness, and knowledge over the course of training;
2) usefulness of course topics and effectiveness of training
methods; and 3) uptake of new skills into work and resulting
program improvements nine months after training.
Population Studied: The trainees were 77 employees (about
20% of all staff) representing all thirteen program divisions of
the 400-employee agency. One program division (food safety)
sent every professional and field-staff member to the training.
Other program chiefs selected employees on the basis of need
for training and other unspecified factors.
Principal Findings: Impacts of the training appear in each of
the three competency-domains and at both the organizational
level and the individual-trainee level. For the analytic
competencies, a comparison of annual program plans pretraining and post-training by the agency’s senior management
showed improved use of appropriate outcome indicators; and,
nine-months after training, a trainee sample confirmed the
uptake of analytic skills. Results of the trainees’ evaluations
revealed inadequacies in the cultural-competency module;
consequently, the agency later devoted an additional half-day
of training to that subject for all 400 employees. For the
communications competencies, trainees initially questioned
the training approach but nevertheless demonstrated
acquisition of the skills that were taught. At nine-month
follow-up, they not only acknowledged the usefulness and
impact of the communications training but also called for
agency-wide policies and procedures to incorporate the
underlying communications principles.
Conclusions: Strategically-designed competency-based
training can improve individual work-products and skills in
the analytic, cultural, and communications domains. Such
training can also improve an agency’s performance of targeted
essential public-health services. However, the impact of such
training depends not only on trainees’ participation and uptake
of new skills but also on the organization’s sustained
commitment to learning and its implementation of
competency-based policies and procedures.
Implications for Policy, Delivery or Practice: Federal
public-health agencies, along with academic trainers and state
and local-agency partners, are currently investing
unprecedented levels of funding, time, and expertise into
development and training programs for the existing public-
health workforce. This evaluation of one such program
provides evidence of positive outcomes when the training
design is strategically focused on essential-service related
competencies.
Primary Funding Source: HRSA
● The Effect of Liability Reform on the Supply of
Practicing Physicians
Dov Rothman, Ph.D., Jason Snyder, MA, Tim Simcoe, M.A.
Presented by: Dov Rothman, Ph.D., Assistant Professor,
Department of Health Policy and Management, Columbia
University, 600 West 168th Street, 6th Floor, New York, NY
10032; Tel: 212.342.4521; E-mail: dbr2104@columbia.edu
Research Objective: A number of states passed liability
reform legislation in the 1970’s, 1980’s and 1990’s. These
reforms capped the damages that individuals can collect from
physicians in malpractice lawsuits. This study examines
whether and how these reforms affected: (1) the supply of
practicing physicians, and (2) health care utilization rates. In
particular, we focus on the supply of OBGYN’s, and
utilization rates of pregnant women (number of prenatal
visits).
Study Design: We construct an annual county-level dataset
from three sources: The Bureau of Health Professions Area
Resource File, Insurance industry publications, and the annual
United States Natality Detail File. The main variables in our
dataset include (at the county-level): the number of practicing
physicians, the number of practicing OBGYN’s, average per
capita income, average number of prenatal visits per
pregnancy, and population.
We estimate the effect of tort reform on our outcomes of
interest using two estimation strategies. First, we use a
difference-in-differences estimator. This estimator compares
changes in our outcomes of interest in states that adopted
liability reform to changes in our outcomes of interest in states
that did/had not adopted liability reform. In this approach,
states that did/had not adopted liability reform serve as control
groups for states that adopted liability reform. Second, we use
a county-level matching estimator. We implement this in two
steps. In the first step, we use observable county-level
demographic, economic and political variables to match
counties in states that adopted liability reform to “very
similar” looking counties in states that did/had not adopted
liability reform. In the second step, we compare changes in
our outcomes of interest across these matches. In this
approach, the counties in the states that did/had not adopted
liability reform serve as control groups for their matches in the
states that had adopted liability reform.
Principal Findings: We find that 1990’s liability reforms are
associated with increases in the supply of total physicians per
capita, and the supply of practicing OBGYN’s per capita. We
also find that 1990’s liability reforms are associated with
decreases in the average number of prenatal visits per
pregnancy. We are in the process of implementing a number
of robustness checks.
Conclusions: The results described above are consistent with
the arguments that medical liability creates negative incentives
for physicians to practice in areas where they are more
vulnerable to malpractice lawsuits, and that medical liability
creates positive incentives for physicians to practice
defensively. In future research, we will examine whether and
how liability reforms affected utilization patterns other than
prenatal visits, and whether and how liability reforms affected
health care outcomes for specific populations.
