Screening for Latent Tuberculosis Infection in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Latent tuberculosis infection (LTBI) can progress to active tuberculosis disease, causing morbidity and mortality. Objective: To review the evidence on benefits and harms of screening for and treatment of LTBI in adults to inform the US Preventive Services Task Force (USPSTF). Data Sources: PubMed/MEDLINE, Cochrane Library, and trial registries through December 3, 2021; references; experts; literature surveillance through January 20, 2023. Study Selection: English-language studies of LTBI screening, LTBI treatment, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of LTBI screening and treatment for public health surveillance or disease management were excluded. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when a sufficient number of similar studies were available. Main Outcomes and Measures: Screening test accuracy; development of active tuberculosis disease, transmission, quality of life, mortality, and harms. Results: A total of 113 publications were included (112 studies; N = 69 009). No studies directly evaluated the benefits and harms of screening. Pooled estimates for sensitivity of the TST were 0.80 (95% CI, 0.74-0.87) at the 5-mm induration threshold, 0.81 (95% CI, 0.76-0.87) at the 10-mm threshold, and 0.60 (95% CI, 0.46-0.74) at the 15-mm threshold. Pooled estimates for sensitivity of IGRA tests ranged from 0.81 (95% CI, 0.79-0.84) to 0.90 (95% CI, 0.87-0.92). Pooled estimates for specificity of screening tests ranged from 0.95 to 0.99. For treatment of LTBI, a large (n = 27 830), good-quality randomized clinical trial found a relative risk (RR) for progression to active tuberculosis at 5 years of 0.35 (95% CI, 0.24-0.52) for 24 weeks of isoniazid compared with placebo (number needed to treat, 112) and an increase in hepatotoxicity (RR, 4.59 [95% CI, 2.03-10.39]; number needed to harm, 279). A previously published meta-analysis reported that multiple regimens were efficacious compared with placebo or no treatment. Meta-analysis found greater risk for hepatotoxicity with isoniazid than with rifampin (pooled RR, 4.22 [95% CI, 2.21-8.06]; n = 7339). Conclusions and Relevance: No studies directly evaluated the benefits and harms of screening for LTBI compared with no screening. TST and IGRAs were moderately sensitive and highly specific. Treatment of LTBI with recommended regimens reduced the risk of progression to active tuberculosis. Isoniazid was associated with higher rates of hepatotoxicity than placebo or rifampin.

Rising to Meet the Moment: What Does the Public Health Workforce Need to Modernize?

OBJECTIVE: This study uses findings from the most recent iterations of the Public Health Workforce Interest and Needs Survey (PH WINS) to describe importance, skill level, and gaps of key public health competencies as well as characteristics associated with gaps. DESIGN: Repeated cross-sectional analysis of the 2017 and 2021 PH WINS data. SETTING: State and local health departments. PARTICIPANTS: Nationally representative population of state and local governmental public health workers. MAIN OUTCOME MEASURES: Gaps of key public health competencies related to data, evidence-based approaches, health equity and social justice, factors that affect public health, cross-sectoral partnerships, and community health assessments and improvement plans. Gaps reflect areas of high importance and low skill level. Differences in gaps among the traditional public health workforce and those hired specifically for COVID-19 response. RESULTS: For most competency areas, more than 20% of the public health workforce perceived a gap. Gaps related to environmental factors that affect public health, social determinants of health and cross-sector partnerships, and community health assessments and improvement plans were the largest. Tenure in public health practice, highest level of education, and having formal public health training were associated with lower odds of gaps in most areas. In a secondary analysis of traditional public health workforce compared with those hired specifically for COVID-19 response, those hired for COVID-19 response reported significantly fewer gaps for all but one competency considered. CONCLUSIONS: A substantial proportion of the public health workforce perceives gaps in competency areas that are of high importance to the evolving role of public health. As public health continues to adjust and modernize in response to the COVID-19 pandemic and other historic changes, understanding and addressing training needs of the workforce will be instrumental to public health's ability to respond to the needs of the public.

Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Eating disorders are associated with adverse health and social outcomes. Objective: To review the evidence on screening for eating disorders in adolescents and adults to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Library, PsycINFO, and trial registries through December 19, 2020; surveillance through January 1, 2022. Study Selection: English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or interventions for eating disorders in populations with screen-detected or previously untreated eating disorders (trials limited to populations who are underweight were ineligible). Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality. Meta-analysis of test accuracy studies and intervention trials. Main Outcomes and Measures: Test accuracy, eating disorder symptom severity, quality of life, depression, and harms. Results: Fifty-seven studies were included (N = 10 773); 3 (n = 1073) limited to adolescents (mean or median age, 14-15 years). No study directly evaluated the benefits and harms of screening. Seventeen studies (n = 6804) evaluated screening test accuracy. The SCOFF questionnaire (cut point ≥2) had a pooled sensitivity of 84% (95% CI, 74% to 90%) and pooled specificity of 80% (95% CI, 65% to 89%) in adults (10 studies, n = 3684). Forty RCTs (n = 3969) evaluated interventions for eating disorders; none enrolled a screen-detected population. Lisdexamfetamine for binge eating disorder (4 RCTs; n = 900) was associated with larger reductions in eating disorder symptom severity on the Yale-Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two RCTs (n = 465) of topiramate for binge eating disorder found larger reductions in YBOCS-BE scores associated with topiramate than placebo, from -6.40 (95% CI, -8.16 to -4.64) to -2.55 (95% CI, -4.22 to -0.88). Nine pharmacotherapy trials (n = 2006) reported on harms. Compared with placebo, lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty. Twenty-four trials (n = 1644) assessed psychological interventions. Guided self-help for binge eating disorder improved eating disorder symptom severity more than control (pooled standardized mean difference, -0.96 [95% CI, -1.26 to -0.67]) (5 studies, n = 391). Evidence on other interventions was limited. Conclusions and Relevance: No studies directly assessed the benefits and harms of screening. The SCOFF questionnaire had adequate accuracy for detecting eating disorders among adults. No treatment trials enrolled screen-detected populations; guided self-help, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder, but pharmacotherapies were also associated with harms.

Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Obstructive sleep apnea (OSA) is associated with adverse health outcomes. Objective: To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force. Data Sources: PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022. Study Selection: English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials. Main Outcomes and Measures: Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms. Results: Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg). Conclusions and Relevance: The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.

Estimating Public Health Workforce Efforts Toward Foundational Public Health Services.

CONTEXT: The Foundational Public Health Services (FPHS) include a core set of activities that every health department should be able to provide in order to ensure that each resident has access to foundational services that protect and preserve health. Estimates of the public health workforce necessary to provide the FPHS are needed. OBJECTIVE: This study assessed the potential use of an FPHS calculator to assess health department workforce needs. DESIGN AND SETTING: Qualitative interviews were conducted via Zoom in December 2020-January 2021. PARTICIPANTS: Seventeen state and local public health leaders. MAIN OUTCOME MEASURES: Qualitative insights into the potential use of an FPHS calculator. RESULTS: Almost all participants expressed that a reliable estimate would help them justify requests for new staff and that a calculator based on the FPHS would help organizations to critically assess whether they are meeting the needs of their communities and the core expectations of public health. Although participants expected that a tool to calculate full-time equivalent needs by the FPHS would be helpful, some participants expressed concerns in regard to using the tool, given ongoing workforce issues such as recruitment challenges, hiring freezes, and funding restrictions. An anticipated positive consequence of using this tool was that it may lead to cross-training the workforce and result in more diverse expertise and skills among existing workers. The other unintended consequences were that an FPHS calculator would require a substantial amount of time assessing the current FPHS efforts of existing staff and the results of the FPHS gap estimate could become the bar rather than the minimum needed. CONCLUSIONS: The current public and political focus on public health infrastructure as a result of the COVID-19 pandemic has created a window of opportunity to create change. An FPHS-based staffing tool may help transform public health and initiate a new era.

Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report.

CONTEXT: Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure. OBJECTIVES: This review examines the influence of the Finance report's 10 recommendations on public health policy and practice. DESIGN: This review utilized peer-reviewed and gray literature published since 2012. ELIGIBILITY CRITERIA: Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community. RESULTS: Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts. DISCUSSION: Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending. CONCLUSIONS: The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine's 2012 Report.

OBJECTIVE: The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." DESIGN: Qualitative study involving key informant interviews. SETTING AND PARTICIPANTS: Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. MAIN OUTCOME MEASURES: Qualitative feedback about changes to public health finance since the report. RESULTS: Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. CONCLUSIONS: Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. IMPLICATIONS FOR POLICY AND PRACTICE: Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.

