Public Health Emergency Preparedness at the Local Level: Results of a National Survey

Objective. To study the relationship between elements of public health infrastructure and local public health emergency preparedness (PHEP).
Data Sources/Study Setting. National Association of County and City Health Officials 2005 National Profile of Local Health Departments (LHDs).
Study Design. Cross-sectional.
Principal Findings. LHDs serving larger populations are more likely to have staff, capacities, and activities in place for an emergency. Adjusting for population size, the presence of a local board of health and the LHDs' experience in organizing PHEP coalitions were associated with better outcomes.
Conclusions. The results of this study suggest that more research should be conducted to investigate the benefit of merging small health departments into coalitions to overcome the inverse relationship between preparedness and population size of the jurisdiction served by the LHD.     

Patterns and Correlates of Public Health Informatics Capacity Among Local Health Departments: An Empirical Typology

Objective: Little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs) and whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range. This study examined patterns and correlates of the presence of public health informatics functionalities within LHDs through the creation of a typology of LHD informatics capacities.Methods: Data were available for 459 LHDs from the 2013 National Association of County and City Health Officials Profile survey. An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, and electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories.Results: Low-informatics capacity LHDs had lower levels of use of each informatics functionality than high-informatics capacity LHDs. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services.Conclusion: Informatics capacity is clustered within LHDs. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to expand capacity across a range of functionalities, taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies.     

Jurisdiction Size and Local Public Health Spending

Objective. To examine if a minimum efficient scale (MES) holds with respect to the population serviced by a local health department (LHD) given the congestability, externality, and scale/scope economy effects potentially associated with public health services. Data Sources/Study Setting. A nationally representative sample of LHDs in 2005. Study Design. Multiple regression analysis is used to isolate the relation between population and spending while controlling for other factors known to influence local public health costs. Data Collection. Data were obtained from the 2005 National Profile of Local Public Health Agencies, a project supported through a cooperative agreement between the National Association of County and City Health Officials and the Centers for Disease Control and Prevention. Principal Findings. The MES of a local public health department is approximately 100,000 people. After that size, additional population has little impact on public health spending per capita. Conclusions. Seventy‐seven percent of LHDs in the sample fall below the 100,000 MES. Higher levels of government may want to provide financial inducements so that smaller LHDs consolidate or enter into agreements with larger public health organizations to provide services.     

The Role of Interorganizational Partnerships in Health Services Provision Among Rural,Suburban, and Urban Local Health Departments

Context: With limited resources and increased public health challenges facing the US, the Centers for Disease Control and Prevention and others have identified partnerships between local health departments (LHDs) and nongovernmental organizations (NGOs) as critical to the public health system. LHDs utilize financial, human, and informational resources and develop partnerships with local NGOs to provide public health services. Purpose: Our study had 2 primary goals: (1) compare resources and partnerships characterizing rural, suburban, and urban LHDs, and (2) determine whether partnerships play a mediating role between LHD resources and the services LHDs provide. Methods: We conducted secondary data analysis using the National Association of County and City Health Officials 2005 Profile Study. We used chi-squared and analysis of variance (ANOVA) to examine differences between rural, suburban, and urban LHDs. We used regression-based mediation methods to test whether partnerships mediated the relationship between resources and service provision. Findings: We found significant differences between LHDs. Urban LHDs serve larger jurisdictions, have larger budgets and more staff, cultivate more partnerships with local NGOs, and provide more health services than suburban or rural LHDs. We found that partnerships were a partial mediator between resources and service provision. In playing a mediating role, partnerships reduce differences in service provision between rural, suburban, and urban LHDs. Conclusions: Partnerships mediate the relationship between resources and service provision in LHDs. LHDs could place more emphasis on cultivating relationships with local NGOs in order to increase service provision. This strategy may be especially useful for rural LHDs facing limited resources and numerous health disparities.     

