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University of Kentucky

UKnowledge

Health Management and Policy Presentations Health Management and Policy

4-1-2015

Geographic Variation in the Delivery of Public

Health Services: Understanding Causes and

Consequences

Glen P. Mays

University of Kentucky, glen.mays@cuanschutz.edu

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Repository Citation

Mays, Glen P., "Geographic Variation in the Delivery of Public Health Services: Understanding Causes and Consequences" (2015).

Health Management and Policy Presentations. 100.

(2)

Geographic Variation in the Delivery

of Public Health Services:

Understanding Causes and Consequences

Glen Mays, PhD, MPH University of Kentucky

glen.mays@uky.edu

National Coordinating Center

(3)

Many evidence-based public health strategies

fail to

reach large segments

of U.S. populations at risk:

Smoking cessation Influenza vaccination Hypertension control

Nutrition & physical activity programs HIV prevention

Family planning

Substance abuse prevention

Interpersonal violence prevention

Maternal and infant home visiting for high-risk populations HPV vaccinations & cancer screening

(4)

Economics & public health implementation

>75%

of US health spending is attributable to

conditions that are largely preventable

– Cardiovascular disease

– Diabetes

– Lung diseases

– Cancer

– Injuries

– Vaccine-preventable diseases and sexually

transmitted infections

<5%

of US health spending is allocated to

prevention and public health

(5)

Other Health & Social

Organizations

Public Health Agencies

Legal authority Participation incentives Intergovernmental relationships Strategic Interactions Leadership Needs Perceptions Preferences

Risks Population &

Environment Distribution of effort Scope of services Staffing levels & mix Governing structure Funding levels & mix Division of responsibility

Nature & intensity of relationships Scope of activity Compatibility of missions Resources & expertise Resources Threats

Outputs and Outcomes

Scale of operations Decision Support •Accreditation •Performance measures •Practice guidelines •Quality improvement Reach Effectiveness Timeliness Efficiency Equity Adherence to EBPs

Complexity in public health delivery systems

Mays et al 2009

Coordination mechanisms

(6)

What’s the role of public health infrastructure?

Foundational Public Health Capabilities

– Epidemiologic surveillance & investigation

– Community health assessment & planning

– Public education and communication

– Community engagement & deliberation

– Environmental health monitoring & assessment

– Policy development and analysis

– Policy compliance monitoring & enforcement

– Convening and planning for school-based,

worksite-based, and community-based health programming

– Workforce development & training

– Fundraising & entrepreneurship

– Financial analysis & resource allocation

Institute of Medicine. For the Public’s Health: Investing in a Healthier

(7)

Strategies to promote health and prevent disease & injury on a population-wide basis: programs, policies, administrative practices

Public Health Services & 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

(8)

How much variation across the U.S.?

− High-value programs & services

− Cross-cutting infrastructure and capabilities

Drivers of variation?

− Need

− Preferences & values − Resource availability

− Delivery system attributes

Consequences of variation?

− Health impact − Cost & efficiency − Equity

(9)

Ongoing studies of implementation

variation in public health

National Longitudinal Survey of Public Health Systems Multi-network Practice and Outcome Variation Study (MPROVE)

Public Health Delivery and Cost Studies (DACS) Costing Foundational Public Health Capabilities

National Coordinating Center

Macro

(10)

Prior work: mortality reductions attributable to

investments in public health delivery, 1993-2008

-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 Infant mortality Heart

disease Diabetes Cancer Influenza All-cause Alzheimers Injury

P er cen t ch a n g e

Hierarchical regression estimates with instrumental variables to correct for selection and unmeasured confounding

(11)

5800 6000 6200 6400 6600 6800 7000 7200 0 20 40 60 80 100 120

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

M ed ic al sp en di ng /p er so n ($ ) . Pu bl ic h ea lth sp en di ng /c ap ita ($ ) .

