Estimating the impact of self-management education, influenza vaccines, nebulizers, and spacers on health utilization and expenditures for Medicaid-enrolled children with asthma.

INTRODUCTION: We quantify the effect of a set of interventions including asthma self-management education, influenza vaccination, spacers, and nebulizers on healthcare utilization and expenditures for Medicaid-enrolled children with asthma in New York and Michigan. METHODS: We obtained patients' data from Medicaid Analytic eXtract files and evaluated patients with persistent asthma in 2010 and 2011. We used difference-in-difference regression to quantify the effect of the intervention on the probability of asthma-related healthcare utilization, asthma medication, and utilization costs. We estimated the average change in outcome measures from pre-intervention/intervention (2010) to post-intervention (2011) periods for the intervention group by comparing this with the average change in the control group over the same time horizon. RESULTS: All of the interventions reduced both utilization and asthma medication costs. Asthma self-management education, nebulizer, and spacer interventions reduced the probability of emergency department (20.8-1.5%, 95%CI 19.7-21.9% vs. 0.5-2.5%, respectively) and inpatient (3.5-0.8%, 95%CI 2.1-4.9% vs. 0.4-1.2%, respectively) utilizations. Influenza vaccine decreased the probability of primary care physician (6-3.5%, 95%CI 4.4-7.6% vs. 1.5-5.5%, respectively) visit. The reductions varied by state and intervention. CONCLUSIONS: Promoting asthma self-management education, influenza vaccinations, nebulizers, and spacers can decrease the frequency of healthcare utilization and asthma-related expenditures while improving medication adherence.

Management Practices to Build Evidence-Based Decision-Making Capacity for Chronic Disease Prevention in Georgia: A Case Study.

BACKGROUND: Research shows that training can improve skills needed for evidence-based decision making, but less is known about instituting organizational supports to build capacity for evidence-based chronic disease prevention. COMMUNITY CONTEXT: The objectives of this case study were to assess facilitators and challenges of applying management practices to support evidence-based decision making in chronic disease prevention programs in the public health system in Georgia through key informant interviews and quantitatively test for changes in perceived management practices and skills through a pre-post survey. METHODS: Leadership of the chronic disease prevention section hosted a multiday training, provided regular supplemental training, restructured the section and staff meetings, led and oversaw technical assistance with partners, instituted transparent performance-based contracting, and made other changes. A 65-item online survey measured perceived importance of skills and the availability of skilled staff, organizational supports, and use of research evidence at baseline (2014) and in 2016 (after training). A structured interview guide asked about management practices, context, internal and external facilitators and barriers, and recommendations. CAPACITY-BUILDING ACTIVITIES AND SURVEY FINDINGS: Seventy-four staff members and partners completed both surveys (70.5% response). Eleven participants also completed a 1-hour telephone interview. Interview participants deemed leadership support and implementation of multiple concurrent management practices key facilitators to increase capacity. Main challenges included competing priorities, lack of political will, and receipt of requests counter to evidence-based approaches. At posttest, health department staff had significantly reduced gaps in skills overall (10-item sum) and in 4 of 10 individual skills, and increased use of research evidence to justify interventions. Use of research evidence for evaluation, but not skills, increased among partners. INTERPRETATION: The commitment of leaders with authority to establish multiple management practices to help staff members learn and apply evidence-based decision-making processes is key to increased use of evidence-based chronic disease prevention to improve population health.

Paying for prevention: a critical opportunity for public health.

Despite spending an increasing amount on health care and more than every other industrialized country, the U.S. ranks 37th in health outcomes. The implementation of the Patient Protection and Affordable Care Act (ACA) promises to ensure better access to health care for many Americans through expanded public and private insurance coverage, including basic preventive health care. Public health must seize this critical opportunity by taking steps to ensure that prevention, especially primary prevention, is embedded in our health system. This manuscript outlines four areas where public health officials across the U.S. can immediately capitalize on opportunities created by the ACA to ensure that prevention is a key component of health reform: (1) leading the way on community health assessments; (2) linking clinical and community prevention; (3) supporting the development of alternative payment methodologies to pay for prevention; and (4) serving as a community resource for the coordination of care and building the non-traditional health workforce.

Preemption of local smoke-free air ordinances: the implications of judicial opinions for meeting national health objectives.

Elimination of state laws that preempt local antismoking ordinances is a national health objective. However, the tobacco industry and its supporters have continued to pursue state-level preemption of local tobacco control ordinances as part of an apparent strategy to avoid the diffusion of grassroots antismoking initiatives. And, an increasing number of challenges to local ordinances by the tobacco industry and persons supported by the tobacco industry are being decided in state supreme courts and courts of appeals. The outcomes of seemingly similar cases about the validity of local smoke-free air ordinances vary significantly by state. This paper examines the common and unique aspects of the decisions and the potential implications of court rulings on preemption for future state tobacco control efforts and achievement of national health objectives around the elimination of preemption. Using a search strategy developed for the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation (STATE) System, cases where a state or federal appellate level court made a finding on the validity of a local smoke-free air ordinance or regulation were identified in 19 states. In contrast to previous studies, we found that cases in approximately half of states were decided for local governments. We also found that across the states, courts were considering similar factors in their decisions including the extent to which: (1) the local government possessed the authority to pass the ordinance, (2) the ordinance conflicted with the state constitution, and (3) state statutes preempt the ordinance.

A comprehensive review of state laws governing Internet and other delivery sales of cigarettes in the United States.

All U.S. states regulate face-to-face tobacco sales at retail outlets. However, the recent growth of delivery sales of tobacco products by Internet and mail-order vendors has prompted new state regulations focused on preventing youth access and tax evasion. To date, there are no comprehensive and systematic analyses of these laws. The objectives of this study were to: (a) document the historical enactment of the laws; (b) assess the nature and extent of the laws; and (c) examine the relationship between the presence of laws and state tobacco control policy and other contextual variables. Between 1992 and 2006, 34 states (67%) enacted a relevant law, with 27 states' laws (45%) effective between 2003 and 2006. Five states banned direct-to-consumer shipment of cigarettes. The remaining 29 states' laws included a combination of requirements addressing minimum age/ID, payment issues, shipping, vendor licensure and related issues, tax collection/remittance, and penalties/enforcement. States with delivery sales laws have stronger youth tobacco access policies and state tobacco control environments, as well as higher state cigarette excise tax rates and revenue, past-month cigarette use rates, and perceptions of risk of use by adolescents. This paper provides the policy context for understanding Internet and other cigarette delivery sales laws in the U.S. It also provides a systematic framework for ongoing policy surveillance and will contribute to future analyses of the impact of these laws on successfully reducing youth access to cigarettes and preventing tax evasion.

Conference synopsis and observations.

The articles reflecting the proceedings of the first-ever national public health law conference, Law and the Public's Health in the 21st Century, make it clear that public health law is the synergistic intersection of public health practices and the law. This article offers, and reflects on, observations organized around five themes expressed at that conference about the present status of public health law. The first is that public health law is indeed in a renaissance, or period of renewal, as evidenced by the rich history of the discipline and the growing body of scholarship. Secondly, legal preparedness, which offers a framework for action, is a critical component of public health preparedness. Third, law can be practiced preventively to positively impact the public's health, but unguided application of the law as a tool is problematic. Fourth, partnerships between public health and the law and among the professionals in the disciplines that touch law and public health are essential to protecting the public's health. Finally, public health law is in an era of extraordinary challenge, but with those challenges comes great opportunity that must be realized if we are to have excellence in public health practice in the 21st century.