Implications for Policy, Delivery or Practice: Our results
suggest that limiting physician liability should increase the
supply of practicing physicians and might lower costs
associated with physicians practicing defensively.
● What Does It Take to Be Prepared for Terrorism and
Other Public Health Emergencies?
Lucy Savitz, Ph.D., M.B.A., Michael Allswede, DO, Samuel
Watson
Presented by: Lucy Savitz, Ph.D., M.B.A., Senior Health
Services Researcher, Health Care Quality and Outcomes, RTI,
3040 Cornwallis Road, RTP, NC 27709; Tel: 919.316.3301;
Fax: 919.541.7384; E-mail: savitz@rti.org
Research Objective: The role of government is to protect and
ensure the health of the population; while the role of hospitals
is to treat the infirmed. Thus, hospitals play a central role in
preparedness. Our work with hospital executives suggests that
preparedness is a daunting task, and it is considered relative to
many competing priorities. Targeted tools that inform
decision making and guide rational resource allocation are
needed.
In order to address expressed needs, our work: (1) creates a
common language for communicating hazard information; (2)
supports evidence-based, planning and investment; and (3)
promotes surge and augmented capacity partnering for
regional preparedness and response.
Study Design: This exploratory study provides retrospective
cost analyses over a 3-year period together with real-time
expert ratings for four pathogen threats—aerosol anthrax,
aerosol smallpox, staph enterotoxin B, and cholera food
contamination. Based on foundational work to create a
pathogen score—composite measure based on key attributes
of communicability, effectiveness of treatment, and
availability of medical treatment—we engaged two expert
panels to independently assign scores across a continuum of
victim load and time of release. These ratings are displayed in
a tool referred to as the Pittsburgh Matrix.
Intervention costs associated with command and control,
capacities and resources, and disease-specific assets were
captured using a standardized tool. Three years worth of data
were pooled and analyzed in developing a series of Bio
Terrorism Unit (BTU) cost metrics.
Population Studied: Two integrated delivery systems (IDSs)
participated in this study—UPMC Health System and
Intermountain Health Care—drawing expert panels from these
two sites. Evidence for threat-specific clinical manifestations
of exposure were abstracted from peer-review literature and
available military reports. Cost information on preparedness
investments was gathered from financial analysts, using cost
accounting system data at these IDSs (n=41 hospitals over 3
states).
Principal Findings: Pathogen scores assigned by
independent, expert panels were highly correlated for all four
threat scenarios studied. Investment in implementing targeted,
preparedness interventions in these health systems were
relatively equal across acquisition/development and
operational costs with $3.4 million invested by a single system
and $1 in annual maintenance. However, we found that the
majority of investment was made in command and control
infrastructure (67%) versus key capacities and resources
(35%) or disease-specific assets (1%).
Conclusions: Health care is legislated as a right, funded as a
commodity, and hospitals are expected to offer their services
as public goods in a time of need. We know that hospitals
operate in a fiscally constrained environment and face
competing resource allocation decisions. We also know that
they are integrally involved with public health in response to
such threats. Findings from this study beg a discussion around
the responsibility and accountability for funding hospital
preparedness.
Implications for Policy, Delivery or Practice: Results
support hospitals’ evidence-based, capacity assessment,
focusing on salient resources. The need for coordinated
planning among public safety and hospitals is supported by a
common language of threat-specific, pathogen scores. Results
can inform policy makers in creating hospital preparedness
incentives and understanding required hospital investments
needed to support preparedness.
Primary Funding Source: AHRQ
● Practicing Public Health: The Relationship between
Public Health System Performance and Programs Offered
F. Douglas Scutchfield, M.D., Evelyn Knight, Ph.D.,
Michelyn Bhandari, M.P.H., Ann Kelly, M.H.A., I. Puiu
Vasilescu, Ph.D., Mary Kay Rayens, Ph.D.
Presented by: F. Douglas Scutchfield, M.D., Principal
Investigator, School of Public Health, University of Kentucky,
121 Washington Avenue, Room 105B, Lexington, KY 405360003; Tel: 859.257.6504; Fax: 859.257.6644; E-mail:
scutch@uky.edu
Research Objective: Relationships between local public
health system performance on the 10 essential public health
services (EPHS) and variation in agency outputs, defined as
programs offered by the local public health agency, were
studied to strengthen the understanding of how performance
effects the practice environment.
