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Health Management and Policy Presentations Health Management and Policy
6-7-2013
Harnessing the Power of Public Health Systems for Injury Prevention & Control
Glen P. Mays
University of Kentucky, glen.mays@cuanschutz.edu
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Mays, Glen P., "Harnessing the Power of Public Health Systems for Injury Prevention & Control" (2013).Health Management and Policy Presentations. 22.
Harnessing the Power of Public Health Systems for Injury Prevention & Control
Glen Mays, PhD, MPH University of Kentucky
glen.mays@uky.edu
WHO 2010
Falling behind in population health
Preventable Deaths per 100,000 populationInequities in population health
Preventable disease burden
and national health spending
>75%
of national 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 national health spending is allocated to public health and preventionPreventable disease burden
and national health spending
$406 Billion
annually in medical costs and lost productivity due to injury$102 Million
annually spent on state injury and violence prevention programsChallenges in public health delivery
Resources ǂ preventable disease burden
Complex, fragmented, variable delivery systems Large inequities in resources & capacity
Variable productivity and efficiency
Gaps in evidence base for public health delivery Inability to demonstrate value/return on investment
Public health delivery systems
Public Health System
Public Health Agency Legal authority Participation incentives Intergovernmental relationships Strategic Decisions Breadth of organizations 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 Reach Effectiveness Timeliness Efficiency Equity Adherence to EBPs
Complexity in public health delivery
Variation in Public Health Delivery
Delivery of recommended public health activities
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%
Variation in Public Health Delivery
Delivery of recommended public health activities
Why study public health delivery?
“The Committee had hoped to provide specificguidance 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.”
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
PHSSR’s place in the continuum
Intervention
Research
What works – proof of efficacy Controlled trials Guide to Community Preventive Services
Services/Systems
Research
How to organize, implement and sustain in the real-world
– Reach
– Enforcement/Compliance
– Quality/Effectiveness
– Cost/Efficiency
– Equity/Disparities
Impact on population health Comparative effectiveness & efficiency
PHSSR and policy relevance
Patient Protection and Affordable Care Act of 2010A national research agenda
to improve public health delivery systems
Public health system organization and structure Public health financing and economics
Public health workforce
Public health information and technology Cross-cutting elements
− Quality
− Law and policy
− Equity and disparities − Metrics and data
− Analytic methods
Emerging evidence:
organization and structure
Who contributes to public health delivery? How are roles and responsibilities divided? How and why do delivery systems vary and change over time?How do system structures affect public health delivery and outcomes?
Organizations engaged
in local public health delivery
-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 Delivery 2012
Private and voluntary organizations contributed more than
of the public health activities performed in the average U.S. community in 2012.
A typology of public health delivery systems
Scope High High High Mod Mod Low Low Centralization Mod Low High High Low High Low
Integration 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
Changes in health associated with delivery system
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 Clusters 1-3
Clusters 1-3
Percent Changes in Preventable Mortality Rates by System
Emerging evidence:
finance and economics
How does public health spending vary across communities and change over time?
What are the health effects attributable to changes in public health spending?
What are the medical cost effects attributable to changes in public health spending?
What are the opportunities for improving efficiency in public health delivery?
Factors driving growth in medical spending
per case
Public health’s share of national health spending $0 $10 $20 $30 $40 $50 $60 $70 $80 $90 19 60 19 62 19 64 19 66 19 68 19 70 19 72 19 74 19 76 19 78 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08
State and Local Federal 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%
$Billions USDHHS National Health Expenditure Accounts %NHE
Funding sources for injury prevention
Federal, 61% State, 36% Other, 3%Variation in Local Public Health Spending
0 .05 .1 .15 P e rc e nt of c ommuni ti e s $0 $50 $100 $150 $200 $250Expenditures per capita, 2010
Changes in Local Public Health Spending 1993-2010 0 .05 .1 .15 .2 .25 P e rc e nt of c ommuni ti e s -100 -50 0 50 100
Change in per-capita expenditures ($)
62% growth 38%
Variation in Injury Prevention Spending, 2011
Determinants of Public Health
Spending Levels
– Delivery system size & structure
– Service mix
– Population needs and risks
– Efficiency & uncertainty
Service mix 16% Demographic, health & economic 33% Governance & decision-making 17% Unexplained 34% Mays et al. 2009
Mortality reductions attributable to local
public health spending, 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
Effects of public health spending
on medical care spending 1993-2008
log regression estimates controlling for community-level and state-level characteristics
*p<0.10 **p<0.05 ***p<0.01
Change in Medical Care Spending Per Capita Attributable to 1% Increase in Public Health Spending Per Capita
Model N Elasticity S.E.
