Trends in Clinical Billing by Local Health Departments

Background: Billing for clinical services is perceived to be increasingly important for local health departments (LHDs). Yet very little evidence exists regarding the frequency and relative financial importance of clinical billing revenues. Purpose: The purpose of this study is to report on trends in the frequency and financial scope of clinical billing by LHDs from 2008 to 2013. Methods: The study used data from the 2008, 2010, and 2013 National Association of City and County Health Officials Profile report surveys. Per capita revenues from clinical billing and percent of total LHD revenues from clinical billing were calculated. Results: Clinical billing became significantly more common between 2008 and 2013, with approximately three quarters of LHDs receiving revenues as of 2013. The mean amount received also significantly increased. The net increase in clinical billing revenues per capita ($2.82) was greater than the overall increase in total revenues per capita from 2008 to 2013. Implications: Clinical billing revenues provided a backfill against erosion in funding for LHDs. While certain regions (e.g., Northeast) have consistently seen smaller clinical billing revenues and other regions (e.g., Southeast) have consistently seen large clinical billing revenues, other regions (e.g., West) are increasingly billing as well. While increasing reliance on clinical billing revenues may present longer-term challenges, these revenues represent a tremendously important source of financial stability during the Great Recession. Current trends indicate that in spite of declines in individually-focused services, revenues from clinical billing are increasing

The Opportunity Cost of COVID for Public Health Practice: COVID-19 Pandemic Response Work and Lost Foundational Areas of Public Health Work

Context: There is little empirical evidence regarding the magnitude of the COVID-19 response across the public health workforce and the extent to which other public health programs were called upon to contribute to the response, potentially leading to less work being done in other public health programs during the COVID-19 pandemic. Objectives: To assess the composition of the workforce that contributed to the COVID-19 pandemic response during 2020-2022. Design: A large, cross-sectional, nationally representative survey of the state and local public health agency workforce through the Public Health Workforce Interest and Needs Survey (PH WINS). Setting: Nearly all state health agency-central offices (SHA-COs) and Big City Health Coalition (BCHC) member public health departments as well as a nationally representative sample of other local health departments (LHDs) with more than 25 staff members and serving more than 25 000 people participated in fall 2021. Participants: A sample of all individuals working at each SHA-CO or LHD as part-time or full-time employees, contractors, or other employee types was used. A total of 44 732 responses (35% of eligible respondents) were received. Main Outcome Measure: Main outcomes included the proportion of full-time equivalent (FTE) effort devoted to COVID-19 response work by quarter (Q) from Q1 2020 through Q1 2022. Predictors of interest included individual- and agency-level demographics, most notably an individual\u27s self-reported public health program area. Results: Staffing and hiring for the COVID-19 pandemic response was an ongoing effort that began in 2020 and lasted through 2022. During the pandemic, all public health program areas contributed at least 20% of their workforce time to COVID-19 response, peaking at 47-83% of the staff time, depending on the program area. Conclusions: There was a considerable public health opportunity cost to the public health systems\u27 large and prolonged COVID-19 response. Persistent understaffing in the public health system remains an important issue

Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers.

BackgroundHealth information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.MethodsWe conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.ResultsWe interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels-regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization's workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.ConclusionsThe adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested

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

An Iterative, Low-Cost Strategy to Building Information Systems Allows a Small Jurisdiction Local Health Department to Increase Efficiencies and Expand Services

Objective and Methods: The objective of this case study was to describe the process and outcomes of a small local health department\u27s (LHD\u27s) strategy to build and use information systems. The case study is based on a review of documents and semi-structured interviews with key informants in the Pomperaug District Health Department. Interviews were recorded, transcribed, coded, and analyzed. Results and Conclusions: The case study here suggests that small LHDs can use a low-resource, incremental strategy to build information systems for improving departmental effectiveness and efficiency. Specifically, we suggest that the elements for this department\u27s success were simple information systems, clear vision, consistent leadership, and the involvement, training, and support of staff

