Crisis & commitment: 150 years of service by Los Angeles county public hospitals

The Los Angeles County University of Southern California Medical Center will open soon, replacing the county's current 74-year-old facility with a modern, although smaller, facility. Los Angeles County has provided hospital care to the indigent since 1858, during which time, the operation of public hospitals has shifted from a state-mandated welfare responsibility to a preeminent part of the county's public health mission. As this shift occurred, the financing of Los Angeles County hospitals changed from primarily county support to state and federal government sources, particularly Medicaid. The success of the new hospital will depend on whether government leaders at all levels provide the reforms needed to help the county and its partners stabilize its funding base.     

CA hospital brands image with a vibrant, colorful campaign. Effort promotes hospital's service lines with "always first" campaign

Hoag Memorial Hospital Presbyterian in Newport Beach, CA, faces tough competition each year. Located in a densely populated county in Southern California, the 511-bed hospital is up against stiff competition for patients in Orange County, where hospitals not only compete with others in that county, but also with hospitals in its more famous neighboring county: Los Angeles.     

Re-engineering the Los Angeles County public health care safety net: recommendations from a Blue Ribbon Health Task Force

Public hospitals throughout the United States are under increasing fiscal and political pressure to survive because of dynamic changes in healthcare delivery, an increasing uninsured population of patients and rapidly declining reimbursement. These safety net health care programs are also saddled with outdated and bureaucratic governmental policies and procedures which make it even more difficult to improve the quality of care and efficiency of the organization. As these pressures mount, some public hospital systems have attempted to be reinvented through the re-engineering process. Los Angeles County, the second largest health system in the United States, has done relatively little to adjust to changing times. Los Angeles County Department of Health Services has been attempting to re-engineer for the past three years, but this has not averted the need for a second billion-dollar waiver in 2000 from the state and federal governments. A Blue Ribbon Health Task Force was appointed to examine the failure of re-engineering to restructure the Los Angeles public health delivery system. In this article, the group's findings and recommendations are reported. They cover three general areas: eliminating bureaucratic hurdles, improving healthcare planning and management of operations and setting priorities on critical investments in health services.     

Hospital Utilization for Injection Drug Use-Related Soft Tissue Infections in Urban versus Rural Counties in California

Drug related-soft tissue infections (DR-STIs) are a significant source of hospital utilization in inner-city urban areas where injection drug use is common but the magnitude of hospital utilization for DR-STIs outside of inner-city urban areas is not known. We described the magnitude and characteristics of hospital utilization for DR-STIs in urban versus rural counties in California. All discharges from all nonfederal hospitals in California in 2000 with ICD-9 codes for a soft tissue infection and for drug dependence/abuse were abstracted from the California Office of Statewide Health Planning and Development discharge database. There were 4,152 DR-STI discharges in 2000 from hospitals in 49 of California's 58 counties. Residents of 12 large metropolitan counties accounted for 3,598 discharges (87% of total). The majority of DR-STI discharges were from urban safety net hospitals with county indigent programs and Medicaid as the expected payment source and opiate related discharge diagnoses. Hospital utilization for DR-STIs in California is highest in large urban metropolitan counties, although DR-STI discharges are widespread. Increased access to harm reduction services and drug treatment may reduce government health care expenditures by preventing unnecessary hospital utilization for DR-STIs. Heinzerling is with the Department of Family Medicine, David Geffen, School of Medicine at UCLA Los Angeles, California, USA; Heinzerling and Asch are with the VA Greater Los Angeles Health Care System, USA; Etzioni is with the Department of Surgery, David Geffen, School of Medicine at UCLA, USA; Hurley and Holtom are with the Keck School of Medicine, University of Southern California, USA; Bluthenthal and Asch are with the Health Program and Drug Policy Research Center, RAND, USA.     

A Pediatric Division Solves Its House Staff Problem

A greatly improved teaching program, backed by topflight staff, competitive salaries, and attention to personal needs of interns and residents, such as housing and recreation, was the key to resolving an intolerable situation at Los Angeles County General Hospital. Without such a comprehensive approach, the authors say, an excellent effort to solve any one part of the problem may well be frustrated.     

