Category Archives: PHSSR
Today’s plenary speaker at the 2013 Keeneland Conference is William Roper, MD, MPH, dean of the school of medicine, vice chancellor for medical affairs and CEO of the UNC Health Care System at the University of North Carolina at Chapel Hill. Earlier in his career, Dr. Roper was senior vice president of Prudential HealthCare, president of the Prudential Center for Health Care Research, director of the Centers for Disease Control and Prevention and administrator of the Health Care Financing System, the precursor to the Center for Medicare and Medicaid Services.
NewPublicHealth spoke with Dr. Roper on his way to the Keeneland Conference about the drive to better use data, instead of anecdotes and personal beliefs, to drive decision-making.
NewPublicHealth: What were some of the early efforts you were involved in that set the stage for the field of public health services and systems research we know today?
Dr. Roper: I didn’t do this by myself; I did it with a lot of other people, but one of the critical early efforts was the publication of Medicare mortality information on all American hospitals beginning in 1986 and continuing for a number of years thereafter. Another was creation of the Agency for Healthcare Policy and Research in 1989, which has since been renamed the Agency for Healthcare Research and Quality. Another was the launching of the Prevention Effectiveness Initiative at CDC in the early 90s. And then subsequently, work that I’ve done at the University of North Carolina, first at the School of Public Health and then at the School of Medicine using the tools of health services research broadly in health care and in public health.
NPH: What are some of the fruits of those efforts?
The Public Health Quality Improvement Exchange (PHQIX) is a brand new online community designed to be a communication hub for public health professionals interested in learning and sharing information about quality improvement (QI) in public health. PHQIX was created by RTI International and funded by the Robert Wood Johnson Foundation. The key goal of the site is to share national QI efforts by health departments of all sizes so that public health experts can learn from the experience of their colleagues across the country. NewPublicHealth recently spoke with Jamie Pina, PhD, MSPH, PHQIX project director, and Pamela Russo, senior program director at the Robert Wood Johnson Foundation about the new resource and its promise for helping health departments continuously improve their performance and achieve the national standards set forth by the Public Health Accreditation Board.
NewPublicHealth: What’s the vision of PHQIX, and how did it come about?
Pamela Russo: Public health departments are looking for ways to be more and more efficient and to eliminate waste and to make their limited budgets have the maximum possible impact. That’s the major value of QI, to show what works and where you can improve.
The new issue of Frontiers in Public Health Services and Systems Research (PHSSR), an online journal that looks at early research on issues related to public health services and delivery, focuses on quality improvement in practice-based research networks.
This issue’s commentary, from the journal’s editor, Glen Mays, PhD, MPH, is about a series of studies sponsored by the Robert Wood Johnson Foundation that look at how public health decision-makers are responding to accreditation, quality improvement, and public reporting initiatives during ongoing fiscal problems. Mays is co-principal Investigator of the National Coordinating Center on PHSSR, Director of the Public Health Practice-Based Research Networks and the F. Douglas Scutchfield Endowed Professor at the University of Kentucky College of Public Health. Mays says that, overall, the current evidence shows that “these initiatives represent promising strategies for strengthening evidence-based decision-making and expanding the delivery of evidence-tested programs and policies in local public health settings.”
Mays adds that continued comparative research and evaluation activities are needed to provide more definitive evidence about which combination of strategies work best, for which population groups, in which community and organizational settings, and why.
Public health has experienced major economic, environmental, and technology upheavals in recent years. A new round of research supported by the Robert Wood Johnson Foundation (RWJF) will examine how recent dramatic changes in the operation of the nation’s public health system impact its effectiveness in such critical roles as emergency preparedness and reporting of disease outbreaks.
Seven new research awards are part of an initiative on “natural experiments” in public health delivery developed by the National Coordinating Center for Public Health Services and Systems Research (PHSSR), a RWJF-funded center housed at the University of Kentucky College of Public Health. The awards of $200,000 each are being administered by the National Network of Public Health Institutes.
NewPublicHealth spoke with Lainie Rutkow, PhD, JD, MPH, assistant professor at the Johns Hopkins Bloomberg School of Public Health, about her award to assess whether state laws influence the public health workforce’s willingness to respond in emergencies. The award will include collaboration with the National Registry of Emergency Medical Technicians; Butler County Health Department in Missouri; and the Multnomah County Health Department in Oregon. Rutkow, a member of the Eastern Region of the Network for Public Health Law, will also be presenting about some of her other emergency preparedness work at the Public Health Law Conference in Atlanta this week.
>>Follow NewPublicHealth coverage of the Public Health Law Conference, with speaker interviews, session coverage and more.
