The Relationships Between State Health Department Practitioners' Perceptions of Organizational Supports and Evidence-Based Decision-Making Skills.

OBJECTIVES: Evidence-based decision making (EBDM) allows public health practitioners to implement effective programs and policies fitting the preferences of their communities. To engage in EBDM, practitioners must have skills themselves, their agencies must engage in administrative evidence-based practices (A-EBPs), and leaders must encourage the use of EBDM. We conducted this longitudinal study to quantify perceptions of individual EBDM skills and A-EBPs, as well as the longitudinal associations between the 2. METHODS: An online survey completed among US state health department practitioners in 2016 and 2018 assessed perceptions of respondents' skills in EBDM and A-EBPs. We used χ2 tests, t tests, and linear regressions to quantify changes over time, differences by demographic characteristics, and longitudinal associations between individual skills and A-EBPs among respondents who completed both surveys (N = 336). RESULTS: Means of most individual EBDM skills and A-EBPs did not change significantly from 2016 to 2018. We found significant positive associations between changes in A-EBPs and changes in EBDM skill gaps: for example, a 1-point increase in the relationships and partnerships score was associated with a narrowing of the EBDM skill gap (ß estimate = 0.38; 95% CI, 0.15-0.61). At both time points, perceived skills and A-EBPs related to financial practices were low. CONCLUSIONS: Findings from this study can guide the development and dissemination of initiatives designed to simultaneously improve individual and organizational capacity for EBDM in public health settings. Future studies should focus on types of strategies most effective to build capacity in particular types of agencies and practitioners, to ultimately improve public health practice.

Engaging Consumers in Medicaid Program Design: Strategies from the States.

Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies. Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance. CONTEXT: Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient-centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done. METHODS: We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio-recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses. FINDINGS: First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer-term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement. CONCLUSIONS: Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.

Evaluating Comprehensive State Tobacco Prevention and Control Programs Using an Outcome Indicator Framework.

The outcome indicator framework helps tobacco prevention and control programs (TCPs) plan and implement theory-driven evaluations of their efforts to reduce and prevent tobacco use. Tobacco use is the single-most preventable cause of morbidity and mortality in the United States. The implementation of public health best practices by comprehensive state TCPs has been shown to prevent the initiation of tobacco use, reduce tobacco use prevalence, and decrease tobacco-related health care expenditures. Achieving and sustaining program goals require TCPs to evaluate the effectiveness and impact of their programs. To guide evaluation efforts by TCPs, the Centers for Disease Control and Prevention's Office on Smoking and Health developed an outcome indicator framework that includes a high-level logic model and evidence-based outcome indicators for each tobacco prevention and control goal area. In this article, we describe how TCPs and other community organizations can use the outcome indicator framework in their evaluation efforts. We also discuss how the framework is used at the national level to unify tobacco prevention and control efforts across varying state contexts, identify promising practices, and expand the public health evidence base.

Cancer survivorship care plans: Processes, effective strategies, and challenges in a Northern Plains rural state.

OBJECTIVES: Health systems face resource and time barriers to developing and implementing cancer survivorship care plans (SCPs) when active cancer treatment is completed. To address this problem, the South Dakota (SD) Department of Health partnered with two of SD's largest health systems to create the SD Survivorship Program. The purpose of this program evaluation study was to describe and compare SCP development and implementation at the two health systems. DESIGN & SAMPLE: A descriptive qualitative design was used. Interview participants were instrumental in the development and implementation of SCPs within their respective health system. MEASURES: Content analysis was used to analyze the interview data. RESULTS: The two health systems used similar processes for (a) early designation of program personnel, (b) developing SCP templates, (c) provider/staff input, and (d) identifying/tracking eligible patients. In contrast, they developed differing processes for SCP completion and delivery. The two health systems also identified effective strategies and challenges in SCP development and implementation. CONCLUSION: This evaluation suggests that partnerships between state health departments and local health systems could be key for meeting the nation-wide goal of universal SCP implementation. Particularly, other low-population rural states like SD can use the findings to help build their SCP programs.

Succession Planning in State Health Agencies in the United States: A Brief Report.

OBJECTIVE: Approximately 25% of the public health workforce plans to retire by 2020. Succession planning is a core capability of the governmental public health enterprise; however, limited data are available regarding these efforts in state health agencies (SHAs). METHODS: We analyzed 2016 Workforce Gaps Survey data regarding succession planning in SHAs using the US Office of Personnel Management's (OPM's) succession planning model, including 6 domains and 27 activities. Descriptive statistics were calculated for all 41 responding SHAs. RESULTS: On average, SHAs self-reported adequately addressing 11 of 27 succession planning activities, with 93% of SHAs adequately addressing 1 or more activities and 61% adequately addressing 1 or more activities in each domain. CONCLUSIONS: The majority of OPM-recommended succession planning activities are not being addressed, and limited succession planning occurs across SHAs. Greater activity in the OPM-identified succession planning domains may help SHAs contend with significant turnover and better preserve institutional knowledge.

