Authors:Brian E. Dixon et al. Abstract: Background: Community health assessments assist health departments in identifying health needs as well as disparities, and they enable linking of needs with available interventions. Electronic health record (EHR) systems possess growing volumes of clinical and administrative data, making them a valuable source of data for ongoing community health assessment.Purpose: To produce population health indicators using data from EHR systems that could be combined and visually displayed alongside social determinants data, and to provide data sets at geographic levels smaller than a county.Methods: Data from multiple EHR systems used by major health systems covering>90% of the population in a metropolitan urban area were extracted and linked using a health information exchange (HIE) network for individuals who had at least two clinical encounters within the HIE network over a 3-year period. Population health indicators of highest interest to public health stakeholders were calculated and visualized at varying levels of geographic granularity.Results: Ten population health indicators were calculated, visualized, and shared with public health partners. Indicators ranged from the prevalence of a disease to the proportion of individuals with poor maintenance of their chronic condition. Calculating rates at the census-tract level or larger (e.g., average population size> 4000 people) is preferable to smaller geographic units of analysis.Implications: Extraction and linking of EHR system data are feasible for public health via an HIE network. While indicators can be derived, biases exist in the data that require more study. Further, HIE networks do not yet possess data for all conditions and measures desired by local public health stakeholders. The data that can be extracted, however, can be combined with public datasets on social determinants PubDate: Wed, 05 Oct 2016 22:19:40 PDT
Authors:Danielle M. Varda et al. Abstract: Background: Health care reform has resulted in changes throughout the health system, including the Affordable Care Act (ACA) and IRS requirements that nonprofit hospitals conduct community health needs assessments and develop implementation plans to guide greater investment in their respective communities. This has led to questions of which factors influence hospital interaction and investment in PH systems.Purpose: This paper presents a comprehensive framework, informed by a literature review and expert panel that introduces hypothesized factors related to these outcomes.Methods: To develop a conceptual framework that identifies hypothesized indicators of increased hospital interaction and investment in PH systems, we completed a thorough and iterative review and coding of the literature. We drafted a first version of the conceptual model and convened an expert panel (n=9) to review, further narrow, and refine the conceptual model of indicators.Results: The finalized conceptual framework includes four primary categories: Community Demographics, Legal/Policy Environment, Market Conditions, and the Public Health and Hospital Organization and Systems. Detailed subcategories are included within each category. While we generally hypothesize that these factors determine the extent to which a hospital will interact and invest in PH systems, we indicate only their relational characteristics, not the direction in which these factors are specified.Implications: Ongoing work will test components of the framework utilizing four published datasets. This paper presents the framework to guide future research and funding priorities in the field. PubDate: Wed, 05 Oct 2016 22:19:35 PDT
Authors:Julie M. Kapp et al. Abstract: Background: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program was created by the 2010 Patient Protection and Affordable Care Act. MIECHV provides comprehensive services to at-risk families through evidence-based home visiting programs.Purpose: The following question is addressed: Does the Missouri MIECHV system meet the definition of a complex adaptive system (CAS)?Methods: A systematic review was conducted of documents related to MIECHV programs (federal, state, and local levels), and to affiliated programs with a home visiting and early childhood (aged birth to 5 years) scope. The organizations’ fit was identified for the scope of early childhood home visiting programs, and then its relationship extracted to MIECHV and its affiliates.Results: MIECHV meets the definition of a CAS, being dynamic, massively entangled, scale independent, transformative, and emergent. Over 250 organizations were identified; 19 federal and 79 state organizations; 24 nonprofits at the federal level, 31 at the state; over 150 community-level agencies; and 13 home visiting models implemented in Missouri.Implications: A considerable amount of organizational complexity exists within the MIECHV system and among its affiliates with a home visiting and early childhood scope. The complexity of the system challenges its potential for effective and efficient implementation, coordination, sustainability, and evaluation, and increases the potential for redundancy, overlap, and fragmentation. Evaluating a CAS requires acknowledgement of its complexity, beyond traditional approaches to evaluation. Creating visualization tools of federal, state, and local stakeholders and their relationships is a practical approach for aligning, organizing, and communicating the work flow. PubDate: Wed, 05 Oct 2016 22:14:09 PDT