Impact of restaurant hygiene grade cards on foodborne-disease hospitalizations in Los Angeles County

Although health departments routinely inspect restaurants to assess compliance with established hygienic standards, few data are available on the effectiveness of these efforts in preventing foodborne disease. The study reported here assessed the impact on foodborne-disease hospitalizations in Los Angeles County of a restaurant hygiene grading system that utilized publicly posted grade cards. The grading systm was introduced in January 1998. Hospital discharge data on foodborne-disease hospitalizations were analyzed for Los Angeles County and, as a control, for the rest of California during the period 1993-2000. Ordinary least-squares regression analysis was done to measure the effect of the grading progam on these hospitalizations. After baseline temporal and geographic trends were adjusted for, the restaurant hygiene grading program was associated with a 13.1 percent decrease (p < .01) in the number of foodborne-disease hospitalizations in Los Angeles County in the year following implementation the program (1998). This decrease was sustained over the next two years (1999-2000). The results suggest that restaurant hygiene grading with public posting of results is an effective intervention for reducing the burden of foodborne disease.     

The crisis of the Los Angeles County public hospital system: a harbinger for the nation.

The public hospital system in Los Angeles County, California, is in the midst of a major fiscal crisis that has already led to a serious reduction of capacity and could continue to worsen. Given the importance of the public system in a county where 30 percent of the population is uninsured and private hospitals provide very little uncompensated care, what happens in L.A. County is a harbinger for other cities and counties in the United States. This article highlights the issue of the extent to which local taxpayers, as opposed to state or federal taxpayers, are responsible for the continued operation of public hospitals and safety-net facilities in their communities.     

Urban health care in transition: challenges facing Los Angeles County.

The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.     

Planning for the control of pandemic influenza A (H1N1) in Los Angeles County and the United States

Mathematical and computer models can provide guidance to public health officials by projecting the course of an epidemic and evaluating control measures. The authors built upon an existing collaboration between an academic research group and the Los Angeles County, California, Department of Public Health to plan for and respond to the first and subsequent years of pandemic influenza A (H1N1) circulation. The use of models allowed the authors to 1) project the timing and magnitude of the epidemic in Los Angeles County and the continental United States; 2) predict the effect of the influenza mass vaccination campaign that began in October 2009 on the spread of pandemic H1N1 in Los Angeles County and the continental United States; and 3) predict that a third wave of pandemic influenza in the winter or spring of 2010 was unlikely to occur. The close collaboration between modelers and public health officials during pandemic H1N1 spread in the fall of 2009 helped Los Angeles County officials develop a measured and appropriate response to the unfolding pandemic and establish reasonable goals for mitigation of pandemic H1N1.     

The Los Angeles system of care for runaway/ homeless youth

Runaway and homeless young people generally do not seek help unless they are in a severe personal crisis. For the past 7 years, the Division of Adolescent Medicine, Childrens Hospital of Los Angeles, has learned a good deal about how to intervene effectively with these youths and divert them from high-risk behaviors such as prostitution and drug abuse. The program model we have developed has five major components: 1) networking and consolidation, 2) outreach, 3) short-term crisis shelter, 4) comprehensive medical and psychosocial care, and 5) long-term shelter and case management. Our approach has been collaborative; we subcontract a substantial portion of the work to other youth agencies in the community in order to build and strengthen the network of existing services. In the process, we have moved steadily closer to developing a comprehensive system of care for homeless street youth throughout Los Angeles County. Where programs previously operated in relative isolation, representatives from 40 private and public agencies now meet regularly at Childrens Hospital of Los Angeles to discuss ways to improve services. Systematized data collection has helped agencies understand how they can work together and has prompted additional funding for needed services.     

Salmonella arizona infections in Latinos associated with rattlesnake folk medicine.