Faculty salaries in health administration: trends and correlates 2015-2021.

In this study, we provide updated information on salaries of academic health administration (HA) faculty members based on data collected in 2015, 2018, and 2021 and examine characteristics associated with earnings. We present mean inflation-adjusted salaries by demographic characteristics, education, experience, productivity, and job activities. We find that salaries of assistant, associate, and full professors have kept up with inflation and there have not been significant changes in salary by any characteristics over time. As in previous iterations of similar survey data, there remain differences in salary by both gender and race. Higher salaries were associated with having a 12-month contract, being tenured or tenure-track, having an administrative position, and being in a department whose focus is not primarily teaching. Findings from our study will be of interest to individuals on the HA job market, hiring committees, and doctoral students preparing for a position after graduation.

Work-life balance among health administration faculty before and during the COVID-19 pandemic.

This current study examines measures of work-life balance among health administration faculty prior to and during the COVID-19 pandemic. A repeated cross-sectional design is used to analyze data collected from a national survey in 2018 and 2021. Changes in six different outcome measures of work-life balance were examined using multivariable logistic regression, controlling for health administration faculty characteristics. Compared to 2018 respondents, faculty respondents in 2021 were more likely to report that family and personal matters were interfering with their ability to do their job (OR = 1.93, p=0.001). Females more frequently reported that their career had suffered because of personal issues/obligations (OR = 1.82, p=0.003) but were less likely to report having enough time to get their teaching (OR = 0.68, p=0.026). Respondents with children 18 years or younger reported higher rates of regularly having to miss a meeting or event at home (OR = 1.88, p<0.001) and an event at work (OR = 3.74, p<0.001). These faculty also more frequently reported that family or personal matters were interfering with their ability to do their job (OR = 3.04, p<0.001) and that their career suffered because of personal issues/obligations (OR = 2.09, p=0.001). Given the implications of work-life conflicts to organizational outcomes, academic leaders and university decision-makers should consider adopting strategies to mitigate the effects of these disruptions to the work-life equilibrium of academics.

Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project.

BACKGROUND: Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. METHODS: This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. RESULTS: The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). CONCLUSIONS: Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.

Screening for Prediabetes and Type 2 Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Type 2 diabetes is common and is a leading cause of morbidity and disability. Objective: To review the evidence on screening for prediabetes and diabetes to inform the US Preventive Services Task Force (USPSTF). Data Sources: PubMed/MEDLINE, Cochrane Library, and trial registries through September 2019; references; and experts; literature surveillance through May 21, 2021. Study Selection: English-language controlled studies evaluating screening or interventions for prediabetes or diabetes that was screen detected or recently diagnosed. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when at least 3 similar studies were available. Main Outcomes and Measures: Mortality, cardiovascular morbidity, diabetes-related morbidity, development of diabetes, quality of life, and harms. Results: The review included 89 publications (N = 68 882). Two randomized clinical trials (RCTs) (25 120 participants) found no significant difference between screening and control groups for all-cause or cause-specific mortality at 10 years. For harms (eg, anxiety or worry), the trials reported no significant differences between screening and control groups. For recently diagnosed (not screen-detected) diabetes, 5 RCTs (5138 participants) were included. In the UK Prospective Diabetes Study, health outcomes were improved with intensive glucose control with sulfonylureas or insulin. For example, for all-cause mortality the relative risk (RR) was 0.87 (95% CI, 0.79 to 0.96) over 20 years (10-year posttrial assessment). For overweight persons, intensive glucose control with metformin improved health outcomes at the 10-year follow-up (eg, all-cause mortality: RR, 0.64 [95% CI, 0.45 to 0.91]), and benefits were maintained longer term. Lifestyle interventions (most involving >360 minutes) for obese or overweight persons with prediabetes were associated with reductions in the incidence of diabetes (23 RCTs; pooled RR, 0.78 [95% CI, 0.69 to 0.88]). Lifestyle interventions were also associated with improved intermediate outcomes, such as reduced weight, body mass index, systolic blood pressure, and diastolic blood pressure (pooled weighted mean difference, -1.7 mm Hg [95% CI, -2.6 to -0.8] and -1.2 mm Hg [95% CI, -2.0 to -0.4], respectively). Metformin was associated with a significant reduction in diabetes incidence (pooled RR, 0.73 [95% CI, 0.64 to 0.83]) and reduction in weight and body mass index. Conclusions and Relevance: Trials of screening for diabetes found no significant mortality benefit but had insufficient data to assess other health outcomes; evidence on harms of screening was limited. For persons with recently diagnosed (not screen-detected) diabetes, interventions improved health outcomes; for obese or overweight persons with prediabetes, interventions were associated with reduced incidence of diabetes and improvement in other intermediate outcomes.

