Harvesting the Power of Public Health Systems for Injury Prevention & Control Glen Mays, PhD, MPH University of Kentucky University of Kentucky [email protected]
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Harvesting the Power of Public Health Systems for Injury Prevention & Control
Glen Mays, PhD, MPH University of KentuckyUniversity of Kentucky
Gaps in health system performanceGaps in health system performance
WHO 2010
Falling behind in population healthPreventable Deaths per 100,000 population
Inequities in population healthInequities in population health
Source: Commonwealth Fund 2012
Preventable disease burden Preventable disease burden and national health spendingand national health spending
>75% of national health spending is attributable to conditions that are largely preventableto conditions that are largely preventable
– Cardiovascular disease– Diabetes– Diabetes– Lung diseases– Cancer– Injuries– Vaccine-preventable diseases and sexually
transmitted infections
<5% of national health spending is allocated to<5% of national health spending is allocated to public health and prevention
CDC 2008 and CMS 2011
Preventable disease burden Preventable disease burden and national health spendingand national health spending
$406 Billion annually in medical costs and$406 Billion annually in medical costs and lost productivity due to injury
$$102 Million annually spent on state injury and violence prevention programs
Safe States Alliance. State of the States Report, 2011
Challenges in public health delivery
Resources ǂ preventable disease burden
C l f t d i bl d li tComplex, fragmented, variable delivery systems
Large inequities in resources & capacity
Variable productivity and efficiency
G i id b f bli h lth d liGaps in evidence base for public health delivery
Inability to demonstrate value/return on investment
Public health delivery systemsPublic health delivery systems
National Longitudinal Survey of Public Health Systems, 2012
Breadth of i i
Scope of
Complexity in public health deliveryComplexity in public health delivery
Public HealthS t
Public Health AgencyLegal authority
organizations
Scope of services GoverningF di l l
Division of responsibility
pactivityScale of
operations
System
P ti i tiIntergovernmental
LeadershipDistribution of effort
servicesStaffing levels
& mix
Governing structure
Funding levels & mix
Compatibility of missionsResources &
expertiseParticipation
incentives
grelationships
N d
of effortNature & intensity
of relationships Decision Support•Accreditation
StrategicDecisions
NeedsPreferences
Risks Population & i
•Accreditation•Performance measures•Practice guidelines
Perceptions
EnvironmentResources
ThreatsOutputs and Outcomes
Reach Adherence to EBPsp ReachEffectivenessTimeliness
EfficiencyEquityMays et al 2009
Variation in Public Health DeliveryVariation in Public Health Delivery
D li f d d bli h lth ti itiD li f d d bli h lth ti itiDelivery of recommended public health activitiesDelivery of recommended public health activities
90%
100% Assurance Policy Assessment
70%
80%
90%
es
40%
50%
60%
f act
iviti
e
20%
30%
40%
% o
f
0%
10%
1998 2006 2012
↑ 10% ↓ 5%National Longitudinal Survey of Public Health Systems 2010; 2012
Variation in Public Health DeliveryVariation in Public Health Delivery
D li f d d bli h lth ti itiD li f d d bli h lth ti itiDelivery of recommended public health activitiesDelivery of recommended public health activities
Trust for America’s Health. 2013
Why study public health delivery?Why study public health delivery?“The Committee had hoped to provide specific guidance elaborating on the types and levels of
kf i f t t l t d dworkforce, infrastructure, related resources, and financial investments necessary to ensure the availability of essential public health services to allavailability of essential public health services to all of the nation’s communities. However, such evidence is limited, and there is no agenda or , gsupport for this type of research, despite the critical need for such data to promoteand protect the nation’s health.”
—Institute of Medicine 2003—Institute of Medicine, 2003
Public health services Public health services & systems research& systems research& systems research& systems research
A field of inquiry examining the organization, financing, and deliveryorganization, financing, and deliveryof public health services at local, state and national levels and the impact ofand national levels, and the impact of these activities on population health
Mays, Halverson, and Scutchfield. 2003
PHSSR’s place in the continuumPHSSR’s place in the continuum
Intervention Research
Services/Systems ResearchResearch
What works – proof of efficacy
ResearchHow to organize, implement and sustain in the real worldof efficacy
Controlled trials
G id t C it
and sustain in the real-world – Reach– Enforcement/Compliance
Guide to Community Preventive Services
p– Quality/Effectiveness– Cost/Efficiency
E it /Di iti– Equity/Disparities
Impact on population health
Comparative effectiveness & efficiency
PHSSR and policy relevancePHSSR and policy relevance
Patient Protection and Affordable Care Act of 2010
A national research agenda A national research agenda to improve public health delivery systemsto improve public health delivery systemsPublic health system organization and structure
Public health financing and economicsPublic health financing and economics
Public health workforce
Public health information and technology
Cross-cutting elementsg− Quality− Law and policy− Equity and disparities− Metrics and data− Analytic methods
http://www.publichealthsystems.org/research-agenda.aspx
Emerging evidence:Emerging evidence:organization and structureorganization and structureorganization and structureorganization and structure
Who contributes to public health delivery?p y
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 engagedOrganizations engagedin local in local ppublic health deliveryublic health delivery
-50% -30% -10% 10% 30% 50%
Local health agency
% Change 2006-2012 Scope of Delivery 2012
Local health agency
Other local government
State health agency
Other state government
Hospitals
Physician practices
Community health centers
Health insurersHealth insurers
Employers/business
Schools
CBOs
National Longitudinal Survey of Public Health Systems, 2012
Private and voluntary organizations t ib t d thcontributed more than
of the public health activities performed i th U S it i 2012in the average U.S. community in 2012.
