The Adoption and Discontinuation of Clinical Services by Local Health Departments

Objectives. We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.Methods. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.Results. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities’ scope over time, increased community partners’ involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.Conclusions. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.The role of local health departments (LHDs) in offering clinical services is hotly contested in public health practice. Some LHD leaders believe that offering clinical services is critical to their mission1 and public image.2 Others embrace the position of the Institute of Medicine (IOM) on the future of public health, which calls for LHDs to focus on core public health functions of assessment, assurance, and policy development and away from clinical services.3,4Most LHDs have decreased clinical service offerings over time (discontinued).1,3,5,6 Some have done so because their leaders believe that offering clinical services is inconsistent with the LHD’s mission,6,7 diverts resources from population-based services,3,8 or distracts from core public health functions.1,7 Leaders of LHDs may rely on non-LHD public health system partner organizations to provide clinical services for vulnerable populations rather than providing them directly.1 They may see the private sector as more appropriate than LHDs in delivering clinical care.1,6,9 For example, in some regions, Medicaid managed care organizations collaborate with LHDs to ensure clinical services.5,10,11However, some LHDs have maintained or increased their clinical service offerings over time (adopted) because their leaders view clinical services as part of their mission,1 derive satisfaction from patient contact,5 or believe that offering such services is part of the core public health function of ensuring access to care to their patients if care is not available elsewhere.2,3,8,12 They offer clinical services if no private sector alternatives exist,6,12 or if the LHD is uniquely qualified in dealing with specific vulnerable populations2,5 or for certain conditions (e.g., infectious disease control).1 These LHDs may offer clinical services if no other safety net providers are available or community need is high. For instance, 63.3% of LHD directors in 2000 believed that LHDs should offer clinical services when no other organization was available to do so, compared with 23.6% of directors who believed that LHDs should offer clinical services unequivocally.7 Other LHDs may offer clinical services to generate revenue to fund other operations.1,13,14We posit that 3 main drivers underlie LHD decisions to offer clinical services. First, a conflicting goal driver suggests that LHD leaders may view offering clinical services as conflicting with core public health functions, particularly when they have few resources.1,7 Performance of these functions by LHDs varies with jurisdiction-level sociodemographic factors, and LHD organizational and public health system attributes.15–18 Second, an assurance driver suggests that LHDs offer clinical services if leaders believe that residents lack access to care, that the LHD has important expertise in providing clinical services to vulnerable patient populations, and that LHDs should provide these services when these services are limited. Third, an entrepreneurial driver suggests that LHDs leverage revenue-generating clinical services to fund needed public health services.5,13,19 The 3 drivers are not mutually exclusive. For instance, an LHD may stop offering comprehensive primary care because of the conflicting goal driver, and simultaneously start offering tuberculosis screening because of the assurance driver.The drivers provide a framework for understanding LHD decisions about the provision of clinical services, elucidating how LHDs change their clinical service offerings in response to strategic and environmental changes. We explored how the 3 drivers relate to 2 decisions: (1) whether an LHD departs from the majority and the IOM recommendations and maintains or offers more clinical services over time (an adoption decision) and (2) conditional on the LHD’s decision to discontinue services, how many fewer clinical services to offer over time (a degree of discontinuation decision). Institutional theory suggests that conformity pressures lead organizations to become more similar in behavior over time,20 but others resist such pressures for strategic reasons.21 Thus, we expected that LHDs adopting clinical services over time (adopters) would do so for different reasons than LHDs following the norm of discontinuing clinical services over time (discontinuers), and that leaders at discontinuer LHDs deciding how many clinical services to discontinue may do so for yet other reasons. Because we compared LHDs that followed the norm of decreasing the number of clinical service offerings1,3,5,6 with those that departed from the norm, we defined adoption to include offering the same number of clinical services over time. Our focus on the number of clinical services does not mean that the actual mix of clinical services offered stayed the same across time.2,5 number of community clinical service providers, and Medicaid reimbursement levels. Public health system attributes measure the LHD jurisdiction’s delivery on core public health functions across 3 dimensions: differentiation, integration, and concentration. Differentiation indicates the jurisdiction’s emphasis on public health needs, with high differentiation indicating that the jurisdiction offers many core programs or services. Integration indicates how different organizations interact in providing these services, with high integration indicating that many partnering organizations offer these services. Concentration measures the LHD’s role, with high LHD concentration indicating that the LHD bears primary responsibility for offering these services. Mays et al.22 described these 3 dimensions in further detail.

TABLE 1—

Conceptual Model Describing the Conflicting Goal, Assurance, and Entrepreneurial Drivers and the Factor Categories Associated With Adoption and Degree of Discontinuation of Clinical Services by Local Health Departments

Identification of the Vitamin D Receptor in Osteoblasts and Chondrocytes But Not Osteoclasts in Mouse Bone

