Characteristics of Population Health Physicians and the Needs of Healthcare Organizations.

INTRODUCTION: Healthcare organizations are transitioning from fee-for-service, volume-based care toward value-based care and the Triple Aim. Physicians have critical roles as leaders and practitioners in this emerging field of population health management; however, the competencies required of these physicians are not well described. The purpose of this study is to explore the approaches of healthcare systems to population health-related functions, the competencies needed, and the characteristics of physicians who lead or staff these functions. METHODS: Investigators conducted semistructured interviews with a convenience sample of 14 healthcare executives and 15 Preventive Medicine physicians and a focus group with 9 healthcare executives. Interviews and the focus group were recorded, transcribed, and coded. Themes and notable quotes were identified. Data were collected and analyzed in 2019. RESULTS: Population health was variously defined by the healthcare executives, often naming specific components or activities. The typical population health activities described by healthcare executives (e.g., quality measurement and process improvement) were reported along with the skills of physicians performing these functions (e.g., data analysis, informatics, leadership, business acumen). A total of 2 types of population health physicians were described: the clinician leader and the population health specialist. CONCLUSIONS: This exploratory study identified several useful competencies for population health physicians in healthcare systems. Findings point to opportunities to promote a more systematic approach to population health and to prepare Preventive Medicine and other physicians for population health management positions.

Using a RE-AIM framework to identify promising practices in National Diabetes Prevention Program implementation.

BACKGROUND: The National Diabetes Prevention Program (National DPP) is rapidly expanding in an effort to help those at high risk of type 2 diabetes prevent or delay the disease. In 2012, the Centers for Disease Control and Prevention funded six national organizations to scale and sustain multistate delivery of the National DPP lifestyle change intervention (LCI). This study aims to describe reach, adoption, and maintenance during the 4-year funding period and to assess associations between site-level factors and program effectiveness regarding participant attendance and participation duration. METHODS: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation from October 2012 to September 2016. Multilevel linear regressions were used to examine associations between participant-level demographics and site-level strategies and number of sessions attended, attendance in months 7-12, and duration of participation. RESULTS: The six funded national organizations increased the number of participating sites from 68 in 2012 to 164 by 2016 across 38 states and enrolled 14,876 eligible participants. By September 2016, coverage for the National DPP LCI was secured for 42 private insurers and 7 public payers. Nearly 200 employers were recruited to offer the LCI on site to their employees. Site-level strategies significantly associated with higher overall attendance, attendance in months 7-12, and longer participation duration included using self-referral or word of mouth as a recruitment strategy, providing non-monetary incentives for participation, and using cultural adaptations to address participants' needs. Sites receiving referrals from healthcare providers or health systems also had higher attendance in months 7-12 and longer participation duration. At the participant level, better outcomes were achieved among those aged 65+ (vs. 18-44 or 45-64), those who were overweight (vs. obesity), those who were non-Hispanic white (vs. non-Hispanic black or multiracial/other races), and those eligible based on a blood test or history of gestational diabetes mellitus (vs. screening positive on a risk test). CONCLUSIONS: In a time of rapid dissemination of the National DPP LCI the findings of this evaluation can be used to enhance program implementation and translate lessons learned to similar organizations and settings.

Twenty Year Trends and Sex Differences in Young Adults Hospitalized With Acute Myocardial Infarction.