Opioid-Related Emergency Department Encounters: Patient, Encounter, and Community Characteristics Associated With Repeated Encounters.

STUDY OBJECTIVE: We describe the prevalence, trends, and factors associated with repeated emergency department (ED) encounters for opioid usage across multiple, independent hospital systems. METHODS: A statewide regional health information exchange system provided ED encounters from 4 Indiana hospital systems for 2012 to 2017. In accordance with a series of International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 diagnosis codes for opioid abuse, adverse effects of opioids, opioid dependence and unspecified use, and opioid poisoning, we identified patients with an ED encounter associated with opioid usage (9,295 individuals; 12,642 encounters). Multivariate logistic regression models then described the patient, encounter, prescription history, and community characteristics associated with the odds of a patient's incurring a subsequent opioid-related ED encounter. RESULTS: The prevalence of repeated nonfirst opioid-related ED encounters increased from 9.0% of all opioid encounters in 2012 to 34.3% in 2017. The number of previous opioid-related ED encounters, unique institutions at which the individual had had encounters, the encounter's being heroin-related, the individual's having a benzodiazepine prescription filled within 30 days before the encounter, and being either Medicaid insured or uninsured compared with private insurance were associated with significantly greater odds of having a subsequent encounter. CONCLUSION: The ED is increasingly a site utilized as the setting for repeated opioid-related care. Characteristics of the individual, encounter, and community associated with repeated opioid-related encounters may inform real-time risk-prediction tools in the ED setting. Additionally, the number of institutions to which the individual has presented may suggest the utility of health information exchange data and usage in the ED setting.

Perceptions of Public Health 3.0: Concordance Between Public Health Agency Leaders and Employees.

CONTEXT AND BACKGROUND: The newest era of public health, deemed "Public Health 3.0," supports cross-sector collaborations to address social determinants of health. These activities often require collaborations with nontraditional public health entities. As this new era begins, it is important to understand perceptions of the public health workforce with regard to Public Health 3.0. OBJECTIVE: To assess perceptions of support toward Public Health 3.0 activities by the public health workforce, identify characteristics associated with support, and measure concordance in support between agency directors and the general workforce. DESIGN: This cross-sectional study utilizes the 2017 Public Health Workforce Interests and Needs Survey to understand support and concordance regarding Public Health 3.0 activities by a nationally representative sample of governmental public health employees. Logistic regression models are used to identify characteristics associated with support of each 3.0 activity and concordance. MAIN OUTCOME MEASURES: Governmental public health employees' opinions on how involved their agency should be in the K-12 education system, the economy, the built environment, transportation, housing, social connectedness, and health equity within their jurisdiction and concordance in support of involvement between agency directors and the general workforce. RESULTS: Overall, individual perceptions supporting involvement were highest for health equity and social connectedness and lowest for transportation. Supervisory status, education, and being at a local health department were associated with greater odds of supporting all 3.0 activities. Concordance with agency directors was greatest among other executives relative to nonsupervisors. CONCLUSIONS: There is overall generally high support of many 3.0 activities, but there are gaps in agreement by supervisory status, gender, race/ethnicity, education, role type, and jurisdiction. Findings may help support agency leaders in better communicating the role of their agencies in Public Health 3.0 activities, and workforce education regarding such activities may be necessary for the success of Public Health 3.0's success.

The Relationship Between Health Department Accreditation and Workforce Satisfaction, Retention, and Training Needs.

