Transcript UNC Clinical Scholars Program Lecture

Public Health Systems
Research:
What, Why, and How?
Public Health Systems
Research:
What, Why, and How?
Lunch and Learn
23 September 2005
Public Health Systems
Research:
What, Why, and How?
23 September 2005
Hugh H. Tilson
Public Health Systems
Research:
What, Why, and How?
Hugh Tilson (Glen Mays)
What is Public Health Systems Research?
A field of inquiry examining the
organization, financing, and delivery of
public health services at local, state and
national levels, and the impact of these
activities on population health
Mays, Halverson, and Scutchfield. JPHMP 2003
What Constitutes a Public Health System?
The collection of governmental and private
entities that contribute to the delivery of public
health services for a defined population.
How to define the population?
Local vs. state systems
Variation in system structure and
composition
But first...
a word from
our sponsors!
THE FUTURE OF
THE PUBLIC’S HEALTH
in the 21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Committee on Assuring
the Health of the Public
in the 21st Century
Background in the Report

Health = Public Good

Government has fundamental, statutory duty to assure the
health of the public, BUT …

Government cannot do it alone

Need for inter-sectoral engagement in partnership with
government

Health = social goal of many sectors and communities
The Committee’s Conclusion

An inter-sectoral public health system is needed

In 1988 report, public health refers to the “organized
efforts of society, both government AND OTHERS,
to assure conditions in which people can be healthy”

THIS report elaborates on the efforts of the other
potential public health system actors.
The Public Health System
Community
Governmental
Public Health
Infrastructure
Health
care delivery
system
ME!!
Academia
Employers
and Business
The Media
The Public Health System
Community
Governmental
Public Health
Infrastructure
Health
care delivery
system
Assuring the
Conditions for
Population
Health
Academia
Employers
and Business
The Media
What Kinds of Work Must the Public
Health System Perform?
Society's Health
Response
General
protection
Targeted
protection
Demand
for
response
Primary
prevention
Secondary
prevention
Demand
for
response
Becoming no
longer vulnerable
Safer,
Healthier
Population
Becoming
Vulnerable
Vulnerable
Population
Becoming
Affected
Population
with
Disease
Tertiary
prevention
Demand
for
response
Developing
Complications
Population with
Complications
Dying from
Complications
Adverse Living
Conditions
more inter-organizationally complex,
slower rate of improvement
Public Work
(organizing, governance, citizenship, mutual accountability)
Milstein and Homer 2003
organizationally complex,
faster rate of improvement
Professional Work
(customers, products, services)
Why Study Public Health Systems?
“Unlike the medical care system, there is
little research and relatively few
measures for studying how well the
public health system operates.”
— Center for Studying Health System Change,
1996
Why Study Public Health Systems?
“The Committee had hoped to provide specific
guidance elaborating on the types and levels of
workforce, infrastructure, related resources, and
financial investments necessary to ensure the
availability of essential public health services to all of
the nation’s communities. However, such evidence is
limited, and there is no agenda or support for this type
of research, despite the critical need for such data to
promote and protect the nation’s health.”
—Institute of Medicine, 2003
Why Study Public Health Systems?

Concerns about preparedness for emerging threats

Wide variation in public health resources

Persistent disparities in outcomes

Difficulties demonstrating accountability/value
for investments in public health

Desire for evidence-based decision-making
Why Study Public Health Systems?
Intervention
Research

What works – proof
of efficacy

Controlled trials

Guide to Community
Preventive Services
Systems &
Services Research
 How
to implement in
real-world settings
– Expand reach
– Improve quality,
efficiency
– Reduce disparities
 Observational
CBPR
studies,
Where Are We Now?
Research topics:
How are public health systems
organized and financed?
Type:
Descriptive
What do they do?
Inferential
What factors influence their work?
How does their work influence the
public’s health?
Interventional
How can we improve performance
and population health?
Translational
The National PH Performance Standards
Program(NPHPSP)

THREE “instruments”

OMB approved with
‘control numbers’

STATE

LOCAL

GOVERNANCE
The local public health system assessment
instrument

OMB Control Number
0920-0555

24 hours per response

“…ALL entities that
contribute to the delivery
…”
The local public health system assessment
instrument

“How much of this
Model Standard is
achieved by the local PHS
collectively?”

What percent of the
answer reported in Q 1 is
the direct contribution of
the local PH agency?
Public health system assessment
instruments and A CCREDITATION

Can achievement of a
“passing grade” on a
performance assessment be
used for accreditation?

