Geographic variation in public health spending: correlates and consequences

Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications

The financing of public health systems and services relies on a complex and fragmented web of partners and funding priorities. Both underfunding and "dys-funding" contribute to preventable mortality, increases in disease frequency and severity, and hindered social and economic growth. These issues were both illuminated and magnified by the COVID-19 pandemic and associated responses. Further complicating issues is the difficulty in constructing adequate estimates of current public health resources and necessary resources. Each of these challenges inhibits the delivery of necessary services, leads to inequitable access and resourcing, contributes to resource volatility, and presents other deleterious outcomes. However, actions may be taken to defragment complex funding paradigms toward more flexible spending, to modernize and standardize data systems, and to assure equitable and sustainable public health investments.

The Impact of Public Health Funding on Population Health Outcomes

Abstract The objective of this study was to assess the impact of local health department (LHD) expenditures on population health measures using counties as the unit of analysis. An observational research design is used to examine whether public health benefits are associated with higher levels of public health funding. Linear probability multivariate regression models with the use of local level cross-sectional and panel data are employed. A 1-year and a 2-year lag structure are also used to quantify the longer term public health effects of changes in LHD expenditures. Analyses were performed at the county level using local data representing 2120 LHDs, covering 48 US states. Expenditure data from the National Association of County and City Health Officials Profile Surveys and public health measures from County Health Rankings Annual Reports are used. Four public health measures are examined-obesity prevalence, sexually transmitted diseases, diabetes prevalence, and human immunodeficiency virus prevalence. Results from cross-sectional, pooled ordinary least squares, and panel data with fixed effects reveal that increased LHD expenditures per capita were not associated with any of the population health outcomes studied. Multivariate linear regression results using a 1- and 2-year lag structure reveal similar results: funding was not significantly predictive of better public health outcomes. The study design did not control for the potential endogeneity of public health funding. More detailed data and robust research approaches are needed to disentangle the effect and effectively answer whether increased public funding translates to improved population health.

Health Equity and the Dynamism of Structural Racism and Public Policy

Policy Points Both public policy and structural racism are dynamic systems that reinforce each other. Efforts to address the health effects of structural racism must account for the nature of these systems. Politics and policy are critical for understanding the persistence of racial health inequities and creating policies and interventions that can mitigate the effects of structural racism on health.

Local Public Health System Capabilities and COVID-19 Death Rates

OBJECTIVES

Efforts to contain the health effects of the COVID-19 pandemic have achieved less success in the United States than in many comparable countries. Previous research documented wide variability in the capabilities of local public health systems to carry out core disease prevention and control activities, but it is unclear how this variability relates to COVID-19 control. Our study explored this relationship by using a nationally representative sample of 725 US communities.

METHODS

We used data collected from the National Longitudinal Survey of Public Health Systems to classify each community into 1 of 3 ordinal categories indicating limited, intermediate, or comprehensive public health system capabilities. We used 2-part generalized linear models to estimate the relationship between public health system capabilities and COVID-19 death rates while controlling population and community characteristics associated with COVID-19 risk.

RESULTS

Across 3 waves of the pandemic in 2020, we found a significant negative association between COVID-19 mortality and public health system capabilities. Compared with comprehensive public health systems, intermediate public health systems had an average of 4.97 to 19.02 more COVID-19 deaths per 100 000 residents, while limited public health systems had an average of 5.95 to 18.10 more COVID-19 deaths per 100 000 residents.

CONCLUSION

Overall, communities with stronger public health capabilities had significantly fewer deaths. Future initiatives to strengthen pandemic preparedness and reduce health disparities in the United States should focus on local public health system capabilities.

Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults

Greater investment in the social determinants of health (SDOH) is positively associated with improved health outcomes of both individuals and their communities, which in turn may help to bend the health care cost curve and reduce health care spending. The purpose of this study was to examine the relationship between local governments' spending on the SDOH and the health care costs of privately insured nonelderly adults. Annual spending by local governments on the SDOH for the years 2007-2017 was obtained from the Census of Governments. Annual health care costs for privately insured nonelderly adults for the years 2013-2017 was obtained from the Health Care Cost Institute. Bivariate and multivariate regression analyses were performed to examine the association between county-level local governments' per capita spending on the SDOH and the per member health care costs of privately insured adults living in these counties controlling for community characteristics. All analyses were conducted in 2021. For near-elderly adults ages 55-64, health care costs were significantly higher in counties with the lowest levels of local governmental spending on the SDOH. For adults ages 18-54, in contrast, health care costs were unrelated to local governmental spending. Investments of local governments in the SDOH may have rather limited potential to yield meaningful savings in health care costs for privately insured nonelderly adults at the population level, especially once such investments exceed a minimum threshold.

Identifying Value-Added Population Health Capabilities to Strengthen Public Health Infrastructure

Policy Points While the coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in delivery systems. The results of our study suggest that the public health system structure can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities can help communities efficiently use limited time and resources and identify the most effective pathways for building a stronger public health system and improving health outcomes over time.

CONTEXT

While the novel coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in public health delivery systems. Information about the relative value in the implementation of recommended population health capabilities can help communities prioritize their use of limited time and resources and identify the most effective pathways for building a stronger public health system.

METHODS

We used a longitudinal cohort design with data from the National Longitudinal Survey of Public Health Systems to examine longitudinal and geographic trends in the delivery of population health capabilities and their impact on system strength across communities in the United States. We used linear probability models to ascertain whether the delivery of certain capabilities added value to public health system strength.

FINDINGS

Those communities with the strongest classification of public health system structure in both urban and rural areas implemented the largest set of population health capabilities. Results from the linear probability model indicate that a set of population health capabilities are associated with increased public health system strength. Key activities include allocating resources based on a community health plan, surveying the community for behavioral risk factors, analyzing the data on preventive services use, and engaging community stakeholders in health improvement planning (p < 0.01).

CONCLUSIONS

The results of this study suggest that public health systems can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities may help communities increase their public health system's capacity and improve health outcomes.

Dance of Dollars: State Funding Effects on Local Health Department Expenditures

OBJECTIVE

We examined changes in total local health department (LHD) expenditures in the state of Washington following introduction of a new state funding program to support core public health services and infrastructure.