Study Design: This cross-sectional study used local public
health system performance data from the National Public
Health Performance Standards Program (NPHPSP) assessment
(test version 5b) collected in 2000. The health system
performance scores include a score for each of 10 EPHS plus a
total score. Outputs were measured using data from the
National Association of County and City Health Officials’
(NACCHO) 1997 National Profile of Local Health
Departments, in which respondents checked programs offered
by their agency from a standard list. To reduce the data for 43
selected programs, factor analysis was used to create three
groups within the 25 programs for which there was variation
across the sample. Bivariate relationships were analyzed
between each of the three factor scores and the 10 EPHS and
total performance scores.
Population Studied: A sample of 152 public health
departments/systems from three states was studied. These
public health jurisdictions had completed the 1997 NACCHO
Profile as well as the 5b test version of the NPHPSP
performance assessment, and represented over 70% of the
jurisdictions in these states.
Principal Findings: Of the 33 bivariate relationships
evaluated between three program group scores and 11
performance scores, 10 were significantly positive, five were
significantly negative, and 18 were not significant. There
were no significant relationships between the first group of 10
“basic” programs and the 11 health system performance
scores. There were five significant negative correlations for
the second group of seven “expanded clinical” programs with
performance scores for EPHS #2 through 6. However, for the
third group of eight “outreach” programs, 10 of the
performance scores had a significant positive relationship.
Conclusions: Local health departments whose systems score
higher on performance measures are likely to offer more
outreach programs. Lower public health system performance
was related to offering more programs with a clinical focus on
chronic disease. With more specific information on the
quantity and quality of programs offered by health
departments, it may be possible to more accurately predict the
impact of higher health system performance on public health
departments and practices in their communities.
Implications for Policy, Delivery or Practice: These results
emphasize the population health orientation of the ten
essential services, as reflected in community oriented
programs. As local public health practice moves toward
implementation of the essential services as the basis for health
system performance improvement, a shift may occur in the
nature of programs offered at the local level. This may have
important implications where public health provides the
medical care safety net for a community. Assuring the
public’s health will then require a close examination of the
role of clinical programs in the larger arena of public health
practice and pursuing highly performing public health
systems.
Primary Funding Source: CDC, ATPM
● Mifepristone: Diffusion of Innovation
Michelle Dawn Seelig, M.D., Lisa Rubenstein, M.D., MSHS,
Lillian Gelberg, M.D., M.S.HS, Paula Tavrow, Ph.D., Martin
Lee, Ph.D.
Presented by: Michelle Dawn Seelig, M.D., Primary Care
Research Fellow, Family Medicine, UCLA School of
Medicine, 924 Westwood Boulevard, Suite 650, Los Angeles,
CA 90095; Tel: 310.794.6049; Fax: 310.794.6097; E-mail:
mseelig@mednet.ucla.edu
Research Objective: To explore the self-reported factors that
predict a physician being unlikely to offer medical abortion
with Mifepristone. We will use this information to identify
potential interventions to help interested physicians who are
not currently offering abortion services to overcome the
obstacles that prevent them from offering medical abortion
with Mifepristone to their patients as an alternative to surgical
abortion in the event of unwanted pregnancy.
Study Design: We conducted secondary analysis of data
collected from a national telephone survey of physicians who
participated in a study conducted by the Kaiser Family
Foundation, KFF, entitled, National Survey of Women’s
Health Care Providers on Reproductive Health: Views and
Practices on Medical Abortion.
Population Studied: The KFF survey was a national random
sample of 790 health care providers, consisting of 595
obstetrician-gynecologists, OBGYN, and 195 family
practitioners, internists, and general practitioners - referred to
as general practice physicians, GPP. Data were collected
between May 15 and August 28, 2001. Because we were
interested in determinants of provider behavior among
potential adopters of Mifepristone, physicians were selected
from the original sample if they indicated that they were not
currently offering Mifepristone and were not personally
opposed to medical abortion.
Principal Findings: Less than one percent of the total sample
currently offered Mifepristone. Of the potential adopters, 24
percent were likely to offer Mifepristone. Controlling for age,
gender, the percentage of women of reproductive age in the
physician's practice, location, and training, legal concerns
related to FDA requirements and other matters, practice
policies prohibiting medical abortion, providers’ lack of
interest in offering abortion services, and being a primary care
physician, GPP, were significantly associated, p<0.05, with
being unlikely to offer Mifepristone.