TGF-β1 modulates microglial phenotype and promotes recovery after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a devastating form of stroke that results from the rupture of a blood vessel in the brain, leading to a mass of blood within the brain parenchyma. The injury causes a rapid inflammatory reaction that includes activation of the tissue-resident microglia and recruitment of blood-derived macrophages and other leukocytes. In this work, we investigated the specific responses of microglia following ICH with the aim of identifying pathways that may aid in recovery after brain injury. We used longitudinal transcriptional profiling of microglia in a murine model to determine the phenotype of microglia during the acute and resolution phases of ICH in vivo and found increases in TGF-β1 pathway activation during the resolution phase. We then confirmed that TGF-β1 treatment modulated inflammatory profiles of microglia in vitro. Moreover, TGF-β1 treatment following ICH decreased microglial Il6 gene expression in vivo and improved functional outcomes in the murine model. Finally, we observed that patients with early increases in plasma TGF-β1 concentrations had better outcomes 90 days after ICH, confirming the role of TGF-β1 in functional recovery from ICH. Taken together, our data show that TGF-β1 modulates microglia-mediated neuroinflammation after ICH and promotes functional recovery, suggesting that TGF-β1 may be a therapeutic target for acute brain injury

Surface Covering of Downed Logs: Drivers of a Neglected Process in Dead Wood Ecology

Many species use coarse woody debris (CWD) and are disadvantaged by the forestry-induced loss of this resource. A neglected process affecting CWD is the covering of the surfaces of downed logs caused by sinking into the ground (increasing soil contact, mostly covering the underside of the log), and dense overgrowth by ground vegetation. Such cover is likely to profoundly influence the quality and accessibility of CWD for wood-inhabiting organisms, but the factors affecting covering are largely unknown. In a five-year experiment we determined predictors of covering rate of fresh logs in boreal forests and clear-cuts. Logs with branches were little covered because they had low longitudinal ground contact. For branchless logs, longitudinal ground contact was most strongly related to estimated peat depth (positive relation). The strongest predictor for total cover of branchless logs was longitudinal ground contact. To evaluate the effect on cover of factors other than longitudinal ground contact, we separately analyzed data from only those log sections that were in contact with the ground. Four factors were prominent predictors of percentage cover of such log sections: estimated peat depth, canopy shade (both increasing cover), potential solar radiation calculated from slope and slope aspect, and diameter of the log (both reducing cover). Peat increased cover directly through its low resistance, which allowed logs to sink and soil contact to increase. High moisture and low temperatures in pole-ward facing slopes and under a canopy favor peat formation through lowered decomposition and enhanced growth of peat-forming mosses, which also proved to rapidly overgrow logs. We found that in some boreal forests, peat and fast-growing mosses can rapidly cover logs lying on the ground. When actively introducing CWD for conservation purposes, we recommend that such rapid covering is avoided, thereby most likely improving the CWD's longevity as habitat for many species

A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?

Objectives Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. Method PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. Results Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. Conclusion Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence

Gas dynamics in tidal dwarf galaxies : disc formation at z=0

Tidal dwarf galaxies (TDGs) are recycled objects that form within the collisional debris of interacting/merging galaxies. They are expected to be devoid of non-baryonic dark matter, since they can form only from dissipative material ejected from the discs of the progenitor galaxies. We investigate the gas dynamics in a sample of six bona-fide TDGs around three interacting and post-interacting systems: NGC 4694, NGC 5291, and NGC 7252 ("Atoms for Peace"). For NGC 4694 and NGC 5291 we analyse existing HI data from the Very Large Array (VLA), while for NGC 7252 we present new HI observations from the Jansky VLA together with long-slit and integral-field optical spectroscopy. For all six TDGs, the HI emission can be described by rotating disc models. These HI discs, however, have undergone less than a full rotation since the time of the interaction/merger event, raising the question of whether they are in dynamical equilibrium. Assuming that these discs are in equilibrium, the inferred dynamical masses are consistent with the observed baryonic masses, implying that TDGs are devoid of dark matter. This puts constraints on putative "dark discs" (either baryonic or non-baryonic) in the progenitor galaxies. Moreover, TDGs seem to systematically deviate from the baryonic Tully-Fisher relation. These results provide a challenging test for alternative theories like MOND.Peer reviewe

Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers

BackgroundHealth information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.MethodsWe conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.ResultsWe interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels-regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization's workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.ConclusionsThe adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested