Public Health Systems
Call for Papers
Towards a Better Understanding of Public Health
Chair: Kristine Gebbie, Columbia University
Monday, June 27 • 11:00 am – 12:30 pm
●How Americans Feel About Terrorism Security: Three
Years After Sepember 11
Roy Grant, MA, Irwin Redlener, M.D., David Markenson, M.D.,
David A. Berman, Paula Madrid, PsyD
Presented By: Roy Grant, MA, Director of Research, Research,
The Children's Health Fund, 317 East 64th Street, New York,
New York, NY 10021; Tel: (212)535-9400; Fax: (212)535-7699;
Email: rgrant@chfund.org
Research Objective: To determine, three years after the terror
attacks of 9/11/01, Americans’ concern about another terrorist
attack, their confidence in government and health care system
to protect and respond, and their disaster preparedness. To
compare results with data from our 2002 and 2003 surveys to
track trends.
Study Design: A survey was conducted by the Marist Institute
for Public Opinion on behalf of the National Center for
Disaster Preparedness (Mailman School of Public Health,
Columbia University) and The Children’s Health Fund.
Telephone interviews in English and Spanish were conducted
between July 19th and 26th, 2004. Telephone numbers were
selected based on a complete list of telephone exchanges
selected to ensure that each region of the continental U.S. was
represented in proportion to its population. A national
random digit dial Equal Probability Selection Method using
Random A methodology was used to draw the telephone
numbers. Margin of error is +/- 3%.
Population Studied: A nationally representative sample of
1,234 adults 18 years or older of whom 407 were parents of
children 18 years or younger.
Principal Findings: Three-fourths (76%) of Americans are
concerned that another terrorist attack will occur in the United
States. This degree of concern nationally is slightly less than
the 81% level of concern in New York City. The lowest regional
level of concern was in the west (71%), where no terrorist
attacks have occurred. Nationally, only 39% think their own
community has an adequate emergency response plan, and
half (53%) are confident in the ability of the American
government to protect the area in which they live from a
terrorist attack. Only 39% of Americans are confident in the
ability of the health care system to respond to an act of
terrorism, a decline from 53% confident in 2002 and 46% in
2003. Yet two-thirds, 63%, of Americans have no family
emergency preparedness plan at all. Barely one-fourth (24%)
of Americans have a plan that meets the minimal criteria for
preparedness, with at least two days of food and water, a
flashlight, a portable radio and batteries, emergency phone
numbers, and a family meeting place. Compared with
identical questions and survey methodology from 2003,
concern about another attack is unchanged (76%), trust in
government to protect declined (53% in 2004 vs. 62% in
2003), and family preparedness is unchanged (24% vs.23%).
Conclusions: There is a disconnect between concern and
preparedness which constitutes a public health and disaster
preparedness problem that must be addressed. The
ubiquitous nature of concern of another attack where one lives
indicates that there is no “psychological ground zero” where
terrorism is concerned.
Implications for Policy, Delivery, or Practice: Building
psychological resilience is integral to terrorism preparedness.
It involves active individual and family disaster planning.
Making mental health services available primarily to the
community that suffered the attack following an act of
terrorism, as was done in New York City after 9/11, misses
large segments of the affected population. Government must
more effectively communicate risk and protective actions
available to all citizens.
Primary Funding Source: Other Foundation
●Evaluating Tuberculosis Surveillance and Action in an
Urban and Rural Setting
Kristine Lykens, MPA, Ph.D., Patrick Moonan, MPH, Anita
Kurian, MPH, Steve Weis, DO
Presented By: Kristine Lykens, MPA, Ph.D., Assistant
Professor, Health Management and Policy, Unversity of North
Texas Health Science Center, 3500 Camp Bowie Boulevard,
Fort Worth, TX 76107; Tel: (817)735-2325; Fax: (817)735-2446;
Email: klykens@hsc.unt.edu
Research Objective: As a nation, we are moving closer
toward Tuberculosis (TB) elimination. It is recognized that
this goal will require a realignment of practices and resources
by public health departments. To guide this realignment,
starting in 2005, the CDC is requiring all public health
departments receiving tuberculosis funds to conduct program
evaluation. As part of a CDC funded project to develop a
“toolkit” for TB program evaluation, CDC staff and researchers
from the University of North Texas Health Science Center are
developing and piloting such an evaluation model. This study
examines the implementation of this evaluation model in one
urban and one rural setting in North Texas.
Study Design: A logic model for tuberculosis surveillance and
action, developed by CDC staff provided the framework for the
study. A process was developed for the public health
departments involved in the project to select their most
important performance indicators based upon a set of
indicators developed by the Tuberculosis Epidemiology Study
Consortium utilizing focus groups of program staff. Data was
collected from the sites through medical record abstraction,
administrative records, and interviews of key personnel.
Population Studied: The population studied comprised the
tuberculosis program staff, and the patients, suspects and
contacts served by these programs. The urban site was
Tarrant County (Fort Worth) Texas and 38 rural counties
which are served by a regional office of the state health
department.
Principal Findings: Very different public health service
delivery models for tuberculosis surveillance and action are
employed in the urban and rural sites. The Tarrant County
site has a centralized Tuberculosis clinic serving an urban and
suburban population. Key performance indicators such as
treatment completion and testing of contacts of TB suspects
were very high, exceeding national and state goals. One
weakness identified was in data management. The rural
counties are served by sub-offices of a regional office located
in Arlington, TX. Each sub-office provides a large range of
services including TB to several rural counties. Initial
assessments and contact investigations are conducted by
public health nurses and case management is provided by
them. Physicians services are provided by local primary care
physicians. Directly observed therapy is conducted by the
public health nurses, contracted local nurses and
paraprofessionals. A statewide database for TB is used for
data management. Treatment compliance rates are high but
constrained by the mobility of patients, particularly
immigrants, which also impact contact investigation and
testing.
Conclusions: Tuberculosis surveillance and action is
conducted through very different delivery models in the urban
and rural settings. Treatment completion is high in both
settings. The centralized urban model allows for highly trained
tuberculosis specialists where the rural model relies of local
physicians backed up by regional tuberculosis consultants.
Case management is very important in the rural setting since
both public health and private providers are involved in care.
Implications for Policy, Delivery, or Practice: The pilot
implementation of the evaluation toolkit has been successful
and adaptable to the substantially different rural and urban
service delivery models. The pilot implementation is also
planned for an additional large urban county and one
suburban county. The primary “product” of this project is a
refined evaluation “toolkit” which is adaptable to the different
models of service delivery found throughout the U.S.
Primary Funding Source: CDC
●Environmental Public Health Tracking: Linking Health,
Environmental Hazard, and Exposure Data
Ying-Ying Meng, DrPH, Rudolph P. Rull, Ph.D., Beate Ritz,
M.D., Ph.D., Michelle Wilhelm, Ph.D., Marlena Kane,
MSWc/MPHc
Presented By: Ying-Ying Meng, DrPH, Senior Research
Scientist, UCLA Center for Health Policy Research, 10911
Weyburn Avenue, Suite 300, Los Angeles, CA 900024; Tel:
(310)794-2931; Fax: (310)794-2686; Email: yymeng@ucla.edu
Research Objective: As part of the new national initiative on
environmental public health tracking led by the Centers for
Disease Control (CDC), we are developing a model
surveillance system that links health effect data from a
population-based survey to air pollution data from ambient
monitors for identifying geographic patterns of chronic
disease and environmental hazards.
Study Design: Using US Census 2000 population densities at
the block level, we identified the population-weighted centroid
of each zip code for California Health Interview Survey (CHIS)
respondents diagnosed with asthma. These centroids were
linked to the nearest monitoring station within a 5-mile radius.
We then estimated the annual ambient ozone and fine
particulate matter (PM2.5) concentrations for each
respondent. We estimated the effects of increases in annual
ambient ozone and fine particulate matter (PM2.5) levels on
uncontrolled asthma in the San Francisco Bay Area, San
Joaquin Valley, and Los Angeles County regions of California.
Uncontrolled asthma was defined as having daily or weekly
symptoms or an asthma-related emergency room visit or
hospitalization within the previous year.
Population Studied: The population studied was 5,275
Californians, who reported that they had been diagnosed with
asthma, including 1,961 from the San Francisco Bay Area,
1,502 from San Joaquin Valley, and 1,802 from Los Angeles
County.
Principal Findings: We observed an increase in the
prevalence of uncontrolled asthma associated with ambient
ozone levels in all three regions after adjusting for age,
gender, race/ethnicity, poverty level, and health insurance
status. For elevated ambient PM2.5 level, we only observed an
increase of uncontrolled asthma for those residing in the San
Joaquin Valley. The regional heterogeneity of the PM2.5 effect
estimates may be related to variations in the characteristics of
PM2.5.
Conclusions: These findings contribute to our understanding
of the role of air pollutants on the control of asthma after
adjusting for individual-level socioeconomic status and access
to care in different regions of California. The linkage of CHIS
health data with air quality monitoring data provides a
potential model for environmental public health tracking in
other states.
Implications for Policy, Delivery, or Practice: The
environment plays an important role in our health. Many
studies have linked exposures to environmental hazards with
the development and exacerbation of specific diseases.
However, no comprehensive systems exist at the state or
national level to track many of the exposures and health
effects that may be related to environmental hazards. We
urgently need an Environmental Public Health Tracking
system to collect and analyze non-infectious disease data and
integrate that information with environmental hazard
monitoring and exposure data. The availability of these types
of data will enable researchers and health authorities to begin
to understand the possible associations between the
environment and adverse health effects.
Primary Funding Source: CDC
●Increasing Influenza Vaccination and Reducing Mortality
Among the Elderly Through Direct-to-Consumer
Advertising
Mitesh Patel, BSChem, Matthew M. Davis, M.D., MAPP
Presented By: Mitesh Patel, BSChem, Medical Student, c/o
Matthew Davis, M.D., MAPP, University of Michigan, 300
NIB, Ann Arbor, MI 48109-0456; Tel: (734) 615-3508; Fax: (734)
764-2599; Email: patelms@umich.edu
Research Objective: Influenza-related mortality
predominately and disproportionately impacts the elderly.
Rates of annual influenza vaccination among the elderly are
approximately 60%-65%, far below the Healthy People 2010
target of 90%. We examined the potential cost-effectiveness
of a federal program of direct-to-consumer (DTC) advertising
for influenza vaccine, as a method of increasing vaccination
rates among persons aged 65 and older.
Study Design: Published data regarding influenza-associated
mortality rates and vaccine efficacy among US elderly were
used to calculate the number needed to vaccinate (NNV) to
prevent one all-cause death due to influenza. The NNV was
then used to calculate the reduction in mortality expected
from a 1% increase in the national elderly vaccination rate.
Data regarding DTC advertising costs and effects for
pharmaceuticals were used to inform estimates of DTC
advertising costs necessary to increase vaccination rates by
1%. Published estimates of the value of one quality-adjusted
life-year (QALY) and the utility of life for the average elderly
person, in combination with the elderly population
distribution from the Census and age-specific life expectancy
for elderly persons from life tables, were used to calculate the
average net present value of a life lost due to influenza
mortality, discounted annually at 3%. This permitted
calculation of the net present value of deaths prevented (lives
saved) as a result of decreased influenza-related all-cause
mortality in the setting of a 1% increase in the vaccination
rate. Costs of the vaccine and vaccine administration were
assumed to be covered by health insurance; adequate vaccine
supply was also assumed.
Population Studied: A hypothetical cohort of the US elderly
population.
Principal Findings: The US elderly population in 2003 was
35.9 million. For influenza among the elderly, the all-cause
mortality rate was .001325 and vaccine efficacy against death
was 68% (95% CI: 56%-76%). The NNV was 1110 (993-1348),
resulting in 321 (264-359) elderly lives saved with a 1%
increase in the vaccination rate. Based on base-case
parameters of $200,000/QALY and utility=0.9 for the average
elderly person, we estimated an average net present value of
$1.9 million for an elder’s life lost to influenza. Total savings
expected with a 1% increase in the influenza elderly
vaccination rate were $610 million ($502m-$682m). At
substantially more conservative parameter estimates of
$50,000/QALY and utility=0.7 for a community-dwelling elder,
the mortality savings were $118m ($98m-$133m). In
comparison, DTC advertising would be expected to cost
$30.9m to achieve a 1% increase in the elderly vaccination
rate; i.e., DTC advertising for elderly flu vaccination was costsaving.
Conclusions: DTC advertising regarding influenza vaccination
for the elderly may represent a not only cost-effective but costsaving strategy for the federal government to pursue as a
means of increasing vaccination rates.
Implications for Policy, Delivery, or Practice: This is the first
study to suggest potential benefits of DTC advertising in
public immunization efforts.
Primary Funding Source: No Funding
●From Theory to Practice: What Drives the Core Business
of Public Health?
Tina Smith, MPH, Chris Parker, MBBS, MPH, Beverly Tyler,
Rachel Ferencik, MPA, Karen Minyard, Ph.D.