NewPublicHealth: Tell us about natural experiments and the opportunity they offer to better understand how the public health system can operate more effectively.
Lainie Rutkow: Natural experiments really capitalize on variations that already exist, particularly within the public health system, and as researchers we can analyze the public health impacts of a natural experiment over time and also in different settings. I see natural experiments as an opportunity to compare populations who are exposed to a particular policy with populations that have not been exposed to that policy. It would be very difficult or impossible to do that kind of thing in a controlled research setting.
NPH: What is your particular award designed to look at?
Developing the next generation of researchers who will examine how the organization, financing and delivery of public health services affect population health is the goal of a new funding opportunity — the Mentored Research Scientist Development Awards — from the National Coordinating Center for Public Health Services and Systems Research (PHSSR) and the Robert Wood Johnson Foundation.
The goal of the grants is to provide relevant information to public health practitioners and policy-makers, which is critically needed to help to improve the quality, efficiency and equity in public health practice, and the nation’s health.
The grants are aimed at supporting early-career investigators for two years for up to $100,000 per scholar. The grants will help the investigators establish independent research careers in PHSSR, and are designed to enhance the researchers’ career development experiences, help them attain advanced research skills in PHSSR and position them for other funding opportunities.
“Solid, relevant research requires that we attract the best and brightest minds to our discipline,” said F. Douglas Scutchfield, M.D., director of the National Coordinating Center for PHSSR, which is funded by RWJF and housed at the University of Kentucky College of Public Health. “We must accelerate, encourage and support a new generation of PHSS researchers, and [these new grants] are designed to bring outstanding scholars to the field and provide them with the support and resources they need to become the next research leaders in PHSSR.”
NewPublicHealth spoke with Dr. Scutchfield recently, about creating this new generation of PHSSR scholars.
Primary care and public health share a common goal but historically have functioned independently of each other. However, health experts say that better integration of the two disciplines could result in critical improvements in the health of individuals and communities. The Centers for Disease Control and Prevention and the Health Resources and Services Administration asked the Institute of Medicine (IOM) to look at issues related to the integration of primary care and public health, and the resulting report was released earlier this year.
The recent report on integrating was so groundbreaking, that it has launched a number of discussions and publications on the issue, including a keynote panel at the recent 2012 Keeneland Conference, a first ever joint issue of the American Journal of Preventive Medicine and the American Journal of Public Health and a session on the report at next week’s AcademyHealth Annual Research Meeting by the IOM report’s committee chair, Paul Wallace, MD. NewPublicHealth spoke with Dr. Wallace, Director of the Center for Comparative Effectiveness Research at the Lewin Group, about the committee’s critical finding and recommendations.
The IOM identifies a set of core principles common to successful integration efforts, such as involving the community in defining and addressing its needs. The principles provided in this report can serve as a roadmap to move the nation toward a more efficient health system.
NewPublicHealth: What were the key findings were in the report?
Dr. Wallace: There are many instances in which communities have figured out aspects of integration but, as we learn over and over again in health care, solutions often need to be locally adaptive, and that holds true in thinking about how integration takes place as well.
I think what was very helpful for us was recognizing that integration is really a continuum, sort of extending from either being disintegrated or, if you will, parallel play on one end up through quite formal partnerships or mergers on the other end. There are opportunities for creating better care and efficiencies along that continuum. For public health to be aware of what primary care is doing and for primary care to be deeply aware of what public health is doing would be a substantial element of progress.
NPH: Why is integration coming about now?
Dr. Wallace: It isn’t quite yet. Until about a hundred years ago health care was the province, almost exclusively, of the clinician-patient relationship. Previously, though, if you go back 150 years, in medical schools, there was really a sort of blending of what we now would think of as public health and what we think of as health care. But the Flexner Report back in the early 20th century re-configured how medical education took place, which changed the structure of medical schools, and public health wasn’t really part of that.
The other thing that happened was that public health was figuring out what it needed as an academic base, and that was about the time that the Rockefeller Foundation stepped up and started funding separate schools of public health. So really what happened is that the education and the academic foundation sort of diverged and they followed separate paths for most of the last century.
NPH: With stronger collaboration between public health and health care, what could be achieved?
Dr. Wallace: I think if you look at it from a patient-centered perspective, there would be rational and consistent availability and access to a whole range of services like healthy food and the ability to exercise, and it would be reinforced by our public policy. There would be a shared awareness of who are the people at greatest risk, perhaps related to data and information systems. There would be an alignment between messaging from public health agencies and what you would hear in your clinician’s office. And in the clinician’s office there would be recognition that it isn’t just about doing physical exams and prescribing pills, it’s also thinking about aspects of healthy living such as active living and healthy eating.
