TickNET—A Collaborative Public Health Approach to Tickborne Disease Surveillance and Research

TickNET, a public health network, was created in 2007 to foster greater collaboration between state health departments, academic centers, and the Centers for Disease Control and Prevention on surveillance and prevention of tickborne diseases. Research activities are conducted through the Emerging Infections Program and include laboratory surveys, high-quality prevention trials, and pathogen discovery.     

Implementation of Mexico’s Health Promotion Operational Model

Mexico is undergoing profound health reform, extending health insurance to previously uninsured populations and changing the way health care services are delivered. Legislation enacted in 2003 and implemented in 2004 mandated funding and infrastructure that will allow 52% of Mexico''s population to access medical care at no cost by 2010. This ambitious social reform has not been without challenges, particularly financial sustainability. Health promotion, because of its potential to prevent or delay chronic diseases and injuries and their associated costs, is a key component of health care reform (1).In 2006, the Ministry of Health''s General Directorate of Health Promotion developed the Health Promotion Operational Model. Based on Ottawa Charter functions, the model integrates health promotion activities within the overall health care system. The main goal of this model is to build strong human capital and to improve organizational capacity for health promotion starting at the local level by training health care personnel to implement health promotion activities. Organizational development workshops started in 2006, and implementation plans in all 32 Mexican states were in place by end of 2008 (2).     

A Statewide Common Elements Initiative for Children’s Mental Health

Many evidence-based treatments (EBTs) for child and adolescent mental health disorders have been developed, but few are available in public mental health settings. This paper describes initial implementation outcomes for a state-funded effort in Washington State to increase EBT availability, via a common elements training and consultation approach focused on four major problem areas (anxiety, posttraumatic stress disorder, depression, and behavioral problems). Clinicians (N?=?180) reported significant improvement in their ability to assess and treat all problem areas at post-consultation. Clinicians from organizations with a supervisor-level “EBT champion” had higher baseline scores on a range of outcomes, but many differences disappeared at post-consultation. Outcomes suggest that a common elements initiative, which includes training and consultation, may positively impact clinician-level outcomes and that having “in-house” EBT expertise may provide additional benefits.     

Enhancement of Health Department Capacity for Health Care–Associated Infection Prevention Through Recovery Act–Funded Programs