Authors:Beth C. Truesdale et al. Abstract: Many researchers and advocates believe that income inequality affects individual health, but empirical evidence has been inconclusive. A large body of research has found that income inequality is negatively correlated with average life expectancy, partly because a transfer of income from the poor to the rich is likely to harm the health of the poor more than it improves the health of the rich. A smaller body of work has investigated socioeconomic disparities in life expectancy, which widened in many countries after 1980, at the same time that income inequality was increasing. These two lines of work should be seen as complementary, because high and rising income inequality is unlikely to affect the health of all socioeconomic groups equally.Understanding the effects of income inequality on health requires attention to the mechanisms that affect the health of different income groups, changing average health, disparities in health, or (more likely) both. Rising income inequality can affect individuals in two ways. Direct effects change individuals’ own income. Indirect effects change other people’s income, which can then change a society’s politics, customs, and ideals, altering even the behavior of those whose own income remains unchanged. Indirect effects can thus change both average health and the slope of the relationship between individual income and health. PubDate: Wed, 05 Oct 2016 22:09:44 PDT
Authors:Heather Wipfli et al. Abstract: This paper focuses on the first century of the global tobacco epidemic and its current status, reviewing the current and projected future of the global tobacco epidemic and the steps that are in progress to end it. In the United States and many countries of western Europe, tobacco consumption peaked during the 1960s and 1970s and declined as tobacco control programs were initiated, motivated by the evidence indicting smoking as a leading cause of disease. Despite this policy advancement and the subsequent reductions in tobacco consumption, the global tobacco epidemic continued to grow in the later years of the twentieth century, as the multinational companies sought new markets to replace those shrinking in high-income countries. In response, the World Health Organization developed between 2000 and 2004 its first public health treaty, the Framework Convention on Tobacco Control (FCTC), which entered into force in 2005. An accompanying package of interventions has been implemented. New approaches to tobacco control, including plain packaging and single representation of brands, have been implemented by Australia and Uruguay, respectively, but have been challenged by the tobacco industry. PubDate: Wed, 05 Oct 2016 21:59:33 PDT
Authors:Joan A. Casey et al. Abstract: Adoption of electronic health records (EHRs) by clinical practices and hospitals in the US has increased substantially since 2009, and offers opportunities for population health researchers to access rich structured and unstructured clinical data on large, diverse, and geographically distributed populations. However, because EHRs are intended for clinical and administrative use, the data must be curated for effective use in research. We describe EHRs, examine their use in population health research, and compare the strengths and limitations of these applications to traditional epidemiologic methods.To date, EHR data have primarily been used to validate prior findings, to study specific diseases and population subgroups, to examine environmental and social factors and stigmatized conditions, to develop and implement predictive models, and to evaluate natural experiments. Although primary data collection may provide more reliable data and better population retention, EHR-based studies are less expensive and require less time to complete. In addition, large patient samples that can be readily identified from EHR data enable researchers to evaluate simultaneously multiple risk factors and/or outcomes while maintaining study power.In addition to current advantages, improved capture of social, behavioral, environmental, and genetic data, and use of natural language processing, clinical biobanks, and personal sensing via smartphone should further enable EHR researchers to understand complex diseases with multifactorial etiologies. Integrating emerging technologies with clinical care could lead to innovative approaches to precision public health, reduce health care spending on individuals, and directly improve population health. PubDate: Wed, 05 Oct 2016 21:59:29 PDT
Authors:Gina Solomon et al. Abstract: Communities located near multiple sources of pollution, including current and former industrial sites, major roadways, and agricultural operations, are often predominantly low-income, with a large percentage of minorities and non-English speakers. These communities face additional challenges that can affect the health of their residents, including limited access to health care, a shortage of grocery stores, poor housing quality, and a lack of parks and open spaces. Research is now showing that environmental exposures can interact with social stressors, thereby worsening health outcomes. Age, nutrition, genetic characteristics, and preexisting health conditions also increase the risk of adverse health effects from exposure to pollutants. There are existing approaches for characterizing cumulative impacts, which vary in their analytical method and level of community engagement. Biomonitoring, health risk assessment, ecological risk assessment, health impact assessment, burden of disease, and cumulative impacts mapping have all been used to evaluate aspects of this issue. Although such approaches have merit, they each also have significant constraints. New developments in exposure monitoring, mapping, toxicology, and genomics, especially when informed by community participation, have the potential to advance the science on cumulative impacts and to improve prioritization, resource allocation, and risk reduction. PubDate: Wed, 05 Oct 2016 21:54:45 PDT