In 1987 two Los Angeles County (California) hospitals reported four Latino patients with serious Salmonella arizona (Salmonella subgroup 3) infections who gave a medical history of taking rattlesnake capsules prior to illness. Capsules supplied by the patients or household members grew Salmonella arizona. We reviewed surveillance data for this Salmonella species and conducted a case-control study to determine the magnitude of this public health problem. Eighteen (82 percent) of the 22 Latino cases in 1986 and 1987 who were questioned reported ingesting snake capsules compared to two (8 percent) of 24 matched Latino controls with non-subgroup 3 salmonellosis or shigellosis (matched pair odds ratio = 18.0, CI = 4.2, 76.3). An average of 18 cases per year of Salmonella arizona were reported in the county between 1980 and 1987. In this investigation the majority of S. arizona cases reporting snake capsule ingestion had underlying illnesses such as acquired immunodeficiency syndrome (AIDS), diabetes, arthritis, cancer. The capsules were obtained primarily from Tijuana, Mexico and from Los Angeles, California pharmacies in Latino neighborhoods. Despite publicity and attempts to remove the capsules from sale in California, Salmonella arizona cases associated with snake-capsule ingestion continue to occur.     

The health care workforce in Los Angeles County and New York City: a comparison and analysis.

New York City and Los Angeles County have the largest health systems in the United States, but they differ significantly in structure. This study compares and analyzes the structural and workforce differences between the two. The health system in New York City is centered around its large hospitals, and as a result New York employs many more health workers than Los Angeles County, where the health system is centered around physician groups. Health care is a significant contributor to the economy of both areas, but a larger contributor to the economy in New York City.     

Residence under an airport landing pattern as a factor in teratism

An analysis of all Los Angeles County birth records for the years 1970, 1971, and 1972 reveals a higher incidence of reportable birth defects in those census tracts lying wholly or partly within the 90 dbA loudness contours under the landing pattern at Los Angeles International Airport than in the rest of the County. While not proving that noise is responsible for the increase in teratism, these results point to a potentially important physical environmental effect with significant public health implications.     

AB 3632 mental health entitlement for special education students in California: Aspects of the Los Angeles experience

California Assembly Bill (AB) 3632, passed in 1984, ushered in an era of entitlement to mental health services for schoolchildren with serious emotional disturbances. This article examines the development of the law, the children’s public mental health context in Los Angeles County, and the significant impact of the legislation on distribution of mental health services in Los Angeles County and in one Los Angeles area community mental health center. Countywide and agency data are presented that document AB 3632 and regular mental health service provision differences in gender, age, ethnic, income, and language domains and, at the agency level, an increasing proportion of AB 3632 clients. Implications of AB 3632 service provision in relation to provision of mental health services to children in general are reviewed.     

Years off Your Life? The Effects of Homicide on Life Expectancy by Neighborhood and Race/Ethnicity in Los Angeles County

Homicide is one of the leading causes of death in Los Angeles County and is known to be elevated in low-income urban neighborhoods and in black males. However, because homicide occurs primarily among young adults, mortality rate statistics may underrepresent its importance. We estimated the impact of homicide on life expectancy by demographic group and geographic area in Los Angeles County, 2001–2006. Life expectancy estimates were calculated using mortality records and population estimates for Los Angeles County. Cause elimination techniques were used to estimate the impact of homicide on life expectancy. Homicide was estimated to reduce life expectancy by 0.4 years for Los Angeles County residents and by 2.1 years for black males. The impact of homicide on life expectancy was higher in low-income neighborhoods. In some low-income urban neighborhoods, homicide was estimated to decrease life expectancy in black males by nearly 5 years. Homicide causes substantial reductions in life expectancy in Los Angeles County. Its impact is magnified among black males and in low-income urban areas, underscoring the need for homicide reduction in urban centers.     

Impacts of the medical malpractice slowdown in Los Angeles County: January 1976.