Objectives. We evaluated capacity built and outcomes achieved from September 1, 2009, to December 31, 2011, by 51 health departments (HDs) funded through the American Recovery and Reinvestment Act (ARRA) for health care–associated infection (HAI) program development.Methods. We defined capacity for HAI prevention at HDs by 25 indicators of activity in 6 categories: staffing, partnerships, training, technical assistance, surveillance, and prevention. We assessed state-level infection outcomes by modeling quarterly standardized infection ratios (SIRs) for device- and procedure-associated infections with longitudinal regression models.Results. With ARRA funds, HDs created 188 HAI-related positions and supported 1042 training programs, 53 surveillance data validation projects, and 60 prevention collaboratives. All states demonstrated significant declines in central line–associated bloodstream and surgical site infections. States that implemented ARRA-funded catheter-associated urinary tract infection prevention collaboratives showed significantly greater SIR reductions over time than states that did not (P = .02).Conclusions. ARRA–HAI funding substantially improved HD capacity to reduce HAIs not targeted by other national efforts, suggesting that HDs can play a critical role in addressing emerging or neglected HAIs.Health care–associated infections (HAIs) are an increasingly recognized cause of preventable morbidity and mortality.1,2 Since 2008, the Department of Health and Human Services (DHHS) has committed substantial resources toward prevention of HAIs. This commitment resulted in the DHHS Action Plan to Prevent HAIs, which identified key strategies to achieve and sustain progress in protecting patients from infections.3 Funding to health departments to carry out this plan came from the American Recovery and Reinvestment Act (ARRA) of 2009. The Epidemiology and Laboratory Capacity Program of the Centers for Disease Control and Prevention (CDC) distributed these funds, granting approximately $35.8 million for state-level capacity building for HAI prevention programs (ARRA–HAI) to 51 health departments in 49 states, the District of Columbia, and Puerto Rico.4The DHHS Action Plan emphasized aligning and coordinating HAI stakeholder efforts, promoting standardized metrics for HAI surveillance, and targeting reduction of device-associated, procedure-associated, and multidrug-resistant HAIs. The goal of ARRA–HAI funding was to enhance the role of state and territorial health departments in executing the Action Plan goals through allocation of funds in 3 domains: infrastructure, surveillance, and prevention. The CDC reviewed applications and distributed funds competitively. Health departments applied for a total of $66 230 990 and received $35 800 000 in Epidemiology and Laboratory Capacity funding; all health departments that applied received some funding. The average award was $210 000 for the 17 health departments that received funding only for infrastructure, $630 000 for the 12 health departments that received funding for 2 of the 3 domains, and $1.1 million for the 22 health departments that received funding for all 3 domains. Most health departments with little to no engagement in HAI activities at the time applications were filed (July 2009) received funds only for infrastructure. Conversely, health departments with more active HAI programs applied to enhance existing infrastructure in addition to proposing surveillance and prevention activities (Figure 1).Open in a separate windowFIGURE 1—Distribution of American Recovery and Reinvestment Act funding to 51 state and territorial health departments among infrastructure, surveillance, and prevention funding domains, 2009–2011.The CDC developed a conceptual program model that guided the evaluation and served as the basis for expectations related to health department performance.5 Health departments awarded funding for infrastructure (n = 48) were expected to dedicate staff time to HAI activities, promote strategic partnerships through regular assembly of a multidisciplinary advisory group of HAI stakeholders, and provide training and technical assistance to health care facilities regarding HAIs. Those awarded funding for surveillance (n = 31) were expected to enhance the quality of HAI surveillance through the National Healthcare Safety Network (NHSN) Surveillance System and to work toward active use of NHSN data to inform decision-making and motivate prevention. The 28 health departments awarded funds for prevention collaborative implementation were expected to lead or support multifacility prevention initiatives targeting HAI reductions through systematic implementation of evidence-based practices, data feedback, and culture change strategies.6We assessed capacity built (i.e., breadth of engagement in key HAI activities) and outcomes achieved (i.e., statewide HAI reductions) from September 1, 2009, to December 31, 2011, by the 51 health departments that received ARRA–HAI funding. The purpose of a systematic evaluation was to enhance accountability for federal dollars spent, assist states in monitoring progress, and inform future planning for state HAI programs. We determined health department capacity at baseline and at the end of the ARRA funding period. We aimed to (1) describe capacity enhancements achieved with ARRA–HAI funding, (2) examine the role of baseline capacity and size of funding award in predicting capacity enhancements achieved with ARRA–HAI funding, and (3) assess whether states with health departments that funded infection-specific prevention collaboratives achieved greater HAI reductions during the ARRA funding period than states that did not.     

Accountable Care for the Poor and Underserved: Minnesota’s Hennepin Health Model

Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals’ quality of life while reducing costs through better care management and reductions in emergency department use.Hennepin Health represents a new model of integrated care targeted to low-income individuals with complex health and social needs—needs very similar to the Affordable Care Act Medicaid expansion population. The program is supported by enhanced data integration to better coordinate medical care with other needed social services in a capitated Accountable Care Organization (ACO) framework. The positive outcomes achieved and the ability to reinvest in the model have helped to garner political support and have motivated providers and care teams who see the opportunities to make a difference in the lives of a largely disenfranchised patient population. Hennepin Health provides an integrated care management model that other care plans can use to improve care and lower costs for the Medicaid expansion population under the Affordable Care Act.     

Peer Reviewed: Wisconsin’s Health Department-University Partnership Model for Comprehensive Cancer Control

Cancer causes substantial morbidity and mortality every year in the United States. To address cancer prevention and control in Wisconsin, the Wisconsin Division of Public Health and the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center forged a unique partnership. Using funds from the state legislature, the university, and the Centers for Disease Control and Prevention, the Wisconsin Comprehensive Cancer Control Program was created.This health department–university partnership model has allowed both institutions to contribute their distinct strengths to projects that neither organization would have been able to complete on its own. Some challenges also have arisen during development and execution of the program, but overall, this collaborative partnership has brought diverse groups together to develop and implement evidence-based cancer control programs and policies in Wisconsin.     

A Preparedness Model for Mother–Baby Linked Longitudinal Surveillance for Emerging Threats

Introduction

Public health responses often lack the infrastructure to capture the impact of public health emergencies on pregnant women and infants, with limited mechanisms for linking pregnant women with their infants nationally to monitor long-term effects. In 2019, the Centers for Disease Control and Prevention (CDC), in close collaboration with state, local, and territorial health departments, began a 5-year initiative to establish population-based mother–baby linked longitudinal surveillance, the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET).