Implementing Updated Recommendations on Hepatitis C Virus Screening: Translating Federal Guidance Into State Practice.

CONTEXT: Chronic viral hepatitis is a leading infectious cause of death. The Centers for Disease Control and Prevention (CDC) released updated recommendations for hepatitis C virus testing, including recommending that all individuals born between 1945 and 1965 be tested once. States' consistency with these national testing guidelines is unknown. OBJECTIVE: To evaluate the extent to which state health departments have current hepatitis C virus testing recommendations listed on their Web sites, consistent with national guidelines. DESIGN: The CDC guidelines were reviewed to identify the risk groups recommended for or against testing. State health department Web sites (50 US states, the District of Columbia, and Puerto Rico) were then systematically reviewed to classify whether, for each risk group, testing is recommended, not recommended, or with unclear recommendations. MAIN OUTCOME MEASURE: States' consistency with national recommendations for each risk group mentioned by the CDC. RESULTS: Among the risk groups that the CDC currently recommends for testing, 50% of states updated their Web sites to include individuals born between 1945 and 1965. All states recommend testing current or former injection drug users, but only 58% recommended testing HIV-positive individuals. Among the risk groups for which the CDC has issued uncertain recommendations, states most frequently recommended testing individuals with tattoos or body piercing done with unsterile materials (46%) or with a history of multiple sex partners (31%). CONCLUSIONS: There is substantial variation in state Web sites' consistency with the CDC guidelines. The public health importance of risk factors is not associated with their inclusion in Web content. Improving the uptake of these recommendations and the manner in which they are conveyed to the public are critical to implementing the national viral hepatitis action plan, thereby increasing diagnoses and averting new infections.

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.

A Statewide Medicaid Enhanced Prenatal and Postnatal Care Program and Infant Injuries.

To compare infant injuries in the first year of life between Maternal Infant Health Program (MIHP) participants and matched comparison groups. The population was the cohort of Medicaid-insured singleton infants born in 2011 in Michigan who had continuous Medicaid insurance and survived the first year after birth (N = 51,078). Propensity score matching was used to compare participants in MIHP to matched comparison groups from among the nonparticipants. Injury episodes were defined based on Medicaid claims in the first year of life. Matched comparisons were performed using McNemar, Bowker, and Wilcoxon signed rank tests to assess the effects of program participation on infant injuries. Infants of MIHP participants were more likely to have injury episodes (11.7 vs. 10.4 %, p < 0.01) and a higher rate of episodes (126.9/1,000 infants vs. 109.6/1,000) compared to matched nonparticipants. Infants of MIHP participants were more likely to have superficial injuries (4.9 vs. 3.9 %, p < 0.01) and a higher rate of episodes related to superficial injuries (49.7/1,000 vs. 39.6/1,000), which mainly accounted for the difference in injury visits between groups. Similar results were found among those enrolled and risk-screened in the program by the 2nd pregnancy trimester and who received a dosage of at least three additional MIHP contacts when compared to matched nonparticipants. MIHP participants did not experience reductions in infant injuries in the first year of life compared to matched nonparticipants. Possible explanations may include increased health-seeking behavior of the mothers participating in MIHP or improved recognition of infant injuries that warrant medical attention.

Pitfalls of using administrative data sets to describe clinical outcomes in sickle cell disease.

BACKGROUND: Administrative data sets are increasingly being used to describe clinical care in sickle cell disease (SCD). We recently used such an administrative database to look at the frequency of acute chest syndrome (ACS) and the use of transfusion to treat this syndrome in California patients from 2005 to 2010. Our results revealed a surprisingly low rate of transfusion for this life-threatening situation. PROCEDURE: To validate these results, we compared California OSPHD (Office of Statewide Health Planning and Development) administrative data with medical record review of patients diagnosed with ACS identified by two pediatric and one adult hospital databases during 2009-2010. RESULTS: ACS or a related pulmonary process accounted for one-fifth of the inpatient hospital discharges associated with the diagnosis of SCD between 2005 and 2010. Only 47% of those discharges were associated with a transfusion. However, chart reviews found that hospital databases over-reported visits for ACS. OSHPD underreported transfusions compared to hospital data. The net effect was a markedly higher true rate of transfusion (40.7% vs. 70.2%). CONCLUSIONS: These results point out the difficulties in using this administrative data base to describe clinical care for ACS given the variation in clinician recognition of this entity. OSPHD is widely used to inform health care policy in California and contributes to national databases. Our study suggests that using this administrative database to assess clinical care for SCD may lead to inaccurate assumptions about quality of care for SCD patients in California. Future studies on health services in SCD may require a different methodology.