METHODS

We used a pre/posttest design regression model to evaluate changes in LHD expenditures 1, 2, and 6 years into the new state program. To address potential endogeneity in the model, we repeated all 3 analyses using 2-stage least squares regression.

RESULTS

In the base case, overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program (2008 and 2009). However, those increases were not sustained over the longer term (2013). In subpopulation analyses, total LHD spending increased more among larger LHDs.

CONCLUSIONS

Between 2006 and 2013, new state investments in core public health functions increased Washington State LHD expenditures in the short term, but those increases did not persist over time. For public health financial modernization efforts to translate into public health infrastructure modernization successes, the way new investments are structured may be as important as the amount of funding added.

US local public health department spending between 2008 and 2016 did not increase for communities in need

BACKGROUND

Greater US local public health department (LPHD) spending has been associated with decreases in population-wide mortality. We examined the association between changes in LPHD spending between 2008 and 2016 and county-level sociodemographic indicators of public health need.

METHODS

Multivariable linear regression was used to estimate the association between changes in county-level per-capita LPHD spending and 2008 sociodemographic indicators of interest: percent of population that was over 65 years old, Black, Hispanic, in poverty, unemployed, and uninsured. A second model assessed the relationship between changes in LPHD spending and sociodemographic shifts between 2008 and 2016.

RESULTS

LPHD spending increases were associated with higher percentage points of 2008 adults over 65 years of age (+$0.53 per higher percentage point; 95% CI: +$0.01 to +$1.06) and unemployment (-$1.31; 95% CI: -$2.34 to -$0.27). Spending did not increase for communities with a higher proportion of people who identified as Black or Hispanic, or those with a greater proportion of people in poverty or uninsured, using either baseline or sociodemographic shifts between 2008 and 2016.

CONCLUSION

Future LPHD funding decisions should consider increasing investments in counties serving disadvantaged communities to counteract the social, political, and structural barriers which have historically prevented these communities from achieving better health.

Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other?

OBJECTIVE

Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State.

DESIGN AND SETTING

We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility.

MAIN OUTCOME MEASURES

LHD revenue and revenue volatility.

RESULTS

Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility.

CONCLUSIONS

Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings.

The Cost of Providing the Foundational Public Health Services in Ohio

OBJECTIVES

To examine levels of expenditure and needed investment in public health at the local level in the state of Ohio pre-COVID-19.

DESIGN

Using detailed financial reporting from fiscal year (FY) 2018 from Ohio's local health departments (LHDs), we characterize spending by Foundational Public Health Services (FPHS). We also constructed estimates of the gap in public health spending in the state using self-reported gaps in service provision and a microsimulation approach. Data were collected between January and June 2019 and analyzed between June and September 2019.

PARTICIPANTS

Eighty-four of the 113 LHDs in the state of Ohio covering a population of almost 9 million Ohioans.

RESULTS

In FY2018, Ohio LHDs spent an average of $37 per capita on protecting and promoting the public's health. Approximately one-third of this investment supported the Foundational Areas (communicable disease control; chronic disease and injury prevention; environmental public health; maternal, child, and family health; and access to and linkages with health care). Another third supported the Foundational Capabilities, that is, the crosscutting skills and capacities needed to support all LHD activities. The remaining third supported programs and activities that are responsive to local needs and vary from community to community. To fully meet identified LHD needs in the state pre-COVID-19, Ohio would require an additional annual investment of $20 per capita on top of the current $37 spent per capita, or approximately $240 million for the state.

CONCLUSIONS

A better understanding of the cost and value of public health services can educate policy makers so that they can make informed trade-offs when balancing health care, public health, and social services investments. The current environment of COVID-19 may dramatically increase need, making understanding and growing public health investment critical.

Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending

IMPORTANCE

Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation.

OBJECTIVE

To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH.

MAIN OUTCOMES AND MEASURES

2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context.

RESULTS

Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk.

CONCLUSIONS AND RELEVANCE

These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.

Geographic Variation in Trends and Disparities in Heart Failure Mortality in the United States, 1999 to 2017

Background Cardiovascular disease mortality related to heart failure (HF) is rising in the United States. It is unknown whether trends in HF mortality are consistent across geographic areas and are associated with state-level variation in cardiovascular health (CVH). The goal of the present study was to assess regional and state-level trends in cardiovascular disease mortality related to HF and their association with variation in state-level CVH. Methods and Results Age-adjusted mortality rates (AAMR) per 100 000 attributable to HF were ascertained using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research from 1999 to 2017. CVH at the state-level was quantified using the Behavioral Risk Factor Surveillance System. Linear regression was used to assess temporal trends in HF AAMR were examined by census region and state and to examine the association between state-level CVH and HF AAMR. AAMR attributable to HF declined from 1999 to 2011 and increased between 2011 and 2017 across all census regions. Annual increases after 2011 were greatest in the Midwest (β=1.14 [95% CI, 0.75, 1.53]) and South (β=0.96 [0.66, 1.26]). States in the South and Midwest consistently had the highest HF AAMR in all time periods, with Mississippi having the highest AAMR (109.6 [104.5, 114.6] in 2017). Within race‒sex groups, consistent geographic patterns were observed. The variability in HF AAMR was associated with state-level CVH (P<0.001). Conclusions Wide geographic variation exists in HF mortality, with the highest rates and greatest recent increases observed in the South and Midwest. Higher levels of poor CVH in these states suggest the potential for interventions to promote CVH and reduce the burden of HF.

Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates

This study evaluated persistency in county-level rates of low birthweight outcomes to identify “hotspot counties” and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

What the HEC? Clinician Adherence to Evidence-Based Antiemetic Prophylaxis for Highly Emetogenic Chemotherapy

Background: Clinician adherence to antiemetic guidelines for preventing chemotherapy-induced nausea and vomiting (CINV) caused by highly emetogenic chemotherapy (HEC) remains poorly characterized. The primary aim of this study was to evaluate individual clinician adherence to HEC antiemetic guidelines. Patients and Methods: A retrospective analysis of patients receiving HEC was conducted using the IBM Watson Explorys Electronic Health Record Database (2012–2018). HEC antiemetic guideline adherence was defined as prescription of triple prophylaxis (neurokinin-1 receptor antagonist [NK1 RA], serotonin type-3 receptor antagonist, dexamethasone) at initiation of cisplatin or anthracycline + cyclophosphamide (AC). Clinicians who prescribed ≥5 HEC courses were included and individual guideline adherence was assessed, noting the number of prescribing clinicians with >90% adherence. Results: A total of 217 clinicians were identified who prescribed 2,543 cisplatin and 1,490 AC courses. Patients (N=4,033) were primarily women (63.3%) and chemotherapy-naïve (92%) with a mean age of 58.6 years. Breast (36%) and thoracic (19%) cancers were the most common tumor types. Guideline adherence rates of >90% were achieved by 35% and 58% of clinicians using cisplatin or AC, respectively. Omission of an NK1 RA was the most common practice of nonadherence. Variation in prophylaxis guideline adherence was considerable for cisplatin (mean, 71%; SD, 29%; coefficient of variation [CV], 0.40) and AC (mean, 84%; SD, 26%; CV, 0.31). Conclusions: Findings showed substantial gaps in clinician adherence to HEC CINV guidelines, including a high variability across clinicians. Clinicians should review their individual clinical practices and ensure adherence to evidence-based CINV guidelines to optimize patient care.

Maternal Mortality and Public Health Programs: Evidence from Florida

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities.

CONTEXT

Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates.

METHODS

We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests.

FINDINGS

Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap.

CONCLUSIONS

Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.

Prices for Medical Services Vary Within Hospitals, but Vary More Across Them

Using commercial claims for 2012-2013 from the Colorado All Payer Claims Database, we examine how medical service prices vary for five hospital-based procedures and the complexity-adjusted inpatient price. We find that prices vary substantially in multiple dimensions. Our analysis indicates that there is significant price variation across payers for the same service in the same hospital. If prices converged to the lowest rate each hospital receives, commercial expenditures would fall by 10% to 20%. Differences across hospitals account for an even more substantial amount of the overall variation. For five out of six prices, we find that differences associated just with hospitals' metropolitan areas account for over 35% of the total variation. We observe substantial residual variation (18%-32%) after accounting for factors specific to a given payer or provider.

Assessing The Value Of 40 Years Of Local Public Expenditures On Health

The US public and private sectors now spend more than $3 trillion on health each year. While critical studies have examined the relationship between public spending on health and health outcomes, relatively little is known about the impact of broader public-sector spending on health. Using county-level public finance data for the period 1972-2012, we estimated the impact of local public hospital spending and nonhospital health spending on all-cause mortality in the county. Overall, a 10 percent increase in nonhospital health spending was associated with a 0.006 percent decrease in all-cause mortality one year after the initial spending. This effect was larger and significant in counties with greater proportions of racial/ethnic minorities. Our results indicate that county nonhospital health spending has health benefits that can help reduce costs and improve health outcomes in localities across the nation, though greater focus on population-oriented services may be warranted.

Estimating the Cost of Providing Foundational Public Health Services

OBJECTIVE

To estimate the cost of resources required to implement a set of Foundational Public Health Services (FPHS) as recommended by the Institute of Medicine.

STUDY DESIGN

A stochastic simulation model was used to generate probability distributions of input and output costs across 11 FPHS domains. We used an implementation attainment scale to estimate costs of fully implementing FPHS.

DATA COLLECTION/EXTRACTION METHODS

We use data collected from a diverse cohort of 19 public health agencies located in three states that implemented the FPHS cost estimation methodology in their agencies during 2014-2015.

PRINCIPAL FINDINGS

The average agency incurred costs of $48 per capita implementing FPHS at their current attainment levels with a coefficient of variation (CV) of 16 percent. Achieving full FPHS implementation would require $82 per capita (CV=19 percent), indicating an estimated resource gap of $34 per capita.

CONCLUSIONS

Substantial variation in costs exists across communities in resources currently devoted to implementing FPHS, with even larger variation in resources needed for full attainment. Reducing geographic inequities in FPHS may require novel financing mechanisms and delivery models that allow health agencies to have robust roles within the health system and realize a minimum package of public health services for the nation.

Cross-Jurisdictional Resource Sharing in Local Health Departments: Implications for Services, Quality, and Cost

Background

Forty one percent of local health departments in the U.S. serve jurisdictions with populations of 25,000 or less. Researchers, policymakers, and advocates have long questioned how to strengthen public health systems in smaller municipalities. Cross-jurisdictional sharing may increase quality of service, access to resources, and efficiency of resource use.

Objective

To characterize perceived strengths and challenges of independent and comprehensive sharing approaches, and to assess cost, quality, and breadth of services provided by independent and sharing health departments in Connecticut (CT) and Massachusetts (MA).

Methods

We interviewed local health directors or their designees from 15 comprehensive resource-sharing jurisdictions and 54 single-municipality jurisdictions in CT and MA using a semi-structured interview. Quantitative data were drawn from closed-ended questions in the semi-structured interviews; municipal demographic data were drawn from the American Community Survey and other public sources. Qualitative data were drawn from open-ended questions in the semi-structured interviews.

Results

The findings from this multistate study highlight advantages and disadvantages of two common public health service delivery models – independent and shared. Shared service jurisdictions provided more community health programs and services, and invested significantly more ($120 per thousand (1K) population vs. $69.5/1K population) on healthy food access activities. Sharing departments had more indicators of higher quality food safety inspections (FSIs), and there was a non-linear relationship between cost per FSI and number of FSI. Minimum cost per FSI was reached above the total number of FSI conducted by all but four of the jurisdictions sampled. Independent jurisdictions perceived their governing bodies to have greater understanding of the roles and responsibilities of local public health, while shared service jurisdictions had fewer staff per 1,000 population.

Implications

There are trade-offs with sharing and remaining independent. Independent health departments serving small jurisdictions have limited resources but strong local knowledge. Multi-municipality departments have more resources but require more time and investment in governance and decision-making. When making decisions about the right service delivery model for a given municipality, careful consideration should be given to local culture and values. Some economies of scale may be achieved through resource sharing for municipalities <25,000 population.