BACKGROUND: Sex differences are known to exist in the management of older patients presenting with acute myocardial infarction (AMI). Few studies have examined the incidence and risk factors of AMI among young patients, or whether clinical management differs by sex. METHODS: The Atherosclerosis Risk in Communities (ARIC) Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified by physician review, using a validated algorithm. Medications and procedures were abstracted from the medical record. Our study population was limited to young patients aged 35 to 54 years. RESULTS: From 1995 to 2014, 28 732 weighted hospitalizations for AMI were sampled among patients aged 35 to 74 years. Of these, 8737 (30%) were young. The annual incidence of AMI hospitalizations increased for young women but decreased for young men. The overall proportion of AMI admissions attributable to young patients steadily increased, from 27% in 1995 to 1999 to 32% in 2010 to 2014 ( P for trend=0.002), with the largest increase observed in young women. History of hypertension (59% to 73%, P for trend<0.0001) and diabetes mellitus (25% to 35%, P for trend<0.0001) also increased among young AMI patients. Compared to young men, young women presenting with AMI were more often black and had a greater comorbidity burden. In adjusted analyses, young women had a lower probability of receiving lipid-lowering therapies (relative risk [RR]=0.87; 95% confidence interval [CI], 0.80-0.94), nonaspirin antiplatelets (RR=0.83; 95% CI, 0.75-0.91), beta blockers (RR=0.96; 95% CI, 0.91-0.99), coronary angiography (RR=0.93; 95% CI, 0.86-0.99) and coronary revascularization (RR = 0.79; 95% CI, 0.71-0.87). However, 1-year all-cause mortality was comparable for women versus men (HR=1.10; 95% CI, 0.83-1.45). CONCLUSIONS: The proportion of AMI hospitalizations attributable to young patients increased from 1995 to 2014 and was especially pronounced among women. History of hypertension and diabetes among young patients admitted with AMI increased over time as well. Compared with young men, young women presenting with AMI had a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these changes is needed to improve care of young patients with AMI.

A Feasibility Study of Supply and Demand for Diabetes Prevention Programs in North Carolina.

INTRODUCTION: Diabetes Prevention Programs (DPPs) have shown that healthy eating and moderate physical activity are effective ways of delaying and preventing type 2 diabetes in people with impaired glucose tolerance. We assessed willingness to pay for DPPs from the perspective of potential recipients and the cost of providing these programs from the perspective of community health centers and local health departments in North Carolina. METHODS: We used contingent valuation to determine how much potential recipients would be willing to pay to participate in DPPs under 3 different models: delivered by registered professionals (traditional model), by community health workers, or online. By using information on the minimum reimbursement rate at which public health agencies would be prepared to provide the 3 models, we estimated the marginal costs per person of supplying the programs. Matching supply and demand, we estimated the degree of cost sharing between recipients and providers. RESULTS: Potential program recipients (n = 99) were willing to pay more for programs led by registered professionals than by community health workers, and they preferred face-to-face contact to an online format. Socioeconomic status (measured by education and employment) and age played the biggest roles in determining willingness to pay. Leaders of public health agencies (n = 27) reported up to a 40% difference in the cost of providing the DPP, depending on the delivery model. CONCLUSION: By using willingness to pay to understand demand for DPPs and computing the provider's marginal cost of providing these services, we can estimate cost sharing and market coverage of these services and thus compare the viability of alternate approaches to scaling up and sustaining DPPs with available resources.

Measuring public health practice and outcomes in chronic disease: a call for coordination.

A strategic opportunity exists to coordinate public health systems and services researchers' efforts to develop local health department service delivery measures and the efforts of divisions within the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to establish outcome indicators for public health practice in chronic disease. Several sets of outcome indicators developed by divisions within NCCDPHP and intended for use by state programs can be tailored to assess outcomes of interventions within smaller geographic areas or intervention settings. Coordination of measurement efforts could potentially allow information to flow from the local to the state to the federal level, enhancing program planning, accountability, and even subsequent funding for public health practice.

Advancing cervical cancer prevention in India: implementation science priorities.

Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.

Cancer Plan Index: a measure for assessing the quality of cancer plans.