Quintiles of public health spending/capita

Public health spending/capita Medicare spending per recipient

Mays et al. 2009, 2013

Prior work: medical cost offsets attributable to

investments in public health delivery, 1993-2008

For every $10 of public health spending, ≈$9 are recovered in lower medical care spending over 15 years

(12)

1 - National Longitudinal Survey

of Public Health Systems

Cohort of 360 communities with at least 100,000 residents Followed over time: 1998, 2006, 2012, 2014**

Measured from local public health official’s perspective:

Scope: availability of 20 recommended

public health activities

Network: types of organizations

contributing to each activity

Effort: contributed by designated

local public health agency

Quality: perceived effectiveness

of each activity

Linked with organizational and financial data from

NACCHO’s National Profile of Local Health Departments, Area Resource File, U.S. Census data

(13)

Delivery of recommended public health activities

in U.S. communities

Public Health Activity 1998 2006 2012

1. Community health needs assessment 71.5 77.5 72.6 2. Behavioral risk factor surveillance 45.8 70.2 73.9 3. Adverse health events investigation 98.6 97.9 99.6 4. Public health laboratory testing services 96.3 97.0 99.2 5. Analysis of health status & health determinants 61.3 73.2 63.5 6. Analysis of preventive services utilization 28.4 26.1 33.2 7. Health information provision to elected officials 80.9 90.1 87.1 8. Health information provision to the public 75.4 88.8 80.9 9. Health information provision to the media 75.2 88.4 87.1 10. Prioritization of community health needs 66.1 71.7 66.8 11. Community participation in health planning 41.5 50.6 49.8 12. Development of community health improvement plan 81.9 86.7 69.7 13. Resource development & allocation to implement health plan 26.2 37.3 27.8 14. Policy development to implement health plan 48.6 51.9 49.0 15. Communication with health-related organizations 78.8 87.2 89.6 16. Implementation of strategies to enhance access to services 75.6 68.7 60.6 17. Implementation of legally mandated PH activities 91.4 92.3 89.2 18. Evaluation of public health programs and services 34.7 37.5 33.2 19. Evaluation of local public health agency performance 56.3 56.2 55.2 20. Implementation of quality improvement processes 47.3 50.4 42.7

A sse ssm en t P o li cy /P la n n in g A ss u ra n ce % Communities

(14)

Delivery of recommended public health

activities in U.S. communities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1998 2006 2012

Assurance Policy Assessment

% o f a c ti v it ie s ↑ 10% ↓ 5%

(15)

Variation in Scope of Public Health Delivery

Delivery of recommended public health activities, 2012

National Longitudinal Survey of Public Health Systems, 2012

% of activities 0 5 % 1 0& Pe rc e n t o f U .S. c o m m u n it ie s 20% 40% 60% 80% 100%

(16)

Variation and Change in Delivery

Delivery of recommended public health activities, 2006-12

Quintiles of communities -40% -20% 0% 20% 40% 60% 80% 100% Q1 Q2 Q3 Q4 Q5 2012 ∆ 2006-12 % of re c om m e nde d act iv it ies p er fo rm ed

(17)

National Longitudinal Survey of Public Health Systems, 2012

Patterns of interaction

(18)

Organizations contributing

to local public health production

-50% -30% -10% 10% 30% 50%

Local health agency Other local government State health agency Other state government Hospitals Physician practices Community health centers Health insurers Employers/business Schools CBOs

% Change 2006-2012 Scope of Production 2012

(19)

Bridging capital in public health delivery systems

Trends in betweenness centrality

* * * * * * * *

(20)

Seven types of public health delivery systems

Scope High High High Mod Mod Low Low

Centrality Mod Low High High Low High Low

Density High High Low Mod Mod Low Mod

Source: Mays et al. 2010; 2012

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 1 2 3 4 5 6 7

Comprehensive Conventional Limited

1998 2006 2012 % of c om m uni ti e s

(21)

Integrated systems do more with less

Type of delivery system

E x pe ndi ture s pe r c a pi ta % of re c om m e nde d a c tiv it ie s pe rf orm e d

(22)

Integrated systems achieve better health outcomes

Fixed-effects models control for population size, density, age composition, poverty status, racial composition, and physician supply

