Glen P. Mays

Institutional and Economic Determinants of Public Health System Performance

OBJECTIVES Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. METHODS Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. RESULTS Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. CONCLUSIONS Reconfiguring the organization and financing of public health systems in some communities-such as through consolidation and enhanced intergovernmental coordination-may hold promise for improving the performance of essential services.

Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths

Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining the value of investments in these program activities, which currently account for less than 5 percent of US health spending. We examine whether changes in spending by local public health agencies over a thirteen-year period contributed to changes in rates of community mortality from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer. We found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. These results suggest that increased public health investments can produce measurable improvements in health, especially in low-resource communities. However, more money by itself is unlikely to generate significant and sustainable health gains; improvements in public health practices are needed as well.

Public Health Delivery Systems: Evidence, Uncertainty, and Emerging Research Needs

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Availability and Perceived Effectiveness of Public Health Activities in the Nation’s Most Populous Communities

OBJECTIVES We examined the availability and perceived effectiveness of 20 basic public health activities in the communities where most Americans reside. METHODS A self-administered questionnaire was mailed to the 497 directors of US local health departments serving at least 100 000 residents. RESULTS On average, two thirds of the 20 public health activities were performed in the local jurisdictions surveyed, and the perceived effectiveness rating averaged 35% of the maximum possible. In multivariate models, availability of public health activities varied significantly according to population size, socioeconomic measures, local health department spending, and presence of local boards of health. CONCLUSIONS Local public health capacity varies widely across the nations most populous communities, highlighting the need for targeted improvement efforts.

Late Preterm Infants: Birth Outcomes and Health Care Utilization in the First Year

OBJECTIVE: To distinguish the effects of late preterm birth from the complications associated with the causes of delivery timing, this study used propensity score–matching methods on a statewide database that contains information on both mothers and infants. METHODS: Data for this study came from Arkansas Medicaid claims data linked to state birth certificate data for the years 2001 through 2005. We excluded all multiple births, infants with birth defects, and infants at <33 weeks of gestation. Late preterm infants (LPIs) (34 to 36 weeks of gestation) were matched with term infants (37–42 weeks of gestation) according to propensity scores, on the basis of infant, maternal, and clinical characteristics. RESULTS: A total of 5188 LPIs were matched successfully with 15303 term infants. LPIs had increased odds of poor outcomes during their birth hospitalization, including a need for mechanical ventilation (adjusted odds ratio [aOR]: 1.31 [95% confidence interval [CI]: 1.01–1.68]), respiratory distress syndrome (aOR: 2.84 [95% CI: 2.33–3.45]), and hypoglycemia (aOR: 1.60 [95% CI: 1.26–2.03]). Outpatient and inpatient Medicaid expenditures in the first year were both modestly higher (outpatient, adjusted marginal effect:

Geographic Variation in Public Health Spending: Correlates and Consequences

108 [95% CI:

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

58–

Self‐Reported Sugar‐Sweetened Beverage Intake among College Students

158]; inpatient,

Not-so-strange bedfellows : Models of interaction between managed care plans and public health agencies

597 [95% CI:

The Association of Changes in Local Health Department Resources With Changes in State-Level Health Outcomes

528–