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

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

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

Patterns and Correlates of Public Health Informatics Capacity Among Local Health Departments

Objective: Little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs) and whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range. This study examined patterns and correlates of the presence of public health informatics functionalities within LHDs through the creation of a typology of LHD informatics capacities.Methods: Data was available for 459 LHDs from the 2013 National Association of County and City Health Officials Profile survey. An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories.Results: Low-informatics capacity LHDs had lower levels of use of each informatics functionalities than high-informatics capacity LHDs. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services.Conclusion: Informatics capacity is clustered within LHDs. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to expand capacity across a range of functionalities, taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies

Associations Between Physician Practice Models and Health Information Exchange

OBJECTIVES: The interaction between emerging physician practice models and the use of health information exchange (HIE) remains understudied. We examined associations between the use of emerging practice models and the use of HIE. We also examined barriers to HIE adoption among physicians who were not utilizing HIE. STUDY DESIGN: Survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3312, or 17.9% of all practicing physicians). METHODS: Primary outcomes were physician-reported HIE use for patient care summaries and for laboratory results. Secondary outcomes were 5 common HIE barriers among non-HIE users. The primary predictor was physician practice model: accountable care organization (ACO), clinically integrated network (CIN), or integrated delivery network (IDN) vs traditional care delivery model. Covariates included physician specialty, age, gender, and county of practice. RESULTS: Compared with physicians in traditional care delivery models, physicians in ACOs, CINs, or IDNs had significantly higher odds of using HIE to share both patient care summaries (P \u3c .01) and laboratory results (P \u3c .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. CONCLUSIONS: Providers in an emerging practice model are more likely to use HIE than those in a traditional care delivery model. However, nuances in these associations suggest a persistence of previously identified HIE gaps, and the barriers cited provide guidance for increasing HIE use among different practice types

Impact of clinical decision support on receipt of antibiotic prescriptions for acute bronchitis and upper respiratory tract infection.

ObjectiveAntibiotics are commonly recognized as non-indicated for acute bronchitis and upper respiratory tract infection (URI), yet their widespread use persists. Clinical decision support in the form of electronic warnings is hypothesized to prevent non-indicated prescriptions. The purpose of this study was to identify the effect of clinical decision support on a common type of non-indicated prescription.Materials and methodsUsing National Ambulatory Medical Care Survey data from 2006 to 2010, ambulatory visits with a primary diagnosis of acute bronchitis or URI and orders for antibiotic prescriptions were identified. Visits were classified on the basis of clinician report of decision-support use. Generalized estimating equations were used to assess the effect of decision support on likelihood of antibiotic prescription receipt, controlling for patient, provider, and practice characteristics.ResultsClinician use of decision support increased sharply between 2006 (16% of visits) and 2010 (55%). Antibiotic prescribing for acute bronchitis and URI increased from ∼35% of visits in 2006 to ∼45% by 2010. Use of decision support was associated with a 19% lower likelihood of receiving an antibiotic prescription, controlling for patient, provider, and practice characteristics.DiscussionIn spite of the increased use of decision-support systems and the relatively fewer non-indicated antibiotic prescriptions resulting from the use of decision support, a secular upward trend in non-indicated antibiotic prescribing offset these improvements.ConclusionsThe overall effect of decision support suggests an important role for technology in reducing non-indicated prescriptions. Decision support alone may not be sufficient to eliminate non-indicated prescriptions given secular trends