The Kentucky plan: an innovative approach to professional doctoral education in public health.

The Doctor of Public Health (Dr.P.H.) degree is designed to prepare graduates for the highest levels of leadership in public health related careers in both public and private settings. The Kentucky School of Public Health has developed an innovative generalist professional degree program offering an extensive battery of courses based on the body of professional public health knowledge. The degree includes extensive supervised field experience as part of the academic training, linking theory with practice. Issues related to professional degrees, curriculum, accreditation and certification, admission, evaluation, plans for institutional cooperation, and demand are addressed.

A database analysis of potentially inappropriate drug use in an elderly medicaid population.

We conducted a cross-sectional retrospective review of 1996 Kentucky Medicaid Pharmacy claims data to examine the prevalence of potentially inappropriate drug use in 64,832 Medicaid recipients aged 65 years and older who received a prescription. Twenty-seven percent of patients received at least one potentially inappropriate agent. Prevalence was higher for nursing home residents (33%) than for community dwellers (24%). Amitriptyline (7.6%), propoxyphene (6.5%), doxepin (4.0%), and indomethacin (2.3%) were the most prescribed potentially inappropriate agents. Education programs and interventions aimed at optimizing the prescribing and dispensing of the most appropriate drugs are needed.

Managed care and public health.

Both public health and managed care organizations share an interest in ensuring the health status of a defined population. We explore the existing and potential relationships between managed care organizations and public health in several major public health areas, specifically clinical preventive services, prevention-oriented social and political policies, and core public health functions. The latter include health information, health education, personal health services provision, work force and research, community partnerships, and evaluation of health care. We believe there is much potential to improve the population's health through the collaboration of these two sectors of the health care system.

Managed care in the United States.

Medical care in the United States continues to consume an increasing amount of the Gross Domestic Product. To control the rising costs of health care many industries have turned to a controlled form of financing and delivery of health care--often referred to as managed care. Many types of managed care exist, including preferred provider organizations (PPO), exclusive provider organization (EPO), and health maintenance organizations (HMO). HMOs involve prepaid premiums, limited panels of providers and assumption of financial risk on the part of the providers. A variety of HMOs are currently operating in the United States. Managed care involves taking risks by those who administer it. Some methods of controlling patient and physician behaviour by taking risks are capitation, risk pools and withholds. With capitation the physician is paid a 'per member per month' fee regardless of whether the patient uses the service. Risk pools are concerned with who shares the risk; for example, the primary physician shares the financial risk with specialists. Withholds involve a fee-for-service with a portion withheld which may be returned to the provider if he/she is parsimonious. A concern expressed about HMOs is the possibility of restricted services. Moreover, hospital expenses make up a large portion of the total health care dollar. In 1995 the average length of stay for a Medicare patient was 6.1 days as opposed to 3.9 days for the non-Medicare patient. Indeed, HMOs were the leaders in the development of same-day surgery and out-patient treatment. Increasingly, in the United States, public and social insurance plans are turning to managed care as a method to control health care expenditure. Some government insurance plans, such as Medicare and Medicaid, also increasingly offer managed health options. The trend, for now, in the United States increases enrollment in managed care plans. Although this is occurring at a rapid pace, managed care will probably not be the final solution to provision of medical care in the United States.

The presence of total quality management and continuous quality improvement processes in California public health clinics.

Total quality management (TQM) and continuous quality improvement (CQI) processes have not been fully integrated into public health practice. Current levels of participation and interest in TQM/CQI were assessed in California's 62 county departments of health services. Survey results indicated that only 18.5 percent of the 54 respondents were using TQM/CQI. Of those not using TQM/CQI, 75 percent were interested in these activities. Improvement of public health clinic ability to compete and to survive in a rapidly changing health care environment requires fostering this interest through public health decision-maker support, increased TQM/CQI training opportunities, and demonstration of TQM/CQI cost-effectiveness in public health.

Compliance with the recommendations of the Institute of medicine report, The Future of Public Health: a survey of local health departments.

In 1989 a survey of state health officials was conducted to ascertain the extent that the recommendations of the 1988 Institute of Medicine's report, The Future of Public Health, were in place. We applied a similar survey in 1996 to assess the level of implementation of the IOM recommendations at the local health department level. Agreement with the specific IOM recommendations at the local level was, in almost all cases, greater than 90%. However, when one views the extent of these recommendations in place, nearly half fall below 50%. While there have been improvements in areas such as education of the public and outreach towards legislators and voluntary health organizations, our results show that there are still major short-comings when it comes to implementing the recommendations. Lack of resources at the local level appears to be the predominant cause of the low level of implementation, with restricted authority and lack of support also contributing to the problem. We feel the IOM recommendations can provide a strong foundation for our public health system, and hope these results help serve as a benchmark for further study.

A survey of state health department compliance with the recommendations of the Institute of Medicine report, The Future of Public Health.

We repeated a survey of state health agencies (SHAs) designed to ascertain the extent that the recommendations of the Institute of Medicine's report, The Future of Public Health, have been implemented. This survey was originally done in 1989 and we repeated the same survey in 1996. While there has been progress in some of the recommendations, such as a separate department of health, agreed-upon public health duties, outreach, infrastructure, and scope of responsibilities, there continue to be problems with the implementation of some of the recommendations. For example, the proportion of agencies reporting that the core public health function of policy development is extant has actually declined since 1989. There continue to be problems, with developing linkages of public health with environmental health and mental health, with strengthening the public health infrastructure, and with expansion of the scope of public health responsibilities. We encourage the continued monitoring of the implementation of the IOM recommendations.