Authors:Kate E. Beatty et al. Abstract: Rural residents in the U.S. face significant health challenges, including higher rates of risky health behaviors and worse health outcomes than many other groups. Rural communities are also typically served by local health departments (LHDs) that have fewer human and financial resources than their suburban and urban peers. As a result of history and need, rural LHDs are more likely than urban LHDs to provide direct health services, which may result in limited resources for population-based activities. This review examines the double disparity facing rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities. PubDate: Wed, 05 Oct 2016 21:44:37 PDT
Authors:Whitney Webber et al. Abstract: Studies that exist on quality improvement efforts within local health departments indicate that there needs to be clearer approaches for achieving a culture of quality. This study describes how a local health department used the National Association of County and City Health Officials (NACCHO’s) Roadmap to an Organizational Culture of Quality Improvement (QI Roadmap) to successfully build a quality culture on its journey to becoming accredited, as reflected in results from a February 2016 survey. Local health departments who invest in and promote QI efforts that are aligned with strategic priorities; establish the necessary infrastructure to regularly track and report performance data, including customer service data; expand the use of different types of teams; offer opportunities to identify areas of improvement and trainings; and promote resources for using various improvement models can establish a solid foundation in QI leading to accreditation. PubDate: Mon, 19 Sep 2016 16:20:01 PDT
Authors:Simone Singh et al. Abstract: Background: More than half of all local health departments (LHDs) in the U.S. are involved in collaborations with nonprofit hospitals on a community health needs assessment (CHNA), yet little is known about the role that LHDs play in hospitals’ implementation plans.Purpose: This study aims to explore the current state of hospital–LHD collaborations around the implementation plan using data from a survey of LHDs across the country.Methods: The study sample included 457 LHDs that completed both the 2015 Forces of Change survey and the 2013 Profile survey conducted by the National Association of County and City Health Officials. Univariate and bivariate analyses were used to compare LHDs involved in hospitals’ implementation plans to LHDs not involved in such activities. All analyses were conducted in 2016.Results: Of the 457 sample LHDs, 62% were involved in at least one activity associated with hospitals’ implementation plans. These LHDs were larger, had greater budgets, and were more likely to be locally governed. In addition, almost all of these LHDs reported that they also collaborated with hospitals around the CHNA.Implications: There is evidence of substantial involvement of LHDs in hospitals’ implementation plans. Importantly, joint CHNAs appear to pave the path for hospital–LHD collaboration in this area. Since LHDs that collaborate with hospitals on their implementation plans tended to be better resourced, policymakers may want to find ways to ensure that smaller LHDs have the necessary human and fiscal resources to be engaged in joint community health needs assessment and improvement planning activities. PubDate: Wed, 14 Sep 2016 15:16:59 PDT
Authors:Margae Knox et al. Abstract: Background: Patient-engagement strategies are increasingly recognized for enriching traditional medical care and improving population health. Accountable Care Organizations (ACOs) may be well positioned to leverage multi-sector organizational partnerships to improve the reach of their patient-engagement strategies, particularly given incentives to meet cost, quality and population health goals. Little is currently known about the relation of multi-sector partnerships and patient engagement in ACOs.Purpose: To examine the relation of patient-engagement strategies and breadth of multi-sectoral organizational partnerships in 71 primary care practices affiliated with one of two ACOs.Methods: Clinical and administrative leaders from each practice were surveyed. Questions assessed practice use of 12 different partnership sectors and the adoption of 14 patient-engagement strategies. Bivariate tests examined associations between patient-engagement strategies and practice use of partnership sectors. Multivariate linear regression estimated the extent to which practices with a greater number of multi-sector organizational partnerships had greater adoption of patient-engagement strategies.Results: Practices reported partnering with a mean of 3.2 (standard deviation, SD= 2.1) out of 12 sectors and implementing a mean of 7.1 (SD=3.4) out of 14 patient-engagement strategies. Each additional type of multi-sector partnership was associated with greater adoption of patient-engagement strategies (β = 0.59, 95% CI = 0.23–0.95, for all partnerships and β = 0.92, 95% CI = 0.42–1.43, when restricted to nonmedical partnerships)Implications: Practices with a greater breadth of multi-sector partnerships, particularly nonmedical partnerships, use a wider range of strategies to engage patients in their own care. PubDate: Wed, 14 Sep 2016 15:16:53 PDT