BACKGROUND: To improve quality and consistency of health departments, a voluntary accreditation process was developed by the Public Health Accreditation Board. Understanding accreditation's role as a mediator in workforce training needs, satisfaction, and awareness is important for continued improvement for governmental public health. OBJECTIVE: To compare differences in training needs, satisfaction/intent to leave, and awareness of public health concepts for state and local health department staff with regard to their agency's accreditation status. DESIGN: This cross-sectional study considered the association between agency accreditation status and individual perceptions of training needs, satisfaction, intent to leave, and awareness of public health concepts, using 2017 Public Health Workforce Interests and Needs Survey (PH WINS) data. Respondents were categorized on the basis of whether their agencies (at the time of survey) were (1) uninvolved in accreditation, (2) formally involved in accreditation, or (3) accredited. RESULTS: Multivariate logistic regression models found several significant differences, including the following: individuals from involved state agencies were less likely to report having had their training needs assessed; staff from accredited and involved agencies identified more gaps in selected skills; and employees of accredited agencies were more aware of quality improvement. While state employees in accredited and formally involved agencies reported less job satisfaction, there were no significant differences in intent to leave or burnout. Differences were identified concerning awareness of various public health concepts, especially among respondents in state agencies. CONCLUSIONS: While some findings were consistent with past research (eg, link between accreditation and quality improvement), others were not (eg, job satisfaction). Several self-reported skill gaps were unanticipated, given accreditation's emphasis on training. Potentially, as staff are exposed to accreditation topics, they gain more appreciation of skills development needs. Findings suggest opportunities to strengthen workforce development components when revising accreditation measures.

Implementation of a Trauma Bay Checklist Improves Antibiotic Prophylaxis Compliance in Open Extremity Fractures.

BACKGROUND: Best practice guidelines from the ACS recommend that patients with open fractures receive antibiotics within 1-hour of presentation. Checklists are effective mechanisms for improving safety and compliance in surgical settings. The current study investigates implementation of a trauma bay checklist, referred to as MARTY, to improve administration of antibiotics in open extremity fractures at a level I trauma center. METHODS: Retrospective pre-post design. Population consisted of trauma alerts from January to December 2021 (pre-MARTY) and 2022 (post-MARTY) with open fractures. Outcome measures included antibiotics administered within 1-hour of presentation and in the trauma bay. Bivariate and multivariate analyses were performed to estimate differences in both measures. RESULTS: Our sample included 339 encounters, 174 pre-MARTY and 165 post-MARTY implementation. In the pre-MARTY period, 57.5% of encounters received antibiotics within 1-hour of presentation with 46.0% occurring in the trauma bay, in comparison to 65.5% and 54.5% in the post-MARTY period. In adjusted models, there were greater odds of antibiotic administration within 1-hour (OR = 1.654, P = .038) and prior to leaving the trauma bay (OR = 1.660, P = .041) than pre-MARTY. Encounters with higher-grade fractures were more likely to receive timely antibiotics (P<=.001). DISCUSSION: Our study estimates improved compliance of antibiotic administration after implementation of MARTY after adjusting for encounter characteristics. Findings from this study demonstrate improved compliance, but this compliance is often still lacking in those with higher injury severity scores. Findings from this study may be used to inform approaches to further improve trauma care.

Health Care and Behavioral Service Use by Medicaid-Enrolled Adults After Release From Incarceration.

OBJECTIVE: This study explored the characteristics and health care utilization of adults released from state prisons and enrolled in Medicaid in Indiana, which has policies to facilitate timely enrollment. METHODS: Medicaid claims and Department of Corrections data were used to examine demographic and incarceration characteristics and health care utilization patterns of adults (N=15,929) released from state prisons and enrolled in Medicaid within 120 days of release, between 2015 and 2018. RESULTS: More than 80% of participants had at least one health encounter within 120 days of initiating coverage, and nearly 50% used the emergency department. Those enrolled in Medicaid within 30 days of release were more likely to have behavioral health needs and to utilize subacute behavioral health care than those who enrolled later. CONCLUSIONS: Understanding these patterns of health care utilization is essential to operationalizing procedures and interventions to support the health care needs of adults involved in the criminal legal system.

State Priorities and Needs: The Role of Block Grants.

OBJECTIVES: Block grant funding provides federal financial support to states, with increased flexibility as to how those funds can be allocated at the community level. At the state level, block grant amounts and distributions are often based on outdated formulas that consider population measures and funding environments at the time of their creation. We describe variation in state-level funding allocations for 5 federal block grant programs and the extent to which funding aligns with the current needs of state populations. METHODS: We conducted an analysis in 2022 of state block grant allocations as a function of state-level characteristics for 2015-2019 for all 50 states. We provide descriptive statistics of state block grant allocations and multivariate regression models for each program. Models include base characteristics relevant across programs plus supplemental characteristics based on program-specific goals and state population needs. RESULTS: Mean state block grant allocations per 1000 population by program ranged from $618 to $21 528 during 2015-2019. Characteristics associated with state allocations varied across block grants. For example, for every 1-percentage-point increase in the percentage of the population living in nonmetropolitan areas, Preventive Health and Health Services Block Grant funding was approximately $7 per 1000 population higher and Community Services Block Grant funding was approximately $40 per 1000 population higher. Few supplemental characteristics were associated with allocations. CONCLUSIONS: Current block grant funding does not align with state characteristics and needs. Future research should consider how funds are used at the state level or allocated to local agencies or organizations and compare state block grant allocations with other types of funding mechanisms, such as categorical funding.