Joint Community Health Needs Assessments as a Path for Coordinating Community-Wide Health Improvement Efforts Between Hospitals and Local Health Departments

OBJECTIVES

To examine the association between hospital-local health department (LHD) collaboration around community health needs assessments (CHNAs) and hospital investment in community health.

METHODS

We combined 2015 National Association of County and City Health Officials (NACCHO) Forces of Change, 2013 NACCHO Profile, and 2014-2015 Area Health Resource File data to identify a sample of LHDs (n = 439) across the United States. We included data on hospitals' community benefit from their 2014 tax filings (Internal Revenue Service Form 990, Schedule H). We used bivariate and multivariate regression analyses to examine LHDs' involvement in hospitals' CHNAs and implementation strategies and the relationship with hospital investment in community health.

RESULTS

The LHDs that collaborated with hospitals around CHNAs were significantly more likely to be involved in joint implementation planning activities than were those that did not. Importantly, LHD involvement in hospitals' implementation strategies was associated with greater hospital investment in community health improvement initiatives.

CONCLUSIONS

Joint CHNAs may improve coordination of community-wide health improvement efforts between hospitals and LHDs and encourage hospital investment in community health improvement activities. Public Health Implications. Policies that strengthen LHD-hospital collaboration around the CHNA may enhance hospital investments in community health.

Factors Driving Local Health Departments' Partnerships With Other Organizations in Maternal and Child Health, Communicable Disease Prevention, and Chronic Disease Control

OBJECTIVES

To describe levels of partnership between local health departments (LHDs) and other community organizations in maternal and child health (MCH), communicable disease prevention, and chronic disease control and to assess LHD organizational characteristics and community factors that contribute to partnerships.

DATA SOURCES

Data were drawn from the National Association of County & City Health Officials' 2013 National Profile Study (Profile Study) and the Area Health Resources File. LHDs that received module 1 of the Profile Study were asked to describe the level of partnership in MCH, communicable disease prevention, and chronic disease control. Levels of partnership included "not involved," "networking," "coordinating," "cooperating," and "collaborating," with "collaborating" as the highest level of partnership. Covariates included both LHD organizational and community factors. Data analyses were conducted using Stata 13 SVY procedures to account for the Profile Study's survey design.

RESULTS

About 82%, 92%, and 80% of LHDs partnered with other organizations in MCH, communicable disease prevention, and chronic disease control programs, respectively. LHDs having a public health physician on staff were more likely to partner in chronic disease control programs (adjusted odds ratio [AOR] = 2.33; 95% confidence interval [CI], 1.03-5.25). Larger per capita expenditure was also associated with partnerships in MCH (AOR = 2.43; 95% CI, 1.22-4.86) and chronic disease prevention programs (AOR = 1.76; 95% CI, 1.09-2.86). Completion of a community health assessment was associated with partnership in MCH (AOR = 7.26; 95% CI, 2.90-18.18), and chronic disease prevention (AOR = 5.10; 95% CI, 2.28-11.39).

CONCLUSION

About 1 in 5 LHDs did not have any partnerships in chronic disease control. LHD partnerships should be promoted to improve care coordination and utilization of limited health care resources. Factors that might promote LHDs' partnerships include having a public health physician on staff, higher per capita expenditure, and completion of a community health assessment. Community context likely influences types and levels of partnerships. A better understanding of these contextual factors may lead to more complete and effective LHD partnerships.

The differential effects of rural health care access on race-specific mortality

We examined the relationship between race-specific rural mortality and the health infrastructure of rural counties in light of America's recent emergence of a rural mortality penalty. Using the Compressed Mortality File from National Center for Health Statistics (2008-2012) and county-level demographic, socioeconomic, and health care indicators from the Area Health Resource File and the US Census, we created a rural public health infrastructure index which encompasses four types of health care access (public health employees, critical access hospital/rural referral centers, rural health clinics, and emergency departments) within counties. We found that each unit increase in the index is associated with a decline in rural Black mortality, but is associated with an increase in rural White mortality. Policymakers could benefit from focusing on the declining rate of mortality improvement in many rural regions, specifically by trying to better understand how decisions concerning public health spending may influence mortality differently for Black and White residents.

Public Health Spending and Medicare Resource Use: A Longitudinal Analysis of U.S. Communities

OBJECTIVE

To examine whether local expenditures for public health activities influence area-level medical spending for Medicare beneficiaries.

DATA SOURCES AND SETTING

Six census surveys of the nation's 2,900 local public health agencies were conducted between 1993 and 2013, linked with contemporaneous information on population demographics, socioeconomic characteristics, and area-level Medicare spending estimates from the Dartmouth Atlas of Health Care.

DATA COLLECTION/EXTRACTION

Measures derive from agency survey data and aggregated Medicare claims.

STUDY DESIGN

A longitudinal cohort design follows the geographic areas served by local public health agencies. Multivariate, fixed-effects, and instrumental-variables regression models estimate how area-level Medicare spending changes in response to shifts in local public health spending, controlling for observed and unmeasured confounders.

PRINCIPAL FINDINGS

A 10 percent increase in local public health spending per capita was associated with 0.8 percent reduction in adjusted Medicare expenditures per person after 1 year (p < .01) and a 1.1 percent reduction after 5 years (p < .05). Estimated Medicare spending offsets were larger in communities with higher rates of poverty, lower health insurance coverage, and health professional shortages.

CONCLUSIONS

Expanded financing for public health activities may provide an effective way of constraining Medicare spending, particularly in low-resource communities.

The American College of Preventive Medicine Policy Recommendations on Public Health Funding

The American College of Preventive Medicine Policy Committee makes policy guidelines and recommendations on Preventive Medicine and Public Health topics for Public Health decision makers. After a review of the current evidence available in 2016, the College is providing policy recommendations designed to inform public health investment. The American College of Preventive Medicine advocates for policies that recognize the health and economic value of public health funding and promote investment in these vital capabilities. Shortfalls in public health infrastructure, particularly workforce funding, must be corrected to ensure lasting benefits. Contingency funding for public health emergencies should be established and fully funded to adequately respond to emerging threats.

