Public Health Systems Research: What, Why, and How?

Public Health Systems Public Health Systems Research: Research:

What, Why, and How? What, Why, and How?

Public Health Systems Public Health Systems Research: Research:

What, Why, and How? What, Why, and How? Lunch and LearnLunch and Learn

23 September 200523 September 2005

Public Health Systems Public Health Systems Research: Research:

What, Why, and How? What, Why, and How? 23 September 200523 September 2005

Hugh H. Tilson Hugh H. Tilson

Public Health Systems Public Health Systems Research: Research:

What, Why, and How? What, Why, and How? Hugh Tilson (Glen Mays)Hugh Tilson (Glen Mays)

What is Public Health Systems Research?What is Public Health 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

Mays, Halverson, and Scutchfield. JPHMP 2003

What Constitutes a Public Health System?What Constitutes a Public Health System?

The collection of governmental and private entities that contribute to the delivery of public health services for a defined population.

How to define the population?

Local vs. state systems

Variation in system structure and composition

But first...But first...

a word from our sponsors!

Committee on Assuring the Health of the Public in the 21st Century

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

THE FUTURE OF

THE PUBLIC’S

HEALTH

in the 21st Century

Background in the ReportBackground in the Report

Health = Public Good

Government has fundamental, statutory duty to assure the health of the public, BUT …

Government cannot do it alone

Need for inter-sectoral engagement in partnership with government

Health = social goal of many sectors and communities

The Committee’s ConclusionThe Committee’s Conclusion

An inter-sectoral public health system is needed

In 1988 report, public health refers to the “organized efforts of society, both government AND OTHERS, to assure conditions in which people can be healthy”

THIS report elaborates on the efforts of the other potential public health system actors.

The Public Health SystemThe Public Health System

ME!! Employersand Business

Academia

GovernmentalPublic Health Infrastructure

The Media

Healthcare delivery

system

Community

The Public Health SystemThe Public Health System

Assuring the Assuring the Conditions for Conditions for

PopulationPopulationHealthHealth

Employersand Business

Academia

GovernmentalPublic Health Infrastructure

The Media

Healthcare delivery

system

Community

more inter-organizationally complex, slower rate of improvement

organizationally complex, faster rate of improvement

What Kinds of Work Must the Public What Kinds of Work Must the Public Health System Perform?Health System Perform?

Public Work (organizing, governance, citizenship, mutual accountability)

Professional Work (customers, products, services)

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Affected

PopulationwithDisease Developing

Complications

Population withComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

Milstein and Homer 2003

Demand for

response

Demand for

response

Demand for

response

Why Study Public Health Systems?Why Study Public Health Systems?

“Unlike the medical care system, there is little research and relatively few measures for studying how well the public health system operates.”

— Center for Studying Health System Change, 1996

Why Study Public Health Systems?Why Study Public Health Systems?

“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.”

—Institute of Medicine, 2003

Why Study Public Health Systems?Why Study Public Health Systems?

Concerns about preparedness for emerging threats

Wide variation in public health resources

Persistent disparities in outcomes

Difficulties demonstrating accountability/value for investments in public health

Desire for evidence-based decision-making

Why Study Public Health Systems?Why Study Public Health Systems?

Intervention Research What works – proof

of efficacy

Controlled trials

Guide to Community Preventive Services

Systems & Services Research

How to implement in real-world settings– Expand reach– Improve quality,

efficiency– Reduce disparities

Observational studies, CBPR

Where Are We Now? Where Are We Now?

Descriptive

Inferential

Interventional

Translational

How are public health systems organized and financed?

What do they do?

What factors influence their work?

How does their work influence the public’s health?

How can we improve performance and population health?

Research topics: Type:

The National PH Performance Standards The National PH Performance Standards Program(NPHPSP)Program(NPHPSP)

THREE “instruments”

OMB approved with ‘control numbers’

STATE

LOCAL

GOVERNANCE

The local public health system assessment The local public health system assessment instrumentinstrument

OMB Control Number 0920-0555

24 hours per response

“…ALL entities that contribute to the delivery …”

The local public health system assessment The local public health system assessment instrumentinstrument

“How much of this Model Standard is achieved by the local PHS collectively?”

What percent of the answer reported in Q 1 is the direct contribution of the local PH agency?

Public health system assessment Public health system assessment instruments and A CCREDITATIONinstruments and A CCREDITATION

Can achievement of a “passing grade” on a performance assessment be used for accreditation?

How should WHO accredit WHOM and HOW? (not to mention WHY?)

Variation in System PerformanceVariation in System Performance

0%

5%

10%

15%

20%

25%

30%

35%

<10% 10.0%-19.9%

20.0%-29.9%

30.0%-39.9%

40.0%-49.9%

50.0%-59.9%

60.0%-69.9%

70.0%-79.9%

80.0%-89.9%

90.0%-99.9%

Range

Pe

rce

nt

of

juri

sd

icti

on

s

Scope of public health activitiesperformed (% of 20 activities)

Perceived effectiveness ofperformance (% of maximum score)

Mays et al. AJPH 2004

Local Jurisdictions with at Least 100,000 Population, 1998Local Jurisdictions with at Least 100,000 Population, 1998

Local Health Department

74%

Other Organizations

26%

Who Contributes?Who Contributes?

Proportion of Effort Contributed by Local Health Departments and Other Organizations

Mays, Halverson, Stevens. Public Health Reports 2001

Who Contributes?Who Contributes?

0

10

20

30

40

50

60

70

80

90

100

Participation in at least one activity

Scope of participation (% of 20 Activities)

State A

gencies

Local A

gencies

Federal

Hospitals

Physicians

CH

Cs

Health P

lans

Universities

Others

Mays, Halverson, Stevens. Public Health Reports 2001

How Does System Composition Affect How Does System Composition Affect Performance?Performance?

