Using a learning health system to understand the mismatch between medicines supply and actual medicines use among adults with cystic fibrosis.

BACKGROUND: Studies in separate cohorts suggest possible discrepancies between inhaled medicines supplied (median 50-60%) and medicines used (median 30-40%). We performed the first study that directly compares CF medicine supply against use to identify the cost of excess medicines supply. METHODS: This cross-sectional study included participants from 12 UK adult centres with ≥1 year of continuous adherence data from data-logging nebulisers. Medicine supply was measured as medication possession ratio (MPR) for a 1-year period from the first suitable supply date. Medicine use was measured as electronic data capture (EDC) adherence over the same period. The cost of excess medicines was calculated as whole excess box(es) supplied after accounting for the discrepancy between EDC adherence and MPR with 20% contingency. RESULTS: Among 275 participants, 133 (48.4%) were females and mean age was 30 years (95% CI 29-31 years). Median EDC adherence was 57% (IQR 23-86%), median MPR was 74% (IQR 46-96%) and the discrepancy between measures was median 14% (IQR 2-29%). Even with 20% contingency, mean potential cost of excess medicines was £1,124 (95% CI £855-1,394), ranging from £183 (95% CI £29-338) for EDC adherence ≥80% to £2,017 (95% CI £1,507-2,526) for EDC adherence <50%. CONCLUSIONS: This study provides a conservative estimate of excess inhaled medicines supply cost among adults with CF in the UK. The excess supply cost was highest among those with lowest EDC adherence, highlighting the importance of adherence support and supplying medicine according to actual use. MPR provides information about medicine supply but over-estimates actual medicine use.

The Evolution of the Healthy People Initiative: A Look Through the Decades.

Each decade, the US Department of Health and Human Services launches a new iteration of the Healthy People initiative. Healthy People strives to create a healthier nation and tracks data-driven outcomes to monitor progress toward achieving the initiative's goals throughout the decade. Although the initiative's mission, vision, and goals have evolved over time, since the initiative's inception in 1979, Healthy People remains dedicated to addressing the social determinants of health and improving the nation's health and well-being. In 2020, the US Department of Health and Human Services released the fifth iteration of the initiative, Healthy People 2030. This decade-long initiative provides a focused set of science-based, national objectives with targets to achieve by the year 2030. Healthy People 2030 is available online and offers users access to updated information and tools and resources for implementation. This article discusses the evolution of Healthy People across the decades, highlights Healthy People 2030 and its tools, and illustrates how stakeholders can use Healthy People to achieve their missions and improve the health and well-being of the nation.

Law and Policy as Tools in Healthy People 2030.

Laws and policies are critical determinants of health and well-being. They can encourage positive behaviors and discourage harmful behaviors, and they can enhance or worsen health, health equity, health disparities, and health literacy. Recognizing their contribution to conditions in the environments in which people are born, live, learn, work, play, worship, and age, and people's experiences of these conditions, the US Department of Health and Human Services considered the roles of law and policy throughout its development of Healthy People 2030. Laws and policies often interrelate, but they have different purposes. A law is an established procedure, standard, or system of rules that members of a society must follow. A policy is a decision or set of decisions meant to address a long-term purpose or problem. Healthy People 2030 offers an opportunity for users in diverse sectors and at all levels to use laws and policies to support or inform the initiative's implementation, address health disparities and health inequities, and improve health and well-being in this decade. Introducing new laws and policies or rescinding existing ones to achieve Healthy People 2030 goals offers a chance to rigorously assess outcomes and weigh the balance of good outcomes against unintended consequences.

Healthy People: The Role of Law and Policy in the Nation's Public Health Agenda.

Each decade since 1979, the Healthy People initiative establishes the national prevention agenda and provides the foundation for disease prevention and health promotion policies and programs. Law and policy have been included in Healthy People objectives from the start, but not integrated into the overall initiative as well as possible to potentially leverage change to meet Healthy People targets and goals. This article provides background on the Healthy People initiative and its use among various stakeholder groups, describes the work of a project aiming to better integrate law and policy into this initiative, and discusses the development of Healthy People 2030 - the next iteration of health goals for the nation. Lessons from the preliminary stages of developing Healthy People by the HHS Secretary's Advisory Committee (Committee) on National Health Promotion and Disease Prevention Objectives for 2030 and a Federal Interagency Workgroup will be included. Efforts by the Committee focused on the role of law and policy as determinants of health and valuable resources around health equity are also shared. Finally, the article discusses ways that law and policy can potentially be tools to help meet Healthy People targets and to attain national health goals.

Healthy People for the 21st Century: Understanding Use of Healthy People 2020 as a Web-Based Initiative.

OBJECTIVE: This study assesses how the nation's preeminent health promotion and disease prevention initiative, Healthy People, is utilized by key stakeholders. METHODS: A Web-based survey was administered to assess awareness and use of Healthy People among state, local, tribal health organizations and other key stakeholder groups. Follow-up interviews were conducted with a subset of respondents. RESULTS: Awareness and use of Healthy People have remained high among state, local, and tribal stakeholders. Healthy People 2020 is most frequently used as a data source. The Leading Health Indicators (LHIs) are an important element of the initiative, and nearly 90% of organizations that use the LHIs found them valuable. Awareness and use of other tools and resources are more limited. CONCLUSIONS: Healthy People continues to be a valued resource among public health stakeholders; however, continued outreach is needed to promote the use of tools and resources available on healthypeople.gov for this decade and beyond. Healthy People is a national initiative used most frequently as a data source by state and local health departments, tribal organizations, and other public health practitioners.