Infant Deaths/1000 Live Births

-6.0 -4.0 -2.0 0.0 2.0 4.0 6.0 8.0

Cluster 3 Clusters 4-5 Cluster 6 Cluster 7

0.0 2.0 4.0 6.0 8.0 10.0

Cluster 3 Clusters 4-5 Cluster 6 Cluster 7

-2.0 -1.0 0.0 1.0 2.0

Cluster 3 Clusters 4-5 Cluster 6 Cluster 7

0.0 1.0 2.0 3.0 4.0

Cluster 3 Clusters 4-5 Cluster 6 Cluster 7

-0.1 0.0 0.1 0.2 0.3 0.4

Cluster 3 Clusters 4-5 Cluster 6 Cluster 7

Cancer deaths/100,000 population Heart Disease Deaths/100,000

Influenza Deaths/100,000 Infectious Disease Deaths/100,000 Infant Deaths/1000 Births

Clusters 1-3

Clusters 1-3 Clusters 1-3

Comprehens | Conventional | Limited | Very Limited

Percent Changes in Preventable Mortality Rates Attributable to

Delivery System Type

Comprehens | Conventional | Limited | Very Limited

Comprehens | Conventional | Limited | Very Limited

Comprehens | Conventional | Limited | Very Limited

(23)

Integrated systems generate larger health

& economic gains in low-resource communities

Log IV regression estimates controlling for community-level and state-level characteristics

Mays et al. forthcoming 2015

Impact in Low-Income vs. High Income Communities

Mortality

Medical costs 95% CI

(24)

Estimated crowd-out in hospital contributions

to public health activities

0% 10% 20% 30% 40% 50% 60% 0 5 10 15 20 25

Hospital charity care $/1000 population

S c ope of hos pi tal c ont ri but ions t o publ ic heal th ac ti v it ies

(25)

2 - Multi-Network Practice and Outcome

Variation Examination Study (MPROVE)

 Identify implementation measures high-value services:

Chronic disease prevention

Communicable disease control

Environmental health protection

 Create registry of measures: consistent across communities  Profile geographic variation in the delivery of selected public

health services across local communities

 Decompose variation into attributable components:

– need-sensitive or preference-sensitive factors

– supply-sensitive factors

 Examine associations between service delivery & outcomes

(26)

MPROVE measurement dimensions

Availability/Scope: specific activities produced

Volume/Intensity: Frequency of producing activity over period of time

Capacity: Labor and capital inputs assigned to an activity

Reach: Proportion of target population reached by activity

Quality: timeliness of activity, guideline concordance

Efficiency: resources required to produce given volume of activity

(27)

Overall Patterns of Variation

in Local Public Health Implementation

% o f T o tal V ar ian ce

(28)

Correlates of Variation

in Local Public Health Implementation

% o f T o tal V ar ian ce

Estimates from state fixed-effects regression models *p<0.05

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Tobacco Policy PA Funding Enteric Investigation STI staffing Food safety staffing

Unexplained local Unexplained state Local BOH LHD $/capita Race Income/capita Popln * * * * * * * * * * * Local governance Expenditures/capita Non-white pop Population size

(29)

3 - Public Health Delivery and Cost

Studies (DACS)

 Adapt & apply established cost measurement/estimation

methodologies to public health settings

 Identify the costs of implementing selected high-value

public health services

 Assess how costs vary across institutional and

community settings

 Examine the determinants and consequences of variation

in the costs of implementation

– Economies of scale and scope

– Efficiency & productivity

– Equity

(30)

DACS cost estimation methods

Retrospective “cost accounting” methods

- Modeling and decomposition using administrative records

- Surveys with staff and/or administrators

Concurrent “actual cost” methods (micro-costing)

- Time studies with staff

- Activity logs with staff

- Direct observation

Prospective “expected cost” methods

- Vignettes

- Surveys with staff and/or administrators

(31)

DACS Example: Returns to Scale in

Implementing Disease Investigation in Colorado

0 500 1000 1500 2000 2500 3000 3500 4000 0 5 10 15 20 25 30 T ot al M inut es Cases

Atherly et al. University of Colorado and Colorado Public Health PBRN.