Geographic Region Matters in the Relation Between Perceived Racial Discrimination and Psychiatric Disorders Among Black Older Adults

Purpose of the Study

This study examined whether the relation between perceived racial discrimination and psychiatric disorders varied by large geographic region among Black older adults in the United States.

Design and Methods

Black adults aged 55 or older who had experienced racial/ethnic-specific discrimination were drawn from the National Survey of American Life (NSAL). Logistic regression analysis was used to examine main and interaction effects.

Results

Results show that there was a significant main effect of perceived racial discrimination, indicating that greater perceived discrimination was significantly associated with increased odds of having any past-year psychiatric disorder. The interaction of region by perceived racial discrimination was significant: The effect of perceived racial discrimination on any past-year psychiatric disorder was stronger among Blacks in the West than those in the South.

Implications

Findings suggest that whereas, in general, perceived racial discrimination is a risk factor for poor mental health among older Blacks, this association may differ by geographic region. Additional research examining reasons for this variation is needed.

Does hospital ownership influence hospital referral region health rankings in the United States

Extensive evidence demonstrates that a hospital's organizational ownership structure impacts its overall performance, but little is known concerning the influence of hospital structure on the health of its community. This paper explores the association between US hospital referral region (HRR) health rankings and hospital ownership and performance. Data from the 2016 Commonwealth Fund Scorecard on Local Health System Performance, the American Hospital Association dataset, and the Hospital Value-Based Purchasing dataset are utilized to conduct a cross-sectional analysis of 36 quality measures across 306 HRRs. Multivariate regression analysis was used to estimate the association among hospital ownership, system performance measures-access and affordability, prevention and treatment, avoidable hospital use and cost, and healthy lives-and performance as measured by value-based purchasing total performance scores. We found that indicators of access and affordability, as well as prevention and treatment, were significantly associated across all 3 hospitals' organizational structures. Hospital referral regions with a greater number of not-for-profit hospitals demonstrated greater indications of access and affordability, as well as better prevention and treatment rankings than for-profit and government hospitals. Hospital referral regions with a greater number of government, nonfederal hospitals had worse scores for healthy lives. Furthermore, the greater the total performance scores score, the better the HRR score on prevention and treatment rankings. The greater the per capita income, the better the score across all 4 dimensions. As such, this inquiry supports the assertion that performance of a local health system is dependent on its community's resources of health care delivery entities and their structure.

Hospital Community Benefit in the Context of the Larger Public Health System: A State-Level Analysis of Hospital and Governmental Public Health Spending Across the United States

CONTEXT

Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status.

OBJECTIVE

In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health.

DESIGN

Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments.

RESULTS

Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states.

CONCLUSIONS

Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.

Political fragmentation and widening disparities in African-American and white mortality, 1972-1988

OBJECTIVE

During the 1970s and 1980s in the U.S., population movement, urban sprawl and urban governance reform led to a proliferation of local, autonomous jurisdictions. Prior literature examines how this creation of local governments, also referred to as political fragmentation, contributes to economic growth and social inequality. We examine the impact of political fragmentation on health equity by testing the hypothesis that the mortality disparity between whites and African-Americans varies positively with political fragmentation.

METHODS

We retrieved mortality data from the multiple cause-of-death file and calculated total number of local governments per 1000 residents in a county to measure the degree of political fragmentation. We focused on 226 U.S. counties with population size greater than 200,000 and restricted the analysis to four distinct periods with overlapping government and mortality data (1972-73, 1977-78, 1982-83, and 1987-88). We applied generalized estimating equation methods that permit analysis of clustered data over time. Methods also controlled for the age structure of the population, reductions in mortality over time, and confounding by county-level sociodemographic variables.

RESULTS

Adjusted coefficients of fragmentation are positive and statistically significant for both whites (coef: 2.60, SE: 0.60, p<0.001) and African-Americans (coef: 5.31, SE: 1.56, p<0.001). The two-fold larger positive coefficient for African-Americans than for whites indicates a greater racial disparity in mortality among more politically fragmented urban counties and/or time periods.

CONCLUSIONS

From 1972 to 1988, political fragmentation in large urban counties moves positively with the racial/ethnic gap in mortality between whites and African-Americans. We discuss intervening mechanisms through which political fragmentation may disproportionately affect mortality among African-Americans.

Self-reported Preparedness to Respond to Mass Fatality Incidents in 38 State Health Departments

CONTEXT

Public health departments play an important role in the preparation and response to mass fatality incidents (MFIs).

OBJECTIVE

To describe MFI response capabilities of US state health departments.

DESIGN

The data are part of a multisector cross-sectional study aimed at 5 sectors that comprise the US mass fatality infrastructure. Data were collected over a 6-week period via a self-administered, anonymous Web-based survey.

SETTING

In 2014, a link to the survey was distributed via e-mail to health departments in 50 states and the District of Columbia.

PARTICIPANTS

State health department representatives responsible for their state's MFI plans.

MEASURES

Preparedness was assessed using 3 newly developed metrics: organizational capabilities (n = 19 items); operational capabilities (n = 19 items); and resource-sharing capabilities (n = 13 items).

RESULTS

Response rate was 75% (n = 38). Among 38 responses, 37 rated their workplace moderately or well prepared; 45% reported MFI training, but only 30% reported training on MFI with hazardous contaminants; 58% estimated high levels of staff willingness to respond, but that dropped to 40% if MFIs involved hazardous contaminants; and 84% reported a need for more training. On average, 76% of operational capabilities were present. Resource sharing was most prevalent with state Office of Emergency Management but less evident with faith-based organizations and agencies within the medical examiner sector.

CONCLUSION

Overall response capability was adequate, with gaps found in capabilities where public health shares responsibility with other sectors. Collaborative training with other sectors is critical to ensure optimal response to future MFIs, but recent funding cuts in public health preparedness may adversely impact this critical preparedness element. In order for the sector to effectively meet its public health MFI responsibilities as delineated in the National Response Framework, resources to support training and other elements of preparedness must be maintained.