Objectives

The objective of this report is to describe an expanded surveillance approach that leverages and modernizes existing surveillance systems to address the impact of emerging health threats during pregnancy on pregnant women and their infants.

Methods

Mother–baby pairs are identified through prospective identification during pregnancy and/or identification of an infant with retrospective linking to maternal information. All data are obtained from existing data sources (e.g., electronic medical records, vital statistics, laboratory reports, and health department investigations and case reporting).

Results

Variables were selected for inclusion to address key surveillance questions proposed by CDC and health department subject matter experts. General variables include maternal demographics and health history, pregnancy and infant outcomes, maternal and infant laboratory results, and child health outcomes up to the second birthday. Exposure-specific modular variables are included for hepatitis C, syphilis, and Coronavirus Disease 2019 (COVID-19). The system is structured into four relational datasets (maternal, pregnancy outcomes and birth, infant/child follow-up, and laboratory testing).

Discussion

SET-NET provides a population-based mother–baby linked longitudinal surveillance approach and has already demonstrated rapid adaptation to COVID-19. This innovative approach leverages existing data sources and rapidly collects data and informs clinical guidance and practice. These data can help to reduce exposure risk and adverse outcomes among pregnant women and their infants, direct public health action, and strengthen public health systems.

     

What Factors Influence States’ Capacity to Report Children’s Health Care Quality Measures? A Multiple-Case Study

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services’ (CMS) core set of children’s health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin’s multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state’s Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.     

A Study of the Relationship between Health and Subjective Well-Being in Parkinson’s Disease Patients

ObjectivesGovernments are turning their attention to evidence on subjective measures of well-being to inform policy decisions. In the context of health, there is, therefore, growing interest in understanding how measures of health-related quality of life relate to subjective well-being and whether subjective well-being could provide a basis for resource allocation decisions in the future. This study investigates the relationship between health-related quality of life, as measured by the EuroQol five-dimensional (EQ-5D) questionnaire, and subjective well-being in Parkinson’s disease.MethodsA paper questionnaire including the EQ-5D questionnaire, four key subjective well-being questions taken from the Integrated Household Survey in England, and other demographic details was distributed to people with Parkinson’s disease in the United Kingdom. Responses were used to estimate multiple regression models explaining subjective well-being using the EQ-5D questionnaire index (UK weights), EQ-5D questionnaire dimensions and the visual analogue scale, and patients’ sociodemographic characteristics.ResultsA total of 199 responses were received. Combining visual analogue scale and EQ-5D questionnaire dimensions, especially anxiety/depression and, to a lesser extent, mobility, yielded the best-fitting models (adjusted R² range 0.36–0.53). Patients with Parkinson’s disease living in care homes report lower levels of subjective well-being than do those living alone. These effects are not captured by the health-related quality-of-life measures in the analysis.ConclusionsUsual health-related quality-of-life measures can partially explain different well-being dimensions, yet they fail to capture part of the broader impact of disease on subjective well-being. Further empirical research into the relationship between subjective well-being and the EQ-5D Parkinson’s disease longitudinally, and in different disease areas, is required, and further standardization of subjective well-being measures is recommended.     

The Agency for Healthcare Research and Quality’s Children’s Health Research Portfolio

The objective of this work was to describe and assess the potential impact of the Agency for Healthcare Research and Quality’s, AHRQ’s, children’s health activities. Using AHRQ databases and publications lists and generic search engines, we developed a comprehensive list of AHRQ’s funded children’s health activities (1990–2005) and related publications (1996–2002). We conducted bibliometric analyses and used Stryer’s (2000) approach to categorize their potential impact. We found that AHRQ’s child health portfolio has changed over time with an increase in activities related to patient safety and health information technology, reflecting trends at AHRQ as a whole. Further, AHRQ has contributed a substantial body of new knowledge as a result of its funding for children’s health activities. The bibliometric analysis suggests that AHRQ’s children’s health activities have successfully disseminated research findings and new knowledge through the published literature. Most of the publications present research findings that can be building blocks early in the translation continuum rather than findings that directly inform policy or change clinical practice. Through its funding of children’s health activities, AHRQ has contributed new knowledge that has been disseminated effectively in the published literature. However, while AHRQ has successfully engaged the child health services research community, efforts to broaden into policy, practice and patient arenas have been less successful.     

