This update describes recent progress on two national health measurement initiatives: The National Health Security Preparedness Index and the National Longitudinal Survey of Public Health Systems. These longitudinal data sources offer valuable perspectives on how health security practices and public health delivery systems are changing across the U.S

Mays, Glen P.

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University of Kentucky

University of KentuckyUKnowledgeHealth Management and Policy Presentations Health Management and Policy4-22-2016Measuring Progress to Comprehensive PublicHealth Systems, National Preparedness, and aCulture of HealthGlen P. MaysUniversity of Kentucky, glen.mays@cuanschutz.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/hsm_presentPart of the Health and Medical Administration Commons, Health Economics Commons, HealthPolicy Commons, and the Health Services Research CommonsThis Presentation is brought to you for free and open access by the Health Management and Policy at UKnowledge. It has been accepted for inclusionin Health Management and Policy Presentations by an authorized administrator of UKnowledge. For more information, please contactUKnowledge@lsv.uky.edu.Repository CitationMays, Glen P., "Measuring Progress to Comprehensive Public Health Systems, National Preparedness, and a Culture of Health"(2016). Health Management and Policy Presentations. 129.https://uknowledge.uky.edu/hsm_present/129Measuring Progress to Comprehensive Public Health Systems, National Preparedness, and a Culture of Health  Glen Mays, PhD, MPH Scutchfield Professor of Health Services & Systems Research University of Kentucky America’s Health Rankings Scientific Advisory Committee Meeting •   Chapel Hill, NC  •   22 April 2016 ﻿An Equal Opportunity University Updates on 2 RWJF National Measurement Initiatives  National Health Security Preparedness Index National Longitudinal Survey of Public Health Systems  ﻿An Equal Opportunity University Why a Preparedness Index? Increase awareness & understanding of preparedness as a shared responsibility of multiple sectors in government and society  Identify strengths and vulnerabilities Track progress Encourage coordination & collaboration  Facilitate planning & policy development Support benchmarking & quality improvement Drive research & development   ﻿An Equal Opportunity University A Brief History Collaborative Development: Partnership led by CDC, ASTHO and >25 collaborating organizations   1st Release: Initial model structure and results − 5 domains and 14 subdomains − 128 measures 2nd Release: Revised model and results − 6 domains and 18 active subdomains − 119 retained + 75 new = 194 measures − 75% of retained measures have updated data Transition to Robert Wood Johnson Foundation − Validation studies and revision to methodology & measures 3rd Release: Revised model and results − 6 domains & 19 subdomains − 65% measures retained, 12% respecified, 8 new additions =134  − 90% of retained measures have updated data from 2nd release  12/2013 12/2014 1/2015 2012 4/2016 ﻿An Equal Opportunity University Current Index Structure 2016 Methodological Enhancements Consolidation: reduce correlated, redundant & noisy measures Composition: expand social, environmental economic indicators of preparedness & resiliency Grouping & weighting: use empirical methods for internal consistency, discriminant power Scaling: reflect distributional properties Comparisons: address accuracy and uncertainty Trending: apply new methods/measures      retrospectively 2016 Changes in Measure Set 42 measures eliminated due to data periodicity >3 years 29 measures eliminated due to poor construct validity 22 measures respecified to improve construct validity 8 newly added measures  Domain 2014 Alpha 2016 Alpha Health security surveillance 0.377 0.712 Community planning & engagement 0.382 0.631 Incident & information management 0.455 0.734 Healthcare delivery 0.354 0.596 Countermeasure management 0.231 0.654 Environmental/occupational health 0.546 0.749 Construct Validity   Staiger D, Dimick JB, Baser O, Fan Z and Birkmeyer JD. Empirically derived composite measures of surgical performance. Medical Care 2009;47: 226- 233. Hays RD, Hayashi T.  