Mays GP et al. National Longitudinal Survey of Public Health Systems, 2013.
A typology of public health delivery systemsA typology of public health delivery systems50%
40%
45%
50%19982006
2012ies
25%
30%
35% 2012
omm
uniti
10%
15%
20%
% o
f co
Scope High High High Mod Mod Low Low0%
5%
10%
1 2 3 4 5 6 7Scope High High High Mod Mod Low LowCentralization Mod Low High High Low High LowIntegration High High Low Mod Mod Low Mod
Source: Mays et al. 2010; 2012
Comprehensive Conventional Limited
Changes in health associated with delivery systemChanges in health associated with delivery systemInfant Deaths/1000 Live Births
0 3
0.4 Infant Deaths/1000 Births
0.0
0.1
0.2
0.3Percent Changes in Preventable Mortality Rates by System Typology (cluster)
6 08.0 10.0
-0.1
Cluster 3 Clusters 4-5 Cluster 6 Cluster 7
Cancer deaths/100,000 population Heart Disease Deaths/100,000Clusters 1-3
-4.0-2.00.02.04.06.0
2.0
4.0
6.0
8.0
-6.0
Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.0
Cluster 3 Clusters 4-5 Cluster 6 Cluster 7
1 0
2.0
3 0
4.0Influenza Deaths/100,000 Infectious Disease Deaths/100,000Clusters 1-3Clusters 1-3
-2 0
-1.0
0.0
1.0
0 0
1.0
2.0
3.0
Fixed-effects models control for population size, density, age composition, poverty status, racial composition, and physician supply
-2.0
Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.0
Cluster 3 Clusters 4-5 Cluster 6 Cluster 7Clusters 1-3Clusters 1-3
Emerging evidence:Emerging evidence:finance and economicsfinance and economicsfinance and economicsfinance and economics
How does public health spending vary across p p g ycommunities and change over time?
What are the health effects attributable toWhat are the health effects attributable to changes in public health spending?
What are the medical cost effects attributable toWhat are the medical cost effects attributable to changes in public health spending?
Wh t th t iti f i iWhat are the opportunities for improving efficiency in public health delivery?
Factors driving growth in medical spendingFactors driving growth in medical spending
per case
Roehrig et al. Health Affairs 2011
Public health’s share of national health spendingPublic health’s share of national health spending$Billions %NHEUSDHHS National Health Expenditure Accounts
$80
$90State and Local
3 00%
3.50%$ %
$60
$70Federal
2.50%
3.00%
$40
$50
$60
1 50%
2.00%
$20
$30
$40
1.00%
1.50%
$
$10
$200.50%
$0
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
0.00%
Funding sources for injury preventionFunding sources for injury prevention
St t
Other, 3%
State, 36%
Federal, 61%
Safe States Alliance. State of the States Report, 2011
Variation in Local Public Health SpendingVariation in Local Public Health Spending
.15
.1uniti
es Gini = 0.485
of c
omm
u.0
5Pe
rcen
t 00
$0 $50 $100 $150 $200 $250Expenditures per capita, 2010
Changes in Local Public Health SpendingChanges in Local Public Health Spending19931993--20102010
.25
.2un
ities
62%
.15
of c
omm
u 62% growth
38%.1Pe
rcen
t 38% decline
.05
0
-100 -50 0 50 100Change in per-capita expenditures ($)
Variation in Injury Prevention Spending, 2011Variation in Injury Prevention Spending, 2011
Safe States Alliance. State of the States Report, 2011
Determinants of Public Health Determinants of Public Health Spending LevelsSpending LevelsSpending LevelsSpending Levels
S i iService mix16%
Demographic
Unexplained34%
Demographic, health &
economic33%
Governance& decision-
making17%
– Delivery system size & structure– Service mix
Population needs and risks– Population needs and risks– Efficiency & uncertainty
Mays et al. 2009
Mortality reductions attributable to localMortality reductions attributable to localpublic health spending, 1993public health spending, 1993--20082008
1
2
Infant mortality
Heart disease Diabetes Cancer Influenza All-cause Alzheimers Injury
-1
0
1
e
4
-3
-2
nt c
hang
e
-6
-5
-4
Perc
en
-9
-8
-7
-9Hierarchical regression estimates with instrumental variables to correct for selection and unmeasured confounding
Mays et al. 2011
Effects of public health spending Effects of public health spending on medical care spending 1993on medical care spending 1993--20082008on medical care spending 1993on medical care spending 1993--20082008
Change in Medical Care Spending Per Capita Attributable to g p g p1% Increase in Public Health Spending Per Capita
Model N Elasticity S.E.
