Cost-Effective Drug Switch Options After Unsuccessful Treatment With an SSRI for Depression.

OBJECTIVE: Multiple treatment options are available for patients who do not respond to initial treatment for major depressive disorder. Previous results show that bupropion, sertraline, and venlafaxine are comparable in terms of therapeutic effectiveness following unsuccessful treatment with citalopram. In this study, we extended these results by incorporating costs of treatment to determine if one option was more cost-effective relative to others. METHODS: In the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, 727 patients were randomly assigned to a switch drug treatment during level 2; 239 (33%) were assigned to bupropion, 238 (33%) to sertraline, and 250 (34%) to venlafaxine. For each study medication, the total costs included the costs of the medication, other concomitant medication and antidepressants, and health care facility utilization. Effectiveness was measured as remission and response. Cost-effectiveness was assessed as net health benefits. Stochastic analysis was performed by using the bootstrapping method. RESULTS: During level 2, mean medication costs were significantly higher for venlafaxine than for bupropion and sertraline ($968, $607, and $703, respectively). There were no significant differences among the switch medications in costs for other medications and health care facility utilization. Although the total costs were significantly different for the three medications (p=.025), none of the pairwise differences between medications were significant. Also, after jointly estimating costs and effects, the analyses found that net health benefits were not significantly different among the three drugs. CONCLUSIONS: After unsuccessful treatment with citalopram, the switch options of bupropion, sertraline, and venlafaxine were not significantly different from each other in terms of cost-effectiveness.

The effects of funding change and reorganization on patterns of emergency response in a local health agency.

Indicators for Stress Adaptation Analytics (ISAAC) is a protocol to measure the emergency response behavior of organizations within local public health systems. We used ISAAC measurements to analyze how funding and structural changes may have affected the emergency response capacity of a local health agency. We developed ISAAC profiles for an agency's consecutive fiscal years 2013 and 2014, during which funding cuts and organizational restructuring had occurred. ISAAC uses descriptive and categorical response data to obtain a function stress score and a weighted contribution score to the agency's total response. In the absence of an emergency, we simulated one by assuming that each function was stressed at an equal rate for each of the two years and then we compared the differences between the two years. The simulations revealed that seemingly minor personnel or budget changes in health departments can mask considerable variation in change at the internal function level.

State procurement law: facilitating the collaboration between health department and school of public health.

The mark of an "academic health department" includes shared activity by academic and practice partners sustained over time. Despite a long history of productive interactivity, the Pennsylvania Department of Health and the University of Pittsburgh's Graduate School of Public Health often faced administrative hurdles in contracting for projects of mutual interest. Seeking to overcome these hurdles, the Commonwealth of Pennsylvania and the University of Pittsburgh's Graduate School of Public Health negotiated a Master Agreement on the basis of statutes designating both as "public procurement units." This provided a template for project specifications, standard financial terms, and a contracting process. Since taking effect, the Master Agreement has supported projects in policy development, capacity building, workforce development, program evaluation, data analysis, and program planning. This experience suggests an approach potentially useful for other states and localities seeking to solidify academic health department partnerships either envisioned for the future or already in place.

Data for preparedness metrics: legal, economic, and operational.

Tracking progress toward the goal of preparedness for public health emergencies requires a foundation in evidence derived both from scientific inquiry and from preparedness officials and professionals. Proposed in this article is a conceptual model for this task from the perspective of the Centers for Disease Control and Prevention-funded Preparedness and Emergency Response Research Centers. The necessary data capture the areas of responsibility of not only preparedness professionals but also legislative and executive branch officials. It meets the criteria of geographic specificity, availability in standardized and reliable measures, parameterization as quantitative values or qualitative distinction, and content validity. The technical challenges inherent in preparedness tracking are best resolved through consultation with the jurisdictions and communities whose preparedness is at issue.

Would school closure for the 2009 H1N1 influenza epidemic have been worth the cost?: a computational simulation of Pennsylvania.

BACKGROUND: During the 2009 H1N1 influenza epidemic, policy makers debated over whether, when, and how long to close schools. While closing schools could have reduced influenza transmission thereby preventing cases, deaths, and health care costs, it may also have incurred substantial costs from increased childcare needs and lost productivity by teachers and other school employees. METHODS: A combination of agent-based and Monte Carlo economic simulation modeling was used to determine the cost-benefit of closing schools (vs. not closing schools) for different durations (range: 1 to 8 weeks) and symptomatic case incidence triggers (range: 1 to 30) for the state of Pennsylvania during the 2009 H1N1 epidemic. Different scenarios varied the basic reproductive rate (R(0)) from 1.2, 1.6, to 2.0 and used case-hospitalization and case-fatality rates from the 2009 epidemic. Additional analyses determined the cost per influenza case averted of implementing school closure. RESULTS: For all scenarios explored, closing schools resulted in substantially higher net costs than not closing schools. For R(0) = 1.2, 1.6, and 2.0 epidemics, closing schools for 8 weeks would have resulted in median net costs of $21.0 billion (95% Range: $8.0 - $45.3 billion). The median cost per influenza case averted would have been $14,185 ($5,423 - $30,565) for R(0) = 1.2, $25,253 ($9,501 - $53,461) for R(0) = 1.6, and $23,483 ($8,870 - $50,926) for R(0) = 2.0. CONCLUSIONS: Our study suggests that closing schools during the 2009 H1N1 epidemic could have resulted in substantial costs to society as the potential costs of lost productivity and childcare could have far outweighed the cost savings in preventing influenza cases.