Toward Standardized, Comparable Public Health Systems Data: A Taxonomic Description of Essential Public Health Work

Objective. To identify taxonomy of task, knowledge, and resources for documenting the work performed in local health departments (LHDs).
Data Sources. Secondary data were collected from documents describing public health (PH) practice produced by organizations representing the PH community.
Study Design. A multistep consensus-based method was used that included literature review, data extraction, expert opinion, focus group review, and pilot testing.
Data Extraction Methods. Terms and concepts were manually extracted from documents, consolidated, and evaluated for scope and sufficiency by researchers. An expert panel determined suitability of terms and a hierarchy for classifying them. This work was validated by practitioners and results pilot tested in two LHDs.
Principal Findings. The finalized taxonomy was applied to compare a national sample of 11 LHDs. Data were obtained from 1,064 of 1,267 (84 percent) of employees. Frequencies of tasks, knowledge, and resources constitute a profile of PH work. About 70 percent of the correlations between LHD pairs on tasks and knowledge were high (>0.7), suggesting between-department commonalities. On resources only 16 percent of correlations between LHD pairs were high, suggesting a source of performance variability.
Conclusions. A taxonomy of PH work serves as a tool for comparative research and a framework for further development.     

The Growth of Partnerships to Support Patient Safety Practice Adoption

Objectives. To document the numbers and types of interorganizational partnerships within the national patient safety domain, changes over time in these networks, and their potential for disseminating patient safety knowledge and practices.
Data Sources. Self-reported information gathered from representatives of national-level organizations active in promoting patient safety.
Study Design. Social network analysis was used to examine the structure and composition of partnership networks and changes between 2004 and 2006.
Data Collection. Two rounds of structured telephone interviews ( n =35 organizations in 2004 and 55 in 2006).
Principal Findings. Patient safety partnerships expanded between 2004 and 2006. The average number of partnerships per interviewed organization increased 40 percent and activities per reported partnership increased over 50 percent. Partnerships increased in all activity domains, particularly dissemination and tools development. Fragmentation of the overall partnership network decreased and potential for information flow increased. Yet network centralization increased, suggesting vulnerability to partnership failure if key participants disengage.
Conclusions. Growth in partnerships signifies growing strength in the capacity to disseminate and implement patient safety advancements in the U.S. health care system. The centrality of AHRQ in these networks of partnerships bodes well for its leadership role in disseminating information, tools, and practices generated by patient safety research projects.     

Managing Costs, Managing Benefits: Employer Decisions in Local Health Care Markets

Objectives.  To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems.
Data Sources/Study Setting.  Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities.
Study Design.  This is an observational study with data collection over a six-year period.
Data Collection/Extraction Methods.  The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions.
Principal Findings.  The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results.
Conclusions.  General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.     

Understanding the Organization of Public Health Delivery Systems: An Empirical Typology

Context: Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.
Methods: This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.
Findings: Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.
Conclusions: Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.     

A network approach to outpatient service delivery systems: resources flow and system influence.

OBJECTIVE: The study tests a path model for the effects on organizational influence of an organization's centrality in four resource exchange networks in order to gain insight into the network relations that may affect coordination and effectiveness of outpatient health and mental health service systems. DATA SOURCES: Primary data are used from face-to-face interviews with the directors of every organization in the predefined service systems in three urbanized counties in Oregon. Each system consisted of 19 to 20 organizations. Data were collected during 1986 and 1987. STUDY DESIGN: The path model contains five variables: the major dependent variable is attributed organizational influence; the independent variables are three sets of primary resource exchanges: funds allocation, client referrals, and client inflow. An intervening variable of general network contacts, as an informational resource, is modeled as an outcome of the three primary resource exchanges, as well as one of the predictors of influence. DATA COLLECTION: Organizations were identified as system members through a modified snowball sampling procedure. Measures of organizational influence and centrality in each of the exchange networks were derived from interviews with all directors about their interactions with each organization in the system. Multiple regression analysis was used to test the path model. PRINCIPAL FINDINGS: The most important resource in predicting centrality in a general contact network is centrality in a client referral network, while contacts and funds allocation centrality are significant predictors of organizational influence. CONCLUSIONS: The organization with the greatest influence within the system (because of its ability to allocate funds) may not be the organization that takes the largest role in terms of coordinating routine contacts (because of its ability to refer clients). This disjuncture may signal a weakness in the coordination network and system effectiveness, since the more influential organization may not be the most knowledgeable one in terms of the needs of the system.     