Presented By: Tina Smith, MPH, Senior Research Associate,
Georgia Health Policy Center, 14 Marietta Street NW, Suite
221, Atlanta, GA 30303; Tel: (404)651-0929; Fax: (404)6513147; Email: tsmith8@gsu.edu
Research Objective: The Public Health Functions Steering
Committee (1994) proffered a description of the Essential
Public Health Services (Essential Services). There remain,
however, questions about the relationship between the roles
defined therein and public health practice at the state level.
This research was undertaken to describe the current core
business of public health in Georgia relative to the Essential
Services and to elucidate the primary drivers of the core
business, with a goal to better understand and address any
misalignment between theory and practice.
Study Design: A case study was conducted to examine
Georgia’s public health system. The study design included
embedded units of investigation related to district and local
programs, flow of resources, stakeholder perceptions, state
policies, relationships between state agencies, strategic
visions, investments, and partnerships. Sources of data
included interviews, focus groups, archival records, and site
visits.
Population Studied: The primary unit of analysis was
Georgia’s $624M (2004) public health system. Individual
interviews were conducted with 50 internal and external
respondents including state, district, and local public health
administrators, other health care providers, trade associations,
legislators, agency board members, and state leaders. Focus
groups were conducted in six geographically diverse
communities across the state.
Principal Findings: (1)The core business of public health is
neither well-defined nor well-understood by internal and
external stakeholders. (2)The current core business is
dominated by the provision of direct services to individual
patients, particularly those who are uninsured and Medicaid
beneficiaries. (3)Resource utilization is significantly different
from what public health leaders in the state and others in the
field define as “ideal” for accomplishing the goal of improved
health for the state’s population. (4)The primary drivers of the
current core business of public health in Georgia were
determined to be: (a)Source and categorical nature of
funding; (b)Fragility of the health care safety net; (c)Rising
numbers of uninsured individuals; (d)Need to measure
performance and document short-term outcomes;
(e)Regulatory environment; and (f)Philosophies of leadership.
Conclusions: The core business of public health in Georgia is
not aligned with the Essential Services. Continued growth in
the number of uninsured, growing threats to the viability of
safety net providers, and inflexible funding create challenges
for state policy makers and public health leaders attempting to
balance the Essential Services in the absence of broader state
and national systemic policy interventions.
Implications for Policy, Delivery, or Practice:
Understanding the drivers of public health practice is essential
to the development of effective public health policy and the
implementation of effective public health systems. Based
upon Georgia’s case study, it appears that public health
systems in other states facing similar health care crises would
also experience imbalance between their defined core
business and the Essential Services. Broader state and
national policy interventions may facilitate alignment. Findings
from this research indicate the need for multi-state studies to
understand (1) the drivers of the core business of public
health in other states and (2) the impact on public health
delivery and practice.
Primary Funding Source: Georgia Department of Human
Resources
Call for Papers
Contemporary Public Health Challenges
Chair: Leslie Beitsch, Florida State University College
of Medicine
Monday, June 27 • 4:30 pm – 6:00 pm
●The Changing Impact of Smoking, Overweight and
Obesity on Health Care Costs and Worker Absenteeism
Curtis Florence, Ph.D., David Howard, Ph.D., Kenneth E.
Thorpe, Ph.D., Kathleen Adams, Ph.D., Peter Joski, MSPH
Presented By: Curtis Florence, Ph.D., Assistant Professor,
Health Policy and Management, Emory University, Rollins
School of Public Health, 1518 Clifton Road NE, Atlanta, GA
30322; Tel: (404) 727-2818; Fax: (404) 727-9198; Email:
cfloren@sph.emory.edu
Research Objective: Smoking, overweight and obesity have
been shown to have substantial negative impacts on health
outcomes. In recent years in the United States, the rate of
smoking has declined, while the rates of overweight and
obesity have increased dramatically. The purpose of this
paper is to quantify the impact of these changes on health
care costs and worker absenteeism for the employed
population of the U.S. between the years 1987 and 2001.
Study Design: We estimate annual number of work loss days
and annual health care expenditures using the 1987 National
Medical Expenditure Survey and the 2001 Medical Expenditure
Panel Survey. These data contain detailed information on
both of these outcomes, as well as current smoking status
and body mass index (BMI). We define overweight as
BMI>25 and <30, and obese as BMI 30+, using the guidelines
developed by the Centers for Disease Control and Prevention.
The impact of smoking, overweight and obesity on work loss
days are estimated using a negative binomial regression
model. The effect of these three factors on health care
expenditures are estimated using a standard two-part model,
where the likelihood of any expenditures is estimated by logit,
while the level of expenditures are estimated by OLS with a
logged dependent variable or with a generalized linear model,
depending on the outcome of various specification test. We
then use the predicted level of our outcomes from these
regressions to calculate the attributable fraction of work loss
days and health care expenditures for smoking, overweight
and obesity in the two years. The changes in attributable
fractions take into account both changes in the prevalence and
the marginal effects of these risk factors.
Population Studied: Working age adults age 18 to 64 in 1987
and 2001.
Principal Findings: In 1987, 32.2% of workers ages 19 to 64
smoked, 30.3% were overweight and 13.5% were obese. By
2001, the rate of smokers had declined to 25.4%, while the
rate of obese had increased to 35.4% and the rate of obese to
24.3%. We find that the decrease in smoking led to a
decrease in the percentage of work loss days (12% to 9%)*
and health care expenditures (6.6% to 4.0%) attributable to
this risk factor. The increase in obesity is associated with an
increase in attributable work loss days (5% to 7%)*, and an
increase in attributable expenditures (0.6% to 6.1%)*. (*statistically significant changes at the 5% level)
Conclusions: Our results show that the impact of this
increase in weight has exceeded the benefits of reduced
smoking (not including reductions in second-hand smoke).
Implications for Policy, Delivery, or Practice: Public policy
and workplace health promotion in the U.S. has focused an
intense effort to lower the rate of smoking in recent years.
While the rate of smoking has decreased substantially, there
has been a concurrent increase in overweight and obesity.
Both government and employers in the U.S. should devote
more attention and resources to preventing weight gain and
reducing obesity, while continuing to discourage smoking.
Primary Funding Source: CDC
●Effects of Physical Activity on Medical Expenditures of
US Adults
Eric Keuffel, MPH
Presented By: Eric Keuffel, MPH, Graduate Student- PhD,
Health Care Systems Department, University of Pennslyvania,
6 Reaney Court, Philadelphia, PA 19103; Tel: (215) 546-9286;
Email: ekeuffel@wharton.upenn.edu
Research Objective: Regular physical activity improves
clinical outcomes in coronary heart disease, hypertension,
diabetes, stroke, obesity, osteoporosis, mental health
disorders and other chronic conditions. While the
epidemiological implications of regular physical activity
(frequently defined as rigorously activity sustained for at least
30 minutes three times per week) are well-established,
particularly in adults with chronic disease; the association
between activity level and medical costs, even short-run
medical costs, is poorly understood. Public and private health
insurers may reevaluate or reconsider disease management
exercise and physical activity programs on the basis of the
treatment effect associated with physical activity programs.
This study extends upon prior economic estimates by using
cross-sectional data to quantify the effect of regular physical
activity (defined as rigorously activity sustained for at least 30
minutes three times per week) on direct medical costs after
adjusting for underlying health status, income, demographic
characteristics and other relevant covariates.
Study Design: The primary dependent variable in this analysis
is log of total medical expenditures in year 2000 (excluding
dental costs). Both unadjusted and adjusted regressions were
conducted on cross sectional data. Independent variables in
various OLS regressions generally include demographic
characteristics, income, education, insurance coverage,
behavioral covariates, health status measures and a dummy
variable for physical activity. Health status was measured with
19 dummy variables that either reflect distinct diagnoses or
conditions, summaries of domains of health and disability
levels.
Population Studied: The sample is comprised of Medical
Expenditure Panel Survey (MEPS-Year 2000) respondents
over age 17 who answered the question about whether or not
they were physically active (n=17,423). The mean (median)
total medical expenditure is $2,266 ($433). Unadjusted
annual mean (median) medical expenditures are $2,914
($565) for inactive adults (n=8,095) and $1,715 ($350) for
active adults (n=9,328). Assuming no selection bias, initial
examination of basic means and correlations are suggestive of
a negative association between log medical cost and physical
activity (Coeff= -.52, p<.01). The coefficient value translates
into 40% lower medical costs for those who are physically
active.
Principal Findings: Controlling for health status and other
patient characteristics eliminates the medical cost discount
associated with physical activity. The association between
participation in physical activity and log medical costs reverses
sign and loses statistical significance (Coeff=+.07, p=.09).
This effect is robust across subgroups as the same
specification for those with particular types of insurance
(public, private, uninsured) exhibit the same coefficient values
and significance levels for the adjusted and unadjusted
analyses. The effect also occurs when the dependent variable
is redefined as the log of medical costs covered by insurance.
Conclusions: This cross-sectional analysis suggests that
short-run cost savings attributed to physical activity may be
overstated in unadjusted analyses which do not account for
health status of individuals.
Implications for Policy, Delivery, or Practice: Public and
private insurers seeking short-run returns may not benefit
from cost reductions within the first year of disease
management programs even if uptake is effective. Panel data
over an extended time period is needed to more carefully
identify the effect of physical activity on short and long run
medical costs in US adults.
Primary Funding Source: AHRQ, NRSA
●The Obesity Epidemic: Are Physicians Responding?
Donna McAlpine, Ph.D., Amy R. Wilson, Ph.D., Anne D. Price,
BA
Presented By: Donna McAlpine, Ph.D., Assistant Professor,
Health Services Research and Policy, School of Public Health,
University of Minnesota, MMC 729, 420 Delaware Street SE,
Minneapolis, MN 555455; Tel: (612)625-9919; Email:
mcalp004@umn.edu
Research Objective: The prevalence of overweight and
obesity is increasing dramatically in the United States.
Concomitantly, physicians are being called upon by major
health organizations such as the United States Preventive
Services Task Force to identify their obese patients and
provide counseling services to help them to lose weight. This
paper assesses whether physicians have responded. We
examine the prevalence of obesity-related counseling (i.e., for
diet/nutrition, exercise or weight loss) from 1996 to 2002. We
describe the characteristics of patients, visits, and physicians
that are associated with obesity-related counseling. The
provision of counseling services to patients who may be most
in need, including those who come to the doctor for weightrelated reasons, and those with diagnoses associated with
obesity is examined.
Study Design: Data come from the National Ambulatory
Medical Care Survey, an annual survey of visits to nonfederally employed office-based physicians, from 1996 to
2002. We examine rates of counseling by patient
(demographics, insurance, reason for visit, diagnosis), visit
(duration, saw physician) and physician (specialty, new vs.
established physician) characteristics.
Population Studied: Analyses are restricted to visits for
patients ages 18 and older. Sample sizes range from 17,542 to
24,929 over the study period. Data are weighted to adjust for
non-response and to produce nationally representative
estimates.
Principal Findings: In 2002, approximately 14% of visits to
physicians included counseling for diet/nutrition, 11% for
exercise, and 4% for weight loss. For the total population, the
prevalence of obesity-related counseling has not significantly
changed since 1996. Patients who went to the doctor for
weight-related concerns or with an obesity-related diagnosis
were more likely to receive counseling for diet, exercise or
weight reduction than the general population. However, even
among patients who identified weight problems as the reason
for visit, many were not counseled about behaviors linked to
weight: in 2001/2002, 31% did not receive diet counseling,
48% did not receive exercise counseling, and 45% did not
receive weight reduction counseling. Moreover, the prevalence
of counseling during visits by patients with obesity-related
complaints decreased significantly over the study period.
Longer visits and visits with a primary care physician were
associated with greater probability of obesity-related
counseling.
Conclusions: These results indicate discordance between
what physicians are advised to do and what they report doing.
Despite increasing recognition of and concern about the
health consequences of obesity and the calls from major
associations for increased detection and treatment, the
proportion of physician visits that include counseling does not
appear to be rising. Most importantly, rates of counseling
appear to be declining for those most in need.
Implications for Policy, Delivery, or Practice: Whether the
failure of physicians to alter practice content in response to
the increasing prevalence of obesity is due to competing
demands during the patient-physician encounter, unease
addressing weight issues or beliefs that treatment is not
effective is not clear. However, the results do suggest a need
go beyond medical solutions to obesity and toward
environmental solutions.
Primary Funding Source: No Funding
●Estimating Prevention Effectiveness: A Simulation Model
Based on NHANES I and III
Louise Russell, Ph.D., Elmira Valiyeva, Ph.D.
Presented By: Louise Russell, Ph.D., Research Professor,
Institute for Health, Health Care Policy and Aging Research,
Rutgers University, 30 College Avenue, New Brunswick, NJ
08901; Tel: (732)932-6507; Fax: (732)932-6872; Email:
lrussell@ihhcpar.rutgers.edu
Research Objective: To make accurate estimates of the
contribution of individual risk factors to population health
outcomes, as a basis for estimating prevention effectiveness,
analysts need to integrate information about single risk factors
and diseases into a comprehensive picture of prevention and
health. Each risk factor’s effect needs to be adjusted for other
risk factors. This paper presents a simulation model designed
to provide comparable estimates of the effects of major risk
factors on mortality, hospital admissions, and nursing home
admissions in a nationally representative sample of adults.