But I think that there really would just be a blending of the whole continuum, and I think that the other really important thing is that a lot of the emphasis would shift from fixing things through health care to more of a proactive context of prevention, and really primary prevention. It’s about not waiting until people have high cholesterol and heart attacks and then trying to treat them with lipid-lowering drugs, but thinking how you get ahead of this in public schools, in the workplace and in our communities.
NPH: Would money be saved with the appropriate integration?
Dr. Wallace: Another way to think about it would be—can we get more health for the dollars we’re spending? We certainly could make the system more efficient. There are a lot of issues of maldistribution, for instance, where we tend to over-treat certain people in certain ways, and as a consequence there are other folks who are poorly treated. The disparities discussion I think is a very rich one that’s right in the middle of this.
Over time, we might start to see spending migrate from very high-risk dollars on things that are very unlikely to work with expensive interventions, to more fundamental upstream interventions that will have dividends over many years.
NPH: Is it sufficient to just have primary care and public health at the table together to solve the massive problems that have been created?
Dr. Wallace: If you really want to create health on a community basis, you need public health and you need the health care delivery system, primary care, but almost all of the successful programs also have some third party. And that third party may be government, it may be schools, it may be a faith-based organizations. It gives you sort of a place to convene. Rather than having public health and primary in a tug of war over who is bigger and brighter and smarter, you realign that effort to think about how we can collectively engage to support this third party. That sort of triangulation I think is a really critical thing about trying to bring these mindsets and forces back together.
NPH: What are the next steps to the report’s findings?
Dr. Wallace: What was different about this report we feel is that it involved people who have a direct interest in this, who are motivated to actually do some things to try and support this. CDC and HRSA, who together commissioned the report, between them have a footprint that really extends into every community. They’re actively thinking together about a lot of things that we’ve suggested, but a lot of our suggestions reflected openness from them to where they want to go. CDC and HRSA are increasingly aware of what each other are doing, they actively cooperated in funding the study and they’re collaborating now in thinking about some funding models.
There are also workforce issues. There probably is a set of workers who are critical to this and they aren’t necessarily traditional health care roles, but they’re more like the community health worker who can help people with education. They’re in the community, they understand the culture, they understand the nuance and may be more effective at translating some of these messages.
NPH: What made it feasible to have a receptive audience for this report now?
Dr. Wallace: There is a growing understanding of what population health is, and in a sense that population health is bigger than either primary care or public health and it’s only going to get addressed if they do it collaboratively. The other really critical factor that makes things different now is the availability of data. That is just fundamentally changing people’s thinking. An example of that would be creating community-wide registries that can be used to recognize where there’s opportunity such as pockets of a city that have a very high incidence of asthma, and then being able to think about what are the community or public health-based interventions.
Data democratization is also creating new levels of transparency and accountability. There’s this growing recognition that you can now know what is going on, where before people always wondered or hypothesized.
Last week’s Keeneland Conference included a session that looked at research in the area of law and legal process. The session was moderated by Scott Burris, JD, director of Public Health Law Research, a program of the Robert Wood Johnson Foundation, based at Temple University.
Burris noted several key presentations during the conference including one by Julia Costich, JD, PhD, who is an associate professor in the Department of Health Services Management at the University Of Kentucky College Of Public Health. Costich presented on the importance of how health agencies enforce the power they have. Burris says there is a huge body of literature from regulatory and governance sources on how effective regulators regulate—and that public health is only beginning to draw on. “That’s really opening a big important door, and we’ll see a lot more about that in future years.”
Jennifer Ibrahim, PhD, MPH, an associate professor of public health at Temple University, looked at how law is being figured out at the local level. Burris said that researchers both at the Public Health Law Research Program and collaborators have conducted research on the relationship between state and local health officers and their lawyers.
National Public Health Accreditation launched last fall, and since then 64 local health departments, three tribal health departments and one state department have submitted applications to the National Public Health Accreditation Board (PHAB). Carol Moehrle, chair of PHAB and director of public health for the Idaho North Central District, spoke about the accreditation process and benefits during a keynote speech at the Keeneland Conference. NewPublicHealth caught up with Carol Moehrle during the meeting.
NewPublicHealth: Are you pleased with the number of applicants you’ve seen so far?
Carol Moehrle: We are pleased. We knew we’d have some early adopters. And to have 68 complete their applications with the last seven months, that’s a great start. We’ve got a long way ahead, but we also know we have many applicants in the queue waiting to apply. We’re hearing lots of good energy, and departments beginning the process now can look to the earlier applicants for best practices, so applying will be easier as time goes on.
NPH: What is the process and timetable for accreditation application review?
