Garland H. Land

Evidence-Based Decision Making in Public Health

A stronger focus on evidence-based decision making in day-to-day public health practice is needed. This article describes the rationale for this need, including (1) the inter-relationships between evidence-based medicine and evidence-based public health (EBPH); (2) commonly used analytic tools and processes; (3) keys to when public health action is warranted; (4) a strategic, six-step approach to more analytic decision making; and (5) summary barriers and opportunities for widespread implementation of EBPH. The approach outlined is being tested through a series of courses for mid-level managers in the Missouri Department of Health--initial results from a pilot test are encouraging. It is hoped that the greater use of an evidence-based framework in public health will lead to more effective programs.

Prioritization MICA: a Web-based application to prioritize public health resources.

Although setting priorities is an important step in making public health policy, the benefit of using epidemiology to prioritize scarce public health resources has not been fully recognized. This situation is mostly due to the complexity of proposed models for setting priorities. We describe a public health priority setting model, Missouri Information for Community Assessment Priority Setting Model (Priority MICA), which uses epidemiologic measures available in most surveillance systems across the United States. Priority MICA uses data from birth and death certificates, hospital discharges, emergency departments, risk factors from the Behavioral Risk Factors Surveillance System, and eight epidemiologic measures to construct six priority criteria: size (the number of emergency department visits, hospitalizations, and deaths), severity (number of deaths of people younger than 65), urgency (trends in deaths and hospital morbidity), preventability (evidence-based score), community support (score of social support for preventive action), and racial-disparity (race comparison through death and morbidity rate ratio). Priority MICA is part of a Web-based interactive tool that makes available data from a wide variety of surveillance systems (http://www.dhss.mo.gov/MICA). The top 10 priority diseases determined by Priority MICA were compared to a more traditional method of ranking diseases by mortality rates. Using the additional criteria in Priority MICA identified four more priority diseases than were identified using just mortality while the ranking of the other six priority diseases differed between methods.

Measuring 2010 national objectives and leading indicators at the state and local level.

This article examines to what extent data are typically available at the state and local level to track the Healthy People 2010 (HP 2010) objectives. It is estimated that there is a data source to track 56 percent of the relevant HP 2010 objectives at the state level and only 33 percent of the objectives can be tracked at the county level. The main solution for tracking more objectives at the state and county level is to expand the number of questions and coverage of the BRFSS and YRBS.

The Missouri experience in providing tools and resources to promote community assessment.

The Missouri Department of Health (MDOH) has dedicated staff that provides technical assistance to communities that are conducting assessments and intervention strategies to meet community health needs. The MDOH developed a web site that is designed to make health data easily available at the local level. The Missouri Hospital Association partners in the process by making funds available to communities that have proposed interventions in response to their community assessment. This article describes this public/private relationship and some of the state and local experiences.

Making public health data available to community-level decision makers--goals, issues, and a case report.

Effective community health assessment and planning depends on the availability of appropriate public health data. Web-based technologies have created an unprecedented opportunity for making data available to community-level public health decision makers. An interactive data retrieval system targeted to the community-level user must provide an intuitive and easy-to-learn user interface with functionality and statistical complexity appropriate to the expected users while maintaining confidentiality of personal health information. The authors use the Missouri Information for Community Assessment Web site as an example to discuss goals and issues involved in the development of such systems.

Missouri's Take a Seat, Please! and program evaluation

In Missouri, injuries from motor vehicle crashes are the leading cause of death to children aged one to four. In 1984, the state legislature enacted child passenger safety legislation, but by 1992, compliance with the law was still disappointingly low. The Missouri Department of Health implemented a program called Take a Seat, Please! in which concerned citizens reported motorists who transported children under age four in a way not compliant with the state law. Two years later, a telephone survey and a pre- and postobservation study at child care centers did not show that the intervention had any effect. The program was discontinued in September 1995.

Developing the Missouri Integrated Public Health Information System

The Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC), an initiative of the Missouri Department of Health (MDOH), is one of the best-known successful undertakings to develop an integrated public health system to serve both state and local public health needs. MOHSAIC was to replace more than 60 different program-specific computer systems serving individual health programs. The challenges faced by system developers were daunting. They included locating sources of funding for a very expensive project, acquiring qualified staff and contractors, coordinating system development across programs that often preferred their own dedicated systems, dealing with conversion of data from legacy systems, and encountering entrenched resistance to business reengineering. The means by which MDOH addressed these challenges to build an integrated system are instructive. The keys to success included locating sources of funding, dealing with both internal and external politics, securing top-level promotion and support, developing a strategic plan to guide the project, and involving users at all levels in the design of the system. The keys also involved the system designers’ developing a solid reputation by beginning construction in areas where support for MOHSAIC already existed, a tactic that helped overcome resistance in other program areas. The wisdom of the decision to design and implement MOHSAIC is already apparent at all levels of use of the integrated system. An integrated immunization register and a surveillance component are only two examples of the many benefits that the integrated system offers.

Missouri's emergency department E-code data reporting: a new level of data resource for injury prevention and control.

This article describes the results of the first statewide external cause of injury (E-code) reporting system that includes emergency department (ED) visits. The results indicate that for every injury-related death, there are 20 hospitalizations and 174 ED visits. Although firearms and motor vehicle crashes were the leading causes of injury-related deaths, falls and motor vehicle crashes were the leading causes of ED visits. An analysis of injuries in one metropolitan statistical area in the state demonstrates similarities and differences from the statewide results. The statewide reporting of cause of injury information in ED visits provides valuable information for injury control efforts.

Building Public Health Goals into the Purchasing Process:: The Missouri Medicaid Agency As Purchaser

INTRODUCTION As managed care radically changes the medical care environment, public health leaders are under increasing pressure to focus more on core public health functions and less on personal health services. As public health re-evaluates its key strategies, it can take advantage of its strategic role in purchasing medical care to forge new partnerships that benefit its constituents. METHODS Specific roles for public health in medical care purchasing are discussed. The state of Missouri is used as an example of successful strategies for positioning public health as a leader in the managed care environment. Key strategies include increasing influence in contracting; selecting and reporting of key health status indicators; promoting use of population-based data files; taking leadership roles in government-sponsored insurance programs; and assuring stability of critical health conditions during managed care transitions. CONCLUSION Public health has unprecedented opportunities to develop new methods for improving health status. Public healths well-developed scientific principles and methods, combined with strategic leadership, will position the discipline in the forefront of the dialogue about our nations health system into the next century.

A better way to kill dragons: parody on the experience of building an integrated information system in Missouri.

The Missouri Department of Health has been developing an integrated information system for all state and local public health activities. When the project began, there were more than 60 separate information systems that supported the state and 115 local public health agencies. This parody describes the process of moving from separate data systems (implements of war) to MOHSAIC, a single information system with a common database (scroll). Considerable progress has been made in overcoming the political, financial, and technical challenges to make MOHSAIC a reality.