Study Design: The simulation model uses projection
equations that link baseline risk factors to mortality, hospital
admissions, and nursing home admissions from all causes
over the subsequent 20 years. The choice of risk factors in the
model was based on reviews of epidemiological and medical
research: all risk factors found by multiple studies to be
statistically significant determinants of death and disease were
included. Weibull regressions link time to death or end of
followup, in days, to smoking, systolic blood pressure,
physical activity, total cholesterol, body mass index, diet, and
alcohol. The equations also control for age, sex, race, and
conditions diagnosed at baseline, including diabetes.
Negative binomial regressions link annual hospital and
nursing home admissions to the same risk factors.
Population Studied: Projection equations were estimated
with data from the NHANES I Epidemiologic Followup Study
(NHEFS), a representative cohort of U.S. adults aged 25-74 at
baseline (1971-1975), whose admissions and deaths were
tracked through 1992. Separate equations were estimated for
six age-sex groups: men and women 25-44, 45-64, and 65-74;
NHEFS excluded older persons. To estimate populationattributable fractions, the projection equations were applied to
adults from NHANES III, conducted 1988-1994, which better
reflects the current prevalence of risk factors.
Principal Findings: First, we present tests of the model.
Because decades of research document the risk factors, their
statistical significance in the projection equations supports the
model’s validity. Further, projection equations based on data
through 1987 accurately forecast 1988-1992 mortality; hospital
admissions were forecast less well due to the rapid growth of
HMOs in the 1980s. Second, we present estimates of
population-attributable fractions in NHANES III adults for
several risk factors. For example, in NHANES III adults aged
45-74, smoking accounted for 6.4% of hospitalizations, 8.1%
of nursing home admissions, and 14.5% of deaths.
Comparable estimates for systolic blood pressures 140 mm
Hg and over (despite treatment in some cases) were 2.3%,
3.2%, and 4.9%. Additional estimates will be included in the
final paper.
Conclusions: A simulation model based on two
comprehensive, representative, and compatible national
surveys, NHEFS and NHANES III, can provide comparable
estimates of population-attributable fractions for individual
risk factors.
Implications for Policy, Delivery, or Practice: To set
priorities for the use of prevention resources, policy makers
need estimates of prevention effectiveness that are consistent
and comparable. The simulation model presented here
provides comparable estimates of population-attributable
fractions as a basis for such estimates.
Primary Funding Source: AHRQ
●Arkansas’s Response to Childhood Obesity: Update on
Statewide Policy Implementation
Kevin Ryan, JD, MA, Joseph W. Thompson, M.D., MPH, James
E. Bost, MS, Ph.D., Jennifer L. Shaw, MAP, MPH, Margaret M.
Harris, Ph.D.
Presented By: Kevin Ryan, JD, MA, Associate Director for
Policy and Projects, University of Arkansas for Medical
Sciences, Arkansas Center for Health Improvement, 5800
West 10th Street, Suite 410, Little Rock, AR 72204; Tel: (501)
660-7584; Fax: (501) 660-7543; Email: ryankevinw@uams.edu
Research Objective: In 2003, the Arkansas legislature passed
Act 1220 to combat the growing epidemic of childhood
obesity. Through this Act, all public schools were required to
improve school nutrition, increase physical activity, and
enhance awareness of obesity. Progress and challenges in
implementing Act 1220 policies that may affect subsequent
legislative activity in the recently opened 2005 general session
are reviewed.
Study Design: Act 1220 requires removal of vending
machines from elementary schools, disclosure by school
districts of all “pouring” contracts with soft drink companies,
annual assessment by school districts of students’ body mass
index (BMIs) to be confidentially reported to parents and
formation of a Child Health Advisory Committee (CHAC) to
set standards of nutrition and physical activity for Arkansas
children. The Arkansas Center for Health Improvement
(ACHI) undertook the task of measuring, collecting data, and
reporting BMI to parents to comply with this legislation and
has made systematic assessment of progress of other Act
1220 requirements. ACHI has systematically assessed the
progress on all Act 1220 activities.
Population Studied: The effected parties of this legislation
include public school students and parents, schools, school
districts, and healthcare professionals.
Principal Findings: Act 1220 was fully implemented in the
2003-2004 school year and is now active in the 2004-2005
school year. Actions required by the Act include elimination of
vending machines in elementary schools, disclosure of
“pouring” contracts, and annual BMI assessments. Status
assessments of these requirements are in progress. By the
end of the 2003-2004 school year, BMI assessments were
successfully completed and confidential Child Health Reports,
including BMI-for-age, healthy lifestyle recommendations, and
provider referral information, were mailed to parents. In
addition, the CHAC developed recommendations for the
Arkansas Department of Education for the 2004-2005 school
year. These recommendations include nutrition education
and standards, food service professional development, and
physical activity standards. Acceptance and implementation
of these recommendations will be determined in the currently
active legislative session. Potential legislative changes to Act
1220 include a parental “opt-out” clause for BMI assessment
that parallels other school health screenings.
Conclusions: Act 1220 has enabled Arkansas to begin
combating the childhood epidemic of obesity. Additional
assessments regarding the effectiveness of programs
developed as a result of Act 1220 are needed to inform local
and national policies and programs.
Implications for Policy, Delivery, or Practice: Implications
of CHAC recommendations and BMI assessments also have
the potential to affect health insurance coverage for obesityrelated conditions.
Primary Funding Source: RWJF
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Communicating with Emergency Departments: What are
the Capabilities?
Angela Anderson, MPP, Gretchen Williams Torres, MPP
Presented By: Angela Anderson, MPP, Research Manager,
HRET/AHA, 1 North Franklin, 30th Floor, Chicago, IL 60606;
Tel: (312) 422-2657; Fax: ; Email: aanderson@aha.org
Research Objective: The purpose of the study is to identify
the capabilities and processes emergency departments (EDs)
use to communicate with local public health departments
(LHDs).
Study Design: Data were collected via a survey of 729 nonfederal, general hospitals with EDs in the 20 largest
metropolitan areas in the United States. Respondents include
ED administrators, nursing directors, and medical directors.
The survey questionnaire addressed the following issues:
methods of communication with the local health department
(LHD); participation in various information systems, resourcesharing, and community-wide planning; and process of
information dissemination. 191 (26%) of 729 hospitals
responded to the survey. Data were weighted to control for
potential non-response bias.
Population Studied: Hospital emergency departments in the
20 largest metropolitan areas of the United States.
Principal Findings: Landline communications methods (such
as phone, fax, and touch tone service) were most important to
EDs when communicating with LHDs (87%). 66% used webbased methods (such as email and internet site), and these
were used in addition to landline methods, not to their
exclusion (56% used both web and landline vs. 7% web only).
With respect to EDs’ participation in disease surveillance with
LHDs, 74% reported using both electronic and non-electronic
systems. Most EDs (87%) had 24/7 contact information for
their LHDs. Three-fourths (75%) of EDs were connected to
the state’s Health Alert Network (HAN). Of these, about half
receive alerts in the ED and distribute them on a 24/7 basis
(54%) or have connections with the state that will work in case
of circuit failure (53%). Survey respondents were asked about
the EDs’ participation in four different types of information
systems: 70% participated in syndromic surveillance; 65%
participated in real-time bed/staff capacity at other EDs; 64%
participated in community-wide resources (e.g. beds, staff,
pharmaceutical) tracking systems; and 60% participated in
centralized patient tracking systems. On average, EDs
participated in 2.54 of these four types of information systems.
One-tenth (10%) of the EDs participated in none of the four
systems.
Conclusions: Most EDs in major metropolitan areas rely on
standard forms of communication (i.e., landline and
telephone), even when they use web-based methods. The
ability of EDs in large metropolitan areas to communicate with
LHDs 24/7 is not universal; with significant proportions
lacking contact information or being unconnected to the
state’s Health Alert Network. Many of those that are
connected to HAN do not receive and distribute them in the
ED 24/7 basis and do not have a system that will work in the
event of circuit failure. These raise the question of reliability in
connecting EDs to appropriate response partners.
Implications for Policy, Delivery, or Practice: Hospitals are
integrating new information technologies and traditional
modes of communication. This examined the communication
systems of EDs in large metropolitan areas; the next challenge
is to explore how EDs communicate with LHDs in smaller
metropolitan and in rural areas.
Primary Funding Source: CDC
●The Estimated Impact of Medicare Part D on Individuals
Living with HIV/AIDS who are Dually Enrolled in Medicaid
and Medicare
Karyn Kai Anderson, Ph.D., MPH, MPH, William Clark
Presented By: Karyn Kai Anderson, Ph.D., MPH, Social
Science Research Analyst, Office of Research, Development
and Information, DHHS, Center for Medicare and Medicaid
Services, 7500 Security Boulevard, MS C3-20-17, Baltimore,
MD 21244-1850; Tel: (410) 786-6696; Fax: (410) 786-5534;
Email: kanderson2@cms.hhs.gov
Research Objective: The wide array of antiretroviral treatment
options is critical not only for controlling the clinical
progression of HIV and AIDS, but also for preventing the
spread of multi-drug resistant strains of HIV in the
population. However, given that HIV/AIDS treatment
medications are prohibitively costly without health insurance,
public health agencies play an indispensable role. Medicaid
and is one of the main sources of health insurance for
individuals diagnosed with HIV or AIDS, a large fraction of
whom are simultaneously “dually eligible” for Medicare,
mostly due to qualifying as disabled beneficiaries under age
65. HIV/AIDS treatment medications for this dually eligible
population are paid by state-specific Medicaid programs.
However, next January 1, 2006 this prescription drug coverage
will shift to Medicare when Part D of the Medicare
Prescription Drug, Improvement and Modernization Act of
2003 (MMA) take effect. This study was conducted to
estimate both the prevalence of HIV/AIDS among dually
eligible individuals as well as the impact that this policy
change will have on these individuals and the public health
system.
Study Design: This study used data from the Medicaid
Analytic eXtract (MAX) database at the U.S. Department of
Health and Human Services (DHHS) Centers for Medicare
and Medicaid (CMS). MAX is the research-oriented
adaptation of the Medicaid Statistical Information System
(MSIS) administrative database. Files specific to calendar
year 1999 were used since they are most recently available
MAX data for all states. To attenuate typical weaknesses of
administrative datasets (e.g., imperfect coding), a range of
HIV/AIDS-specific diagnosis and procedure codes were used
to capture as many HIV and AIDS cases as possible. The
development of these criteria was informed by previous
research on HIV/AIDS case-finding algorithms applied to this
Medicaid database (Walkup et al., 2004; Thornton et al., 1997;
Keyes et al., 1991).
Population Studied: Individuals diagnosed with HIV or AIDS
who are dually enrolled in Medicaid and Medicare.
Principal Findings: The prevalence of HIV/AIDS among
dually eligible individuals is presented nationally as well as by
geographic area and state. Also presented are prescription
drug utilization and expenditure findings. Taking into account
the Medicaid policies that are specific to each state, a key
focus of this analysis will be estimating the extent and
direction to which dual beneficiaries’ cost-sharing obligations
(e.g., co-pays) will shift after Medicare Part D takes effect.
Conclusions: The study conclusions focus on estimated
impact of Medicare Part D at both the individual level and the
public health care systems level.
Implications for Policy, Delivery, or Practice: The public
health system has the grave responsibility of controlling the
progression and proliferation of the HIV virus. With the bulk
of all HIV/AIDS public health services in the U.S. managed by
three major programs (Medicaid, Medicare, and the Ryan
White CARE Act), it can be expected that a shift between any
two is likely to have an effect on the third. This is especially
true in the context of Medicare Part D given that Ryan White is
the payer of last resort for HIV/AIDS care. It is hoped that the
findings presented in this session will open a forum for
discussion among health care analysts and decision makers.
Primary Funding Source: CMS
than the commensurate changes over two years (25%,
p<0.10), and it is not significant in later periods.
Conclusions: The benefits of physical activity for total health
care costs are substantial and manifest across various sociodemographic groups, chronic health conditions and
behaviors. Among people in late middle age, physical
inactivity is associated with future health care costs that are on
average almost a third above medical expenditure of active
individuals. Given that almost every fourth American adult is
sedentary, whereas late middle age people are even less
active, millions of dollars could be saved in national health
expenditure if Americans get more physically active.
Implications for Policy, Delivery, or Practice: Physical
inactivity imposes a substantial burden on the health care
system. More thought is necessary in the research and
policymaking world on how to promote active lifestyle and
help reduce national health care costs.
Primary Funding Source: No Funding Source
●Physical Activity and Future Health Care Costs among
People in Late Middle Age
Tatiana Andreyeva, MA, MPHil, Roland Sturm, Ph.D.
Presented By: Prue Bagley, MA (Hons), Associate Lecturer,
School of Public Health, La Trobe University, Bundoora,
Victoria, 3086; Tel: 61 3 9479 3526; Email:
p.bagley@latrobe.edu.au
Research Objective: The research objective was to explore
infrastructure requirements for population health services at
the local level. Within Australia’s three-tiered system of
government, states have, for historical and political reasons,
organised the delivery of population health services in
different ways. The result is a public health system with a
complex and diverse organisational framework. This system is
expected to both deal with existing concerns and respond to
emerging issues. Whilst significant population health gains
have been made, the system faces a number of challenges.
