The Public Health Uniform National Data System (PHUND$): A Platform for Monitoring Fiscal Health and Sustainability of the Public Health System.

CONTEXT: Leaders of government agencies are responsible for stewardship over taxpayer investments. Stewardship strengthens agency performance that is critical to improving population health. Most industries, including health care, and public enterprises, such as education, have policies for uniform data reporting and financial systems for the application of theoretical analytical techniques to organizations and entire systems. However, this is not a mainstreamed practice in local and state government public health. PROGRAM: The Public Health Uniform National Data System (PHUND$) is a financial information system for local health departments that advances the application of uniform practices to close financial analytical gaps. A 10-year retrospective overview on the development, implementation, and utility of PHUND$ is provided and supported by documented program and agency improvements to validate the analytical features and demonstrate a best practice. RESULTS: Benefits found from utilizing PHUND$ included reducing financial risks, supporting requests for increased revenues, providing comparative analysis, isolating drivers of costs and deficits, increasing workforce financial management skills, enhancing decision-making processes, and fostering agency sustainability to support continuous improvements in quality and population health. The PHUND$ financial data definitions in the data dictionary provided the structure needed for standardized data collection and confirmed the feasibility of a standardized public health chart of accounts. CONCLUSION: PHUND$ analysis provided evidence on the relationship between financial and operational performance, as well as informing strategies for managing risks and improving quality. Such analysis is critical to identifying financial and operational problems and essential to mitigating financial crisis, avoiding disruption of services, and fostering agency sustainability. PHUND$ additionally serves as an instrument that can guide development of standards that measure for agency sound financial management systems.

Proposal to Cut USPHS Commissioned Corps Includes Nursing Positions.

Move is called 'misguided and premature.'

Can Regenerative Medicine Help Close the Gap Between the Medicine Pipeline and Public Health Burden of Cardiovascular and Musculoskeletal Diseases?

PURPOSE: This commentary discusses the therapeutic and economic potentials of regenerative medicine (RM) by addressing how the reprioritization of resources in drug development may alleviate unmet medical need across many diseases, but especially cardiovascular diseases (CVDs) and musculoskeletal diseases (MSDs), the leading causes of mortality and morbidity, respectively, in the United States. METHODS: Data and perspectives represented in this commentary were obtained through an online literature search, public press releases from federal agencies and companies, online opinion pieces, published journal articles, and consulting agency reports; however, there were limitations to the available data because of the breadth and novelty of the therapeutic modalities involved. FINDINGS: Currently, the misallocation of resources within the therapeutic areas of CVDs and MSDs are possibly contributing to low approval rates, high cost of drug treatments, and consequently, disease burden. With a 2025 global market estimate of US $50.5 billion, RM is expected to become a major player in the pharmaceutical industry, with a potential to change the treatment paradigm and lessen disease burden across multiple disease areas, most notably in CVDs and MSDs. IMPLICATIONS: While the public sector appears to be doing its fair share by funding basic research and revamping regulatory regimes to address the vagaries of RM as a rapidly emerging novel technology, the support framework necessary for transforming the field from a promising concept to available therapy requires levels of resource allocation and marketing support that only the private sector can provide.

Impact of Culture-Independent Diagnostic Testing on Recovery of Enteric Bacterial Infections.

Background: Culture-independent diagnostic tests (CIDTs) are increasingly used to identify enteric pathogens. However, foodborne illness surveillance systems have relied upon culture confirmation to estimate disease burden and identify outbreaks through molecular subtyping. This study examined the impacts of CIDT and estimated costs for culture verification of Shigella, Salmonella, Shiga toxin-producing Escherichia coli (STEC), and Campylobacter at the Tennessee Department of Health Public Health Laboratory (PHL). Methods: This observational study included laboratory and epidemiological surveillance data collected between years 2013-2016 from patients with the reported enteric illness. We calculated pathogen recovery at PHL based on initial diagnostic test type reported at the clinical laboratory. Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated with modified Poisson regression. Estimates of cost were calculated for pathogen recovery from CIDT-positive specimens compared to recovery from culture-derived isolates. Results: During the study period, PHL received 5553 specimens from clinical laboratories from patients with the enteric illness. Pathogen recovery was 57% (984/1713) from referred CIDT-positive stool specimens and 95% (3662/3840) from culture-derived isolates (PR, 0.61 [95% CI, .56-.66]). Pathogen recovery from CIDT-positive specimens varied based on pathogen type: Salmonella (72%), Shigella (64%), STEC (57%), and Campylobacter (26%). Compared to stool culture-derived isolates, the cost to recover pathogens from 100 CIDT-positive specimens was higher for Shigella (US $6192), Salmonella (US $18373), and STEC (US $27783). Conclusions: Pathogen recovery was low from CIDT-positive specimens for enteric bacteria. This has important implications for the current enteric disease surveillance system, outbreak detection, and costs for public health programs.