0

5

10

15

20Scope of ServicesPerceived Effectiveness

Increases in System Performance Associated with ParticipationIncreases in System Performance Associated with Participation by Other Organizations by Other Organizations

Mays, Halverson, Stevens. Public Health Reports 2001

% C

han

ge in

Per

form

ance

Performance Associated with System SizePerformance Associated with System Size

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 1,600,000Population size

Per

form

ance

sco

re

Monitor

Investigate

Inform

Partnerships

Policy/plan

Spline Regression Estimates After Controlling for other Variables in the Model

Mays et al. AJPH in press

Performance Associated with Local Agency Performance Associated with Local Agency Spending Per CapitaSpending Per Capita

0

2

4

6

8

10

% C

han

ge in

Per

form

ance

Mays et al. JPHMP 2004

Priorities for Future ResearchPriorities for Future Research

Measuring “performance” and “quality”

Measuring public health spending/cost

Estimating impact on population health

Evidence-based decision making regarding society’s investments in public health

More Questions than Answers?More Questions than Answers?Priorities for Future ResearchPriorities for Future Research

What strategies and interventions are effective in improving PH system performance & outcomes?

– Performance measurement ─ NPHPSP

– Local and state QI collaboratives

– Agency accreditation

– Workforce training & competencies

– Financing

WORKFORCE RESEARCH ADAPTABILITYLocal

(ACHD)

Federal

(HRSA)

Academics

(POPHTC) Evaluation

Public Health Specialists

Adult Educators

LEARNINGINTERVENTION

Content Expertise

Capacity building: Employees’ time and organizational improvement

Effective teaching

methods, attitudes, beliefs,

the use of skills, and the

quality of trainingManagerial

Expertise: Valid,

reliable tools,

systematic

individual tracking

Accountability to

taxpayers:

Standardized data

collection

Quality of effectiveness of

learning experience

Developing a Public Health Systems Developing a Public Health Systems Research Agenda: CDC ExperienceResearch Agenda: CDC Experience

Dennis Lenaway, Paul Halverson, Hugh Tilson (2), Sergey Sotnikov, Liza Corso, & Wayne Millington

(1) Div of Public Health Systems Development and Research, Public Health Practice Program Office, CDC

(2) School of Public Health, University of North Carolina

The 14 Major Themes (and votes)The 14 Major Themes (and votes)

Agency structure & performance (40)

Dimensions of public health systems (33)

Performance & health outcomes (30)

Characteristics of high-performing agencies (29)

Social determinants & system performance (28)

The 14 Major Themes (and votes)The 14 Major Themes (and votes)

Cost of optimal system performance (27)

Infrastructure & categorical programs (27)

Framework for high-performing systems (26)

Health outcomes & system performance (26)

Accreditation & performance improvement (21)

The 14 Major Themes (and votes)The 14 Major Themes (and votes)

Policy, finance & system performance (19)

Community involvement, NPHPS & system improvement activities (19)

High performing systems & preparedness (19)

Effectiveness of governance structures (16)

But first...But first...

a word from our sponsors!

Council on Linkages Between Academia and Public Health PracticeCouncil on Linkages Between Academia and Public Health Practice

16 NATIONAL MEMBER ORGANIZATIONS

American College of Preventive Medicine

American Public Health Association

Association of Schools of Public Health

Association of State and Territorial Health Officials

Association of Teachers of Preventive Medicine

Association of University Programs in Health Administration

Centers for Disease Control and Prevention

Community-Campus Partnerships for Health

Council on Accredited Master of Public Health Programs

Health Resources and Services Administration

National Association of County and City Health Officials

National Association of Local Boards of Health

National Environmental Health Association

National Network of Public Health Institutes

QUAD Council of Public Health Nursing Organizations

Society for Public Health Education

The overall objective of the Council is to improve the relevance of public health education to practice

Grew out of the Public Health Faculty / Agency Forum

Grew out of the 1988 IOM Report

Funded by HRSA and Funded by HRSA and Staffed by PHFStaffed by PHF

What’s been achieved...What’s been achieved...

Public health systems research agendas - general, workforce, rural, preparedness

“Centers of Excellence” - several universities

Customers and demand for research - NACCHO resolution

PHSR “support group” - AcademyHealth

Research fellowship program - Pfizer

APHA Forum annually

THIS wonderful effort … THANKS RWJ!!

The road from here: FULL of The road from here: FULL of opportunities!opportunities!

Whaddya’ mean “Opportunities”? In Whaddya’ mean “Opportunities”? In THIS mess? THIS mess?

What’s left to be done...What’s left to be done...

Turning pennies into dollars

Examples of Examples of Organizational CommitmentsOrganizational Commitments

APHA – Host leadership forum– Publish article– Executive Board action

CDC– Convene federal agencies– Support PH Affiliate– Develop specific agendas

NACCHO– Executive Board input– Annual meeting presentations– Process to develop agenda

Pfizer, Inc.– Develop fellowship

Research!America– Develop case for PHSR

– Seek ideas for opinion polls

AHRQ– Meet with leadership

– Promote PHSR in solicitations

ACPM– Annual meeting presentations

– Communicate with members

The Road from Here … FULL of opportunitiesThe Road from Here … FULL of opportunities

AcademyHealth Public Health Systems Research Interest Group

Council on Linkages/PHF

CDC Futures Initiative

Foundation initiatives, e.g. HCFO,

RWJ’s strong commitment

State-supported efforts

The road from here: YOU drive!The road from here: YOU drive!