OBJECTIVE: To (1) conduct an in-depth assessment of the content of comprehensive cancer control plans and (2) obtain data that can be used to provide guidance to grantees supported by the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) as they refine their plans, and to other health professionals as similar planning is done. DESIGN: Through an iterative development process, a workgroup of subject matter experts from NCCCP and Research Triangle Institute International (RTI International) identified 11 core or essential components that should be considered in cancer plans on the basis of their professional experience and expertise. They also developed a tool, the Cancer Plan Index (CPI), to assess the extent to which cancer plans addressed the 11 core components. SETTING: Sixty-five comprehensive cancer control programs in states, tribes, territories, and jurisdictions funded by the NCCCP. DATA SOURCE: Raters reviewed and abstracted all available cancer plans (n = 66), which included plans from 62 funded programs and 4 states of the Federated States of Micronesia funded by Centers for Disease Control and Prevention as a subcontractor of one funded program. Of the 66 plans, 3 plans were used to pilot test the CPI and the remaining 63 plans were subsequently reviewed and abstracted. MAIN OUTCOME MEASURE(S): The primary outcome measures are national-level component scores for 11 defined domains (global involvement of stakeholders, developing the plan, presentation of data on disease burden, goals, objectives, strategies, reduction of cancer disparities, implementation, funds for implementation of plan, evaluation, usability of plan), which represent an average of the component scores across all available cancer plans. RESULTS: To aid in the interpretation and usability of findings, the components were segmented into 3 tiers, representing a range high (average score = 2.01-4.00), moderate (average score = 1.01-2.00), and low (average score = 0-1.00) levels of description of the component. Programs overall provided relatively comprehensive descriptions of goals, objectives, and strategies; moderate description of the plan development process, presentation of data on disease burden, and plans on the reduction of cancer disparities; and little to no description of stakeholder involvement plans for implementation, funds for implementation, and evaluation of the plan. CONCLUSIONS: Areas of the CPI with low average component scores should stimulate technical assistance to the funded programs, either to increase program activities or to increase discussion of key activities in the plan.

Public health case studies in diabetes prevention and control: innovation, partnerships, and funding.

BACKGROUND: In 2006, we conducted case studies of 4 North Carolina local health departments (LHDs) that scored highly on an index of diabetes prevention and control performance, to explore characteristics that may serve as barriers or facilitators of diabetes prevention and control services. METHODS: Case studies involving in-depth interviews were conducted at 4 LHDs. Sites were selected on the basis of 2 variables, known external funding for diabetes services and population size, that were associated with performance in diabetes prevention and control in a 2005 survey of all North Carolina LHDs. Fourteen interviews (individual and group) were conducted among 17 participants from the 4 LHDs. The main outcome measures were LHD characteristics that facilitate or hinder the performance of diabetes programs and services. RESULTS: Interviews revealed that all 4 high-performing LHDs had received some sort of funding from a source external to the LHD. Case study participants indicated that barriers to additional service delivery included low socioeconomic status of the population and lack of financial resources. Having a diabetes self-management education program that was recognized by the American Diabetes Association appeared to be a facilitator of diabetes services provision. Other facilitators were leadership and staff commitment, which appeared to facilitate the leveraging of partnerships and funding opportunities, leading to enhanced service delivery. LIMITATIONS: The small number of LHDs participating in the study and the cross-sectional study design were limitations. CONCLUSION: Leadership, staff commitment, partnership leveraging, and funding appear to be associated with LHD performance in diabetes prevention and control services. These factors should be further studied in future public health systems and services research.

The diabetes primary prevention initiative interventions focus area: a case study and recommendations.

BACKGROUND: In 2005, CDC began the Diabetes Primary Prevention Initiative Interventions Focus Area (DPPI-IFA), which funded five state Diabetes Prevention and Control Programs (DPCPs) to translate diabetes primary prevention trials into real-world settings by developing and implementing a framework for state-level diabetes primary prevention. PURPOSE: The purpose of this case study, conducted in 2007, was to describe DPPI-IFA implementation, including facilitators and challenges to the initiative. METHODS: Case studies of the five DPCPs in the DPPI-IFA involving site visits with key informant interviews of state staff and partners and archival record collection. RESULTS: Partners recruited for DPPI-IFA activities included local or state public health agencies (three of five DPCPs); regional or state nonprofit organizations (five DPCPs); businesses or employers (three DPCPs); and healthcare organizations (four DPCPs). The DPCPs implemented a variety of interventions in three main domains: diabetes primary prevention and prediabetes awareness, screening activities and lifestyle interventions, and prediabetes-related health policy efforts. Preliminary outcomes are described at the individual and organization/partnership levels. Results suggest the importance of utilizing preexisting partnerships to extend work into diabetes prevention, providing even small amounts of funding to partners, and prior program planning for diabetes prevention. Challenges for the DPPI-IFA included recruiting participants, establishing links with providers to obtain diagnostic testing for people screened for prediabetes, and offering a lifestyle intervention. CONCLUSIONS: The DPPI-IFA represents a unique effort by state public health programs in the translation of diabetes primary prevention trials into real-world settings. The experiences of the DPPI-IFA programs offer valuable lessons for future community-based diabetes prevention initiatives, especially regarding the need to strengthen clinical-community partnerships for referral of people with prediabetes to evidence-based lifestyle programs.