Exploring Costing Methods for Environmental Health Services in North Carolina.

All local health departments in North Carolina are mandated to provide a defined set of environmental health services, yet few have the tools to understand the costs incurred in delivering these services. The objectives of this study were to (1) derive cost estimates for 2 commonly provided environmental health services-food and lodging inspections and on-site water services-and (2) explore factors that drive variations in costs, focusing on the roles of economies of scale and scope. Using data from 15 local health departments in North Carolina, we found that costs varied substantially. A bivariate analysis found evidence of economies of scale: higher volumes of services were associated with lower costs per service. Providing a greater scope of services, however, was not consistently associated with reduced costs. In-depth cost data provide public health officials with key information when deciding how to best serve their communities.

Hospital Community Benefit in the Context of the Larger Public Health System: A State-Level Analysis of Hospital and Governmental Public Health Spending Across the United States.

CONTEXT: Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. OBJECTIVE: In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. DESIGN: Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments. RESULTS: Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states. CONCLUSIONS: Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.

Pellagra Pre-Goldberger: Rupert Blue, Fleming Sandwith, and The "Vitamine Hypothesis".

The conquest of pellagra is commonly associated with one name: Joseph Goldberger of the US Public Health Service, who in 1914 went south, concluded within 4 months that the cause was inadequate diet, spent the rest of his life researching the disease, and--before his death from cancer in 1929--found that brewer's yeast could prevent and treat it at nominal cost. It does Goldberger no discredit to emphasize that between 1907 and 1914 a patchwork coalition of asylum superintendents, practicing physicians, local health officials, and others established for the first time an English-language competence in pellagra, sifted through competing hypotheses, and narrowed the choices down to two: an insect-borne infection hypothesis, championed by the flamboyant European Louis Westerna Sambon, and the new "vitamine hypothesis," proffered by Casimir Funk in early 1912 and articulated later that year by two members of the American Clinical and Climatological Association, Fleming Mant Sandwith and Rupert Blue. Those who resisted Goldberger's inconvenient truth that the root cause was southern poverty drew their arguments largely from the Thompson-McFadden Pellagra Commission, which traces back to Sambon's unfortunate influence on American researchers. Thousands died as a result.

China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?

BACKGROUND: There is a growing recognition of China's role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China's engagement as a donor with that of more traditional global health donors. METHODS: Using newly released data from AidData on China's development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000-2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China's activities to projects from traditional donors using data from the OECD's Development Assistance Committee (DAC) Creditor Reporting System. RESULTS: Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China's contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries. CONCLUSIONS: China is an important global health donor to Africa but contrasts with traditional DAC donors through China's focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China's approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Decline in mortality with the Belize Integrated Patient-Centred Country Wide Health Information System (BHIS) with embedded program management.

BACKGROUND: Belize deployed a country-wide fully integrated patient centred health information system with eight embedded disease management algorithms and simple analytics in 2007 for $4 (Cad)/citizen. OBJECTIVES: This study evaluated BHIS uptake by health care workers, and pre and post BHIS deployment mortality in selected areas and public health care expenditures. METHODS: BHIS encounter data were compared to encounter data from required Ministry of Health reports from licensed health care entities. De-identified vital statistics death data for the eight BHIS protocol disease domains and three non-protocol domains were compared from 2005 to 2011. Belize population data came from the Statistical Institute of Belize (2005-2009) and from Belize census (2010) and estimate (2011). Public health system expenditures were compared by fiscal years (2000-2012). RESULTS: BHIS captured over 90% healthcare encounters by year one, 95% by year two. Mortality rates decreased in the eight BHIS protocol domains (each 2005 vs. 2011, all p<0.02) vs. an increase or little change in the three domains without protocols. Hypertension related deaths dropped from 1st cause of death in 2003 to 9th by 2010. Public expenditures on healthcare steadily rose until 2009 but then declined slightly for the next 3 years. CONCLUSION: For modest investment, BHIS was well accepted nationwide and following deployment, mortality in the eight BHIS disease management algorithm domains declined significantly and expenditures on public healthcare stabilized.

Medical loss ratio requirements under the Patient Protection and Affordable Care Act. Final rule with comment period.

This final rule with comment period revises the regulations implementing medical loss ratio (MLR) requirements for health insurance issuers under the Public Health Service Act in order to address the treatment of "mini-med" and expatriate policies under these regulations for years after 2011; modify the way the regulations treat ICD-10 conversion costs; change the rules on deducting community benefit expenditures; and revise the rules governing the distribution of rebates by issuers in group markets.