How should WHO accredit
WHOM and HOW? (not to
mention WHY?)
Variation in System Performance
Percent of jurisdictions
Local Jurisdictions with at Least 100,000 Population, 1998
35%
Scope of public health activities
performed (% of 20 activities)
30%
Perceived effectiveness of
performance (% of maximum score)
25%
20%
15%
10%
5%
0%
<10%
10.0%19.9%
20.0%29.9%
30.0%39.9%
40.0%49.9%
Range
Mays et al. AJPH 2004
50.0%59.9%
60.0%69.9%
70.0%79.9%
80.0%89.9%
90.0%99.9%
Who Contributes?
Proportion of Effort Contributed by Local Health Departments
and Other Organizations
Other
Organizations
26%
Local Health
Department
74%
Mays, Halverson, Stevens. Public Health Reports 2001
Who Contributes?
Participation in at least one activity
Scope of participation (% of 20 Activities)
100
Others
10
0
Mays, Halverson, Stevens. Public Health Reports 2001
Health Plans
20
CHCs
30
Federal
40
Universities
50
Physicians
60
Hospitals
70
Local Agencies
80
State Agencies
90
How Does System Composition Affect
Performance?
% Change in Performance
Increases in System Performance Associated with Participation
by Other Organizations
20
Scope of Services
Perceived Effectiveness
15
10
5
0
N
its
of
pr
on
ies
nc
ge
s
an
pl
la
ca
lth
ea
Lo
H
s
ian
ic
ys
ls
ta
pi
os
Ph
H
Mays, Halverson, Stevens. Public Health Reports 2001
Performance Associated with System Size
Spline Regression Estimates After Controlling for other Variables in the Model
100%
90%
Investigate
Inform
80%
Performance score
70%
60%
Monitor
50%
40%
Policy/plan
30%
Partnerships
20%
10%
0%
0
200,000
400,000
600,000
800,000 1,000,000 1,200,000 1,400,000 1,600,000
Population size
Mays et al. AJPH in press
ga
tio
g
n
or
m
/e
du
ca
te
Pa
rtn
er
sh
ip
Po
s
lic
y/
pl
an
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ng
En
fo
rc
em
Se
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rv
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ic
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in
ka
ge
W
or
kf
or
ce
Ev
alu
at
io
n
Re
se
ar
ch
In
f
es
ti
In
v
rin
ito
M
on
% Change in Performance
Performance Associated with Local Agency
Spending Per Capita
10
8
6
4
2
0
Mays et al. JPHMP 2004
Priorities for Future Research
 Measuring
“performance” and “quality”
 Measuring
public health spending/cost
 Estimating
impact on population health
 Evidence-based
decision making regarding
society’s investments in public health
More Questions than Answers?
Priorities for Future Research

What strategies and interventions are effective in
improving PH system performance & outcomes?
– Performance measurement ─ NPHPSP
– Local and state QI collaboratives
– Agency accreditation
– Workforce training & competencies
– Financing
WORKFORCE RESEARCH
ADAPTABILITY
Local
Federal
(ACHD)
(HRSA)
Academics
(POPHTC)
LEARNING
INTERVENTION
Public Health Specialists
Evaluation
Adult Educators
Developing a Public Health Systems
Research Agenda: CDC Experience
Dennis Lenaway, Paul Halverson, Hugh Tilson (2), Sergey
Sotnikov, Liza Corso, & Wayne Millington
Div of Public Health Systems Development and Research, Public Health
Practice Program Office, CDC
(1)
(2)
School of Public Health, University of North Carolina
The 14 Major Themes (and votes)

Agency structure & performance (40)

Dimensions of public health systems (33)

Performance & health outcomes (30)

Characteristics of high-performing agencies (29)

Social determinants & system performance (28)
The 14 Major Themes (and votes)

Cost of optimal system performance (27)

Infrastructure & categorical programs (27)

Framework for high-performing systems (26)

Health outcomes & system performance (26)

Accreditation & performance improvement (21)
The 14 Major Themes (and votes)

Policy, finance & system performance (19)

Community involvement, NPHPS & system
improvement activities (19)

High performing systems & preparedness (19)

Effectiveness of governance structures (16)
But first...
a word from
our sponsors!
Council on Linkages Between Academia and Public Health Practice

The overall objective of the
Council is to improve the
relevance of public health
education to practice
16 NATIONAL MEMBER ORGANIZATIONS
American College of Preventive Medicine
American Public Health Association
Association of Schools of Public Health
Association of State and Territorial Health Officials


Grew out of the Public
Health Faculty / Agency
Forum
Grew out of the 1988 IOM
Report
Association of Teachers of Preventive Medicine
Association of University Programs in Health Administration
Centers for Disease Control and Prevention
Community-Campus Partnerships for Health
Council on Accredited Master of Public Health Programs
Health Resources and Services Administration
National Association of County and City Health Officials
National Association of Local Boards of Health
National Environmental Health Association
Funded by HRSA and
Staffed by PHF
National Network of Public Health Institutes
QUAD Council of Public Health Nursing Organizations
Society for Public Health Education
What’s been achieved...
 Public
health systems research agendas general, workforce, rural, preparedness
 “Centers
of Excellence” - several universities
 Customers
and demand for research - NACCHO
resolution
 PHSR
“support group” - AcademyHealth
 Research
 APHA
 THIS
fellowship program - Pfizer
Forum annually
wonderful effort … THANKS RWJ!!
The road from here: FULL of
opportunities!
Whaddya’ mean “Opportunities”? In THIS
mess?
What’s left to be done...
Turning pennies into dollars
Examples of
Organizational Commitments

APHA
– Host leadership forum
– Publish article
– Executive Board action


Research!America
– Develop case for PHSR
– Seek ideas for opinion polls

AHRQ
– Meet with leadership
– Promote PHSR in solicitations
NACCHO
– Executive Board input
– Annual meeting presentations
– Process to develop agenda
Pfizer, Inc.
– Develop fellowship
CDC
– Convene federal agencies
– Support PH Affiliate
– Develop specific agendas



ACPM
– Annual meeting presentations
– Communicate with members
The Road from Here … FULL of opportunities
 AcademyHealth
Public Health Systems Research
Interest Group
 Council
 CDC
on Linkages/PHF
Futures Initiative
 Foundation
 RWJ’s
initiatives, e.g. HCFO,
strong commitment
 State-supported
efforts
The road from here: YOU drive!