Beyond internal consistency reliability: rationale and user’s guide for multitrait analysis program on the microcomputer. Behavioral Research Methods 1990;22(2):167-75. ﻿An Equal Opportunity University Current Index Structure and Methodology 134 individual measures    19 subdomains   6 domains   State overall values   National overall values   Normalized to 0-10 scale using min-max scaling to preserve distributions Imputations based on multivariate longitudinal models Empirical weights based on Delphi expert panels Bayesian credible intervals reflect sampling and measurement error Annual estimates for 2013, 2014 and 2015 Weighted average Weighted average Weighted average Unweighted average Index Delphi Weights & Foundational Capabilities Surveillance & MonitoringCommunity Planning & EngagementIncident & Information ManagementHealthcare DeliveryCountermeasure ManagementEnvironmental & Occupational HealthSurveillance & Epidemiologic InvestigationBiological Monitoring & Laboratory TestingCross -Sector Planning & CoordinationProtections for Children & At -Risk PopulationsManagement of Volunteers for Emergency ResponseSocial Capital & CohesionIncident Management & Multi -Agency CoordinationEmergency Public Information& WarningLegal & Administrative ProtectionsPre-Hospital CareInpatient CareNursing & Long Term CareBehavioral Health CareHome CareMaterial Distribution & DispensingCountermeasure Utilization & EffectivenessNon-Pharmaceutical InterventionFood and Water SecurityEnvironmental MonitoringHealth Security & PreparednessSubdomainDomainFoundational Capabilities0.5000.5000.1820.3640.2720.1820.5000.3500.1500.3000.3000.1000.2000.1000.4500.3000.2500.6000.400Foundational Capabilities0.1900.2060.7940.0570.9430.190Foundational Capabilities0.4060.5940.190Foundational Capabilities0.0620.938Foundational Capabilities0.1890.8110.1520.0880.190NOTE: numbers indicate Delphi expert panel weights﻿An Equal Opportunity University 1. National preparedness trended upward in most functional areas during 2013-15, except in environmental health and healthcare delivery Preliminary Results: Not for Quotation or Attribution  +3.6% -4.5% +8.4% +7.5% +1.9% +5.9% -0.1% 2. Preparedness improved in most states during 2013-15, but significant geographic differences remain.  Preliminary Results: Not for Quotation or Attribution  % increase 2013-2015 % decrease 2013-2015 Significantly below national average in 2015 Within national average confidence interval Significantly above national average in 2015 Preliminary Results: Not for Quotation or Attribution  Preparedness Level 3. Preparedness levels improved by an average of 3.6% between 2013 and 2015.  Individual state trends ranged from a 9.1% improvement to a 3.5% decline. 4. Improvements in preparedness occurred across the U.S. in both above-average and below-average states.  However, some below-average states continued to lose ground.  Preliminary Results: Not for Quotation or Attribution  -50510% Change from 20135 .5 0 6 .0 0 6 . 5 0 7 . 0 0 7 .5 0  2015 State Preparedness Result Below national average Within national average Above national average 5. Gaps in preparedness between the highest and lowest states are large and persistent, and they have increased in environmental health and in healthcare delivery. Preliminary Results: Not for Quotation or Attribution  ﻿An Equal Opportunity University Caveats and cautions Imperfect measures & latent constructs Missing capabilities Timing and accuracy of underlying data sources      ﻿An Equal Opportunity University Next Steps Now: state preview period 2016 Public Release on April 26  www.nhspi.org National convening to showcase uses: Fall 2016 Continued work to incorporate advances in measurement: ASPR, CDC, NIH, AHRQ, HP2020 Additional analysis to understand causes and consequences of change      ﻿An Equal Opportunity University National Advisory Committee Members  |  2015-16   1.  Tom Inglesby, (Chair) UPMC Center for Health Security   2.  Robert Burhans, Emergency Management Consultant   3.  Anita Chandra, RAND   4.  Ana-Marie Jones, Collaborating Agencies Responding to Disasters   5.  Eric Klinenberg, New York University   6.  Jeff Levi/Dara Lieberman, Trust for America’s Health   7.  