Building analytic capacity, facilitating partnerships, and promoting data use in state health agencies: a distance-based workforce development initiative applied to maternal and child health epidemiology.

The purpose of this article is to summarize the methodology, partnerships, and products developed as a result of a distance-based workforce development initiative to improve analytic capacity among maternal and child health (MCH) epidemiologists in state health agencies. This effort was initiated by the Centers for Disease Control's MCH Epidemiology Program and faculty at the University of Illinois at Chicago to encourage and support the use of surveillance data by MCH epidemiologists and program staff in state agencies. Beginning in 2005, distance-based training in advanced analytic skills was provided to MCH epidemiologists. To support participants, this model of workforce development included: lectures about the practical application of innovative epidemiologic methods, development of multidisciplinary teams within and across agencies, and systematic, tailored technical assistance The goal of this initiative evolved to emphasize the direct application of advanced methods to the development of state data products using complex sample surveys, resulting in the articles published in this supplement to MCHJ. Innovative methods were applied by participating MCH epidemiologists, including regional analyses across geographies and datasets, multilevel analyses of state policies, and new indicator development. Support was provided for developing cross-state and regional partnerships and for developing and publishing the results of analytic projects. This collaboration was successful in building analytic capacity, facilitating partnerships and promoting surveillance data use to address state MCH priorities, and may have broader application beyond MCH epidemiology. In an era of decreasing resources, such partnership efforts between state and federal agencies and academia are essential for promoting effective data use.

Public health spending in 2008: on the challenge of integrating PHSSR data sets and the need for harmonization.

In recent years, state and local public health department budgets have been cut, sometimes drastically. However, there is no systematic tracking of governmental public health spending that would allow researchers to assess these cuts in comparison with governmental public health spending as a whole. Furthermore, attempts to quantify the impact of public health spending are limited by the lack of good data on public health spending on state and local public health services combined. The objective of this article is to integrate self-reported state and local health department (LHD) survey data from 2 major national organizations to create state-level estimates of governmental public health spending. To create integrated estimates, we selected 1388 LHDs and 46 states that had reported requisite financial information. To account for the nonrespondent LHDs, estimates of the spending were developed by using appropriate statistical weights. Finally, funds from federal pass-through and state sources were estimated for LHDs and subtracted from the total spending by the state health agency to avoid counting these dollars in both state and local figures. On average, states spend $106 per capita on traditional public health at the state and local level, with an average of 42% of spending occurring at the local level. Considerable variation exists in state and local public health funding. The results of this analysis show a relatively low level of public health funding compared with state Medicaid spending and health care more broadly.

Assessing the validity of self-reported community benefit expenditures: evidence from not-for-profit hospitals in California.

CONTEXT: In its revised Form 990 Schedule H, the Internal Revenue Service requires not-for-profit hospitals to provide detailed financial information on their community benefits, yet no standardized reporting guidelines exist for how these activities should be quantified. As a result, little is known currently about whether a hospital's self-reported community benefit expenditures provide an accurate picture of its commitment to serving the community. OBJECTIVE: To assess the validity of hospitals' self-reported community benefit expenditures. DATA AND METHODS: Data for this study came from California hospitals. Self-reported community benefit expenditures were derived from hospitals' annual community benefit reports for the year 2009. Bivariate correlation analysis was used to compare self-reported expenditures to a set of indicators of hospitals' charitable activity. Of the 218 private, not-for-profit California hospitals that were required to submit community benefit reports for 2009, 91 (42%) provided sufficient information for our analysis. RESULTS: California hospitals' self-reported community benefit expenditures were strongly correlated with indicators of charitable activity. Hospitals that reported higher community benefit expenditures engaged in more charitable activities than hospitals that reported lower levels of community benefit spending. CONCLUSION: Expenditure information from California hospitals' community benefit reports was found to be a valid indicator of charitable activity. Self-reported community benefit spending may thus provide a fairly accurate picture of a hospital's commitment to serving its community, despite the lack of standardized reporting guidelines.

Effective state-based surveillance for multidrug-resistant organisms related to health care-associated infections.

In September 2008, the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention sponsored a meeting of public health and infection-control professionals to address the implementation of surveillance for multidrug-resistant organisms (MDROs)-particularly those related to health care-associated infections. The group discussed the role of health departments and defined goals for future surveillance activities. Participants identified the following main points: (1) surveillance should guide prevention and infection-control activities, (2) an MDRO surveillance system should be adaptable and not organism specific, (3) new systems should utilize and link existing systems, and (4) automated electronic laboratory reporting will be an important component of surveillance but will take time to develop. Current MDRO reporting mandates and surveillance methods vary across states and localities. Health departments that have not already done so should be proactive in determining what type of system, if any, will fit their needs.