Conclusions: Since FDA approval in September 2000, less
than one percent of physicians have begun to offer medical
abortion using Mifepristone. Because medical abortions can
be performed in GPP’s offices without surgical equipment, the
diffusion of medical abortion services could significantly
increase access to abortion in the United States. Most
physicians were not personally opposed to abortion, but were
discouraged by barriers such a legal requirements that are
potentially remediable through educational and policy
initiatives. Increased understanding of these barriers is critical
for ensuring patient access to safe, medically supervised
abortion.
Implications for Policy, Delivery or Practice: Extending
participation in medical abortion to new providers by
addressing the factors associated with being unlikely to offer
Mifepristone is essential for overcoming the problem of access
to abortion for women living in the 87% of US counties
without an abortion provider.
Primary Funding Source: HRSA
● Social Networks Analysis Methods to Define and
Quantify Dimensions of Public Health Systems
Sergey Sotnikov, Ph.D., Deborah Gibbons, Ph.D.
Presented by: Sergey Sotnikov, Ph.D., Economist, PHPPO,
Centers for Disease Control and Prevention, 4770 Buford
Highway., N.E., Mail Stop K-39, Atlanta, GA 30341-3724;
Tel: 770.488.2528; Fax: 770.488.2474; E-mail: ann0@cdc.gov
Research Objective: The recent report from Institute of
Medicine (IOM), “The Future of the Public’s Health in the
21st Century,” emphasizes the need for a “systems” approach
to public health. “Public health system” in that report is
defined as a complicated web of different entities that include
the governmental public health infrastructure, community
organizations, health care delivery systems, employers and
businesses, media, and academia. The multiplicity of
interactions between these elements of the public health
systems was recognized, but no framework for quantitative
evaluation of these ties proposed. This study developed a
method to measure and quantify dimensions of public health
systems.
Study Design: An extensive literature review enabled
identification and description of quantitative indicators of the
dimensions of the public health systems that are new to public
health. Different approaches to measuring aspects of public
health systems were classified, described, and documented.
Survey and interview instruments were then developed and
purified through interviews with public health experts.
Population Studied: We used the National Library of
Medicine (NLM) Gateway to search multiple on-line
databases and identify relevant methodologies both within and
beyond the realm of public health (public administration,
operations research, management, etc.) that can be used to
measure interorganizational networks in public health.
Principal Findings: Two approaches to evaluation and
measurement of public health partnerships have been
identified. Qualitative description of interorganizational
cooperation in public health reveals the importance and nature
of some linkages, but it does not allow to assess structural
aspects of public health systems or test the effects of
interorganizational cooperation on public health system
performance. The new methods that enable quantitative
assessment of networks of linkages within complex public
health systems were identified and their usefulness for public
health has been evaluated.
Conclusions: Proposed methods of measuring the public
health systems will make it possible to assess the effects of
cooperation within interorganizational networks on systems’
performance and facilitate appropriate interventions to
improve public health service delivery coordination. An
optimal strategy in practical application of these new methods
is to utilize a mix of different quantitative performance
indicators and measures. For example, density measures can
be used to reveal the extent of decentralized cooperation that
is occurring among member organizations. Centrality
measures can be used to identify network leaders, potential for
rapid information saturation, and the level of hierarchy within
the network. Equivalence measures will show the extent to
which certain participants occupy similar positions and serve
similar functions, or roles, within the network structure.
Implications for Policy, Delivery or Practice: Public heath
policymakers and practitioners can use our methods to
measure and evaluate health system structure. A new typology
of public health systems based on quantifiable system
characteristics can be created. Quantifying the dimensions of
public health systems will also provide a metric for evaluation
of organizational capacity that influences efficient functioning
of the public health infrastructure. Finally, by identifying
weaknesses in public health system networks, policymakers
can target appropriate interventions.
Primary Funding Source: CDC
● Turning the Tide: A Community Based Approach to
Developing Successful Intervention Strategies for At-Risk
Adolescents
Patricia Sweeney, R.N., M.P.H., J.D., Ralph Ricci, M.S.
Presented by: Patricia Sweeney, R.N., M.P.H., J.D., Visiting
Assistant Professor, Center for Public Health Practice,
University of Pittsburgh, 3109 Forbes Avenue, #210,
Pittsburgh, PA 15260; Tel: 412.383.2231; Fax: 412.383.2228;
E-mail: psweeney@pitt.edu
Research Objective: To review community studies, reports
and data sets reporting on the prevalence of risk factors which
are precursors to adolescent substance abuse, pregnancy,
school dropout, delinquency, and violence. The findings and
data from these sources were compared to national and state
data and were synthesized into a strategic plan outlining
intervention tactics and modalities to assist at-risk adolescents
and their families.