Authors:William C. Livingood et al. Abstract: This case study illustrates how a quality improvement (QI) Collaborative supports an implementation study of using mobile phone texting technology for notification of sexually transmitted infections (STI) test results. The County Health Departments making up the QI Collaborative meet monthly to discuss their progress in using QI to advance the use of texting for STI test results. The main purpose of QI Collaboratives is to maximize implementation outcomes through sharing of successes and challenges. The case study report describes how implementation research can adapt to the context of each unique CHD and the users of new knowledge rather than emphasizing the creation of new knowledge. PubDate: Wed, 14 Sep 2016 15:16:47 PDT
Authors:Diana M. Prieto et al. Abstract: In the United States, the status of coordination among pediatric care services is not well understood. Through the use of quality improvement (QI) techniques, coordination gaps were systematically identified in the interagency network of pediatric services in Kalamazoo MI. Gaps were found in transportation resources, follow-up procedures, awareness of services, interagency communication, insurance limitations, population behaviors, and resource utilization. This preliminary study reveals the need for (1) protocols for intra- and inter-agency communication, (2) mechanisms for easy and fast retrieval of pediatric resources, and (3) health information exchange. PubDate: Wed, 14 Sep 2016 15:16:41 PDT
Authors:Riyad Haq et al. Abstract: Background: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is a federal public health initiative which supports at-risk families through evidence-based programs and promising approaches for pregnant women, and childhood development for children aged 0 to 5. These public health program funding mechanisms commonly include process evaluation mandates.Purpose: The use of process mining was explored as a methodology to assess the fidelity of the MIECHV programs’ actual workflow to that of their intended models.Methods: Research Electronic Data Capture (REDCap) data files that were populated with program process data elements from the local implementing agencies were mined. The focus was on three main variables: participant identification, activity labels, and timestamps. These variables were imported into the Disco process-mining software. Disco was used to develop process maps to track process pathways and compare the actual workflow against the intended model.Results: Using process mining as a diagnostic tool, fidelity to the MIECHV process model was assessed, identifying a total of 262 different process variations. The 15 most frequent variations represent 60.7% of the total pool of process variations, 13 of which were deemed to have fidelity to the intended model. Analysis of the variations indicated that many activities in the intended process were skipped or implemented out of sequence.Implications: Process mining is a useful tool for organizations to visually display, track, understand, compare, and improve their workflow processes. This method should be considered by programs as complex as MIECHV to improve the data reporting and the identification of opportunities to strengthen programs. PubDate: Wed, 14 Sep 2016 15:16:35 PDT
Authors:William Riley et al. Abstract: The application of quality improvement (QI) methods and techniques in public health departments has accelerated rapidly over the last decade catalyzed by the Public Health Accreditation Board (PHAB) with extensive support from the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention (CDC). Quality improvement is a distinct management process that deploys a coordinated set of techniques to assist departments in meeting the health needs of their communities. PubDate: Wed, 14 Sep 2016 15:16:29 PDT
Authors:Steven H. Woolf et al. Abstract: The research community faces a growing need to deliver useful data and actionable evidence to support health systems and policymakers on ways to optimize the health of populations. Translating science into policy has not been the traditional strong suit of investigators, who typically view a journal publication as the endpoint of their work. They are less accustomed to seeing their data as an input to the work of communities and policymakers to improve population health. This article offers four suggestions as potential solutions: (1) shaping a research portfolio around user needs, (2) understanding the decision-making environment, (3) engaging stakeholders, and (4) strategic communication. PubDate: Thu, 14 Jul 2016 14:09:41 PDT