Budget cuts in health have been borne disproportionately by
infrastructure even as the range of what is considered
population health business has expanded significantly. In this
environment interest in the system’s capacity and
performance has grown. The question of appropriate levels of
infrastructure is a critical component of this interest. While
something is known about infrastructure for population health
at the national and state level, comparatively little is known
about the level of infrastructure required at the local level. It is
at this level that the majority of population health services are
delivered through a diverse array of organisational
arrangements.
Study Design: To explore the question of infrastructure at the
local level, senior population health managers in two
Australian states were interviewed. These are Australia’s two
most populace states. They also represent something of the
diversity in the delivery systems for population health services.
Population Studied: Senior population health managers
Principal Findings: Respondents were asked to identify and
reflect on the critical components of infrastructure required at
the local level. These in-depth interviews revealed that senior
managers have clear ideas about those elements of
infrastructure they believe act as facilitators or barriers to the
effective delivery of population health services, particularly in
regard to systems for financing, planning and workforce
development.
Presented By: Tatiana Andreyeva, MA, MPHil, Doctoral
fellow, RAND Graduate School, 1776 Main Street, Santa
Monica, CA 90401; Tel: (310)393-0411 x6047; Fax: (310)2608155; Email: tatiana@rand.org
Research Objective: The beneficial health effects of physical
activity are well-established, yet commensurate differences in
health care costs are less studied. This paper estimates the
association between physical activity and future health care
costs for a nationally representative sample of individuals ages
54-72 over 1996-2002.
Study Design: The data is from the Health and Retirement
Study, a nationwide biennial longitudinal survey of Americans
in late middle age. The main outcome is total health care
costs two and four years ahead from physical activity at
baseline. Multivariate regression analysis corrects for the
independent effects of socio-demographic and behavioral
confounders. Sub-sample analyses include estimation across
behavioral factors and chronic health conditions.
Population Studied: Nationally representative adults ages 5472 surveyed over 1996-2002 (N=18,271).
Principal Findings: Among adults ages 54-72 without physical
limitations, active people have significantly lower average total
health care costs than physically inactive individuals. In
multivariate analyses, the average annual health care costs
two years ahead from baseline are 29% higher for inactive
persons than for active people (in 2003 dollars, $7,677 vs.
$5,932; p<0.05). The increase in health care costs due to
physical inactivity is higher for women (34%, p<0.05) than for
men (27%, p=0.13). Across the chronic health conditions
examined, vigorous physical activity is related to significantly
lower future health care costs for people with cardiovascular
disease, lung disease and back problems. Future health care
costs are particularly high for inactive persons among
smokers (33%, p<0.05). The effect of physical activity on
health care costs four years ahead from baseline is less strong
●Infrastructure for Population Health at the Local Level
Prue Bagley, MA (Hons), Professor Vivian Lin, DrPH
Conclusions: Senior public health managers are able to
readily identify those elements of infrastructure that are critical
to their work. Infrastructure requirements may vary across
delivery systems and organisational frameworks. The public
health system is responsible for a variety of health issues and
concerns. Infrastructure requirements may vary in response
to these issues.
Implications for Policy, Delivery, or Practice: This research
suggests that diverse organisational structures may result in
different requirements in terms of appropriate levels of
infrastructure. In addition, it raises broader questions about
reasonable expectations of a public health system. Given that
this system is expected to respond to issues as diverse as
disaster preparedness and the obesity ‘epidemic’, is it possible
to specify what levels of infrastructure are required and what
measure of capacity the system should contain?
Primary Funding Source: Australian Research Council
●Building Emergency Health Workforce Surge Capacity-Reserach and Policy Analysis
Marilyn Biviano, Ph.D., Atila Omer, MBA, Steve Tise, MA,
James G. Hodge, Jr., JD, LLM
Presented By: Marilyn Biviano, Ph.D., Director, Emergency
System for Advance Registration of Volunteer Health
Professionals Program, Health and Human Services, Health
Resources and Services Administratiion, 5600 Fishers Lane,
Room 13C-05, Rockiville, MD 20857; Tel: (301)443-0036; Fax:
(301)443-4920; Email: mbiviano@hrsa.gov
Research Objective: Develop comprehensive model for
successful state-based Emergency Sytems for Advance
Registration of Volunteer Health Professionals
Study Design: Assess the entire spectrum of health
professional volunteer advance registration components and
policy issues and identify options and standards and
definitions for advance credentialing of each health profession
occupation. Then test the comprehensive model in 10 States.
Population Studied: physicians, registered nurses,
psychologists, clinical social workers, marriage and family
therapists
Principal Findings: Standards for credentialing and resource
typing (per the National Incident Management System)
developed for physicians, registered nurses, and behavioral
health occupations. By varying the credentialing requirements
through typing of health professional volunteers, emergency
health personnel resources can be maximized, recruitment is
improved and the cost of the states volunteer advance registry
can be controlled.
Conclusions: A state and regional system of advance
registries of health workforce volunteers can form an effective,
surge capacity that may be needed in a declared emergency.
Implications for Policy, Delivery, or Practice: An effective,
well thought-out set of emergency authorities and welldeveloped health professional volunteer advance registry
system can provide an effective, qualified health workforce
surge capacity for the state, region and nation.
Primary Funding Source: HRSA
●The Integration of Hospitals into Community Emergency
Preparedness Planning and Response: A National Baseline
Assessment
Barbara I. Braun, Ph.D., Nicole Wineman, MA, MPH, MBA,
Nicole Finn, MA, Stephen Schmaltz, Ph.D., Jerod M. Loeb,
Ph.D.
Presented By: Barbara I. Braun, Ph.D., Project Director,
Research, Joint Commission on Accreditation of Healthcare
Organizations, 1 Renaissance Boulevard, DIVR, Oakbrook
Terrace, IL 60181; Tel: (630)792-5928; Fax: (630)792-4928;
Email: bbraun@jcaho.org
Research Objective: To conduct a national baseline
assessment of the existence of linkages among hospitals,
public health agencies and traditional first responders in
relation to community emergency preparedness. Specifically,
to assess the prevalence of hospital participation in
community-wide preparedness and response planning and
test whether better linkages were associated with a perceived
high number of community threats/hazards, experience in
planning for a national event or responding to an actual event.
Study Design: With input from an expert panel, a mailed
questionnaire was utilized to conduct the cross-sectional
assessment on linkage issues related to training and drills,
equipment, surveillance, lab testing, surge capacity, incident
management systems and communication mechanisms in
early 2004.
Population Studied: A nation-wide sample of 593 acute care
hospitals. Respondents included hospital personnel
responsible for environmental safety, emergency
management, infection control, administration, emergency
department services, quality improvement and other areas.
Principal Findings: Of 1750 randomly selected general
medical-surgical hospitals invited to participate, 678 agreed
and 575 returned a completed questionnaire. Eighteen
additional hospitals volunteered for the study. Eighty percent
of responding hospitals had participated in community-wide
training and 93% in drills. Fifty-eight percent had seen the
community plan for distributing the Strategic National
Stockpile (SNS); 27% had been involved in exercising the
distribution of the SNS. Fifty-six percent had a direct
electronic link into the state health alert network. Eighty-six
percent of hospitals’ emergency response plans were built
around an incident management system (IMS); 65% were
developed in collaboration with the community emergency
management agency. Multivariate logistic regression models
identified factors associated with better linkages. Completion
of a threat and vulnerability analysis together with community
responders was associated with average daily census (ADC)
and urban location. Presence of a community plan addressing
acquisition of additional hospital supplies and
decontamination capability was associated with prior
preparation for a large scale event, but not number of
community hazards, location or ADC. Sharing information
among health care entities on the availability of ventilators and
decontamination capacity was associated with ADC and
having a high number of perceived community hazards.
Sharing information on the availability of negative pressure
rooms was associated with ADC, urban location and having a
high number of perceived community hazards. Availability of
a live answer 24/7 with public health (overall 43%) was
associated with urban location.
Conclusions: Responses suggesting the presence of strong
linkages with the community were more commonly reported
among large hospitals in urban areas, which is consistent with
targeted funding for areas at higher risk. Across the sample,
most hospitals are integrated, either directly or by
representation, into community emergency preparedness and
response planning. Nevertheless, opportunities for improving
linkages exist, particularly in the areas of mass casualty
logistics and communication.
Implications for Policy, Delivery, or Practice: The first 72
hours of disaster response will be local. The effectiveness of
hospital staff response is greatly enhanced by collaborative
planning and assessment of integration into the community
response process. Because this is among the first attempts to
assess linkages, additional research is needed to evaluate the
depth of relationships and adequacy of planning activities.
Primary Funding Source: AHRQ
●Public Health Genetics: Assessing the State’s Role
Gayle Byck, Ph.D., Amy A. Lemke, MS, Ph.D., Dale Lea, RN,
MPH, APNG, Marianne B. Brennan, MA, Daniel Beckett, MA
Presented By: Gayle Byck, Ph.D., Deputy Director, Institute
for Health Research and Policy, Midwest Center for Health
Workforce Studies, 1747 West Roosevelt Road, Suite 558,
Chicago, IL 60608; Tel: (847)607-0319; Fax: (312)996-0065;
Email: gaylebyck@comcast.net
Research Objective: Advances in genetic knowledge and
technology are presenting significant challenges to public
health. Traditionally focused on maternal child health and
newborn screening, state public health agencies are facing
increasingly pressing questions about the role of genetics in
all of their disease prevention and health promotion
programs. At a national level, genetics/genomics has been
positioned by the Institute of Medicine as one of eight key
areas for public health education in the 21st century. Muin
Khoury, Director of the CDC’s Office of Genomics and
Disease Prevention, has argued for the integration of genetics
and public health stating, “the new genetics will eventually
change the face of public health.” At a local level, health
departments face increasing public demand for information
and services as mainstream news outlets cover stories of
genetic health breakthroughs. In response, many states are
re-evaluating their public health programs to determine their
role in the shifting context of medical genetics. This project
reports the findings of the Illinois Statewide Genetics Needs
Assessment (2004), which assessed both the current status
and future need for public health genetic services in Illinois,
and the impact of emerging genetic information and services
on the role and function of the state department of public
health.
Study Design: This project applied a mixed methods design,
utilizing statewide surveys of genetic providers and local
health department nurses, semi-structured key informant
interviews with representatives of clinical genetics, general
medicine and public health, and focus groups with
representatives from consumer advocacy organizations.
Surveys assessed genetics practice across the state and
interviews and focus groups probed into issues of access,
need, critical concerns, and the role of the state. N*Vivo was
utilized in the analysis of the qualitative data.
Population Studied: Public and private genetic service
systems through samples that were drawn from five distinct
populations: genetic providers (MD/PhD geneticists, genetic
counselors, and genetic nurses), health care providers
(representatives of general medicine and chronic disease
specialties), local health department nurses (responsible for
genetic or maternal/child health programs), public health
administrators (from four key state agencies), and
consumer/health advocacy organizations.
Principal Findings: Preliminary review indicates a distinct role
for the state department of public health in bridging public
and private health care initiatives in genetics, addressing
educational needs of the public and providers, responding to
geographical and other access barriers, assuring increased
screening capacity corresponds to actual availability of care,
and ensuring public safety in the face of an increasingly
complex array of technologies.
Conclusions: This study identified a variety of clearly defined
roles for state departments of public health with respect to
public health genetics in the domains of education, training,
service provision, surveillance, and integration.
Implications for Policy, Delivery, or Practice: Genetics is
becoming an increasingly central component of health
promotion, care, and disease prevention. The speed with
which genetics is affecting and altering the practice of health
care is placing significant demands on the public and the
public health system. The state department of public health
will play a vital role in assuring the capacity, quality, and
accessibility of future genetic services.
Primary Funding Source: Illinois Department of Public
Health
●State Sponsored Early Hearing Detection and
Intervention Programs: Integrating Genetics
Judith Cooksey, M.D., MPH, Judith Benkendorf, MS, CGC,
Daniel Beckett, MA, Dale H Lea, MS, CGC, Cynthia Gordon,
PhD, Helen Travers, MS, CGC
Presented By: Judith Cooksey, M.D., MPH, Department of
Epidemiology and Preventive Medicine, University of Maryland
School of Medicine, 660 West Redwood Street, Baltimore,
MD 21201; Tel: (410)706-1277; Email:
jcookseyumuic@aol.com
Research Objective: Severe congenital deafness, affects
about one in every 500 newborns, about 80,000 babies each
year. Early diagnosis and intervention enhances child’s
language skills and social and cognitive development. In
recent years, all states have established early hearing detection
and intervention (EHDI) programs; the number of hospital
newborns screened increased from 3% (1993) to 95% (2003).