Study Design: Representatives from government, juvenile
justice, social services, health care, law enforcement,
education, religion, ethnic and minority groups, civic
organizations, public health, media and families, were
intentionally recruited to join the community planning team.
The 120 member team was divided into 6 work groups. Data
was collected and analyzed to identify the most significant risk
factors present in the community. Community assets to
address risk factors were assessed, the juvenile justice system
decision making processes were analyzed, and the legal and
policy issues constraining cross system collaboration were
studied. Plenary meetings were held to synthesize the finding
of each team and then a strategic plan of intervention tactics
and modalities was developed.
Population Studied: The target population was the youth and
families residing in Mahoning County, OH, an economically
challenged community of 240,000 in Northeast Ohio.
Principal Findings: The reviews of evidence analyzed by the
teams showed that the four issues posed the greatest risk for
youth and families in Mahoning County, Oh include: 1)
extreme economic deprivation, 2) parental involvement in the
problem behavior, 3) early and persistent antisocial behavior,
and 4) youth who feel disenfranchised and as a result
demonstrate alienation and rebelliousness. With minor
exceptions, social and community services were adequately
available to meet these youth and family needs. However,
systemic issues were identified which universally affected
commitment to reducing risk: community acceptance of crime,
systemic community prejudice and isolationism.
Conclusions: The need to create a set of strategies to address
the issues reported in the Findings was the paramount
conclusion of the planning team. Specifically, this study
shows that adequately addressing adolescent risk factors
requires cross-system, cross-community cooperation to
identify and alter existing institutional and attitudinal barriers.
Such systematic changes are required to build trust and change
the community culture away from a culture of acceptance and
tolerance of crime and prejudice to a culture that exemplifies
strong character and quality of life for all members of the
community.
Implications for Policy, Delivery or Practice: Community
planning efforts which focus solely upon the direct service
needs of youth and families fail to address the societal
conditions which underlie the risk factors. Developing
strategic intervention to address these issues far exceed
traditional community planning initiatives. Funders and
community planners need to recognize that such systematic
changes require long term assistance and support and a long
term commitment from community leaders.
In Mahoning County, Ohio, this commitment to address
systemic and attitudinal problems has resulted in increased
community capacity to collaboratively address community
issues, and successfully secure funding for needed services
and has resulted in the successful implementation of the
identified strategic interventions.
Primary Funding Source: U. S. Department of Justice and
Ohio Department of Youth Services
● The Effect of Financial Incentives on Smoking Cessation
Program Attendance and Completion
Kevin Volpp, M.D., Ph.D., Andrea Gurmankin, Ph.D., David
Asch, M.D., J. Murphy, M.D., H. Sox, M.D., C. Lerman,
Ph.D.
Presented by: Kevin Volpp, M.D., Ph.D., Assistant Professor
of Medicine and Health-Care Systems, Philadelphia VAMC,
University of Pennsylvania, CHERP, University and
Woodland Avenues, Philadelphia, PA 19104; Tel:
215.573.0270; Fax: 215.823.6330; E-mail:
volpp70@mail.med.upenn.edu
Research Objective: Approximately 70 percent of smokers
want to quit smoking, but only about 3 percent of smokers quit
each year. Smoking cessation programs are an underutilized
cost effective way to help people quit smoking. Our objective
was to determine whether modest financial incentives increase
the rate of smoking cessation program enrollment, completion,
and quit rates.
Study Design: Eligible patients were randomized into
incentive and non-incentive groups. Both groups were invited
to join a 5-class smoking cessation program at no out-ofpocket cost. In addition, the incentive group was offered $20
for each class attended and $100 if they quit smoking
(biochemically confirmed). Subjects were blinded as to the
existence of the other group. Intention to treat analysis was
used for each of the outcome variables. Chi-Square tests were
used to test for significant differences in enrollment and
completion between the two groups.
Population Studied: 179 patients at the Philadelphia Veterans
Affairs Medical Center who reported smoking at least 10
cigarettes per day and who did not have any contraindications
to nicotine patch utilization.
Principal Findings: Subjects had smoked an average of 29.8
years, with a mean consumption of 23.4 cigarettes per day.