Demonstrating excellence in the scholarship of practice-based service for public health.

Practice-based scholarship in public health addresses community health issues. The accredited schools of public health (SPHs) have played a significant role in defining and implementing the multidisciplinary, interprofessional, ecological approach to improving the health and safety of communities through academic public health practice. These schools have addressed the challenges raised by the Institute of Medicine for enhancing academic-practice linkages. The Association of Schools of Public Health (ASPH) established the Council of Public Health Practice Coordinators (Practice Council), whose members are delegates from each of the SPHs accredited by the Council on Education for Public Health (CEPH); there were 40 as of 2008. The Practice Council's priorities are to (1) promote greater commitment to scholarship in public health practice-based research, teaching, and service within SPHs, and (2) facilitate recognition and reward for practice-based scholarship in academic institutions. Extensive alignment of efforts by the Practice Council, SPHs, federal agencies, private institutions, and the practice sector have invigorated scholarship in academic public health practice.

A public health training center experience: professional continuing education at schools of public health.

The Public Health Training Center (PHTC) national program was first established at accredited schools of public health in 2000. The PHTC program used the US Health Resources and Services Administration's grants to build workforce development programs, attracting schools as training providers and the workforce as training clients. This article is a reflection on the experience of two schools, whose partnership supported one of the PHTCs, for the purpose of opening a conversation about the future of continuing education throughout schools and degree programs of public health. This partnership, the Pennsylvania & Ohio Public Health Training Center (POPHTC), concentrated its funding on more intensive training of public healthcare workers through a relatively narrow inventory of courses that were delivered typically in-person rather than by distance-learning technologies. This approach responded to the assessed needs and preferences of the POPHTC's workforce population. POPHTC's experience may not be typical among the PHTCs nationally, but the collective experience of all PHTCs is instructive to schools of public health as they work to meet an increasing demand for continuing education from the public health workforce.

State funding for local public health: observations from six case studies.

The purpose of this study is to describe state funding of local public health within the context of state public health system types. These types are based on administrative relationships, legal structures, and relative proportion of state funding in local public health budgets. We selected six states representing various types and geographic regions. A case study for each state summarized available information and was validated by state public health officials. An analysis of the case studies reveals that the variability of state public health systems--even within a given type--is matched by variability in approaches to funding local public health. Nevertheless, some meaningful associations appear. For example, higher proportions of state funding occur along with higher levels of state oversight and the existence of local service mandates in state law. These associations suggest topics for future research on public health financing in relation to local accountability, local input to state priority-setting, mandated local services, and the absence of state funds for public health services in some local jurisdictions.

Demonstrating excellence in practice-based research for public health.

This document explores the opportunity for scholarship to enhance the evidence base for academic public health practice and practice-based research. Demonstrating Excellence in Practice-Based Research for Public Health defines practice-based research; describes its various approaches, models, and methods; explores ways to overcome its challenges; and recommends actions for its stakeholders in both academic and practice communities. It is hoped that this document will lead to new partnership opportunities between public health researchers and public health practitioners to strengthen the infrastructure of public health and add new dimensions to the science of public health practice. Demonstrating Excellence in Practice-Based Research for Public Health is intended for those who produce, participate in, and use practice-based research. This includes academic researchers and educators, public health administrators and field staff, clinical health professionals, community-based organizations and professionals, and interested members of the public.

The public health infrastructure and our nation's health.

Threats to Americans' health-including chronic disease, emerging infectious disease, and bioterrorism-are present and growing, and the public health system is responsible for addressing these challenges. Public health systems in the United States are built on an infrastructure of workforce, information systems, and organizational capacity; in each of these areas, however, serious deficits have been well documented. Here we draw on two 2003 Institute of Medicine reports and present evidence for current threats and the weakness of our public health infrastructure. We describe major initiatives to systematically assess, invest in, rebuild, and evaluate workforce competency, information systems, and organizational capacity through public policy making, practical initiatives, and practice-oriented research. These initiatives are based on applied science and a shared federal-state approach to public accountability. We conclude that a newly strengthened public health infrastructure must be sustained in the future through a balancing of the values inherent in the federal system.