One year lag 8532 0 088 0 013***One year lag 8532 -0.088 0.013
Five year lag 6492 -0.112 0.053**
Ten year lag 4387 -0.179 0.112
log regression estimates controlling for community-level and state-level characteristics
*p<0.10 **p<0.05 ***p<0.01 Mays et al. 2013
Medical cost offsets attributable to localMedical cost offsets attributable to localpublic health spending, 1993public health spending, 1993--20082008
For every $10 of public health spending, ≈$9 are recovered in lower medical care spending over 15 years
7000
7200120
) .
. Public health spending/capita
6600
6800
7000
80
100
ng/person ($)
ng/capita
($)
Medicare spending per recipient
6200
640040
60
edical sp
endin
ealth spen
din
5800
6000
0
20
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
Me
Public he
Quintiles of public health spending/capitaMays et al. 2009, 2013
Economies of scale and scope in public health deliveryin public health delivery
Gains in effectiveness and efficiency from:y
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
Economies of scale and scope in local public health delivery systems
J i di i Si
90%
100%
500k+
Jurisdiction Size
70%
80%
50%
60% 50k –499k
30%
40%
10%
20%<50k
Source: 2010 NACCHO National Profile of Local Health Departments Survey
0%% of Agencies % of Population Served
Scale (Population in 1000s) Scope (% of Activities)
Empirical estimates of scale and scope effects Empirical estimates of scale and scope effects in local public health deliveryin local public health delivery
$1,500
$2,000
$4,000
$5,000Scale (Population in 1000s) Scope (% of Activities)
s)
$500
$1,000
$1 000
$2,000
$3,000
Cos
t ($
1000
s
$0
$500
0 200 400 600 800 1000$0
$1,000
0% 20% 40% 60% 80% 100%
Q lit (P i d Eff ti )
C
Quality (Perceived Effectiveness)
0s)
$1,500
$2,000
Cos
t ($
1000
$500
$1,000
$0
$500
0% 20% 40% 60% 80% 100% Source: Mays et al. 2012
Simulated Effects of Regionalization
15%
5%
10%
ge
0%
nt C
hang
‐10%
‐5%
Per Capita Cost
S
Perc
en
%
‐15%Scope
Quality
‐20%<25,000 <50,000 <100,000 <150,000
Regionalization Thresholds Source: Mays et al. 2012
Scale effects in delivery of local injury prevention programsj y p p g
70%Injury preventionVi l ti
ncie
s
50%
60% Violence preventionInjury surveillance
t of a
gen
30%
40%
Perc
ent
20%
30%
0%
10%
<25 000 25k 49k 50k 99k 100k 499k 500k+Population size
<25,000 25k‐49k 50k‐99k 100k‐499k 500k+
Source: 2010 NACCHO National Profile of Local Health Departments Survey
Scale and scope issues in state injury prevention: centralization
2009 2011IVP activities decentralized
IVP activities centralized
2009 2011
Safe States Alliance. State of the States Report, 2011
2012 Institute of Medicine 2012 Institute of Medicine RecommendationsRecommendations
Double current federal spending on public health
All fl ibili i h d l li i 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 deliveryp y
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 deliveryForces of change in public health delivery
Next Generation Public HealthPublic Health
Delivery
Harvesting the power of public health systems:Toward “rapid-learning systems”
Green SM et al. Ann Intern Med. 2012;157(3):207-210
Can Practice-Based Research Networks Help?
Can Practice-Based Research Networks Help?
Practice partners to help identify the most pressing ti tquestions to answer
Multiple practice settings for analysis and comparison
Research partners to help design studies that balance rigor, relevance, feasibility, y
Collaborative interpretation of results context
Translating results to timely practiceand policy actions
Public Health Practice-Based Research Networks (PBRNs)
First cohort (December 2008 start‐up)Second cohort (January 2010 start‐up)Affiliate/Emerging PBRNs (2011‐13)Affiliate/Emerging PBRNs (2011 13)
PBRNs and Delivery System Change
Local Health Departments Engaged in Research Implementation & Translation Activities During Past 12 months
PBRN Agencies National SampleActivity Percent/Mean Percent/Mean
Implementation & Translation Activities During Past 12 months
Identifying research topics 94.1% 27.5% ***Planning/designing studies 81.6% 15.8% ***Recruitment, data collection & analysis 79.6% 50.3% **
84 5% 36 6%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)Research implementation composite 84.04 (27.38) 30.20 (31.38) **N 209 505
Moving delivery systems forwardMoving delivery systems forward
Public health delivery systems are engines for injury prevention & controlinjury prevention & control
Compelling opportunities for improving capacity, effectiveness, & efficiency
Growing urgency to demonstrate value and ROI
Imperatives to achieve equity in public health protectionprotection
Connecting research and practice is key
For More InformationFor More Information
Supported by The Robert Wood Johnson Foundation
Glen P. Mays, Ph.D., [email protected]
Email: [email protected]: www.publichealthsystems.orgJournal: www FrontiersinPHSSR orgJournal: www.FrontiersinPHSSR.org
Archive: www.works.bepress.com/glen_mays
University of Kentucky College of Public HealthLexington, KY
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