There were no significant differences between the incentive
and enrollment groups in the number of cigarettes smoked per
day, the length of time patients had been smoking, degree of
addiction, quitting intentions, risk perception of smokingrelated risks, sociodemographic characteristics, and distance
from the VA hospital. The incentive group had higher rates of
program enrollment (43.3% vs. 20.2%, p<.001) and program
completion (25.8% vs. 12.2%, p=.02). Data on quit rates 30days post-program completion will be collected for the entire
cohort by the end of January, 2004.
Conclusions: Modest financial incentives are associated with
significantly higher rates of smoking cessation program
enrollment and completion.
Implications for Policy, Delivery or Practice: The use of
financial incentives could be an effective strategy for
increasing tobacco cessation rates. Since tobacco quit rates are
low and smoking-related illnesses are a leading cause of death
in the United States, this should be further considered.
Primary Funding Source: VA
● Hepatitis C, Whose Diagnosis Are We Missing?
Barbara Yawn, M.D. M.Sc.
Presented by: Barbara Yawn, M.D. M.Sc., Director of
Research, Olmsted Medical Center, 210 Ninth Street, S.E.,
Rochester, MN 55904; Tel: 507.287.2758; Fax: 507.287.2758;
E-mail: yawnx002@umn.edu
Research Objective: Hepatitis C is reported to be present in 1
to 4 % of all Americans according to estimates based on
information from the National Health and Nutrition Survey
(NHANES). In previous studies of diagnosed cases of
hepatitis C in Olmsted County, Minnesota, the prevalence was
only 1/10 that reported from NHANES. The purpose of this
study was to see if additional community members had
identified risk factors for hepatitis C but had no HCV testing.
Study Design: This study used an electronic summary of the
routine yearly self adminsitered health histories used in all
Olmsted County medical facilities to identify people who
might be at risk for hepatitis C. This list was compared to the
list of those who have been tested for hepatitis C and those
with a diagnosis of hepatitis C. This comparison allowed
identification of a cohort that might be at increased risk of
hepatitis C but have not been screened for the infection.
Population Studied: All adults in Olmsted County who
attended any office, emergency department or were
hospitalized at any medical care facility in Olmsted County
during 2000 and 2001.
Principal Findings: A total of 58,481 adult residents of
Olmsted County had at least one health history completed or
updated during 2000 or 2001. Of those individuals, 643 people
(1.1%) were identified as reporting one or more risk factors
for hepatitis C during 2000 or 2001. Of these people 300
(0.5%) reported having tattoos done by non-professionals, 346
(0.6%) reported use of injectable drugs at some time in their
life, 185 (0.3%) reported use of a "substance like intranasal
cocaine" and 402 (0.7%) reported having more than 6 sexual
partners during some year of their life. Over 8.6% (5037
adults) did not answer yes or no to one or more of these
questions.
There were no gender differences in the number of people
with risk factors who had not been tested for HCV. However,
those with risk factors and no testing for HCV were primarily
less than 40 years of age (82%). Most of the people reporting
risk factors of tattoos (84%) and multiple sex partners (78%)
who were tested for HCV also had a history of intravenous
drug use (IVDU) at some time in the past. All (100%)of those
that were diagnosed with HCV and reported risk factors of
multiple sex partners or tattoos also had a history of IVDU.
Conclusions: In Olmsted County almost 40% of people who
reported any potential risk factors for hepatitis C had not been
tested for HCV. However, the percent not tested varied
considerably by the type of risk factor. For those with IVDU
history only 16% had no records of being tested. The
percentage of not screening was much higher in risk factors
with less likelihood of HCV transmission such as tattoos or
multiple sex partners. Since most of the people in these
categories who were tested for HCV (and all that were HCV
positive) also had a history of IVDU, it appears that reported
IVDU is the prime driver of HCV testing.
Implications for Policy, Delivery or Practice: A simple self
administered history sheet can identify additional people at
increased risk for hepatitis C. These forms should be used by
all clinics and public health services to identify people willing
to report hepatitis C risk factors. Those with risk factors
should be evaluated and tested to increase recognition and
therapeutic opportunities for this treatable disease.
Primary Funding Source: Scherring Plough
Invited Papers
Public Health & Disaster Preparedness
Chair: Robert Valdez, Ph.D., M.H.S.A.
Tuesday, June 8 • 11:15 a.m.-12:45 p.m.
•
Panelists: Kristine Gebbie, Columbia University; Nicole
Lurie, RAND; Carmen Nevarez (no abstracts provided)