Creating a Taxonomy of Local Boards of Health Based on Local Health Departments' Perspectives

OBJECTIVES

To develop a local board of health (LBoH) classification scheme and empirical definitions to provide a coherent framework for describing variation in the LBoHs.

METHODS

This study is based on data from the 2015 Local Board of Health Survey, conducted among a nationally representative sample of local health department administrators, with 394 responses. The classification development consisted of the following steps: (1) theoretically guided initial domain development, (2) mapping of the survey variables to the proposed domains, (3) data reduction using principal component analysis and group consensus, and (4) scale development and testing for internal consistency.

RESULTS

The final classification scheme included 60 items across 6 governance function domains and an additional domain-LBoH characteristics and strengths, such as meeting frequency, composition, and diversity of information sources. Application of this classification strongly supports the premise that LBoHs differ in their performance of governance functions and in other characteristics.

CONCLUSIONS

The LBoH taxonomy provides an empirically tested standardized tool for classifying LBoHs from the viewpoint of local health department administrators. Future studies can use this taxonomy to better characterize the impact of LBoHs.

Patterns and predictors of local health department accreditation in Missouri

BACKGROUND

The Healthy People 2020 goal for the public health system is "to ensure that Federal, State, Tribal, and local health agencies have the necessary infrastructure to effectively provide essential public health services." To address this goal, Missouri established the first statewide, voluntary accreditation program of local health departments (LHDs) and began accrediting the LHDs in 2003. The purpose of this study was to identify organizational, structural, and workforce factors related to accreditation status of LHDs in Missouri.

METHODS

Using data from the National Association of County & City Health Officials (2010) and the Missouri Department of Health & Senior Services (2012), binary logistic regression analysis was performed to predict accreditation status of LHDs. Likelihood ratio tests were used to examine whether the addition of each predictor added significantly to the model compared with a model including total revenues alone. Adjusted odds ratios (aORs), 95% confidence intervals, the significance level of the likelihood ratio test, and the overall Nagelkerke pseudo-R for each model are reported.

RESULTS

Having a community health improvement plan (aOR = 6.2), a strategic plan (aOR = 7.9), evaluating programs (aOR = 3.6), being in a region with a high proportion of accredited LHDs (aOR = 5.5), and participating in multijurisdictional collaborations (aOR = 6.4) all increased the likelihood of accreditation. Barriers of time (aOR = 0.1) and cost (aOR = 0.3) were negatively associated with accreditation.

CONCLUSIONS

Accredited LHDs were more likely to have completed the prerequisites for accreditation and collaborate with other LHDs. These activities help LHDs meet the accreditation standards. In addition, with shrinking budgets, LHDs will need additional financial and technical support to achieve accreditation. Assisting LHDs to find ways to increase the staff is important. Through collaborations with other LHDs, regional or multicounty positions can be created. Also collaborations with universities, specifically colleges or schools of public health, can provide opportunities for internships at LHDs giving practical experience while providing important assistance to LHDs.

Local public health department adoption and use of electronic health records

CONTEXT

Electronic health records (EHRs) may help local health departments (LHDs) to improve services and thereby promote and protect population health. Yet, little is known about nationwide trends and correlates of EHR use by LHDs.

OBJECTIVE

We examine relative contributions of LHD finances, leadership, and governance to EHR adoption and use from 2010 to 2013. The impact of LHD service provision and meaningful use factors on EHR use is explored in depth.

DESIGN

Combining data from the National Association of County & City Health Officials Profile survey and the Area Health Resource File, logistic regression models were used to examine EHR use in 2013. Multinomial logistic models examined EHR adoption, use, or discontinuation from 2010 to 2013.

PARTICIPANTS

EHR usage data were available for 514 and 488 LHDs in 2010 and 2013, respectively. A total of 117 LHDs had data for both 2010 and 2013.

MAIN OUTCOME MEASURES

Outcomes included dichotomized measures of LHD self-reported use of EHRs in 2010 and 2013. For LHDs with 2 years of data, a 4-category variable measuring self-reported EHR use, nonuse, adoption, or discontinuation was analyzed.

RESULTS

Overall LHD EHR use did not increase significantly between 2010 (19.3%) and 2013 (22.0%). While 15% of LHDs reported adopting EHRs from 2010 to 2013, another 8.5% reported discontinuing use of EHRs during this time. Likelihood of EHR use was strongly associated with LHD clinical service characteristics, per capita expenditures, and state governance structure.

CONCLUSIONS

EHRs do not appear to be rapidly diffusing across LHDs, and retention of current systems may be a concern. Given trends away from clinical service provision and other pressing demands for LHD resources, the benefits of EHR adoption are unclear.

Organizational characteristics of large urban health departments

This study discusses the organizational characteristics of the country's largest health departments, including those that form the Big Cities Health Coalition and quantifies the differences and variation among them.

Approximately 150 million Americans lived in large metropolitan jurisdictions in 2013. About 1 in 7 Americans is served by a member of the Big Cities Health Coalition (BCHC), a group of 20 of the largest local health departments (LHDs) in the United States. In this brief, we describe the organizational characteristics of the country's largest health departments, including those that form the BCHC, and quantify the differences and variation among them. We conducted secondary analyses of the 2013 National Association of County & City Health Officials Profile, specifically characterizing differences between BCHC members and other large LHDs. The data set contained 2000 LHDs that responded to National Association of County & City Health Officials' 2013 Profile. While LHDs serving 500 000 or more people account for only 5% of all LHDs, they covered 50% of the US population in 2013. The BCHC members served approximately 46 million people. The BCHC LHDs had a greater number of staff, larger budgets, and were more involved in policy than their larger peers.

Using a positive deviance framework to identify Local Health Departments in Communities with exceptional maternal and child health outcomes: a cross sectional study

BACKGROUND

The United States spends more than most other countries per capita on maternal and child health (MCH), and yet lags behind other countries in MCH outcomes. Local health departments (LHDs) are responsible for administering various maternal and child health programs and interventions, especially to vulnerable populations. The goal of this study was to identify local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers - positive deviants (PDs) - in Washington, Florida and New York in order to support the identification of strategies that can improve community health outcomes.