Bone is clearly a target of vitamin D and as expected, the vitamin D receptor (VDR) is expressed in osteoblasts. However, the presence of VDR in other cells such as osteocytes, osteoclasts, chondroclasts, and chondrocytes is uncertain. Because of difficulties in obtaining sections of undecalcified adult bone, identification of the site of VDR expression in adult bone tissue has been problematic. In addition, the antibodies to VDR used in previous studies lacked specificity, a property crucial for unambiguous conclusions. In the present study, VDR in the various cells from neonatal and adult mouse bone tissues was identified by a highly specific and sensitive immunohistochemistry method following bone decalcification with EGTA. For accurate evaluation of weak immunosignals, samples from Demay VDR knockout mice were used as negative control. Molecular markers were used to identify cell types. Our results showed that EGTA‐decalcification of bone tissue had no detectable effect on the immunoreactivity of VDR. VDR was found in osteoblasts and hypertrophic chondrocytes but not in the multinucleated osteoclasts, chondroclasts, and bone marrow stromal cells. Of interest is the finding that immature osteoblasts contain large amounts of VDR, whereas the levels are low or undetectable in mature osteoblasts including bone lining cells and osteocytes. Proliferating chondrocytes appear devoid of VDR, although low levels were found in the hypertrophic chondrocytes. These data demonstrate that osteoblasts and chondrocytes are major targets of 1α,25‐dihydroxyvitamin D, but osteoclasts and chondroclasts are minor targets or not at all. A high level of VDR was found in the immature osteoblasts located in the cancellous bone, indicating that they are major targets of 1α,25‐dihydroxyvitamin D. Thus, the immature osteoblasts are perhaps responsible for the vitamin D hormone signaling resulting in calcium mobilization and in osteogenesis. © 2014 American Society for Bone and Mineral Research.     

Balloon Cinch Deformity during Angioplasty Procedures: An Indication for Impending Rupture

Percutaneous transluminal balloon angioplasty (PTA) is a commonly performed procedure for hemodialysis vascular access dysfunction including thrombosis. While PTA is generally safe, balloon rupture during the procedure is a potential complication. Because such a rupture can cause damage to the blood vessel, indication of an imminent balloon rupture might help avoid such a complication. This analysis reports on six PTA procedures that were complicated by balloon rupture. All cases demonstrated terminal (caudal/cranial) cinch deformation. There was a loss of sharp terminal tapering and its replacement with banana silhouette before the balloon rupture. Importantly, the contour deformation and balloon rupture occurred at a pressure that was lower than the rated burst pressure. The cinch deformity can be used as an indication for impending balloon rupture. We suggest deflation of balloons that demonstrate shape deformations to avoid vascular injury.     

An evolutionary perspective on maladaptive traits and cultural conformity

The problem of maladaptive cultural traits is explored through the notion of adaptive psychological mechanisms. It is suggested that the theory of a specific conformity mechanism is plausible, supported by multidisciplinary data, and helpful in explaining the proliferation and persistence of human maladaptive behavior. © 1996 Wiley-Liss, Inc.     

Use of Private Sector Workforce Respiratory Disease Short-Term Disability Claims to Assess SARS-CoV-2, Mexico, 2020

We examined respiratory disease short-term disability claims submitted to the Mexican Social Security Institute during 2020. A total of 1,631,587 claims were submitted by 19.1 million insured workers. Cumulative incidence (8.5%) was 3.6 times higher than that for January 2015‒December-2019. Workers in healthcare, social assistance, self-service, and retail stores were disproportionately affected.     

Gut Microbiome and Metabolome Variations in Self-Identified Muscle Builders Who Report Using Protein Supplements

Muscle builders frequently consume protein supplements, but little is known about their effect on the gut microbiota. This study compared the gut microbiome and metabolome of self-identified muscle builders who did or did not report consuming a protein supplement. Twenty-two participants (14 males and 8 females) consumed a protein supplement (PS), and seventeen participants (12 males and 5 females) did not (No PS). Participants provided a fecal sample and completed a 24-h food recall (ASA24). The PS group consumed significantly more protein (118 ± 12 g No PS vs. 169 ± 18 g PS, p = 0.02). Fecal metabolome and microbiome were analyzed by using untargeted metabolomics and 16S rRNA gene sequencing, respectively. Metabolomic analysis identified distinct metabolic profiles driven by allantoin (VIP score = 2.85, PS 2.3-fold higher), a catabolic product of uric acid. High-protein diets contain large quantities of purines, which gut microbes degrade to uric acid and then allantoin. The bacteria order Lactobacillales was higher in the PS group (22.6 ± 49 No PS vs. 136.5 ± 38.1, PS (p = 0.007)), and this bacteria family facilitates purine absorption and uric acid decomposition. Bacterial genes associated with nucleotide metabolism pathways (p < 0.001) were more highly expressed in the No PS group. Both fecal metagenomic and metabolomic analyses revealed that the PS group’s higher protein intake impacted nitrogen metabolism, specifically altering nucleotide degradation.     

DNA hypermethylation is associated with invasive phenotype of malignant melanoma

Tumor cell invasion is one of the key processes during cancer progression, leading to life-threatening metastatic lesions in melanoma. As methylation of cancer-related genes plays a fundamental role during tumorigenesis and may lead to cellular plasticity which promotes invasion, our aim was to identify novel epigenetic markers on selected invasive melanoma cells. Using Illumina BeadChip assays and Affymetrix Human Gene 1.0 microarrays, we explored the DNA methylation landscape of selected invasive melanoma cells and examined the impact of DNA methylation on gene expression patterns. Our data revealed predominantly hypermethylated genes in the invasive cells affecting the neural crest differentiation pathway and regulation of the actin cytoskeleton. Integrative analysis of the methylation and gene expression profiles resulted in a cohort of hypermethylated genes (IL12RB2, LYPD6B, CHL1, SLC9A3, BAALC, FAM213A, SORCS1, GPR158, FBN1 and ADORA2B) with decreased expression. On the other hand, hypermethylation in the gene body of the EGFR and RBP4 genes was positively correlated with overexpression of the genes. We identified several methylation changes that can have role during melanoma progression, including hypermethylation of the promoter regions of the ARHGAP22 and NAV2 genes that are commonly altered in locally invasive primary melanomas as well as during metastasis. Interestingly, the down-regulation of the methylcytosine dioxygenase TET2 gene, which regulates DNA methylation, was associated with hypermethylated promoter region of the gene. This can probably lead to the observed global hypermethylation pattern of invasive cells and might be one of the key changes during the development of malignant melanoma cells.