Authors:Sharla Smith et al. Abstract: Introduction: This research examines a state-level public health, health care, and policy network focused on efforts to reduce unintentional childhood injuries. The network is composed of 12 organizations: four public health, four health care, and four policy.Methods: A 23-item survey was administered to the 12 organizations between January and June 2015. Analyses were conducted using HyperResearch and UCInet 6.Results: More organizations worked together on assessment and planning efforts that identify and quantify the nature of at-risk infants in the community and strategies for reducing injury-related infant deaths. The Injury Prevention Center, the most central organization, interacted most frequently with organizations in an effort to reduce unintentional childhood injuries.Implications: The identification of these relationships, central organization, and the level of importance viewed by the network organizations may help create an integrated network positioned to change and improve service and program delivery as well as policy. PubDate: Tue, 05 Jul 2016 20:04:27 PDT
Authors:Georgeen Polyak PhD et al. Abstract: Background: The lack of a stable and adequate funding system for local health departments in the U.S. has been well documented. The lack of a comprehensive financial reporting system in public health, including a uniform chart of accounts, hampers the ability of local health departments to make a case to legislators and administrators for increased funding from local and state sources.Purpose: This study examined potential sources of revenue reporting by local health departments in Illinois to identify an accurate picture of total revenues and sources of revenues being invested.Methods: A literature review identified four sources of revenue reporting: the 2013 National Association of County and City Health Officials (NACCHO) Profile of Local Health Departments; the Public Health Uniform National Data System (PHUND$) sponsored by NACCHO; a 2015 survey by the Illinois Association of Public Health Administrators; and individual reports published by local health departments in Illinois. Researchers evaluated each source for level of participation, timeliness of reports, comparability of account categories, and access to information. Individual reports by local health departments in Illinois were compared for consistency.Results: None of the examined sources provided a complete total of revenues for all Illinois local health departments. None had total participation. The chart of accounts was different in each source. Access to information was limited. There was significant variation in categorization of revenues in the Illinois local annual financial reports.Implications: State and local health departments should work toward a uniform chart of accounts and comprehensive, timely, transparent financial reporting system consistent with national efforts. PubDate: Tue, 05 Jul 2016 20:04:23 PDT
Authors:Nancy L. Winterbauer et al. Abstract: Introduction: The cost of providing a basic set of public health services necessary not been well-described. Recent work suggests public health practitioners are unlikely to have the empirically-based financing information necessary to make informed decisions regarding practice. The purpose of this paper is to describe the development of a costing tool used to collect primary data on the number of services provided, staff employed, and costs incurred for two types of mandated environmental health services: food and lodging inspections and onsite water services.Methods: The tool was iteratively reviewed, revised, and piloted with local health department (LHD) environmental health and finance managers. LHDs (n=15) received technical support to estimate costs for fiscal year 2012.Results: The tool contained the following sections: Agency/Respondent Information, Service Counts, Direct Labor Costs, Direct Non-Labor Costs, and Indirect/Overhead Costs. The time required to complete the tool ranged from 2 to 12 hours (median = 4).Implications: LHDs typically did not track costs by program area, nor did they acknowledge indirect costs or costs absorbed by the county. Nonetheless, this costing tool is one of the first to estimate costs associated with environmental health programs at the LHD level and has important implications for practitioners and researchers, particularly when these limitations are recognized. PubDate: Tue, 05 Jul 2016 19:49:03 PDT
Authors:Steven H. Woolf et al. Abstract: A recently released map of Kentucky demonstrates how life expectancy varies across the state’s 120 counties. The map vividly shows a decline in life expectancy as one travels east from the “Golden Triangle” in central urban Kentucky to the mountains of Appalachia. The lowest life expectancies are largely in the far southeastern portion of the state, where residents of the Central Highlands have confronted adverse social determinants of health for generations. Indeed, companion maps released by the Center on Society and Health, which plot median household income, poverty, and educational attainment at the census tract level, show the stark socioeconomic disadvantage in this distressed Appalachian region. The maps are intended as “conversation starters” to stimulate public discourse about the factors that shape health outcomes and to mobilize community concern and policy action to address health disparities in Appalachia. Meaningful change at the local level will be essential to transform the social and economic factors responsible for the region’s health. PubDate: Tue, 05 Jul 2016 19:49:00 PDT
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