Local public health system partnerships

OBJECTIVES: Interorganizational collaboration aimed at community health improvement is an expectation of local public health systems. This study assessed the extent to which such collaboration occurred within one state (Wisconsin), described the characteristics of existing partnerships, and identified factors associated with partnership effectiveness. METHODS: In Stage 1, local health department (LHD) directors in Wisconsin were surveyed (93% response rate). In Stage 2, LHDs completed self-administered mailed surveys for each partnership identified in Stage 1 (85% response rate). Two-level hierarchical logit regression methods were used to model relationships between partnership and LHD variables and partnership outcomes. Data from 924 partnerships associated with 74 LHDs were included in the analysis. RESULTS: Partnerships most frequently addressed tobacco prevention and control, maternal and child health, emergency planning, community assessment and planning, and immunizations. Partnering was most frequent with other government agencies, hospitals, medical practices or clinics, community-based organizations, and schools. Partnership effectiveness was predicted by having a budget, having more partners contributing financially, having a broader array of organizations involved, and having been in existence for a longer period of time. A government mandate to start the partnership was inversely related to successful outcomes. Characteristics of LHDs did not predict partnership effectiveness. CONCLUSIONS: Financial support, having a broader array of partners, and allowing sufficient time for partnerships to succeed contribute to partnership effectiveness. Further study-using objective outcome measures-is needed to examine the effects of organizational and community characteristics on the effectiveness of local public health system partnerships.     

Geographic Variation in Public Health Spending: Correlates and Consequences

Objectives. To examine the extent of variation in public health agency spending levels across communities and over time, and to identify institutional and community correlates of this variation.
Data Sources and Setting. Three cross-sectional surveys of the nation's 2,900 local public health agencies conducted by the National Association of County and City Health Officials in 1993, 1997, and 2005, linked with contemporaneous information on population demographics, socioeconomic characteristics, and health resources.
Study Design. A longitudinal cohort design was used to analyze community-level variation and change in per-capita public health agency spending between 1993 and 2005. Multivariate regression models for panel data were used to estimate associations between spending, institutional characteristics, health resources, and population characteristics.
Principal Findings. The top 20 percent of communities had public health agency spending levels >13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health agency spending was inversely associated with local-area medical spending.
Conclusions. The mechanisms that determine funding flows to local agencies may place some communities at a disadvantage in securing resources for public health activities.     

Private Care and Public Health: Do Vaccination and Prenatal Care Rates Differ between Users of Private versus Public Sector Care in India?

Objective. To determine whether patients who use private sector providers for curative services have lower vaccination rates and are less likely to receive prenatal care.
Data Sources/Study Setting. This study uses data from the 52d round of the National Sample Survey, a nationally representative socioeconomic and health survey of 120,942 rural and urban Indian households conducted in 1995–1996.
Study Design. Using logistic regression, we estimate the relationship between receipt of preventive care at any time (vaccinations for children, prenatal care for pregnant women) and use of public or private care for outpatient curative services, controlling for demographics, household socioeconomic status, and state of residence.
Data Collection/Extraction Methods. We analyzed samples of children ages 0 to 4 and pregnant women who used medical care within a 15-day window prior to the survey.
Principal Findings. With the exception of measles vaccination, predicted probabilities of the receipt of vaccinations and prenatal care do not differ based on the type of provider at which children and women sought curative care. Children and pregnant women in households who use private care are almost twice as likely to receive preventive care from private sources, but the majority still obtains preventive care from public providers.
Conclusions. We do not find support for the hypothesis that children and pregnant women who use private care are less likely to receive public health services. Results are consistent with the notion that Indian households are able to successfully navigate the coexisting public and private systems, and obtain services selectively from each. However, because the study employed an observational, cross-sectional study design, findings should be interpreted cautiously.     