One year lag 8532 -0.088 0.013***
Five year lag 6492 -0.112 0.053**
Ten year lag 4387 -0.179 0.112
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
Medical cost offsets attributable to local
public health spending, 1993-2008
For every $10 of public health spending, ≈$9 are recovered in lower medical care spending over 15 years
Economies of scale and scope
in public health delivery
Gains in effectiveness and efficiency from:
Delivering programs that reach larger populations Pooling resources & expertise across multiple
organizations, communities, states
Realizing synergies across multiple related programs & services
Economies of scale and scope
in local public health delivery systems
Source: 2010 NACCHO National Profile of Local Health Departments Survey
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% of Agencies % of Population Served
<50k 50k – 499k 500k+
$0 $500 $1,000 $1,500 $2,000 0 200 400 600 800 1000 $0 $1,000 $2,000 $3,000 $4,000 $5,000 0% 20% 40% 60% 80% 100%
Scale (Population in 1000s) Scope (% of Activities)
Quality (Perceived Effectiveness)
C os t ($ 10 0 0s ) C os t ($ 10 0 0s ) $0 $500 $1,000 $1,500 $2,000 0% 20% 40% 60% 80% 100%
Empirical estimates of scale and scope effects in local public health delivery
Simulated Effects of Regionalization
-20% -15% -10% -5% 0% 5% 10% 15% <25,000 <50,000 <100,000 <150,000 Per Capita Cost Scope Quality Regionalization Thresholds P e rc e nt C ha ngeScale effects in delivery
of local injury prevention programs
Population size P er cen t o f ag en ci es 0% 10% 20% 30% 40% 50% 60% 70% <25,000 25k-49k 50k-99k 100k-499k 500k+ Injury prevention Violence prevention Injury surveillance
Scale and scope issues in state injury prevention: centralization
Safe States Alliance. State of the States Report, 2011
IVP activities decentralized IVP activities centralized
2012 Institute of Medicine
Recommendations
Double current federal spending on public health
Allow greater flexibility in how states and localities
use federal public health funds
Identify components and costs of a minimum
package of public health services
Implement national chart of accounts
for tracking spending & funds flow
Expand research on costs and effects
of public health delivery
Institute of Medicine. For the Public’s Health: Investing in a Healthier Future. Washington, DC: National Academies Press; 2012.
Forces of change in public health delivery
Next Generation Public Health
Green SM et al. Ann Intern Med. 2012;157(3):207-210
Harvesting the power of public health systems: Toward “rapid-learning systems”
Can Practice-Based Research Networks
Help?
Practice partners to help identify the most pressing questions to answer
Multiple practice settings for analysis and comparison
Research partners to help design studies that balance rigor, relevance, feasibility
Collaborative interpretation of results context Translating results to timely practice
Public Health Practice-Based Research
Networks (PBRNs)
First cohort (December 2008 start-up) Second cohort (January 2010 start-up) Affiliate/Emerging PBRNs (2011-13)
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
Moving delivery systems forward
Public health delivery systems are engines for injury prevention & control
Compelling opportunities for improving capacity, effectiveness, & efficiency
Growing urgency to demonstrate value and ROI
Imperatives to achieve equity in public health
protection
For 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: www.works.bepress.com/glen_mays