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University of Kentucky

UKnowledge

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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Repository Citation

Mays, Glen P., "Harnessing the Power of Public Health Systems for Injury Prevention & Control" (2013).Health Management and Policy Presentations. 22.

(2)

Harnessing the Power of Public Health Systems for Injury Prevention & Control

Glen Mays, PhD, MPH University of Kentucky

glen.mays@uky.edu

(3)

WHO 2010

(4)

Falling behind in population health

Preventable Deaths per 100,000 population
(5)

Inequities in population health

(6)

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 prevention
(7)

Preventable 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 programs
(8)

Challenges 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

(9)

Public health delivery systems

(10)

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

(11)

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%

(12)

Variation in Public Health Delivery

Delivery of recommended public health activities

(13)

Why study public health delivery?

“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.”

(14)

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

(15)

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

(16)

PHSSR and policy relevance

Patient Protection and Affordable Care Act of 2010
(17)

A 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

(18)

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?

(19)

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

(20)

Private and voluntary organizations contributed more than

of the public health activities performed in the average U.S. community in 2012.

(21)

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

(22)

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

(23)

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?

(24)

Factors driving growth in medical spending

per case

(25)

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

(26)

Funding sources for injury prevention

Federal, 61% State, 36% Other, 3%
(27)

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 $250

Expenditures per capita, 2010

(28)

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%

(29)

Variation in Injury Prevention Spending, 2011

(30)

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

(31)

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

(32)

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

(33)

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

(34)

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

(35)

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+

(36)

$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

(37)

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 nge
(38)

Scale 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

(39)

Scale and scope issues in state injury prevention: centralization

Safe States Alliance. State of the States Report, 2011

IVP activities decentralized IVP activities centralized

(40)

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.

(41)

Forces of change in public health delivery

Next Generation Public Health

(42)

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

Harvesting the power of public health systems: Toward “rapid-learning systems”

(43)

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

(44)

Public Health Practice-Based Research

Networks (PBRNs)

First cohort (December 2008 start-up) Second cohort (January 2010 start-up) Affiliate/Emerging PBRNs (2011-13)

(45)

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

(46)

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

(47)

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

Health Management and Policy Presentations Health Management and Policy Community Health and Preventive Medicine Commons, Health EconomicsCommons Health Services Research Commons https://uknowledge.uky.edu/hsm_present/22 context

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