F. Douglas Scutchfield

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.

Understanding the Organization of Public Health Delivery Systems: An Empirical Typology

CONTEXT Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure. METHODS This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system. FINDINGS Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations. CONCLUSIONS Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Recent Advances in Public Health Systems Research in the United States

Recognizing the publics health is the outcome of dynamic, adaptive, and complex systems of agencies; infrastructure, relationships, and interactions that dictate how to improve health outcomes; and reducing health risks in a population is based on systems thinking and evidence. New methods such as network analysis and public health practice-based research networks demonstrate the potential for new insight to our understanding of how systems and infrastructure influence population health. We examine advances in public health systems research since 1988 and discuss the relevance of this type of research to public health practice. We assess the current infrastructure for conducting public health systems research, suggest how the research infrastructure can be improved, and conclude with a discussion of how health reform in the United States will require research focused on understanding the adaptive complexity inherent in public health and health care systems and strengthening the systems research infrastructure.

Public Health Performance

This review examines past, current, and future issues in developing and using public health performance data for improving the public health system. Issues are explored relating to public health performance data collection and analysis, and inferences made from those data, largely by examining public health performance data collected since the Year 2000. More research is needed to improve understanding of the context in which public health systems operate and how that context affects performance and its relationship to health outcomes. There are major areas of concern that must be addressed by the public health practice organizations, governmental public health entities, and the public health systems research communities, such as ensuring that data are collected on public health infrastructure, practice, and performance and that data from various sources are collected in a harmonious fashion. At issue also is the examination of the impact of new arrivals to the public health system, such as accreditation and credentialing of the public health workforce, on public health system performance.

The effect of physician continuity on diabetic outcomes in a resident continuity clinic.

BACKGROUNDConflicting data exists regarding the effect of continuity on diabetes care. Resident physicians frequently treat patients with diabetes in their continuity clinics; however, maintaining continuity in a resident clinic can be very challenging.OBJECTIVETo determine if resident continuity is associated with improvement in diabetic outcomes (HgA1c, LDL, blood pressure) in a resident clinic.DESIGN AND SETTINGRetrospective analysis of data obtained from a medical record review of diabetic patients seen in a resident physician clinic.MEASUREMENTSWe measured continuity, using the Usual Provider of Continuity Index (UPC) for residents and faculty preceptors. We measured changes in HgA1c, LDL, and blood pressure over a 3-year period. Using repeated measures analysis of variance (ANOVA), we assessed the relationship between UPC and change in these diabetic outcomes.RESULTSThe resident UPC was 0.43, and the faculty preceptor UPC was 0.76. The overall change in HgA1c was -0.3. There was a statistically significant relationship between improvement in HgA1c and resident UPC (p = 0.02), but not faculty preceptor UPC. There was no association between resident or faculty preceptor continuity and change in LDL or blood pressure.CONCLUSIONThis study showed a link between resident continuity and improvement in glycemic control in diabetic patients. Resident physicians have a greater opportunity to develop a personal relationship with their patients. This interpersonal continuity may be of benefit in patients with illnesses that requires a significant amount of self-management behaviors. Medical training programs should focus efforts on improving continuity in resident primary care clinics.

Applying Health Services Research to Public Health Practice: An Emerging Priority

Achieving an effective, efficient, and equitable health system has proven to be an elusive goal for health policy makers in the United States, but the field of health services research (HSR) has become increasingly central in charting the path toward this destination. HSR has evolved in tandem with the information needs of decision makers in government and the private sector, from perennial interests in coverage and cost containment to more recent concerns about quality, safety, and health disparities. Over much of this history, the producers and users of health services research have focused heavily on the production and consumption of medical care, while giving comparatively little attention to another important component of the health system—that of public health services. These services include population-wide efforts to identify and investigate health threats, promote healthy lifestyles, prevent disease and injury, prepare for emergencies and disasters, and assure the quality of water, food, air, and other resources that affect human health (Institute of Medicine, Committee for the Study of the Future of Public Health 1988). The relative paucity of studies on this aspect of health system performance reflects the relatively low priority given to public health practice during the last half of the 20th century. In recent years, public health has undergone a notable resurgence in visibility among both policy makers and the public at large. Concerns about gaps in the availability and quality of public health services have grown rapidly in response to both new and persistent health risks, including infectious diseases like SARS and pandemic influenza, the threat of bioterrorism, natural disasters like the 2005 Gulf hurricanes, and the rapid advance of obesity and preventable chronic diseases. Since 2001, the federal government has invested >

Public Health Department Accreditation: Setting the Research Agenda

10 billion in new funds to support public health activities, with a primary focus on helping communities prepare for and respond to large-scale public health emergencies (Trust for Americas Health 2006). The increased attention and resources have generated expanded interest in using the concepts and methods of health services research to develop better ways of organizing, financing, and delivering public health services. This emerging focal point within health services research has become known as public health services and systems research (Mays, Halverson, and Scutchfield 2003; Scutchfield et al. 2007;).

Accelerating the Production and Application of Evidence for Public Health System Improvement: the Search for New Frontiers

Health department accreditation is one of the most important initiatives in the field of public health today. The Public Health Accreditation Board (PHAB) is establishing a voluntary accreditation system for more than 3000 state, tribal, territorial, and local health departments using domains, standards, and measures with which to evaluate public health department performance. In addition, public health department accreditation has a focus on continuous quality improvement to enhance capacity and performance of health departments in order to advance the health of the population. In the accreditation effort, a practice-based research agenda is essential to build the scientific base and advance public health department accreditation as well as health department effectiveness. This paper provides an overview of public health accreditation and identifies the research questions raised by this accreditation initiative, including how the research agenda will contribute to better understanding of processes underlying the delivery of services by public health departments and how voluntary accreditation may help improve performance of public health departments.

Recommendations from testing of the National Public Health Performance Standards instruments.

The new journal Frontiers in Public Health Services and Systems Research provides a platform for rapidly and widely communicating emerging findings and lessons learned from studies of public health services and delivery systems.

Teaching Population Health: A Competency Map Approach to Education

The National Public Health performance Standards Program (NPHPSP) has developed assessment instruments based on the ten essential public health services (EPHS) for state and local health departments. The article reviews validity testing of the state and local instruments. The study employed multiple approaches to validity testing with state and local health departments in Florida, Hawaii, Minnesota, Mississippi, and New York. The New York State validity checks included the judgments of community partners. The study found that the EPHS have content and face validity as a basis for measuring public health system performance. The article includes recommendations for continued development of the NPHPS.