A striking finding is that 50% or more of these infants have a
genetic basis (a gene mutation) for their deafness, yet
genetics has not been a part of EHDI programs. Recent
genomics advances now allow genetic testing to pinpoint the
gene defect, and help guide the medical evaluation and
management decisions. We studied the EHDI process to
assess factors affecting the integration of genetics into
established public health and medical care practice; our
findings may be applicable to other new population-based
screening.
Study Design: An in-depth case study of the EHDI process
conducted through qualitative research process using semi-
structured interviews with key informants directly or indirectly
involved with state sponsored EHDI programs. QSR NVivo
qualitative analysis software was used to manage data, and
assist with coding and analysis.
Population Studied: Fifty-five key informants representing
eight state health departments and two federal agencies (16),
newborn nursery nurses, audiologists, speech-language
pathologists (7), MD-otolaryngologists (8), clinical genetics
professionals (15), and national leaders in research of hearing
loss and genetics (9).
Principal Findings: A conceptual framework for the five
common steps in the EDHI process was developed and used
to identify specific areas where genetics informants indicated
genetic integration. We found varied approaches among state
programs. Within health departments positive factors for
stronger genetics integration included an organizational
proximity between the EHDI program/staff and the state
genetics program/staff; EHDI advisory committees that
included geneticists; staff education on genetics; and
combined reporting of newborn screening results by hospitals
for both hearing screening and metabolic screening.
Otolaryngologists varied across a spectrum of strong to weak
interest in genetic evaluation as part of their medical
evaluation. Factors that positively influenced genetics
evaluation included their personal experience with referrals to
geneticists, the level of genetics exposure during training, and
the perspectives of leaders within their profession. Genetics
research leaders predict that genetic evaluation and testing
will be integrated into the medical evaluation step of the EDHI
process. However, there were mixed opinions on integration
of genetic testing into the newborn screening step. They
noted that ongoing population-based research would help
provide needed data on the population genetics of congenital
deafness. However, several researches expect CHIP
technology that tests for multiple gene defects may be
available and affordable shortly.
Conclusions: State EHDI programs have varied
organizational and staffing arrangements and have limited
genetics perspective or programmatic integration. Although
EHDI programs do appear to be potential emerging areas for
genetics services.
Implications for Policy, Delivery, or Practice: Public health
EHDI programs, like other several other public health
programs for children with specific conditions (birth defects
surveillance, Children with Special Health Care Needs),
generally omit genetics evaluation from program design,
despite a high prevalence of an underlying genetic cause for
the condition. A better understanding of the process from
multiple perspectives may guide efforts to bring useful
genetics to these programs and improve patient and family
outcomes.
Primary Funding Source: HRSA, NHGRI-ELSi
●Evaluating Public Health Preparedness: Are We There
Yet?
Margo Edmunds, Ph.D.
Presented By: Margo Edmunds, Ph.D., Adjunct Associate
Professor, American Institutes for Research, Johns Hopkins
Bloomberg School of Public Health, Department Health Policy
and Management, 10720 Columbia Pike, Silver Spring, MD
20901; Tel: (301) 592-3373; Email: medmunds@air.org
Research Objective: This evaluation was designed to assess
regional communications and technology use during a twoday bioterrorism field exercise conducted in a mid-Atlantic
metropolitan area during the summer of 2003. The evaluation
produced recommendations for regional leaders in several
cross-cutting areas, including interagency technology
planning, mutual aid agreements across jurisdictions and
organizations, and future training activities.
Study Design: A multi-agency evaluation team met regularly
for several months to develop a protocol for the evaluation
and followed guidelines issued by the Department of
Homeland Security in March 2003. The team developed a
secure, Web-based survey tool that was completed by 86
trained evaluators who were observing response teams in a
variety of field locations during the two-day exercise. Using a
simple checklist format, the tool assessed the management of
information flow, use of various kinds of communications
equipment and devices, the availability of contact and other
needed information, interactions with the media and the
public, and other areas of activity. It also included an openended section for commentary and suggestions. All data were
anonymized and aggregated to ensure that individuals and
specific agencies were non-identifiable in the After Action
Report.
Population Studied: More than 1,200 people from dozens of
agencies participated in the exercise, including a local elected
official; state and local health departments; hospitals; other
healthcare providers (clinics and a community health center);
several other government agencies, such as transportation
and public works; universities; and other private
organizations.
Principal Findings: On average, exercise participants had
about 60% of the contact information they needed and
actually reached about 40% of their target contacts. Few
participants other than first responders relied on pre-existing
response plans or protocols, such as Incident Command
Systems (ICS). In general, response strategies were guided by
verbal agreements among personnel who had worked together
previously, and in 30-40% of the health departments and
hospitals, there were no back-up personnel. Needs for
information technology and equipment upgrades and training
were widely noted.
Conclusions: Evaluators commented on the high levels of
professionalism they observed among the exercise
participants, as well as the ingenuity of those who were able to
work around problems they found. The exercise yielded timely
and useful information, and much of it was actionable
immediately. Exercising is a useful test of strengths and gaps
in capacity and skills, with the added benefit of increasing
regional awareness and support for coordinated all-hazards
planning, training, and technology investments.
Implications for Policy, Delivery, or Practice: Current CDC
bioterrorism funding to states emphasizes the importance of
drills and exercises, and jurisdictions that have conducted
exercises are encouraged by U.S. Department of Homeland
Security guidelines to disseminate lessons learned and
promising practices. By sharing information about exercise
design and evaluation, this presentation could assist with
preparedness planning and capacity building among other
agencies and organizations.
Primary Funding Source: CDC, AHRQ, HRSA, several state
and local agencies
●Economic Evaluation of HIV Rapid Testing Programs
Paul G. Farnham, Ph.D., Angela B. Hutchinson, Ph.D., MPH
Presented By: Paul G. Farnham, Ph.D., Associate Professor,
Economics, Georgia State University, 14 Marietta Street NW,
Room 531, Atlanta, GA 30303; Tel: (404) 651-2624; Fax: (404)
651-4985; Email: pfarnham@gsu.edu
Research Objective: Although the annual number of new HIV
infections cases has remained relatively constant at 40,000
and AIDS deaths at 16,000 since 1998, policy makers have
been concerned about increases in HIV incidence in some
communities. Many HIV-infected individuals do not get
tested until late in their infections, and an estimated 25% of
infected individuals are unaware of their serostatus. The
development of new rapid HIV tests, such as OraQuick, which
can be performed outside clinical settings and provide results
in 20 minutes (though persons who test positive must return
to the testing center for confirmatory results), offers new
opportunities for individuals to learn their serostatus and gain
access to prevention and treatment services. Because
numerous questions exist regarding the costs and impacts of
implementing rapid testing in various settings, this paper
analyzes the economic evaluation studies of HIV rapid testing
to summarize their results for policy makers.
Study Design: This paper reviews economic evaluation
studies from 1995 to 2004 focusing on the costs and effects of
HIV rapid testing in various settings to catalog the
assumptions, methodology, and results of the studies.
Studies were selected through searches of several large
electronic data bases, including AIDSLINE, Medline, and
PsycINFO, using combinations of the following key words:
HIV rapid tests, HIV counseling and testing, costs, costeffectiveness, HIV prevention, AIDS prevention, and HIV
infection. Only peer-reviewed journal articles discussing
interventions in the U.S. were included. Studies of mandatory
HIV counseling and testing were excluded.
Population Studied: HIV rapid testing programs in the
following settings: HIV testing centers, sexually transmitted
disease (STD) clinics, emergency departments and urgent
care centers, and outreach settings.
Principal Findings: Key variables in all of the studies were:
the amount of time spent in pre- and post-test counseling
sessions; the costs of screening and confirmatory tests;
transportation, travel, and wait times; test sensitivity and
specificity; seropositivity rates; and the probability of both
infected and uninfected individuals receiving preliminary
screening and confirmatory test results.
Conclusions: In general, rapid testing procedures that
provide results at the initial time of testing are more costeffective than conventional HIV testing programs that require
a follow-up visit to obtain test results. Clients tested with
rapid tests are more likely to receive their results than those
with conventional testing. This conclusion is typically the
strongest for HIV-uninfected clients, many of whom would not
have returned to receive their test results with conventional
testing.
Implications for Policy, Delivery, or Practice: Because the
use of rapid HIV testing typically eliminates the need for a
return visit to learn test results, hospitals, health departments,
and health care providers should increase their use of this
testing process so that more individuals receive their test
results and learn their HIV serostatus. These changes will
help HIV-infected individuals access treatment and care for
their illness and will further prevention efforts for both infected
and uninfected individuals.
Primary Funding Source: CDC
●The Effect of Workplace Smoking Restrictions on
Cigarettes Consumed, Worker Absenteeism and Health
Care Utilization
Curtis Florence, Ph.D., Kathleen Adams, Ph.D.
Presented By: Curtis Florence, Ph.D., Assistant Professor,
Health Policy and Management, Emory University, Rollins
School of Public Health, 1518 Clifton Road NE, Atlanta, GA
30322; Tel: (404) 727-2818; Fax: (404) 727-9198; Email:
cfloren@sph.emory.edu
Research Objective: Cigarette smoking has well known
negative impacts on the health of both smokers and nonsmokers who are exposed to second-hand smoke. These
adverse health effects have lead governments and employers
to restrict, and in some cases ban, smoking in public areas.
The effect of these restrictions in terms of reducing exposure
to cigarette smoking and improving health outcomes is not
well understood. This study examines the impact of
workplace smoking restrictions on smoking and health
outcomes for workers in the United States.
Study Design: The National Health Interview Survey (NHIS)
is used to gather nationally representative information on
health status and health care utilization. The survey also
gathers information on health risk factors such as cigarette
smoking. In 1998, the NHIS contained a special prevention
supplement which gathered information on workplace health
promotion. Included in this supplement were questions on
whether or not smoking was allowed in the workplace. If
smoking was allowed, questions were asked concerning any
restrictions on smoking in the workplace, such as limiting it to
certain areas. This data is used to determine the percentage
of workers who have a workplace smoking restriction. The
effect of these restrictions is then found by estimating
regression models for the following outcomes: the number of
cigarettes smoked per day (conditional on smoking), the
number of work days missed due to illness, and the likelihood
of visiting a doctor or emergency room. The results show the
impact of the smoking restrictions on both smoking behavior
for smokers and health outcomes for all workers, therefore
incorporating the effects of any reduction in second hand
smoke exposure.
Population Studied: Workers age 18 to 64 in 1998.
Principal Findings: In 1998, 70.4% of workers had a
workplace smoking ban, 14.1% had a workplace where
smoking was limited to certain areas, and 15.5% had a
workplace where there were no restrictions on smoking.
24.1% of workers reported being current smokers. Smokers
who face a workplace ban smoke 8% fewer cigarettes a day
than smokers who have no workplace restrictions. Smokers
who face restrictions, but not bans, do not have significantly
lower cigarette consumption than those who face no
restrictions. Smokers who have some workplace restriction
(either a ban or more limited restriction) have on average one
less work day per year missed to illness, and have fewer
doctors’ office and emergency room visits, than smokers who
face no workplace restriction. Workplace smoking restrictions
are not shown, however, to impact lost work days or health
care utilization for non-smokers.
Conclusions: Public policy and workplace health promotion in
the U.S. has focused an intense effort to reduce exposure to
cigarette smoke in the workplace. These restrictions help to
reduce the number of cigarettes smoked by current smokers,
and to improve health outcomes for smokers. The results of
this study do not indicate, however, that workplace smoking
restrictions also have positive health effects for non-smokers.
Implications for Policy, Delivery, or Practice: These results
suggest that future policy changes should focus on
eliminating opportunities for smokers to smoke while at work
to improve the health outcomes of smokers.
Primary Funding Source: CDC
●The Role of Public Hospitals in an Era of Emerging
Infectious Diseases- Taiwan’s Experience During the SARS
Epidemic
Yea-Jen Hsu, MS, Yiing-Jenq Chou, M.D., Ph.D., Shu-Fang
Shih, MS, Nicole Huang, Ph.D.
Presented By: Yea-Jen Hsu, MS, Research Assistant,
Department of Social Medicine, National Yang Ming
University, 155 Li-Nong Street, Section 2, Taipei, 112; Tel: 8862-28201458; Fax: 886-2-28261002; Email: yjhsu@ym.edu.tw
Research Objective: The uproar of privatization and the
declining availability of resources raise a series of debates on
the role of public hospitals in today’s health care system. As
privatization likely allows public hospitals to gain operating
efficiency and effectiveness, many start to challenge the
existence of public hospitals. Opponents of privatization
defend the survival of public hospitals for these hospitals’
charitable and public missions. Previous studies have
centered on the associations between hospital ownerships
and quality of care, health care spending, and the effect of
ownership type on firm conduct in hospital markets under
regular situation. However, as we are facing an increasing
number of emerging deadly infectious diseases, surprisingly,
relatively little systematic attention has been devoted on the
role of public hospitals in serving the needed under a large
outbreak or other public emergency. It is important to
consider how ownership would affect hospital’s responses
during a large outbreak or public emergency, especially when
public interests conflicts with financial interests of hospitals.
The outbreak of the severe acute respiratory syndrome (SARS)
in Taiwan in 2003 and the comprehensive data available offer
an unique opportunity to evaluate whether hospital ownership
plays any role in determining the provision of care to SARS
patients in Taiwan during the SARS epidemic.