Medical loss ratio rebate requirements for non-federal governmental plans. Interim final rule with request for comments.

This interim final rule with comment period revises the regulations implementing medical loss ratio (MLR) requirements for health insurance issuers under the Public Health Service Act in order to establish rules governing the distribution of rebates by issuers in group markets for non-Federal governmental plans.

Research interests and funding of members of the American Pediatric Surgical Association: report from 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee.

OBJECTIVE: There is lack of data relating to the research interests and funding of pediatric surgeons within the United States and Canada. These data may be helpful in promoting basic and clinical research among pediatric surgeons. METHODS: The American Pediatric Surgical Association (APSA) Outcomes and Clinical Trials Committee developed and administered an online survey via e-mail to the APSA membership to help characterize research activities and funding. The survey was available for completion during December of 2009. The survey contained 10 items with a drop-down menu for multiple choice answers and required 5 to 10 minutes to complete. Results based on research interests as well as funding sources were compiled and analyzed. RESULTS: A total of 275 members, which comprises 27.4% of the APSA membership, completed the survey. Of the respondents, 177 (64%) described being in an academic practice, 44 (16%) in an academically associated private practice, 9 (3.3%) in a private solo practice, 17 (6.2%) in private group practice, and 3 (1%) in the military. A total of 189 (68.7%) respondents stated that they participated in formal research. Respondents also categorized their research interests, and the following were the most common subjects of study (decreasing order of frequency): appendicitis, trauma and critical care, outcomes, minimally invasive surgery, and congenital diaphragmatic hernia. Of those participating in research, 64.5% stated that they have no formal financial support. Of those supported through the National Institutes of Health, funding grants achieved were as follows: R01 (n = 29), K08 (n = 9), K23 (n = 2), and U01 (n = 8). CONCLUSIONS: Research activities are common among APSA members and encompass a wide range of pediatric surgery topics. Strikingly, the overall financial support of these efforts is limited, predominantly supported by the surgeons themselves. Funded respondents attained grants through Public Health Service grants, departmental grants, or private institutions.

Collaboration for the integration of HIV prevention at Title X family planning service delivery sites.

Since 2001, the U.S. Department of Health and Human Services' Office of Family Planning (OFP), in collaboration with the Minority AIDS Initiative, has provided supplemental grant funds to Title X-funded family planning service delivery sites to expand the availability of human immunodeficiency virus (HIV) prevention services. This work has resulted in three major outcomes: (1) increased institutional capacity for the delivery of HIV-prevention services at Title X family planning service delivery sites, (2) the successful implementation of HIV-prevention services at these sites, and (3) the identification of HIV-positive individuals who were referred to care services. These efforts resulted in a total of 539,667 unduplicated individuals being tested for HIV. These tests resulted in the identification of 1,692 HIV-positive individuals who otherwise may not have been tested for HIV. More than 85% of the HIV-positive cases were detected among clients who self-identified as members of racial/ethnic minority groups. The integration of HIV-prevention services is a feasible and effective strategy for detecting HIV infection among women, including women in racial/ethnic minority groups.

The costs of HIV antiretroviral therapy adherence programs and impact on health care utilization.

From a trial comparing interventions to improve adherence to antiretroviral therapy-directly administered antiretroviral therapy (DAART) or an intensive adherence case management (IACM)-to standard of care (SOC), for HIV-infected participants at public HIV clinics in Los Angeles County, California, we examined the cost of adherence programs and associated health care utilization. We assessed differences between DAART, IACM, and SOC in the rate of hospitalizations, hospital days, and outpatient and emergency department visits during an average of 1.7 years from study enrollment, beginning November 2001. We assigned costs to health care utilization and program delivery. We calculated incremental costs of DAART or IACM v SOC, and compared those costs with savings in health care utilization among participants in the adherence programs. IACM participants experienced fewer hospital days compared with SOC (2.3 versus 6.7 days/1000 person-days, incidence rate ratio [IRR]: 0.34, 97.5% confidence interval [CI]: 0.13-0.87). DAART participants had more outpatient visits than SOC (44.2 versus 31.5/1000 person-days, IRR: 1.4; 97.5% CI: 1.01-1.95). Average per-participant health care utilization costs were $13,127, $8,988, and $14,416 for DAART, IACM, and SOC, respectively. Incremental 6-month program costs were $2,120 and $1,653 for DAART and IACM participants, respectively. Subtracting savings in health care utilization from program costs resulted in an average net program cost of $831 per DAART participant; and savings of $3,775 per IACM participant. IACM was associated with a significant decrease in hospital days compared to SOC and was cost saving when program costs were compared to savings in health care utilization.