Nicole Lurie, Assistant Secretary for Preparedness and Response   8.  Stephanie Lynch, Caddo Parish (LA) Commissioner   9.  Suzet McKinney, Chicago Department of Public Health 10. Stephen Redd, CDC Office of Public Health Preparedness & Response 11. Richard Reed, American Red Cross (through 2/2016) 12. Martin Jose Sepulveda, IBM Corporation 13. Claudia Thompson, NIH National Institute of Environmental Health Sci. 14. John Wiesman, Washington State Secretary of Health For More Information Glen P. Mays, Ph.D., M.P.H.  glen.mays@uky.edu National Program Office Supported by The Robert Wood Johnson Foundation Email:    NHSPI@uky.edu Web:       www.nhspi.org    www.systemsforaction.org Journal:  www.FrontiersinPHSSR.org Archive:  works.bepress.com/glen_mays Blog:       publichealtheconomics.org   N a t i o n a l  C o o r d i n a t i n g  C e n t e r  How do we support effective  population health improvement strategies? Designed to achieve large-scale health improvement: neighborhood, city/county, region Target fundamental and often multiple  determinants of health Mobilize the collective actions of multiple stakeholders in government & private sector   Mays GP.  Governmental public health and the economics of adaptation to population health strategies.  National Academy of Medicine Discussion Paper.  2014.  http://nam.edu/wp-content/uploads/2015/06/EconomicsOfAdaptation.pdf  What foundational services are needed to support collective actions in health?  Public health agency as chief health strategist for the system:  Articulate population health needs & priorities Engage community stakeholders Plan with clear roles & responsibilities Recruit & leverage resources Develop and enforce policies Ensure coordination across sectors Promote equity and target disparities Support evidence-based practices Monitor and feed back results Ensure transparency & accountability: resources, results, ROI What do we call a system that delivers a broad scope of foundational public health services through a  dense network of  multi-sector relationships?  COMPREHENSIVE One of RWJF’s 41 Culture of Health  National Metrics http://www.cultureofhealth.org/en/integrated-systems/access.html What do we know about the benefits of Comprehensive Public Health Systems?  Greater concordance with national recommendations − IOM Core Functions − Essential Public Health Services − PHAB national accreditation standards − Foundational Public Health Services Fewer governmental resources per capita: more for less Over time, larger gains in population health  Prevalence of Public Health System Configurations 1998-2014 % of recommended activities performed   Scope High   High          High   Mod   Mod  Low  Low          Centrality Mod Low High High Low High Low   Density  High  High  Mod  Mod    Mod  Low   Mod Comprehensive Conventional Limited (High System Capital) Data: public health delivery systems National Longitudinal Survey of Public Health Systems Cohort of 360 communities with at least 100,000 residents Followed over time: 1998, 2006, 2012, 2014**, 2016 Local public health officials report: – Scope: availability of 20 recommended  public health activities – Network density: types of organizations  contributing to each activity – Centrality of effort: contributed by designated  local public health agency – Quality: perceived effectiveness  of each activity ** Expanded sample of 500 communities<100,000 added in 2014 wave Cluster and network analysis to identify “system capital” Cluster analysis is used to classify communities into one of 7 categories of public health system capital based on: Scope of activities contributed by each type of organization  Density of connections among organizations jointly producing public health activities Degree centrality of the local public health agency Mays GP et al. Understanding the organization of public health delivery systems: an empirical typology. Milbank Q. 2010;88(1):81–111.  