The Los Angeles County (California) physician strike of January 1976 resulted in a partial withdrawal of physician services. Among recorded impacts were a $17.5 million loss in hospital revenues and an $8.5 million pay loss for hospital employees. Several surveys revealed no evidence of a significant impact on the general public in finding medical care. Analysis of emergency room visits and paramedical ambulance calls showed no significant increases during the strike. County mortality statistics for the strike were not affected. Eighty-eight fatalities among 2,171 patients transferred during the strike were analyzed; a Case Attributable Mortality Probability generated on 21 cases selected for final review by a five-physician multispecialist panel indicated that 29 per cent of the Attributable Mortality could be ascribed to the strike itself and 71 per cent to ongoing "patient dumping" from private sector to County hospitals. Even if sample attributable mortality rates were generalized to overall county deaths, the resultant figures are below the estimated range of 55 to 153 deaths that did not occur because of the number of elective operations not performed secondary to the strike.     

Uncompensated emergency care in hospital markets in Los Angeles County.

A survey of hospital emergency rooms in Los Angeles County was conducted in March 1987. Analysis of the distribution of uninsured emergency care patients revealed that private hospitals play a significant frontline role in terms of entry into the hospital system for patients who are unable to pay--almost one-half of such patients were treated in the emergency rooms of private hospitals. Hospitals serving markets in which a higher proportion of residents had incomes below the poverty level provided a greater share of uncompensated emergency room services.     

Peer Reviewed: Starting School Healthy and Ready to Learn: Using Social Indicators to Improve School Readiness in Los Angeles County

Background

School readiness is an important public health outcome, determined by a set of interdependent health and developmental trajectories and influenced by a child''s family, school, and community environments. The same factors that influence school readiness also influence educational success and health throughout life.

Context

A California cigarette tax ballot initiative (Proposition 10) created new resources for children aged 0 to 5 years and their families statewide through county-level First 5 commissions, including First 5 LA in Los Angeles County. An opportunity to define and promote school readiness indicators was facilitated by collaborative relationships with a strong emphasis on data among First 5 LA, the Children''s Planning Council, and the Los Angeles County Public Health Department, and other child-serving organizations.

Methods

A workgroup developed school readiness goals and indicators based on recommendations of the National Education Goals Panel and five key domains of child well-being: 1) good health, 2) safety and survival, 3) economic well-being, 4) social and emotional well-being, and 5) education/workforce readiness.

Consequences

The Los Angeles County Board of Supervisors and First 5 LA Commission adopted the school readiness indicators. First 5 LA incorporated the indicators into the results-based accountability framework for its strategic plan and developed a community-oriented report designed to educate and spur school readiness-oriented action. The Los Angeles County Board of Supervisors approved a countywide consensus-building plan designed to engage key stakeholders in the use of the indicators for planning, evaluation, and community-building activities.

Interpretation

School readiness indicators in Los Angeles County represent an important step forward for public health practice, namely, the successful blending of an expanded role for assessment with the ecological model.     

Small Area Estimates Reveal High Cigarette Smoking Prevalence in Low-Income Cities of Los Angeles County

Los Angeles County has among the lowest smoking rates of large urban counties in the USA. Nevertheless, concerning disparities persist as high smoking prevalence is found among certain subgroups. We calculated adult smoking prevalence in the incorporated cities of Los Angeles County in order to identify cities with high smoking prevalence. The prevalence was estimated by a model-based small area estimation method with utilization of three data sources, including the 2007 Los Angeles County Health Survey, the 2000 Census, and the 2007 Los Angeles County Population Estimates and Projection System. Smoking prevalence varied considerably across cities, with a more than fourfold difference between the lowest (5.3%) and the highest prevalence (21.7%). Higher smoking prevalence was generally found in socioeconomically disadvantaged cities. The disparities identified here add another layer of data to our knowledge of the health inequities experienced by low-income urban communities and provide much sought data for local tobacco control. Our study also demonstrates the feasibility of providing credible local estimates of smoking prevalence using the model-based small area estimation method.     

COUNTY HEALTH ADMINISTRATION IN LOS ANGELES COUNTY

Progress in public health work demands simplified administration. Los Angeles County is striving to meet the demands of efficiency plus economy by effecting consolidation of health services with cities. The County has already established a coordinated social service with the cities within it. The County Health Office is meeting the problem by making contracts with the cities for specified units of service.