METHODS

We used MCH expenditure data for all LHDs in FL (n = 67), and WA (n = 35), and most LHDs in NY (n = 48) for 2009-2010 from the Public Health Activities and Services Tracking (PHAST) database. We conducted our analysis in 2014-2015. Data were linked with variables depicting local context and LHD structure. We used a cross-sectional study design to identify communities with better than expected MCH outcomes and multiple regression analysis to control for factors outside of and within LHD control.

RESULTS

We identified 50 positive deviant LHD jurisdictions across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Overall, internal factor variables improved model fit for identifying PD LHD jurisdictions, but individual variables were not significant.

CONCLUSIONS

We empirically identified LHD jurisdictions with better MCH outcomes compared to their peers. Research is needed to assess what factors contributed to these exceptional MCH outcomes and over which LHDs have control. The positive deviance method we used to identify high performing local health jurisdictions in the area of maternal and child health outcomes can assist in better understanding what practices work to improve health outcomes. We found that funding may not be the only predictor of exceptional outcomes, but rather, there may be activities that positive deviant LHDs are conducting that lead to improved outcomes, even during difficult financial circumstances. This method can be applied to other outcomes, communities, and/or services.

The Double Disparity Facing Rural Local Health Departments

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Community Health Assessment and Improved Public Health Decision-Making: A Propensity Score Matching Approach

OBJECTIVES

We analyzed the likelihood of chronic disease prevention activities delivery, as a proxy measure of public health decision-making and actions, given that local health agencies (LHAs) implemented a community health assessment and improvement plan in their communities.

METHODS

Using a propensity score matching approach, we linked data from the 2010 National Association of County and City Health Officials profile of LHAs and the 2010 County Health Rankings to create a statistically matched sample of implementation and comparison LHAs. Implementation LHAs were those that implemented a community health assessment and improvement plan. We estimated the odds of chronic disease prevention activities delivery and the average treatment effect on the treated.

RESULTS

Implementation group LHAs were 2 times as likely (95% confidence interval = 1.60, 2.64) to deliver population-based chronic disease prevention programs than comparison group LHAs. Furthermore, chronic disease prevention activities were more likely to be delivered among implementation group LHAs (6.50-19.02 percentage points higher) than in comparison group LHAs.

CONCLUSIONS

Our results signal that routine implementation of a community health assessment and improvement plan in LHAs leads to improved public health decision-making and actions.

Local Fiscal Allocation for Public Health Departments

INTRODUCTION

We examined the percentage of local government taxes ("fiscal allocation") dedicated to local health departments on a national level, as well as correlates of local investment in public health.

METHODS

Using the most recent data available--the 2008 National Association of City and County Health Officials Profile survey and the 2007 U.S. Census Bureau Census of Local Governments-generalized linear regression models examined associations between fiscal allocation and local health department setting, governance, finance, and service provision. Models were stratified by the extent of long-term debt for the jurisdiction. Analyses were performed in 2014.

RESULTS

Average fiscal allocation for public health was 3.31% of total local taxes. In multivariate regressions, per capita expenditures, having a local board of health and public health service provision were associated with higher fiscal allocation. Stratified models showed that local board of health and local health department taxing authority were associated with fiscal allocation in low and high long-term debt areas, respectively.

CONCLUSIONS

The proportion of all local taxes allocated to local public health is related to local health department expenditures, service provision, and governance. These relationships depend upon the extent of long-term debt in the jurisdiction.

Effects of Economic Conditions and Organizational Structure on Local Health Jurisdiction Revenue Streams and Personnel Levels in Connecticut, 2005-2012

OBJECTIVE

We investigated whether or not changes in economic conditions during the 2008-2010 U.S. recession were associated with changes in Connecticut local health jurisdictions' (LHJs') revenue or personnel levels.

METHODS

We analyzed Connecticut Department of Public Health 2005-2012 annual report data from 91 Connecticut LHJs, as well as publicly available data on economic conditions. We used fixed- and random-effect regression models to test whether or not LHJ per capita revenues and full-time equivalent (FTE) personnel differed during and post-recession compared with pre-recession, or varied with recession intensity, as measured by unemployment rates and housing permits.

RESULTS

On average, total revenue per capita was significantly lower during and post-recession compared with pre-recession, with two-thirds of LHJs experiencing per capita revenue reductions. FTE personnel per capita were significantly lower post-recession. Changes in LHJ-level unemployment rates and housing permits did not explain the variation in revenue or FTE personnel per capita. Revenue and personnel differed significantly by LHJ organizational structure across all time periods.

CONCLUSION

Economic downturns can substantially reduce resources available for local public health. LHJ organizational structure influences revenue levels and sources, with implications for the scope, quality, and efficiency of services delivered.

Provision of Personal Healthcare Services by Local Health Departments: 2008-2013

INTRODUCTION

The scope of local health department (LHD) involvement in providing personal healthcare services versus population-based services has been debated for decades. A 2012 IOM report suggests that LHDs should gradually withdraw from providing personal healthcare services. The purpose of this study is to assess the level of LHD involvement in provision of personal healthcare services during 2008-2013 and examine the association between provision of personal healthcare services and per capita public health expenditures.

METHODS

Data are from the 2013 survey of LHDs and Area Health Resource Files. The number, ratio, and share of revenue from personal healthcare services were estimated. Both linear and panel fixed effects models were used to examine the association between provision of personal healthcare services and per capita public health expenditures. Data were analyzed in 2014.

RESULTS

The mean number of personal healthcare services provided by LHDs did not change significantly in 2008-2013. Overall, personal services constituted 28% of total service items. The share of revenue from personal services increased from 16.8% in 2008 to 20.3% in 2013. Results from the fixed effect panel models show a positive association between personal healthcare services' share of revenue and per capita expenditures (b=0.57, p<0.001).

CONCLUSIONS

A lower share of revenue from personal healthcare services is associated with lower per capita expenditures. LHDs, especially those serving <25,000 people, are highly dependent on personal healthcare revenue to sustain per capita expenditures. LHDs may need to consider strategies to replace lost revenue from discontinuing provision of personal healthcare services.