Study Design: This study is a population-based descriptive
study. Chi-square tests were used to test the difference of
inpatient capacity, number of patients with infectious diseases
treated, and the number and severity of SARS patients treated
between public and private hospitals.
Population Studied: All 3,005 reported SARS cases during the
outbreak from March to July 2003 were observed. The
National Health Insurance claims files and the hospital
registry were two main data used.
Principal Findings: Public hospitals treated 58% of total
reported SARS cases, and 63% of the probable and suspected
SARS cases while non-profit hospitals shared 31% and 27%,
and private hospitals were only cared 11% and 10%.
Compared to their market shares in all inpatients services
(30%) or other infectious diseases (28%) under regular
situations, public hospital took on exceedingly greater burdens
by treating more and severe SARS patients during the
epidemic. The differences were statistically significant.
Conclusions: Due to the public’s fears of SARS, non-SARS
patients avoided seeking care from the hospitals treating
SARS patients and these hospitals could lose market shares in
either outpatient or inpatient services. Under the emergency
situation whereas public interests conflict with financial
interests of hospitals, public hospitals were found to take on
the major responsibility for treating SARS patients during the
SARS epidemic.
Implications for Policy, Delivery, or Practice: Over the past
decades, government subsidies to public hospitals have been
decreasing. According to the results of our study, public
hospitals played a major role in nation’s response system to
major outbreaks such as the SARS epidemic, while non-profit
and private hospitals only shared small portions of the
burden. Public hospital’s prompt responses to their public
missions during such large outbreaks should not be
overlooked in the discussions of privatization.
Primary Funding Source: National Science Council
●How is Excess Body Weight Related to Health Service
Utilization?
I-Chan Huang, Ph.D., Albert W. Wu, M.D.
Presented By: I-Chan Huang, Ph.D., Post-doctoral fellow,
Health Policy and Management, Johns Hopkins University,
624 N Broadway, Room 663, Baltimore, MD 21218; Tel:
(410)949-4238; Email: ichuang@jhsph.edu
Research Objective: Studies have examined the impact of
excess body weight on mortality, health-related quality of life,
and cost. However, relatively little is known about the effects
on health services utilization, and by what mechanism they
may be related. We examined relationships of overweight and
obesity to health service utilization using a sample from
Taiwan.
Study Design: This was a cross-sectional study. Body weight
was classified using WHO Asian-Pacific body mass index
definitions (BMI in kg/m2): normal (18.5-22.9), overweight
(23-24.9), and obese (>=25). Utilization includes outpatient
visits, hospitalization, emergency room visits, dental services,
traditional Chinese medicine, and chiropractic services. For
binary outcomes (e.g., use vs. none in the past month), we
used logistic regression to examine the body weight-utilization
relationships. For continuous outcomes (e.g., intensity of
use), we used Tobit model that takes into account the skewed
distribution of utilizations. In multivariable models, we
adjusted for patient covariates including age, gender,
education background, smoking status, chronic conditions,
and self-reported heath status (SF-36 PCS and MCS). We
used Sobel tests to examine whether chronic condition and
health status mediate the relationships between body weight
and utilization.
Population Studied: A nationally representative adult sample
(n=13,179) collected from the 2001 Taiwan National Health
Interview Survey.
Principal Findings: In this Taiwan sample, 49.7% were
normal weight, 21.7% were overweight, and 28.5% were obese.
In unadjusted results, obese people used more outpatient
services, hospitalization, and emergency room visits than
overweight and normal weight people (all P<0.05). For
example, 40.1% of obese vs. 36.7% of overweight and 32.6%
of normal weight visited a primary care physician during the
past month. However, after adjusting for covariates,
utilization patterns were similar among BMI groups for all
types of health services (P>0.05). Sobel tests suggested that
chronic conditions and physical health significantly mediate
the relationship between body weight and utilization,
particularly for outpatient visits, hospitalization, and
emergency room visits (all P<0.05). The mediating effects
were strong for people with hypertension, hyperlipidemia and
coronary heart disease. Stratification by number of chronic
conditions suggested that obese people with more chronic
conditions utilized more outpatient, hospitalization, and
emergency room visits than other subjects. However,
overweight subjects with more chronic conditions tended to
utilize more dental services, tradition Chinese medicine, and
chiropractic services.
Conclusions: Obesity and overweight are related to
significant increases in various types of health services
utilization. The influence of body weight on service utilization
appears to be mediated by chronic conditions.
Implications for Policy, Delivery, or Practice: Better
management of chronic conditions for people with excess
body weight may help to reduce the health services utilization.
Primary Funding Source: No Funding Source
sets used. MEPS is a nationally representative survey that
includes data about medical spending, insurance status, and
sociodemographic characteristics. NHIS captures height and
weight, used to determine the Body Mass Index (BMI). The
MEPS sampling frame is drawn from the previous year's
NHIS. We created a unique person level file by merging
MEPS data for the 1996 to 2000 years with the related NHIS
data. A four-equation regression approach was then used to
predict annual overweight- and obesity-attributable medical
spending. The regressions included each person's BMI
category, insurance category, and sociodemographics.
Population Studied: Adults in the southern states, including
Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana,
Mississippi, North Carolina, South Carolina, Tennessee,
Virginia, and West Virginia. The final sample included 20,307
adults.
Principal Findings: Between 1996-2000, 36% of adults in the
south were overweight and 19% were obese. Prevalence of
obesity was highest among Medicaid enrollees (27%). per
capital spending increase attributable to overweight was $261
(9.7%), inflated to 2003 dollars, and ranged between $78 for
the uninsured and $414 for Medicare. Per capita spending
increase attributable to obesity was $832 (30.3%) and ranged
between $209 for the uninsured and $1,497 for Medicare.
Aggregate spending attributable to overweight and obesity
combined was $25.4 billion (8.5% of total spending) and
ranged between 7.7% for Medicare and 9.9% for Medicaid.
Conclusions: States and the federal government are paying
heavily for obesity and its care.
Implications for Policy, Delivery, or Practice: Much of the
morbidity and mortality associated with obesity could be
prevented through actions of the public health system to
increase physical activity and promote healthy eating habits.
State public health systems should use the findings to justify
and further their efforts in the fight against obesity.
Primary Funding Source: Southern Rural Development
Center
●Overweight and Obesity Related Medical Spending in the
South: Impact on Payers
Amal Khoury, Ph.D., MPH, Jerome Kolbo, Ph.D., Wendy
Bounds, Ph.D.
●How HMO Market Penetration Rates Affect Older Adults’
Prevention Behaviors
Ying-Chun Li, Ph.D., Edward C. Norton, Ph.D.
Presented By: Amal Khoury, Ph.D., MPH, Associate
Professor, Health Services Research, Management & Policy,
University of Florida, PO Box 100195, Gainesville, FL 32610;
Email: akhoury@phhp.ufl.edu
Research Objective: Two out of three US adults are
overweight or obese. Prevalence of obesity has increased in
the last two decades. Obesity is associated with several
serious and costly chronic conditions and poses substantial
challenges to the health of Americans, state budgets, the
public health system, the healthcare system, and employers.
Obesity rates are particularly high in the southern states,
which also have fewer public health resources and tighter state
budgets than other states. The objective of this study is to
estimate medical spending attributable to overweight and
obesity in the south for adults overall and for payers, including
Medicaid, Medicare, private insurance, and out-of-pocket
payments (which include payments by the uninsured).
Study Design: The Medical Expenditure Panel Survey (MEPS)
and the National Health Interview Survey (NHIS) are the data
Presented By: Ying-Chun Li, Ph.D., Research Associate,
Health Policy and Management, Harvard School of Public
Health, 124 Mount Auburn Street, South 410, Cambridge, MA
02138; Tel: (617) 496-8851; Fax: (617) 496-8833; Email:
ycli@hsph.harvard.edu
Research Objective: Clinical prevention can reduce
premature mortality for older adults, however, the observed
rates of prevention services vary widely across states. We test
the hypothesis that HMOs, which have a strong interest in
providing prevention services, increase population rates of
prevention services and thereby explain the variation across
states. Furthermore, we predict that HMOs have both a direct
and indirect effect influencing people's prevention behavior.
Increased prevention by HMO enrollees may spillover to nonHMO enrollees either through changes of provider practice
pattern or people's seeking care behavior.
Study Design: This study evaluated six clinical prevention
services (influenza vaccination, pneumococcal vaccination,
mammography, pap smear test, colorectal cancer screening,
and cholesterol screening) for older adults. We estimated
separate logistic models with state fixed-effects for each of six
clinical prevention utilizations. State HMO penetration rates
were adjusted into quartile indicators for each observation.
Population Studied: Two national data sets were linked at the
state level. Individual-level information about the clinical
prevention utilizations of 556,044 noninstitutionalized older
adults were from Behavior Risk Factor Surveillance System
1994-2002. The state HMO penetration rates were measured
based on information from the National Center of Health
Statistics. The study assessed the clinical prevention
utilization in past 12 months and ever had such service by
elderly persons and aged 50–64 groups.
Principal Findings: State HMO penetration rates have a
significant positive effect on the probability of receiving most
of the studied clinical prevention services. However, the
positive HMO effects are stronger for older adults who ever
had clinical preventions. One of the most significantly
positive results is associated with vaccinations for elderly
persons. Compared to people live in the lowest HMO
penetration quartile areas, those elderly persons who live in
the highest HMO penetration areas have a 70 percent higher
probability of receiving an influenza vaccination in past 12
months or five times higher probability of ever having a
pneumococcal vaccination. The magnitudes of the positive
HMO effects on vaccinations for elderly persons are
consistently higher for persons living in areas with higher
HMO penetration.
Conclusions: The empirical results support our hypotheses
that HMO spillover effects may influence the clinical
prevention utilization by older adults, but the positive HMO
effects may not consistently exist in different HMO
penetration quartiles for all of the studied clinical preventions.
Implications for Policy, Delivery, or Practice: The results
show that the rapid expansion Medicare beneficiaries into
HMOs during the 1990s may have had positive health
benefits for both HMO and non-HMO enrollees under public
health system, at least for those living in areas with high HMO
penetration.
Primary Funding Source: No Funding Source
●Analysis of Vaccines for Children Quality Assurance
Survey Data
Pamela Mathison, MA, BSN, Lori Rizzo, MBA, BSN, Karen
Hess
Presented By: Pamela Mathison, MA, BSN, Senior Health
Services Consultant, Business Development, Texas Medical
Foundation, Barton Oaks Plaza Two, Suite 200, 901 Mopac
Expressway South, Austin, TX 78746; Tel: (512) 329-6610; Fax:
(512) 328-2921; Email: pamm@tmf.org
Research Objective: 1. Utilize data abstracted from quality
assurance site surveys at enrolled Vaccines for Children (VFC)
providers over multiple years to assess the impact of VFC site
visit feedback and education. 2. Utilize site survey data to
identify significant indicators and trends that could affect
provider-based immunization rates and determine the
educational needs of providers.
Study Design: Under contract with the Texas Department of
State Health Services, the Texas Medical Foundation (TMF)
has conducted quality assurance site visits for providers since
September, 2001. The major purposes of the Vaccines for
Children (VFC) site visits are to: 1. Improve the quality of
immunization practices in VFC provider sites, 2. Increase the
immunization levels in children under two years of age, and
3. Fulfill Centers for Disease Control and Prevention (CDC)
contract/grant requirements. Feedback about site survey
results is provided during the site survey, along with education
and resources for quality improvement of immunization
practices and immunization rates. In March, 2002, TMF staff
implemented use of a newly-developed electronic site survey
tool by TMF reviewers performing the site visits. This tool was
used by TMF reviewers for 830 site surveys in 2002; for 2,408
surveys during 2003; and for 2,405 surveys during 2004. The
electronic tool was also used by local and state health
department staff in 2004 for an additional 222 site surveys
conducted at public health department and Women, Infant
and Children (WIC) clinics enrolled in the VFC Program. Data
was drawn from these surveys for statistical analyses.
Population Studied: The target audience for the quality
assurance site surveys was providers enrolled in the Texas
Vaccines for Children Program. While the vast majority of
enrolled providers are private practice physicians, other types
of VFC providers include public and private hospitals, local
and state public health clinics, WIC providers, Federally
Qualified Health Centers, Rural Health Centers, public and
private schools, colleges and universities, pharmacies, local
and state youth correctional facilities, and mobile clinics. Site
visits are conducted every 9-15 months on all enrolled
providers, beginning at least six months after they receive their
first shipment of VFC-supplied vaccines.
Principal Findings: Results indicate notable improvements in
provider performance over time on immunization rates and
several indicators of compliance with VFC regulations or
recommended immunization practices. However, there were
some reversions and variances that posed interesting
questions to be addressed by further investigation.
Conclusions: Quantitative analyses, coupled with other
inputs (e.g., provider feedback), has provided indications of
the site survey effectiveness. However, because quality
assurance site visits are a once-a-year event and other
variables could influence provider performance, a direct cause
and effect relationship based on this data cannot be assumed.