公共卫生决策数据元概念框架的研究

目的建立公共卫生决策数据元（指标）概念框架,确定框架的维度、子维度及其关联关系。方法应用文献分析法和概念分析法确定概念框架的结构、维度和子维度。概念框架是建立在健康影响因素模型的基础上,总体框架遵循科学性、实用性、关联性、系统性和可扩展性的5个原则。维度和子维度的确定依照概念化、目标化、独立性和数目不宜过多的4个原则。维度间的关系则根据公共卫生的特点和公共卫生理论确定。结果提出了健康结果、非医学健康因素、公共卫生系统绩效、公共卫生系统资源、社区特征和保障体系5个维度和20个子维度组成的概念模型,并说明了维度间的相互关系。健康结果维度包括健康状态、人体功能和死亡3个子维度;非医学健康因素的4个子维度是健康行为、生活和工作条件、个人资源和环境因素;公共卫生系统的绩效包括有效性、可及性、效率、安全性和反应性;公共卫生资源包括机构资源、人力资源、财政资源、设施资源和信息资源;社区特征和保障体系维度由社区特征、公共卫生政策法规和保障体系组成。结论作为对公共卫生系统的抽象,概念框架全面地反映了公共卫生系统的组成和复杂的公共卫生过程。可指导公共卫生系统指标体系、乃至公共卫生信息系统的建立。概念框架与以结构、过程、条件和结果所组成的卫生服务质量评价模型相吻合。     

Succession Planning For Local Health Department Top Executives: Reducing Risk To Communities

This study assessed the degree to which local health departments (LHDs) are preparing to replace retiring top executives. Questionnaires were sent to all 134 local health departments in Ohio. It is typical of many states in terms of the organization of LHDs. Ninety-two LHD top executives responded. The questionnaire addressed aspects of departmental succession planning and demographic parameters of their departments. Approximately half (51.7%) of responding LHD top executives rated having succession plans as being important. Overall, local boards of health are not very concerned about actually having a succession plan. One in four (27.6%) local health departments reported that they have succession plans. Half of those were grooming a successor. Succession planning is not a high priority among the majority of LHDs, despite the fact that 43.7% of top executives reported planning to leave their current position within six years. Experienced and continuous LHD leadership is important for strong responses to public health crises like major disease outbreaks and natural disasters. Having a succession plan in place that identifies how leadership voids are filled can help minimize risks to populations in an emergency.     

Managed Care Organizational Characteristics and Health Care Use among Children with Special Health Care Needs

Objective. To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.
Data Sources. Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data.
Study Design. Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee-for-Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations.
Data Collection/Extraction Methods. The telephone and MCO-administrator survey data were linked to the enrollment and claims files.
Principal Findings. The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges.
Conclusion. After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.     

Employee Choice of Consumer-Driven Health Insurance in a Multiplan, Multiproduct Setting

Objective. To determine who chooses a Consumer-Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool.
Study Design. We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans—a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system.
Principal Findings. Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher-income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out-of-pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price-sensitive.
Conclusions. This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out-of-pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.     

Impact of state Medicaid expansion on cross-sector health and social service networks: Evidence from a longitudinal cohort study

Objective

To examine the impact of state Medicaid expansion on the delivery of population health activities in cross-sector health and social services networks. Community networks are multisector, interorganizational networks that provide services ranging from the direct provision of individual social services to the implementation of population-level initiatives addressing community outcomes.

Data Sources

We used data measuring the composition of cross-sector population health networks 2006–2018 National Longitudinal Survey of Public Health Systems (NALSYS) linked with the Area Health Resource File.

Study Design

A difference-in-differences approach was used to examine the impact of expansion on organization engagement in population health activities and network structure.

Data Collection/Extraction Methods

Stratified random sampling of local public health jurisdictions in the United States. We restricted our data to jurisdictions serving populations of 100,000 or more and states that had NALSYS observations across all time periods, resulting in a final sample size of 667.