Considering disability and health: Reflections on the Healthy People 2020 Midcourse Review.

The Healthy People 2020 (HP2020) Midcourse Review (MCR) presents an opportunity for professionals in the disability and health field to contemplate preliminary progress toward achieving specific health objectives. The MCR showed notable progress in access to primary care, appropriate services for complex conditions associated with disability, expansion of health promotion programs focusing on disability, improving mental health, and reducing the unemployment rate among job seekers with disabilities. This commentary presents potential considerations, at least in part, for such progress including increased access to health care, greater awareness of appropriate services for complex conditions, and opportunities for societal participation. Additional considerations are provided to address the lack of progress in employment among this population -- a somewhat different measure than that for unemployment. Continuing to monitor these objectives will help inform programs, policies, and practices that promote the health of people with disabilities as measured by HP2020.

Civil Rights Laws as Tools to Advance Health in the Twenty-First Century.

To improve health in the twenty-first century, to promote both access to and quality of health care services and delivery, and to address significant health disparities, legal and policy approaches, specifically those focused on civil rights, could be used more intentionally and strategically. This review describes how civil rights laws, and their implementation and enforcement, help to encourage health in the United States, and it provides examples for peers around the world. The review uses a broad lens to define health for both classes of individuals and their communities--places where people live, learn, work, and play. Suggestions are offered for improving health and equity broadly, especially within societal groups and marginalized populations. These recommendations include multisectorial approaches that focus on the social determinants of health.

Policies for healthier communities: historical, legal, and practical elements of the obesity prevention movement.

The U.S. population is facing an obesity crisis wrought with severe health and economic costs. Because social and environmental factors have a powerful influence over lifestyle choices, a national obesity prevention strategy must involve population-based interventions targeted at the places where people live, study, work, shop, and play. This means that policy, in addition to personal responsibility, must be part of the solution. This article first describes the emergence of and theory behind the obesity prevention movement. It then explains how government at all levels is empowered to develop obesity prevention policy. Finally, it explores eight attributes of a promising state or local obesity prevention policy and sets the obesity prevention movement in the context of a larger movement to promote healthy communities and prevent chronic disease.

Effects on violence of laws and policies facilitating the transfer of youth from the juvenile to the adult justice system: a report on recommendations of the Task Force on Community Preventive Services.

The independent, nonfederal Task Force on Community Preventive Services (Task Force), which directs the development of the Guide to Community Preventive Services (Community Guide), conducted a systematic review of published scientific evidence concerning the effectiveness of laws and policies that facilitate the transfer of juveniles to the adult criminal justice system to determine whether these transfers prevent or reduce violence among youth who have been transferred and among the juvenile population as a whole. For this review, transfer is defined as placing juveniles aged <18 years under the jurisdiction of the adult criminal justice system. The review followed Community Guide methods for conducting a systematic review of literature and for providing recommendations to public health decision makers. Available evidence indicates that transfer to the adult criminal justice system typically increases rather than decreases rates of violence among transferred youth. Available evidence was insufficient to determine the effect of transfer laws and policies on levels of violent crime in the overall juvenile population. On the basis of these findings, the Task Force recommends against laws or policies facilitating the transfer of juveniles to the adult criminal justice system for the purpose of reducing violence.

Effects on violence of laws and policies facilitating the transfer of juveniles from the juvenile justice system to the adult justice system: a systematic review.

The independent, nonfederal Task Force on Community Preventive Services (Task Force), which directs development of the Guide to Community Preventive Services (Community Guide), has conducted a systematic review of published scientific evidence concerning the effectiveness of laws and policies that facilitate the transfer of juveniles to the adult criminal justice system, on either preventing or reducing violence (1) among those youth who experience the adult criminal system or (2) in the juvenile population as a whole. This review focuses on interpersonal violence. Violence may lead to the juvenile's initial arrest and entry into the justice system and, for those who are arrested, may be committed subsequent to exiting the justice system. Here transfer is defined as the placement of juveniles aged less than 18 years under the jurisdiction of the adult criminal justice system, rather than the juvenile justice system, following arrest. Using the methods developed by the Community Guide to conduct a systematic review of literature and provide recommendations to public health decision makers, the review team found that transferring juveniles to the adult justice system generally increases, rather than decreases, rates of violence among transferred youth. Evidence was insufficient for the Task Force on Community Preventive Services to determine the effect of such laws and policies in reducing violent behavior in the overall juvenile population. Overall, the Task Force recommends against laws or policies facilitating the transfer of juveniles from the juvenile to the adult judicial system for the purpose of reducing violence.

Child and adolescent violent deaths: an epidemiologic investigation.

OBJECTIVES: An apparent increase in violent deaths among children and adolescents in Detroit, MI in 2002 prompted a coordinated epidemiologic investigation involving federal, state and local organizations. METHODS: A descriptive analysis of cases and violent deaths (homicide, suicide or firearm-related) among juveniles <17 years was conducted, along with a case-control study using records from the medical examiner, police, schools and social service agencies. RESULTS: Twenty-nine cases were identified. Median age was 10 years (range 1 day-16 years), and 15 (52%) were male. There were 25 homicides, two suicides and two unintentional firearm-related deaths. Nine (31%) homicides resulted from child abuse and neglect, and eight (28%) were among bystanders. The most common mechanism of fatal injury was firearm (63%). Victims' families were more likely to have a history of familial violence, prior contact with the state social services agency, > or = 2 adults and > or = 4 persons in the household (P<0.05). CONCLUSIONS: The 2002 deaths did not represent a statistically significant increase from previous years. Several findings were remarkable: the proportion of deaths among bystanders, females and children age <5.

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.