Average public health system structure in 2014 Node size = degree centrality Line size = % activities jointly contributed (tie strength) Changes in system prevalence and coverage System Capital Measures 1998 2006 2012 2014 2014 (<100k) Comprehensive systems       % of communities 24.2% 36.9% 31.1% 32.7% 25.7%      % of population 25.0% 50.8% 47.7% 47.2% 36.6% Conventional systems      % of communities 50.1% 33.9% 49.0% 40.1% 57.6%      % of population 46.9% 25.8% 36.3% 32.5% 47.3% Limited systems      % of communities 25.6% 29.2% 19.9% 20.6% 16.7%      % of population 28.1% 23.4% 16.0% 19.6% 16.1% Delivery of recommended public health activities 1998-2014 % of recommended activities performed Assurance (-18.4%) Assessment (+5.6%) Policy/Planning (+15.8%) Total (+1.1%) Delivery of recommended public health activities 1998-2014 Variation in public health service delivery % of activities 0 5% 10& Percent of U.S. communities 20% 40% 60% 80% 100%   Percent of activities performed National Longitudinal Survey of Public Health Systems Equity in Delivery Delivery of recommended public health activities, 2006-14 Quintiles of communities -40%-20%0%20%40%60%80%100%Q1 Q2 Q3 Q4 Q52012∆ 2006-12 % of recommended activities performed 2014 ∆ 2006-14 Organizational contributions to recommended  public health activities, 1998-2014 % of recommended activities performed Type of Organization 1998 2006 2012 2014 Local public health agency 60.7% 66.5% 62.0% 67.4% Other local govt agencies 31.8% 50.8% 26.3% 32.7% State public health agency 46.0% 45.3% 36.4% 34.0% Other state govt agencies 17.2% 16.4% 13.0% 12.7% Federal agencies 7.0% 12.0% 8.7% 7.1% Hospitals 37.3% 41.1% 39.3% 47.2% Physician practices 20.2% 24.1% 19.5% 18.0% Community health centers 12.4% 28.6% 26.9% 28.3% Health insurers 8.6% 10.0% 9.8% 11.1% Employers/business 25.5% 16.9% 13.4% 15.0% Schools 30.7% 27.6% 24.9% 24.7% Universities/colleges 15.6% 21.6% 21.2% 22.2% Faith-based organizations 24.0% 19.2% 15.7% 16.8% Other nonprofits 31.9% 34.2% 31.6% 33.6% Other organizations 8.5% 8.8% 5.4% 5.4% Bridging capital in public health delivery systems Trends in betweenness centrality   * * * * * * * * * Change from prior years is statistically significant at p<0.05 2014 Health and economic impact  of comprehensive systems Models also control for racial composition, unemployment, health insurance coverage, educational attainment, age composition, and state and year fixed effects.   N=779 community-years  **p<0.05    *p<0.10 Fixed Effects and IV Estimates: Effects of Comprehensive  System Capital on Mortality and Spending   Making the case for equity: larger gains  in low-resource communities Log IV regression estimates controlling for community-level and state-level characteristics Effects of Comprehensive Public Health Systems  in Low-Income vs.  High-Income Communities Mortality Medical costs 95% CI Comprehensive systems do more with less Type of delivery system Expenditures per capita % of recommended activities performed Assessing public health system change under PHNCI Pre and Post surveys with the National Longitudinal Survey of Public Health Systems Comparative feedback reports of results Comparison of PHNCI sites with non-participating communities Qualitative interviews to explore more granular measures of system innovation and change  For more information • Survey instrument http://works.bepress.com/glen_mays/38/  • Defining Comprehensive Public Health Delivery Systems https://works.bepress.com/glen_mays/198/  • Original methodology: Milbank Quarterly 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888010/ • Most recent analysis of health/economic benefits of comprehensive systems: AJPH 2015 http://www.ncbi.nlm.nih.gov/pubmed/25689201  • Example customized report http://works.bepress.com/glen_mays/67/      For More Information Glen P. Mays, Ph.D., M.P.H. glen.mays@uky.edu @GlenMays Supported by The Robert Wood Johnson Foundation Email:    systems4action@uky.edu Web:       www.systemsforaction.org      www.publichealthsystems.org Journal:  www.FrontiersinPHSSR.org Archive:  works.bepress.com/glen_mays Blog:       publichealtheconomics.org   N a t i o n a l  C o o r d i n a t i n g  C e n t e r  Appendix: specifications Appendix: specifications 

Measuring Progress to Comprehensive Public Health Systems, National Preparedness, and a Culture of Health

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Measuring Progress to Comprehensive Public Health Systems, National Preparedness, and a Culture of Health

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