Local Health Department Collaborative Capacity to Improve Population Health

Local health departments (LHDs) can more effectively develop and strengthen community health partnerships when leaders focus on building partnership collaborative capacity (PCC), including a multisector infrastructure for population health improvement. Using the 2008 National Association of County and City Health Officials (NACCHO) Profile survey, we constructed an overall measure of LHD PCC comprised of the five dimensions: outcomes-based advocacy, vision-focus balance, systems orientation, infrastructure development, and community linkages. We conducted a series of regression analyses to examine the extent to which LHD characteristics and contextual factors were related to PCC. The most developed PCC dimension was vision-focus balance, while infrastructure development and community linkages were the least developed. In multivariate analyses, LHDs that were locally governed (rather than governed by the state), LHDs without local boards of health, and LHDs providing a wider range of clinical services had greater overall PCC. LHDs serving counties with higher uninsurance rates had lower overall PCC. LHDs with lower per capita expenditures had less developed partnership infrastructure. LHD discontinuation of clinical services may result in an erosion of collaborative capacity unless LHD partnerships also shift their foci from services delivery to population health improvement

Hospital Responses to the Emergency Medical Treatment and Labor Act (EMTALA): Noncompliance, Hospital Utilization and Readmissions, and Strategic Ambulance Diversions

EMTALA requires Medicare-participating hospitals to provide emergency care to all patients regardless of payer. We examine the effect of EMTALA in three studies. (1) In key informant interviews, we examine causes for and solutions to EMTALA noncompliance. We find that hospitals may violate EMTALA for five reasons: financial pressure, complexity/lack of knowledge about the law, a high referral burden that makes it difficult to comply with EMTALA, inter-hospital relationships that discourage reporting on borderline inappropriate transfers, and a principal-agent problem with differing physician and hospital priorities. We propose several ways to strengthen the Act, including requiring Medicaid to fully reimburse required EMTALA screening exams and amending EMTALA to permit informal mediation sessions between hospitals. (2) We measure changes in hospital utilization and readmissions when EMTALA is extended to inpatients. In 2009, the Federal Court of Appeals for the Sixth Circuit ruled that EMTALA obligations continued until a patient was stabilized, regardless of whether s/he was admitted. However, hospitals outside the court’s jurisdiction continued to follow 2003 regulations that EMTALA obligations cease after a good faith admission. This study uses a difference-in-difference-in-differences design, comparing Medicaid/uninsured with commercially-insured patients before and after the case in hospitals inside and outside the Sixth Circuit. We find that although more unprofitable inpatients are discharged with a short length of stay after extending EMTALA to inpatients, they are substantially less likely to be readmitted. These results suggest that extending EMTALA to inpatients may encourage hospitals to fully stabilize unprofitable patients admitted from the emergency department (ED).(3) We explore whether hospitals strategically avoid treating uninsured and Medicaid patients by temporarily closing part of their EDs (through an ambulance diversion) when nearby safety net hospitals declare diversion. We find that hospitals are more likely to declare diversions when nearby safety net hospitals go on diversion, as compared to when nearby non-safety safety net hospitals (matched by size and distance) do so. Furthermore, hospitals that divert when a nearby safety net hospital diverts have a slightly lower ED occupancy than hospitals that divert when a nearby non-safety net hospital diverts. In addition, we theorized that, like musical chairs, hospitals do not want to be last one with an open ED after a nearby safety net hospital declares a diversion. Consistent with this theory, when multiple hospitals in a market are on diversion, the third hospital in a market to declare a diversion does so sooner if the first hospital declaring a diversion is a safety net hospital than if the first hospital is a non-safety net hospital. Hospitals also end their diversions differently depending on whether the nearby diverting hospital was a safety net hospital or non-safety net hospital. Specifically, hospitals are on diversion longer and end their diversions later after a nearby safety net hospital ended its diversion than after a nearby non-safety net hospital ends its diversion. Perhaps hospitals that are strategically diverting are waiting to make sure that the nearby safety net hospital will not go back on diversion.Our results suggest that hospitals engage in strategic diversions, reducing access to emergency services to unprofitable patients and circumventing the goals of EMTALA

Local Health Department Collaborative Capacity to Improve Population Health.

Local health departments (LHDs) can more effectively develop and strengthen community health partnerships when leaders focus on building partnership collaborative capacity (PCC), including a multisector infrastructure for population health improvement. Using the 2008 National Association of County and City Health Officials (NACCHO) Profile survey, we constructed an overall measure of LHD PCC comprised of the five dimensions: outcomes-based advocacy, vision-focus balance, systems orientation, infrastructure development, and community linkages. We conducted a series of regression analyses to examine the extent to which LHD characteristics and contextual factors were related to PCC. The most developed PCC dimension was vision-focus balance, while infrastructure development and community linkages were the least developed. In multivariate analyses, LHDs that were locally governed (rather than governed by the state), LHDs without local boards of health, and LHDs providing a wider range of clinical services had greater overall PCC. LHDs serving counties with higher uninsurance rates had lower overall PCC. LHDs with lower per capita expenditures had less developed partnership infrastructure. LHD discontinuation of clinical services may result in an erosion of collaborative capacity unless LHD partnerships also shift their foci from services delivery to population health improvement

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field