Community Health Development: A Strategy for Reinventing America’s Health Care System One Community at a Time

The purpose of this article is to propose a set of ideas for reinventing America’s health care system, one community at a time. Community health development is proposed as a strategy and approach to population health improvement, the ultimate goal of health care reform. The practice of community health development, particularly the partnership approach, provides guidance about how this approach might be employed as a national health care reform strategy. Examples of two communities successfully using the partnership approach illustrate the methods described. Six specific recommendations for policy makers and public administrators in the new administration resulting from our experience with community health development are presented. First, adopt and apply community health development (CHD) as the American approach for facilitating population health improvement and building community capacity. Second, the partnership approach should be promoted as a model for communities to use in implementing CHD. Third, make the community-level the focus for planning, implementing, evaluating, and sustaining a full continuum of health and human services. Fourth, formally recognize the social determinants of health as a key component of a new population/community health status model and as a public policy driver for health care reform, marketplace issues, and population health status improvement at all levels of society. Fifth is a call for a national strategy for the recruitment, training, education, and support of individuals to facilitate this community movement. Sixth, Congress and the Obama Administration adopt and apply CHD as a national strategy and utilize American community-based experiences to bring about a national plan.     

Update from CDC’s Public Health Surveillance & Informatics Program Office (PHSIPO)

Objective

To provide updates on current activities and future directions for the National Notifiable Diseases Surveillance System (NNDSS), BioSense 2.0, and the Behavioral Risk Factor Surveillance System (BRFSS) and on the role of PHSIPO as the “home” at CDC for addressing cross-cutting issues in surveillance and informatics practice.

Introduction

The practice of public health surveillance is evolving as electronic health records (EHRs) and automated laboratory information systems are increasing adopted, as new approaches for health information exchange are employed, and as new health information standards affect the entire cascade of surveillance information flow. These trends have been accelerated by the Federal program to promote the Meaningful Use of electronic health records, which includes explicit population health objectives. The growing use of Internet “cloud” technology provides new opportunities for improving information sharing and for reducing surveillance costs. Potential benefits include not only faster and more complete surveillance but also new opportunities for providing population health information back to clinicians.For public health surveys, new Internet-based sampling and survey methods hold the promise of complementing existing telephone-based surveys, which have been plagued by declining response rates despite the addition of cell-phone sampling. While new technologies hold promise for improving surveillance practice, there are multiple challenges, including constraints on public health budgets and the workforce. This panel will explore how PHSIPO is addressing these opportunities and challenges.

Methods

Panelists will provide updates on 1) PHSIPO’s role in engaging health departments, the organizations that represent them, and CDC programs in shaping national policies for implementing the Meaningful Use program, 2) how the BioSense 2.0 program is supporting growth in syndromic surveillance capacity, including its partnership with ISDS in developing standards for syndromic surveillance as part of Meaningful Use, 3) improvements that are underway in strengthening the NNDSS, including efforts to improve CDC’s support for health department disease reporting systems and to develop a “shared services” approach that could provide a platform for streamlining the exchange of information between health departments and CDC, 4) pilot development of Internet-based panels of survey volunteers to supplement existing telephone-based sampling in the BRFSS and of approaches to extend BRFSS survey information through consent-based linkage of survey responses to selected measures recorded in respondents’ EHRs.

Results

Potential questions or discussion points that might arise include: What can or should be done to assure that the population health objectives of Meaningful Use are fulfilled? What are the lessons learned to date in leveraging investments in the Meaningful Use of EHRs to improve disease reporting and syndromic surveillance systems? What are the next steps in developing BioSense 2.0 to assure that it leads to strengthened surveillance capacity at both state/local and regional/national levels? How can insights from the BioSense redesign be applied to improve case reporting and other surveillance capacities? What is CDC doing to address states’ concerns about the growing number of CDC surveillance systems? How will national discussions about the future of public health affect the future surveillance practice? What can be done to assure the ongoing representativeness of population health surveys? Is it feasible to link BRFSS responses to information obtained from EHRs? How can data from surveillance become part of the real-time evidence base for clinical decision making?

Conclusions

The intended outcome of the panel is to foster a conversation between the panelists and the audience, to inform the audience about recent developments in PHSIPO, to obtain insights from the audience about innovations and ideas arising from their experience, and to generate new ideas for approaches to meeting the needs of public health for surveillance information.