Principal Findings

Results from our adjusted difference-in-differences estimates indicated that Medicaid expansion was associated with a 2.3 percentage point increase in the density of population health networks (p < 0.10). Communities in states that expanded Medicaid experienced significant increases in the participation of local public health, local government, hospital, nonprofit, insurer, and K-12 schools. Of the organizations with significant increases in expansion communities, nonprofits (7.7 percentage points, p < 0.01), local public health agencies (6.5 percentage points, p < 0.01), hospitals (5.8 percentage points, p < 0.01), and local government agencies (6.0 percentage points, p < 0.05) had the largest gains.

Conclusions

Our study found increases in cross-sector participation in population health networks in states that expanded Medicaid compared with nonexpansion states, suggesting that additional coverage gains are associated with positive changes in population health network structure.     

Classifying Local Health Departments on the Basis of the Constellation of Services They Provide

Objectives. We explored service variation among local health departments (LHDs) nationally to allow systematic characterization of LHDs by patterns in the constellation of services they deliver.Methods. We conducted latent class analysis by using categorical variables derived from LHD service data collected in 2008 for the National Profile of Local Health Departments Survey and before service changes resulting from the national financial crisis.Results. A 3-class solution produced the best fit for this data set of 2294 LHDs. The 3 configurations of LHD services depicted an interrelated set of narrow or limited service provision (limited), a comprehensive (core) set of key services provided, and a third class of core and expanded services (core plus), which often included rare services. The classes demonstrated high geographic variability and were weakly associated with expenditure quintile and urban or rural location.Conclusions. This empirically derived view of how LHDs organize their array of services is a unique approach to categorizing LHDs, providing an important tool for research and a gauge to monitor how changes in LHD service patterns occur.Nationwide shifts in public health practice in recent decades, including recent responses to economic decline,1–6 have moved many local health departments (LHDs) away from providing intensive, individually focused, personal health services and toward the transfer of public health investments into more population-focused domains of practice such as assessment, planning, and population-based primary prevention.2,4 Wide variation in the breadth and scale of services provided by LHDs nonetheless persists.5,7,8 This variation has been attributed to differences of perspective in the primary “role” of governmental public health agencies,9 the complex sources of categorical funding that often drive the array of local services delivered,7 varied legal statutes and policies,10 and assessments of local need along with the availability of community resources.7Evidence suggests that LHD investments overall11 and in relation to specific services12 have a beneficial relationship to population health outcomes. It may also be the comprehensive and interactive nature of a specific constellation of LHD services that most effectively contributes to healthy outcomes in a community.8,13 For example, a related mix of individually focused services for women and children (e.g., the Special Supplemental Nutrition Program for Women, Infants, and Children; family planning; and maternal and child home visits) may be most effective for families when provided together as a package by the LHD. An LHD that couples these maternal and child services with an active assessment and surveillance system that helps prioritize services among those populations for whom poor birth outcomes are particularly high may achieve even better results. The constellation of services, therefore, may be more important to the performance of an LHD in promoting health improvement than the delivery of various individual services in isolation. No apparent studies, however, have classified LHDs themselves in terms of their constellation of services provided.Recent studies in public health systems and services research have made advancements in establishing a typology of the systems delivering local public health services.14 Using data collected in 1998 and 2006, Mays et al. developed this typology, measuring interorganizational network structures and identifying 7 local public health system configurations that include the scope of activities provided by LHDs and by other organizations in their jurisdictions.14 The urban systems they have tracked over time appear “highly adaptable” and “dynamic,” suggesting opportunities for modifying complex public health system features to improve performance.14^(p103)As central figures in these local systems, LHDs play a critical role in ensuring adequate public health service delivery. Yet little is known about how their own services tend to be organized and how their constellations of services can be adapting to change. Identifying underlying patterns in these constellations with routinely collected, national data would provide a means to monitor the adaptations of LHDs themselves and to examine how these service constellations are related to local conditions and health outcomes. We describe a major step in exploring service variation among LHDs nationally to characterize LHDs by patterns in the constellation of services they deliver.