Barriers to cancer pain management: home-health and hospice nurses and patients.

GOALS: Undertreatment of cancer pain remains a major health-care problem. We utilized focus groups of hospice and home-health nurses and patients to elucidate factors contributing to inadequate pain management and to generate solutions for closing the gap between the current reality and optimal pain management. PATIENTS AND METHODS: Focus groups were conducted among hospice and home-health-care nurses (two groups; n=22) and patients (six groups; n=54) using a standardized question guide. Audiotapes were transcribed and analyzed using NUD*IST software. Themes discovered among patients and nurses were analyzed for similarities and differences. MAIN RESULTS: Of 22 participants in the two home-health and hospice nurses focus groups, all were white women, the average age was 43 (range 29-64) years, and the average number of years in nursing was 21 (range 8-47) years. Of 54 participants in the six cancer patient focus groups, 80% were women, the average age was 54 (range 25-76) years, and 76% were white. Fifty-four percent of patients reported a history of pain associated with their cancer, and almost 30% had pain that they rated as 8 or higher on the pain scale. Barriers to adequate pain management fell into four categories: fears; attitudes, beliefs, and values; patient and provider behaviors; and structural barriers. Patients and nurses reported similar barriers to pain management; however, patients identified more barriers related to provider behavior and structure of the health care system. CONCLUSIONS: This study identified several barriers to cancer pain control not previously identified in the literature. Strategies to improve cancer pain control are suggested.

Caring for the underserved: current practice of alumni of the National Health Service Corps.

The objective of this study was to examine the number and characteristics of National Health Service Corps (NHSC) alumni who currently practice with an underserved population. The study design was a cross-sectional survey mailed in 1998 to a sample of 2,160 alumni. The response rate was 58.9 percent; overall, 52.5 percent of respondents reported currently working with the underserved. In bivariate analyses, retention in practice with the underserved was associated with several clinician and service experience variables. In a logistic regression model, higher initial desire to work with the underserved, older age, job satisfaction, and higher salary were associated with current service. The authors conclude that more than half of the NHSC alumni responding to the survey reported working with an underserved population in 1998. Associations between clinician and service experience characteristics and retention in practice with the underserved can inform policy and research to improve retention.

Provision of care to the underserved populations by National Health Service Corps alumni dentists.

OBJECTIVE: This study examined factors associated with dentists continuing to provide care to the underserved populations beyond their National Health Service Corps (NHSC) obligation period. METHODS: Self-administered questionnaires were mailed in 1998 to 404 dentists who had completed their service obligation between 1980 and 1997. The outcome variable was dentist self-report of continuing to work with the underserved population past NHSC obligation. RESULTS: Among 249 respondents (62% response rate), 46 percent of alumni dentists continued to work with an underserved population. Multivariate analyses found that being an African American (odds ratio [OR] = 3.2), higher final salary during the NHSC assignment (OR = 1.2), and higher altruistic motivation to work with the underserved populations prior to entering NHSC (OR = 1.1) were significantly associated with continued service to the underserved populations. CONCLUSIONS: A small number of factors were associated with alumni NHSC dentists' decisions to continue to provide care for the underserved populations. Targeting African-American students and students interested in caring for the underserved may improve the long-term commitment of dentists to provide care for the underserved populations. Attention will also need to be given to increased salary as a potential intervention to increase the numbers of dentists who continue to serve the underserved populations.

Quality of care for uninsured patients with diabetes in a rural area.

OBJECTIVE: We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs). RESEARCH DESIGN AND METHODS: We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project. RESULTS: Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA(1c) (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found. CONCLUSIONS: In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.