Implications for Policy, Delivery, or Practice: Conducting an
individualized assessment of immunization practices and
immunization rates provides the opportunity to present
individualized feedback and offer education, resources and
motivation to make changes in the provider’s system to
improve those practices and, consequently, the provider’s
immunization rate. These clinic-based improvements result
in a higher level of protection against vaccine-preventable
diseases for the general population.
Primary Funding Source: CDC
●Sexual Violence Victims: Are Emergency Rooms Ready?
Stacey Plichta, Sc.D., Tancy Vandecar Burdin, MS, Rebecca
Odor, MS, Shani Reams, BA
Presented By: Stacey Plichta, Sc.D., Associate Professor,
School of Community and Environmental Health, Old
Dominion University, 105 Spong Hall, Norfolk, VA 23529; Tel:
(757) 683-4989; Fax: (757) 683-4410; Email: splichta@odu.edu
Research Objective: This study explores the structure and
process characteristics of emergency departments (ED’s) in
Virginia as they relate to assisting victims of sexual violence.
A state-wise survey estimates that roughly 27,000 people per
year are victims of sexual violence in Virginia, yet only 10% of
women and 2.2% of men seek medical care following an
assault. Sexual violence has both immediate and long-term
health consequences, and appropriate early intervention is
critical to the recovery of victims and their families.
Study Design: All 82 publicly accessible emergency
departments in Virginia were surveyed via mail with a
telephone survey follow-up for non-responders. The
respondent ED’s (RR 75%) were distributed proportionately
across the state. Questions about available services and
resources were based upon the AMA's recommendations for
the treatment and prevention of sexual assault, forensic
Nursing guidelines and upon input from an expert panel from
Virginia Sexual & Domestic Violence Action Alliance, the
Virginia Department of Health and practicing forensic nurses.
The expert panel, also reviewed and approved the final version
of the survey.
Population Studied: All 82 publically accessible emergency
departmetns in Virginia, 62 (75%) responded.
Principal Findings: ED’s serve an average of 36.5 victims per
year (range 0-310). They generally report providing the
recommended immediate care to victims of sexual violence,
with most conducting a complete forensic exam or referring to
a sister hospital. However, trained staff and critical linkages
to the community are lacking. One-half report that they do
not have a trained sexual assault nurse examiner (SANE/FNE)
on staff, 60% are not part of a community sexual assault
response team (SART) and one-quarter do not have a
relationship with a rape crisis center. Further, both screening
and followup could be improved. The majority do not screen
for sexual violence unless it is suspected or disclosed. Training
in sexual violence is an area where most ED’s could improve.
Almost half do not have a formal training plan in place, over
half do not provide training to new staff and the great majority
(85%) have not provided training to medical staff in the past
year.
Conclusions: Emergency departments report serving many
fewer victims than expected given estimates of the prevalence
of sexual victimization in Virginia. It may be that victims in
Virginia do not perceive the ED as a place that they can go to
for help. The majority of the ED’s provide immediate care, but
do not have the staff or training to provide comprehensive
care to victims of sexual violence.
Implications for Policy, Delivery, or Practice: There is a
clear need to ensure that SANE/FNE staff are available at
every hospital and that medical staff are trained on a regular
basis. State agencies and sexual assault crisis centers need to
partner with the ED’s to help them provide the care necessary
to victims.
Primary Funding Source: State of Virginia
●Local (public) Health Systems in the 21th century: Who
Cares? -An Explorative Study on Health System
Governance in Amsterdam
Thomas Plochg, MSc, D. Delnoij, Ph.D., N.S. Klazinga, M.D.
Ph.D., W. Hogervorst, M.D., P. van Dijk, M.D.
Presented By: Thomas Plochg, MSc, Scientific Researcher,
Department of Social Medicine, Academic Medical Center,
University of Amsterdam, PO Box 22660, Amsterdam, 1100
DD; Tel: +31 20 5668719; Fax: +31 20 6972316; Email:
t.plochg@amc.uva.nl
Research Objective: It is argued that there should be a public
health perspective to health system governance practices. Its
intrinsic population health orientation provides the ultimate
ground for determining the health needs and for governing
collaborative care arrangements within which these needs can
be met. However, population health concerns are not central
in European health system reforms. Governments currently
withdraw leaving governance roles to competing care
providers and/or financiers. Incentives that trigger the uptake
of a public health perspective are often ignored. The relevance
of this issue can be illustrated by the current situation in the
Dutch health system.
Study Design: We explored whether there is a public health
perspective to the governance practices of the municipality
and the major care insurer in Amsterdam, The Netherlands.
And if so, what the scope of this perspective is. We conducted
document analysis of relevant municipal policy papers, 10
semi-structured interviews with key executives of the care
insurer, and observations of public debates on local health
policy. We analysed the data against the concept of
'community-based integrated care', which we used as an
operationalisation of a public health perspective.
Principal Findings: - There is a public health perspective to
municipal health system governance, but its scope is limited.
The municipality facilitates rather than governs health care
provision in Amsterdam.- The insurer runs financial risks
when adapting a public health perspective. It covers an
population that partly overlaps the Amsterdam population.
Returns on investments in population health are therefore
uncertain.
Conclusions: There seems to be a vacuum in the governance
of the local health system in Amsterdam, as the municipality
and insurer are cautious to take up a public health
perspective. Consistent governance of the local (public) health
system towards population health is therefore not assured.
Implications for Policy, Delivery, or Practice: The described
vacuum in governance is not an ideological problem but
primarily a practical one, as both actors are willing but unable.
This is illustrated by their collaborative activities in selected
fields. In order to develop and maintain this collaborative
governance, it is crucial to develop a shared vision, to invest in
human resources, and to build trust. Moreover, the incentive
structure should be made more supportive.
Primary Funding Source: No Funding Source
●A Good Outbreak is Hard to Find: Seeking Performance
Indicators for Evaluation of Preparedness Training
Margaret A. Potter, JD, MS, Danielle Iulliano, MPH, Patricia
Sweeney, RN, JD, MPH
Presented By: Margaret A. Potter, JD, MS, Associate Dean
and Director, Center for Public Health Practice, University of
Pittsburgh Graduate School of Public Health, 3109 Forbes
Avenue, Pittsburgh, PA 15260; Tel: (412)383 2400; Fax:
(412)383 2228; Email: potterm@edc.pitt.edu
Research Objective: As an academic center for public health
preparedness, we must evaluate the practical results of
training activities. The objective of this research was to
identify performance-based indicators of timeliness and
effectiveness in the detection and containment of infectiousdisease outbreaks. These indicators are intended for
evaluation of performance in drills and exercises involving
infectious-disease outbreaks.
Study Design: We reviewed published medical-epidemiologic
case reports describing the response to outbreaks caused by
nine different pathogens between 1988 and 2004. This review
focused on the processes and outcomes of response as
indicated by pathogen-specific criteria, detection-phase
criteria, and containment-phase criteria. The nine pathogens
were selected because each had a public record of outbreak,
including media and government reports in addition to the
medical-epidemiologic reports, that was sufficient to construct
a teaching case study: anthrax, brucellosis, hantavirus,
hepatitis-A, monkeypox, plague, SARS, and West Nile virus.
Population Studied: Each outbreak affected a different
population; however, this study focused on the performance
of clinical and public health professionals.
Principal Findings: The outbreak reports were inconsistent in
their detailing of performance-related process and outcome
indicators. Usually included in the reports were pathogen
characteristics relevant to the field epidemiologist and the
clinician including route and source of exposure, incubation
time, and symptoms. Inconsistently included were numbers
relevant to overall response effectiveness such as secondary
cases and health care workers infected. In the detection phase,
decisions made by clinicians and public-health officials during
the time elapsed between sample collection and diagnosis of
the pathogen – such as how to treat affected persons, what to
tell the public, and what precautions to recommend to health
workers – would be crucial to the overall effectiveness of
response. Nevertheless, few reports specified this time period
or its associated activities. For practitioners seeking to
improve performance in the containment phase, the quality
and timing of advice given to the public, mitigation efforts,
and inter-agency and inter-professional communication would
be likely correlates of overall response effectiveness. However,
virtually none of the reports included information about these
activities.
Conclusions: The outbreak reports for these nine pathogens
emphasized epidemiologic information but had limited
usefulness in identifying performance indicators for evaluating
the training of public health practitioners. Future outbreak
reports would better serve this need by including process and
outcome indicators geared to population outcomes, timing,
communications, and practical decision-making.
Implications for Policy, Delivery, or Practice: The evaluation
of preparedness training requires practical benchmarks to
serve as standards for performance. Drills and exercises
based on disease outbreaks should be evaluated on the basis
of such outcomes, depending on the specific pathogen, as:
time elapsed from first clinical observation to confirmed
diagnosis; number of secondary cases; and appropriate
communications among medical, public health, and law
enforcement professionals. A body of authoritative case
reports that include such outcomes would provide a
foundation for systematic evaluation and improvement of
practice in the detection and containment of disease
outbreaks.
Primary Funding Source: Centers for Disease Control &
Prevention
●Closing The Gap Between Biological Agent Detection
And Response
Rasa Silenas, M.D., Janine C. Edwards, Ph.D., Ralitsa Akins,
Ph.D., Josie Williams, M.D.
Presented By: Rasa Silenas, M.D., Medical Director, Office of
Homeland Security, Texas A&M University Health Science
Center, PO Box 35399, Brooks City Base, TX 78235; Tel: (210)
534-7227 x 241; Fax: (210) 534-7238; Email:
silenas@tamhsc.edu
Research Objective: To assess infectious disease surveillance
methods in use in a region of Texas for how they would affect
delivery of health care in terrorism or natural disasters.
Study Design: Case study, semistructured interviews, taped,
transcribed and analyzed with ethnographic software.
Population Studied: Public health officials in eight local
offices, one regional office and at State level in the Texas
Department of State Health Services, one federal (US Air
Force) surveillance organization, and one local health
department in a commmunity in Mexico which borders on a
Texas subject community.
Principal Findings: 1. Detection and analysis of disease
surveillance are compartmentalized. 2. A major part of the
surveillance system is an informal network of complex
communications pathways. 3. Local public health workforce
issues lead to underutilization of this insufficient resource. 4.
Preparedness for orderly public health response and surge
capacity are lagging in outlying areas.
Conclusions: A number of opportunities to improve the
effectiveness of disease surveillance and response to
emerging health disasters are indentified.
Implications for Policy, Delivery, or Practice: This study
identifies at three broad categories of interventions, not
necessarily expensive, that could optimize public health
capabilities in infectious disease surveillance and response:
workforce development and support, improved
communications pathways and planning considerations.
Specific recommendations will be discussed.
Primary Funding Source: AHRQ
●Multivariate Methods for Aberration Detection: A
Simulation Study Using the District of Columbia's
Syndromic Surveillance Data
Michael Stoto, Ph.D., Ronald Fricker, Ph.D., Arvind Jain, MS,
John O. Davies-Cole, Ph.D., MPH
●Hospital Mortality Risk for Acute Myocardial Infarction
Patients and the Effect of Adjustments for Diagnoses
Present At Admission
George Stukenborg, MA, Ph.D., Douglas P. Wagner, Ph.D.,
Frank E. Harrell, Jr., Ph.D., Alfred F. Connors, Jr., M.D.
Presented By: Michael Stoto, Ph.D., Senior Statistical
Scientist, RAND, 1200 South Hayes Street, Arlington, VA
22202-5050; Tel: (703)413-1100 x5472; Fax: (703)413-8111;
Email: mstoto@rand.org
Research Objective: Monitoring data from multiple hospitals
and/or a variety of symptoms can improve the sensitivity of
syndromic surveillance systems, but the number of false
positives will increase with the number of series monitored.
Multivariate detection algorithms combine the available data
to achieve the optimal tradeoff among sensitivity specificity,
and timeliness. The aim of this analysis is to investigate the
improvement in performance characteristics of detection
algorithms that might be expected with effective use of
multiple data streams.
Study Design: ER logs are faxed to the health department,
where they are coded them on the basis of chief complaint.
Our analysis focuses on four symptom groups (respiratory,
gastrointestinal, unspecified infection, and rash) and on seven
hospitals. We simulate a variety of disease outbreaks and test
four classes of detection algorithms: (1) methods that analyze
each series independently, controlling the probability that any
of the series will flag; (2) summing the count in each
symptom group across all hospitals; (3) combining the Pvalues from each individual series into an overall P-value; and
(4) a multivariate detection algorithm that take into account
the observed correlation among data streams. In each class
we consider both algorithms that look at a single day’s data
and methods such as CUSUM that integrate deviations over
multiple days.
Population Studied: ER visits in the District of Columbia.
Principal Findings: Over a range of simulated outbreak types,
the univariate and multivariate CUSUM algorithms performed
more effectively. Both were nearly certain to detect an
outbreak appearing in all hospitals and all syndrome groups
on day 2, but when the simulated outbreak was limited to one
syndrome group or hospital, 4 to 6 days were needed until it
was likely that the algorithm would flag. The multivariate
CUSUM was preferred to the univariate CUSUM for some
outbreak types but not others.