Impact of Economic Constraints on Public Health Delivery Systems Structures

OBJECTIVES

We estimated the effect of economic constraints on public health delivery systems (PHDS) density and centrality during 3 time periods, 1998, 2006, and 2012.

METHODS

We obtained data from the 1998, 2006, and 2012 National Longitudinal Study of Public Health Agencies; the 1993, 1997, 2005, and 2010 National Association for County and City Health Officials Profile Study; and the 1997, 2008, and 2011 Area Resource Files. We used multivariate regression models for panel data to estimate the impact of economic constraints on PHDS density and centrality.

RESULTS

Findings indicate that economic constraints did not have a significant impact on PHDS density and centrality over time but population is a significant predictor of PHDS density, and the presence of a board of health (BOH) is a significant predictor of PHDS density and centrality. Specifically, a 1% increase in population results in a significant 1.71% increase in PHDS density. The presence of a BOH is associated with a 10.2% increase in PHDS centrality, after controlling for other factors.

CONCLUSIONS

These findings suggest that other noneconomic factors influence PHDS density centrality.

Addressing psychological, mental health and other behavioural healthcare needs of the underserved populations in the United States: the role of local health departments

Aims:

(1) To assess the extent to which local health departments (LHDs) implement and evaluate strategies to target the behavioural healthcare needs for the underserved populations and (2) to identify factors that are associated with these undertakings.

Methods:

Data for this study were drawn from the 2013 National Profile of Local Health Departments Study conducted by National Association of County and City Health Officials. A total of 505 LHDs completed the Module 2 questionnaire of the Profile Study, in which LHDs were asked whether they implemented strategies and evaluated strategies to target the behavioural healthcare needs of the underserved populations. To assess LHDs’ level of engagement in assuring access to behavioural healthcare services, descriptive statistics were computed, whereas the factors associated with assuring access to these services were examined by using logistic regression analyses. To account for complex survey design, we used SVY routine in Stata 11.

Results:

Only about 24.9% of LHDs in small jurisdiction (<50,000 population) and 35.3% of LHDs in medium-size jurisdiction implemented/evaluated strategies to target the behavioural healthcare services needs of underserved populations in their jurisdiction in 2013. Logistic regression model results showed that LHDs having city/multicity jurisdiction (adjusted odds ratio (AOR) = .16, 95% confidence interval (CI): .04–.77), centralised governance (AOR = .12, 95% CI: .02–.85), and those located in South Region (AOR = .25, 95% CI: .08–.74) or the West Region (AOR = .36, 95% CI: 14–.94), were less likely to have implemented/evaluated strategies to target the behavioural healthcare needs of the underserved.

Conclusions:

The extent to which the LHDs implemented or evaluated strategies to target the behavioural healthcare needs of the underserved population varied by geographic regions and jurisdiction types. Different community needs or different state Medicaid programmes may have accounted for these variations. LHDs could play an important role in improving equity in access to care, including behavioural healthcare services in the communities.

Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States

This study assessed the importance of county characteristics in explaining county-level variations in health insurance coverage. Using public databases from 2008 to 2012, we studied 3112 counties in the United States. Rates of uninsurance ranged widely from 3% to 53%. Multivariate analysis suggested that poverty, unemployment, Republican voting, and percentages of Hispanic and American Indian/Alaskan Native residents in a county were significant predictors of uninsurance rates. The associations between uninsurance rates and both race/ethnicity and poverty varied significantly between metropolitan and non-metropolitan counties. Collaborative actions by the federal, tribal, state, and county governments are needed to promote coverage and access to care.

Geographic variations in cardiovascular health in the United States: contributions of state- and individual-level factors

Background

Improving cardiovascular health (CVH) of all Americans by 2020 is a strategic goal of the American Heart Association. Understanding the sources of variation and identifying contextual factors associated with poor CVH may suggest important avenues for prevention.

Methods and Results

Cross-sectional data from the Behavioral Risk Factor Surveillance System for the year 2011 were linked to state-level coronary heart disease and stroke mortality data from the National Vital Statistics System and to state-level measures of median household income, income inequality, taxes on soda drinks and cigarettes, and food and physical activity environments from various administrative sources. Poor CVH was defined according to the American Heart Association definition using 7 self-reported CVH metrics (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Linked micromap plots and multilevel logistic models were used to examine state variation in poor CVH and to investigate the contributions of individual- and state-level factors to this variation. We found significant state-level variation in the prevalence of poor CVH (median odds ratio 1.32, P<0.001). Higher rates of poor CVH and cardiovascular disease mortality were clustered in the southern states. Minority and low socioeconomic groups were strongly associated with poor CVH and explained 51% of the state-level variation in poor CVH; state-level factors explained an additional 28%. State-level median household income (odds ratio 0.89; 95% CI 0.84–0.94), taxes on soda drinks (odds ratio 0.94; 95% CI 0.89–0.99), farmers markets (odds ratio 0.91; 95% CI 0.85–0.98), and convenience stores (odds ratio 1.09; 95% CI 1.01–1.17) were predictive of poor CVH even after accounting for individual-level factors.

Conclusions

There is significant state-level variation in poor CVH that is partly explained by individual- and state-level factors. Additional longitudinal research is warranted to examine the influence of state-level policies and food and physical activity environments on poor CVH.

Minimum package of public health services: the adoption of core services in local public health agencies in Colorado

OBJECTIVES

We examined the effect of a state law in Colorado that required local public health agencies to deliver a minimum package of public health services.

METHODS

We used a longitudinal, pre-post study design, with baseline data collected in 2011 and follow-up data collected in 2013. We conducted means testing to analyze the change in service delivery and activities. We conducted linear regression to test for system structure effects on the implementation of core services.

RESULTS

We observed statistically significant increases in several service areas within communicable disease, prevention and population health promotion, and environmental health. In addition to service and program areas, specific activities had significant increases. The significant activity increases were all in population- and systems-based services.

CONCLUSIONS

This project provided insight into the likely effect of national adoption of a minimum package as recommended by the Institute of Medicine. The implementation of a minimum package showed significant changes in service delivery, with specific service delivery measurement over a short period of time. Our research sets up a research framework to further explore core service delivery measure development.