(32)

4 – Costing Foundational Capabilities

2012 Institute of Medicine Recommendations

 Identify the components and costs of a minimum

package of public health services

– Foundational capabilities

– Basic programs

 Examine variation in costs across

community and institutional settings

 Identify population and delivery system

attributes that influence costs

Institute of Medicine. For the Public’s Health: Investing in a Healthier Future. Washington, DC: National Academies Press; 2012.

(33)

Costing Methodology Targets

Foundational Capabilities (FCs) Costs

− Health Assessment

− Emergency Preparedness

− Communications

− Policy Development and Support

− Community Partnership Development

− Organizational Competencies

Foundational Program Areas (FA) Costs

− Communicable Disease Control

− Chronic Disease & Injury Prevention

− Environmental Health

− Maternal and Child Health

− Access and Linkage to Clinical Care

(34)

Estimation of “projected” costs

from current implementation ratings

Imp le me n ta tio n level Cost

A. Cost at current implementation level B. Projected cost of full implementation

A

B 100

%

0%

Estimating the Costs of Foundational Public Health Capabilities: A Recommended Methodology

(35)

5.0% 90.0% 5.0% 52.7 78.3 FPHS_TOTAL Mean = 65.036 5% = 52.750 95% = 78.323 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 5.0% 90.0% 5.0% 76.7 127.5 FPHS_TOTAL_need Mean = 101.82 5% = 76.75 95% = 127.46

Pilot Estimates: Current and Projected Costs of Foundational Capabilities

Projected Current

(36)

Sampling for national cost estimates

National stratified, nested sample of state and local

jurisdictions

Selection of 9 states stratified by administrative structure:

Centralized: AR, SC

Shared:

FL, GA, (KY)

Decentralized: NY, CA, OH, (WA)

Selection of 3 local jurisdictions in each state, stratified by

population: <50k | 50-299k | >=300k

Supplement data already collected from KY, WA

(37)

Learning from variation:

Dissemination & Translation

Customized reporting of results

Collaborative interpretation of patterns & determinants

− Disentangling demand (need) from supply − System structure

− Geospatial

− Within and across domains of activity: composite measures

Follow-on studies: qualitative & quantitative Many dissemination channels

− Rapid-cycle journal: www.FrontiersinPHSSR.org

− Research archive: works.bepress.com/glen_mays

− Blog: PublicHealthEconomics.org

− Web: publichealthsystems.org

− RE-ACT podcast series

(38)

Public Health PBRNs: mechanisms for

research production & translation

First cohort (December 2008 start-up) Second cohort (January 2010 start-up) Affiliate/Emerging PBRNs (2011-14)

>1900 public health agencies

56 universities

(39)

PBRN Agencies National Sample

Activity Percent/Mean Percent/Mean

Identifying research topics 94.1% 27.5% ***

Planning/designing studies 81.6% 15.8% ***

Recruitment, data collection & analysis 79.6% 50.3% **

Disseminating study results 84.5% 36.6% **

Applying findings in own organization 87.4% 32.1% **

Helping others apply findings 76.5% 18.0% ***

Research implementation composite 84.04 (27.38) 30.20 (31.38)

**

N 209 505

Local Health Departments Engaged in Research Implementation & Translation Activities During Past 12 months

PBRNs and Research Translation

(40)

Green SM et al. Ann Intern Med. 2012;157(3):207-210

Toward a “rapid-learning system”

in population health

(41)

More Information

Glen P. Mays, Ph.D., M.P.H.

glen.mays@uky.edu

University of Kentucky College of Public Health Lexington, KY

Supported by The Robert Wood Johnson Foundation

Email: publichealthPBRN@uky.edu Web: www.publichealthsystems.org Journal: www.FrontiersinPHSSR.org Archive: works.bepress.com/glen_mays Blog: publichealtheconomics.org

Health Management and Policy Presentations Health Management and Policy Health and Medical Administration Commons, Health Economics Commons, HealthPolicy Commons Health Services Research Commons https://uknowledge.uky.edu/hsm_present/100 http://works.bepress.com/glen_mays/128/

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