Barriers to recruiting primary care practices for implementation research during COVID-19: A qualitative study of practice coaches from the Stop Unhealthy (STUN) Alcohol Use Now trial.

Background: The COVID-19 pandemic has brought widespread change to health care practice and research. With heightened stress in the general population, increased unhealthy alcohol use, and added pressures on primary care practices, comes the need to better understand how we can continue practice-based research and address public health priorities amid the ongoing pandemic. The current study considers barriers and facilitators to conducting such research, especially during the COVID-19 pandemic, within the context of recruiting practices for the STop UNhealthy (STUN) Alcohol Use Now trial. The STUN trial uses practice facilitation to implement screening and interventions for unhealthy alcohol use in primary care practices across the state of North Carolina. Methods: Semistructured interviews were conducted with a purposive sample of 15 practice coaches to discuss their recruitment experiences before and after recruitment was paused due to the pandemic. An inductive thematic analysis was used to identify themes and subthemes. Results: Pandemic-related barriers, including challenges in staffing, finances, and new COVID-19-related workflows, were most prominent. Competing priorities, such as quality improvement measures, North Carolina's implementation of Medicaid managed care, and organizational structures hampered recruitment efforts. Coaches also described barriers specific to the project and to the topic of alcohol. Several facilitators were identified, including the rising importance of behavioral health due to the pandemic, as well as existing relationships between practice coaches and practices. Conclusions: Difficulty managing competing priorities and obstacles within existing practice infrastructure inhibit the ability to participate in practice-based research and implementation of evidence-based practices. Lessons learned from this trial may inform strategies to recruit practices into research and to gain buy-in from practices in adopting evidence-based practices more generally. Plain Language Summary: What is known: Unhealthy alcohol use is a significant public health issue, which has been exacerbated during the COVID-19 pandemic. Screening and brief intervention for unhealthy alcohol use is an evidence-based practice shown to help reduce drinking-related behaviors, yet it remains rare in practice. What this study adds: Using a qualitative approach, we identify barriers and facilitators to recruiting primary care practices into a funded trial that uses practice facilitation to address unhealthy alcohol use. We identify general insights as well as those specific to the COVID-19 pandemic. Barriers are primarily related to competing priorities, incentives, and lack of infrastructure. Facilitators are related to framing of the project and the anticipated level and type of resources needed to address unhealthy alcohol use especially as the pandemic wanes. Implications: Our findings provide information on barriers and facilitators to recruiting primary care practices for behavioral health projects and to implementing these activities. Using our findings, we provide a discussion of suggestions for conducting these types of projects in the future which may be of interest to researchers, practice managers, and providers.

Many States Were Able To Expand Medicaid Without Increasing Administrative Spending.

With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.

Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions.

BACKGROUND: Since the inception of Accountable Care Organizations (ACOs), many have acknowledged the potential synergy between ACOs and health information technology (IT) in meeting quality and cost goals. OBJECTIVE: We conducted a systematic review of the literature in order to describe what research has been conducted at the intersection of health IT and ACOs and identify directions for future research. METHODS: We identified empirical studies discussing the use of health IT via PubMed search with subsequent snowball reference review. The type of health IT, how health IT was included in the study, use of theory, population, and findings were extracted from each study. RESULTS: Our search resulted in 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. Studies were divided into three streams by purpose; those that considered health IT as a factor for ACO participation, health IT use by current ACOs, and ACO performance as a function of health IT capabilities. Although most studies found a positive association between health IT and ACO participation, studies that address the performance of ACOs in terms of their health IT capabilities show more mixed results. CONCLUSIONS: In order to better understand this emerging relationship between health IT and ACO performance, we propose future research should consider more quasi-experimental studies, the use of theory, and merging health, quality, cost, and health IT use data across ACO member organizations.