Richard J. Umbdenstock, American Hospital Association: Opportunities for Collaboration Between Health and Health Care
The intersection of health and health care was an important theme at this year’s Keeneland Conference—during sessions on recent IOM reports, in hallway conversations, in discussions of Public Health Services and Systems Research that explores the most efficient ways to deliver public health services, and, notably, during the keynote address by Richard Umbdenstock, president and CEO of the American Hospital Association.
In his presentation, Umbdenstock talked about hospitals and public health, "collaborating for communities," and said that as health care providers, hospitals had tended to focus on treating the individual, rather than on prevention for the population. Now, he said, the money is gone and the public cares more about health, meaning it makes less and less sense for either hospitals or public health to be concerned with protecting their turf. “We need to incent health and deglamourize consumption.” Quoting a colleague, Umbdenstock said “what we need to do is create an epidemic of health.”
Umbdenstock spoke frankly when he told the attendees, “hospitals want to improve the lives of their patients, and not just their health care. Rather than wait for an [hospital] admission that won’t be paid, they’d rather get upstream on primary care.”
“Public health departments must be funded and supported so that wellness and prevention touches all and there are enough resources to do that,” said Umbdenstock. “And this is where research can play a big part—collaborative health research. We need to know the most effective collaborative models and the most effective ways to advocate for greater personal and community responsibility.”
NewPublicHealth caught up with Richard Umbdenstock following his talk.
NewPublicHealth: What are you hearing from hospitals about the new IRS community benefit requirement?
Richard Umbdenstock: Some hospitals have had similar responsibilities at the state level and many have had to put out accountability reports to their communities, so for many it’s not a new concept. In addition, hospitals have long been under a microscope and they also understand that community benefit is a wonderful community education tool. If they can tell it in a clear and consistent fashion, there’s a real opportunity for the public to better understand what hospitals and public health departments do.
NPH: Do hospitals and public health understand the critical community roles each one plays?
Richard Umbdenstock: I don’t think there’s any question what public health departments do after you’ve see them spring into action after a disaster, just as a lot of people don’t value what hospitals do until after they’ve been a patient. On a day-to-day basis we can all get so deep in our work that we just don’t see what the other person is doing. What we’re learning is that we all serve the same person.
Frontiers in Public Health Services & Systems Research: Making Critical Research Accessible, Quickly
Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. Today, Glen Mays, MPH, PhD, F. Douglas Scutchfield Endowed Professor of Health Services and Systems Research at the University of Kentucky College of Public Health, talks about the launch of a brand new online journal covering public health systems and services research, and why it is so critical right now, to inform smart investments in public health and prevention. The new journal, Frontiers in PHSSR, is designed to disseminate the most critical early findings from PHSSR research much faster—making these findings accessible far in advance of the fully-developed scientific manuscript. To be eligible for inclusion in Frontiers, findings must have the potential to guide future public health practice, health policy, and research. Mays is the editor in chief of the new journal.
Portions of the post below are adapted from the opening commentary in Frontiers, authored by Mays, F. Douglas Scutchfield, Paul K. Halverson, William Riley and Peggy Honore.
The need for a strong and effective public health system in the United States is perhaps more urgent today than at any other time in our nation’s history. Preventable diseases and injuries account for more than three-fourths of the $2.6 trillion in health care expenditures incurred annually in the U.S. The growing prevalence of obesity, diabetes and other preventable conditions constrains the nation’s economic productivity and global competitiveness. The American public health system—the diffuse constellation of governmental public health agencies and their peers and partners in community-based settings and the private sector—is tasked with developing and delivering strategies that promote health and prevent disease and injury on a population-wide basis. They share the mission of creating conditions in which people can be healthy.
The public health system is uniquely positioned—but not optimally equipped or resourced—to take on these challenges. Only about 3 percent of the nation’s $2.6 trillion in annual health expenditures is devoted to public health activities. Some of our greatest uncertainties now lie in how best to organize, finance, and deliver effective public health prevention strategies to communities across the U.S. The field of public health services and systems research (PHSSR) has emerged to fill this void.
Frontiers in PHSSR
The American public health system and the populations it serves do not have the luxury of waiting the 15 years typically required to get research-tested solutions widely adopted into practice. The costs associated with missed opportunities for disease prevention and health promotion are straining government and household budgets now.
To help develop and grow this scientific learning community, we have launched a new, open-access, peer-reviewed journal, Frontiers in Public Health Services and Systems Research. This journal provides a platform for rapidly and widely communicating emerging findings and lessons learned from studies of public health services and delivery systems. Frontiers will feature brief descriptions of preliminary findings from ongoing or recently completed empirical studies and quality improvement projects that answer important questions regarding the organization, financing, and delivery of public health services.