Conclusions: Multivariate detection algorithms offer only
limited potential for improving the efficiency of statistical
detection algorithms for syndromic surveillance. Given the
number of days that even the best algorithms need to detect
outbreaks, the value of syndromic surveillance may be highest
for natural outbreaks such as influenza rather than for
bioterrorism.
Implications for Policy, Delivery, or Practice: Multivariate
analysis of syndromic surveillance data cannot be
recommended as a substitute for careful analysis of individual
data series.
Primary Funding Source: CDC
Presented By: George Stukenborg, M.A., Ph.D., Associate
Professor, Health Evaluation Sciences, University of Virginia
School of Medicine, P.O. Box 800821, Charlottesville, VA
22908-0821; Tel: (434)924-8430; Fax: (434)924-8437; Email:
gstukenborg@virginia.edu
Research Objective: To develop a better in-hospital mortality
risk adjustment model for use in studies of patients with fresh
Acute Myocardial Infarction (AMI). Our new model adjusts for
comorbid disease measured using secondary diagnoses
reported as present at admission. We compare the statistical
performance of the new model to other mortality risk
adjustment models that use existing methods for measuring
comorbid disease.
Study Design: This is a retrospective observational cohort
study using California hospital discharge abstract data. This
study closely reproduces the study population selection
criteria and mortality risk adjustment methods used in the
1996-1998 California Hospital Outcomes Project study of AMI.
The original study population qualification and exclusion
criteria are closely replicated and applied to publicly available
California hospitalization data for 1996 through 1999. Record
linkage using encrypted unique identifiers is used to define
patient characteristics and hospitalization related events
occurring during the patient’s episode of care. The original
study population could not be exactly duplicated because
several data elements used to define the original study
population, including exact dates of admission, were not
available for this study. Multivariable logistic regression
analysis is used to develop a set of in-hospital mortality risk
models using different methods of measuring comorbid
disease. The set includes the mortality risk adjustment model
developed in the original study, a model using the method of
Elixhauser et al. to measure comorbid disease, and a model
using present at admission diagnoses to measure comorbid
disease. The discrimination between observed and predicted
mortality achieved by each model was measured using the C
statistic, and was validated by using the developed models to
predict mortality outcomes in an identically defined
independent study population.
Population Studied: The study population included 120,706
AMI hospitalizations identified for the period from January
1996 through November 1998, which is 93.9% of the 128,509
cases identified in the original study. The mortality rate was
10.1%, which closely matches the 9.9% mortality rate reported
in the original study. The distribution of patient demographic
characteristics and other measured variables also closely
matched the original study population.
Principal Findings: The mortality risk adjustment model we
developed using present at admission diagnoses to measure
comorbid disease obtained a validated C statistic of 0.86. This
level of statistical performance substantially exceed that
achieved by any of the other models we evaluated. The model
using the Elixhauser et al. method had a validated C statistic
of 0.79. The model that was originally developed for use in the
California study had a validated C statistic of 0.76 in our study
population, which was nearly equivalent to the C statistic value
of 0.77 reported in the original study.
Conclusions: States that require hospitals to identify which
secondary diagnoses are present at admission can use this
information to substantially improve the statistical
performance of AMI mortality risk models that adjust for
patient differences in comorbid disease.
Implications for Policy, Delivery, or Practice: Mortality risk
adjustment models using present at admission diagnoses to
measure comorbid disease can provide more accurate
adjustments for patient differences in studies comparing
observed to expected hospital mortality rates.
Primary Funding Source: AHRQ, This project was supported
by grant number R01 HS10134 and by grant number K02
HS11419 from the Agency for Health Care Research and
Quality
●Hospital Response to Public Health Emergencies: A
Study of Hospital Collaboration with Community
Response Partners
Gretchen Torres, MPP, Angela Anderson, MPP
Presented By: Gretchen Torres, MPP, Deputy Director,
Research & Evaluation, Health Research & Educational Trust,
1 North Franklin Street, 30th FLoor, Chicago, IL 60606; Tel:
(312)422-2638; Fax: (312)422-4568; Email: gtorres@aha.org
Research Objective: To identify collaborative strategies
hospitals and public health partners can use in developing
surge capacity for public health emergencies.
Study Design: Data were collected via semi-structured
interviews with 40 informants in hospitals, public health and
EMS at state and community levels. Interview protocols
explored public health and hospital planning for surge
capacity, resource development, and inter-organizational
relationships.
Population Studied: Eight communities in 6 states, most
with previous disaster experience, representing large and
small urban and rural communities.
Principal Findings: Most sites developed three-tiered
response strategies that triage, stabilize and transfer patients
to higher and lower level facilities. A predesignated hospital
took on a regional coordinating role and interfaced with the
public sector on behalf of all hospitals. Designated hospitals
were often trauma facilities. In some cases, any hospital could
volunteer. Some sites developed outpost models, which
evacuated ambulatory, less acute, or infectious patients away
from disaster sites. Outposts included rural hospitals,
outpatient sites, or any hospital outside the disaster vicinity.
Some collaborative planning processes were marked by
tensions due to different perspectives of public and private
entities or competitive hospital markets. Ensuring consistent
planning across sectors was a universal concern that some
states addressed through 1. unified health care-public health
planning committees, 2. hospital-focused advisory groups to
collect and disseminate information and connect public and
private activities, or 3. subcontracts to hospital associations
for hospital-specific planning and grant deliverables. Some
communities created 501(c)3s to forge partnerships among a
more diverse set of actors, creating access to more funding
and neutral zones where usual competitors could collaborate
in areas such as resource sharing. Preparedness planning
provided an opportunity for some communities to break down
barriers to working together. There was a universal sense that
true preparedness required access to resources and expertise
in all sectors. Many reported that planning’s true value was
not the plans, policies and procedures that resulted, but the
process itself because it facilitated communications across
organizations and established working relationships through
which to build trust, mutual understanding and shared
worldviews.
Conclusions: Despite histories of operating in silos, many
stakeholders in hospitals and public health supported
interorganizational preparedness planning. State and
community context—resources, experience, and market
conditions—highly influenced the planning process and
nature of response systems that emerged. All study sites took
a system-wide approach to developing surge capacity and
preparedness planning more generally. Using federal
resources to address gaps and build on existing infrastructure
helped many sites avoid reinventing the wheel.
Implications for Policy, Delivery, or Practice: The process of
working across organizations and sectors is valuable in
addressing the turf issues that impede progress on large
systemic issues such as public health preparedness. Getting
all players to the table and building the trust and shared
experience productive, collaborative working relationships
require is no small feat. It is important that the agents of any
system-level change consider histories and existing
infrastructure and create processes that 1. support and build
on them where they are effective and 2. provide the flexibility
to address gaps in a way that best connects and creates local
and unique resources.
Primary Funding Source: CDC
●Agroterrorism and Defending the Food Supply: State of
Preparedness
Rachel D. Vasconez, RD, MBA, MPH, Peter M. Ginter, Ph.D.,
Raymond William Bruer, MPH, MPA Candidate, Dugald C. A.
Hall, Ph.D.
Presented By: Rachel D. Vasconez, RD, MBA, MPH, Program
Coordinator II, Health Care Organization and Policy, UAB
South Central Center for Public Health Preparedness, RPHB
330 1530 3rd Avenue South, Birmingham, AL 35294; Tel: (205)
934-7122; Fax: (205) 934-3347; Email: rvascone@uab.edu
Research Objective: This paper examines the issues and
available discussions of recent agroterrorism conferences and
meetings and provides a synthesis of the issues and
recommendations. More specifically, the paper outlines why
agroterrorism is an emerging issue of extreme importance to
national security. It examines the vital issues inherent in the
nation’s food supply, including producer control, fractured
production and distribution systems, centralized processing,
inadequate systems for monitoring, surveillance, screening
and control of disease spread and lack of a nationwide
integrated laboratory network system for diagnostic purposes.
Discussion includes issues for both natural- and man-initiated
events and the paper recommends specific courses of action
to minimize the threat. Lastly, this paper discusses the
planning and results of a pilot conference designed to initiate
a multi-agency dialogue to minimize the impact of an
agricultural event on the southeastern economy.
Study Design: Literature, meeting and conference
proceedings review.
Implications for Policy, Delivery, or Practice: Presidential
Directive/HSPD-9 established national policy to protect
agriculture and the food supply from disasters, terrorist
attacks, and other emergencies. This 2004 directive was the
first public presidential-based acknowledgement that the U.S.
food supply is at risk and should be regarded as critical
infrastructure. Criticisms of the preparedness level of the
nation’s food supply have been a topic of considerable debate
since the September 11, 2001 terror attacks. The vulnerability
of U.S. food production and distribution to attack and
disruption became even more glaringly evident with outgoing
Secretary of Health and Human Services, Tommy
Thompson’s comment, "For the life of me, I cannot
understand why the terrorists have not attacked our food
supply because it is so easy to do.” Because of the
significance of the food supply and the psychological and
economic consequences of a successful disruption; federal
and state agencies, producers, and consumers have been
actively promoting the importance of implementing food
supply protection measures. The importance of these issues
are especially apparent in states in which a substantial portion
of the gross state product is agriculturally based. The
culmination of the attention and dialogue has resulted in an
increasing emphasis placed on the nation’s food supply
system and an understanding that a coordinated multi-agency
initiative will be required to decrease its vulnerability level. A
number informational sessions have been initiated to ensure
the safety of the food supply, but little consensus has resulted
despite nationwide attention. For example, there have been a
number of conferences, proceedings, and meetings dedicated
to agroterrorism including Biosecurity 2003, Louisiana Food
and Agricultural Biosecurity: Producer Awareness Conference,
National Multi-Hazard Symposium: “One Medicine”
Approach to Health Security, New Mexico Biosecurity
Conference, Agro-Security/Terrorism Work Conference, and
the 2005 Alabama Agroterrorism Conference. To date, no
comprehensive review or synthesis has been conducted of the
discussions at these conferences or their proceedings.
Primary Funding Source: Contract with State Health
Department
●How Can the United States Prioritize the Targeted
Testing of Tuberculosis?
Steve Weiss, DO, Thaddeus Miller, MPH, Peter Hilsenrath,
Ph.D., Kristine Lykens, Ph.D., Scott McNabb, Ph.D.
Presented By: Steve Weiss, D.O., Professor, Department of
Medicine, Unversity of North Texas Health Science Center,
3500 Camp Bowie Boulevard, Fort Worth, TX 76107; Tel:
(817)321-4937; Fax: (817)321-4920; Email: sweis@hsc.unt.edu
Research Objective: Improving efficiency of health spending
is critical to controlling escalating national health care
expenditures. Monitoring and evaluation activities can direct
resources towards efficient use. Tuberculosis (TB) control
policies in the U.S. emphasize prevention of Latent
Tuberculosis Infection (LTBI) but do not guide efficient
program design. Legal mandates exist for the screening of
only some high risk populations, but it is not known if these
mandates are directed toward the population most likely to
yield efficient returns. The objective of this study is to
determine the relative benefits and costs of a state law
mandated TB screening program and a non state law
mandated TB screening program in terms of cost, morbidity,
treatment, and disease averted.
Study Design: We conducted a retrospective comparison of
the estimated costs and outcomes between the Tarrant
County (TC), Texas homeless person TB screening program
and the TC jail inmate screening program. This evaluation
was part of the Tuberculosis Epidemiologic Studies
Consortium, New Model for Assessing Tuberculosis
Surveillance and Action Performance and Cost, funded by the
Centers for Disease Control (CDC). The study period was
from December 2001 to December 2003. Data were
abstracted from monthly reports compiled by Tarrant County
Public Health Department personnel. We gathered
population information from the U.S. Census Bureau. We
modeled risk reduction from LTBI treatment as a cumulative
reduction of disease risk for these groups from the annual
expected risk.
Population Studied: Tarrant County, Texas homeless
population residing in homeless shelters and Tarrant County
jail inmates.
Principal Findings: A non state mandated TB program for
homeless persons in Tarrant County screened 4.5 persons to
identify one with LTBI and 82 to identify one with TB. A statelaw mandated TB program for jail inmates screened 109
persons to identify one with LTBI and 3,274 persons to identify
one with TB. The number of patients with LTBI treated to
prevent one case of active TB case was 12.1 and 15.3 for the
homeless and jail inmate TB programs, respectively.
Treatment of LTBI by the homeless and jail inmate TB
screening programs will avert 11.9 and 7.9 active TB cases at a
cost of $14,350 and $34,761, respectively.
Conclusions: Mandated TB screening programs should be
risk-based, not population-based. Non mandated targeted
testing for TB in congregate settings for the homeless was
more efficient and effective than state law mandated targeted
testing for TB among jailed inmates.
Implications for Policy, Delivery, or Practice: TB screening
is recommended in many situations by public health
treatment guidelines and mandated in situations by legal
statute. This study illustrates how monitoring and evaluation
can be used to help set priorities so as to maximize return on
public spending to TB interventions. By directing prevention
and control programs towards reservoirs of latent disease and
populations who risk makes them effective and efficient
screening targets, we can improve our progress towards
achieving TB elimination in the United States.
Primary Funding Source: CDC