Patient characteristics and neighborhood attributes associated with hepatitis C screening and positivity in Philadelphia.

Among patients of an urban primary care network in Philadelphia with a universal hepatitis C virus (HCV) screening policy for patients born during 1945-1965, we examined whether being unscreened and HCV positivity were associated with attributes of the census tracts where patients resided, which we considered as proxies for social health determinants. For patients with at least one clinic visit between 2014 and mid-2017, we linked demographic and HCV screening information from electronic health records with metrics that described the census tracts where patients resided. We used generalized estimating equations to estimate adjusted relative risk ratios (aRRs) for being unscreened and HCV positive. Overall, 28% of 6,906 patients were unscreened. Black race, male gender, and residence in census tracts with relatively high levels of violent crime, low levels of educational attainment and household incomes, and evidence of residential segregation by Hispanic ethnicity were associated with lower aRRs for being unscreened. Among screened patients, 9% were HCV positive. Factors associated with lower risks of being unscreened were, in general, associated with higher HCV positivity. Attributes of census tracts where patients reside are probably less apparent to clinicians than patients' gender or race but might reflect unmeasured patient characteristics that affected screening practices, along with preconceptions regarding the likelihood of HCV infection based on prior screening observations or implicit biases. Approaching complete detection of HCV-infected people would be hastened by focusing on residents of census tracts with attributes associated with higher infection levels or, if known, higher infection levels directly.

Neighborhood Effects on Missed Appointments in a Large Urban Academic Multispecialty Practice.

BACKGROUND: Missed appointments diminish the continuity and quality of care. OBJECTIVE: To determine whether missing scheduled appointments is associated with characteristics of the populations in places where patients reside. DESIGN: Retrospective cross-sectional study using data extracted from electronic health records linked to population descriptors for each patient's census tract of residence. PATIENTS: A total of 58,981 patients ≥18 years of age with 275,682 scheduled appointments during 2014-2015 at a multispecialty outpatient practice. MAIN MEASURES: We used multinomial generalized linear mixed models to examine associations between the outcomes of scheduled appointments (arrived, canceled, or missed) and selected characteristics of the populations in patients' census tracts of residence (racial/ethnic segregation based on population composition, levels of poverty, violent crime, and perceived safety and social capital), controlling for patients' age, gender, type of insurance, and type of clinic service. KEY RESULTS: Overall, 17.5% of appointments were missed. For appointments among patients residing in census tracts in the highest versus lowest quartile for each population metric, adjusted odds ratios (aORs) for missed appointments were 1.27 (CI 1.19, 1.35) for the rate of violent crime, 1.27 (CI 1.20, 1.34) for the proportion Hispanic, 1.19 (CI 1.12, 1.27) for the proportion living in poverty, 1.13 (CI 1.05, 1.20) for the proportion of the census tract population that was Black, and 1.06 (CI 1.01, 1.11 for perceived neighborhood safety. CONCLUSIONS: Characteristics of the places where patients reside are associated with missing scheduled appointments, including high levels of racial/ethnic segregation, poverty, and violent crime and low levels of perceived neighborhood safety. As such, targeting efforts to improve access for patients living in such neighborhoods will be particularly important to address underlying social determinants of access to health care.

Personal and Neighborhood Attributes Associated with Cervical and Colorectal Cancer Screening in an Urban African American Population.

INTRODUCTION: Assessing individual social determinants of health in primary care might be complemented by consideration of population attributes in patients' neighborhoods. We studied associations between cervical and colorectal cancer screening and neighborhood attributes among an African American population in Philadelphia. METHODS: We abstracted demographic and cancer screening information from records of patients seen during 2006 at 3 federally qualified health centers and characterized patients' census tracts of residence by using census, survey, and other data to define population metrics for poverty, racial segregation, educational attainment, social capital, neighborhood safety, and violent crime. We used generalized estimating equations to obtain adjusted relative risks of screening associated with individual and census tract attributes. RESULTS: Among 1,708 patients for whom colorectal cancer screening was recommended, screening was up to date for 41%, and among 4,995 women for whom cervical cancer screening was recommended, screening was up to date for 75%. After controlling for age, sex (for colorectal cancer screening), insurance coverage, and clinic site, people living in the most racially segregated neighborhoods were nearly 10% more likely than others to be unscreened for colorectal cancer. Other census tract population attributes were not associated with differences in screening levels for either cancer. CONCLUSIONS: The association between lower rates of colorectal cancer screening and neighborhood racial segregation is consistent with known barriers to colonoscopy among African Americans combined with effects of segregation on health-related behaviors. Recognition of the association between segregation and lower colorectal cancer screening rates might be useful in informing and targeting community outreach to improve screening.

Identifying neighborhood characteristics associated with diabetes and hypertension control in an urban African-American population using geo-linked electronic health records.

For health care providers, information on community-level social determinants of health is most valuable when it is specific to the populations and health outcomes for which they are responsible. Diabetes and hypertension are highly prevalent conditions whose management requires an interplay of clinical treatment and behavioral modifications that may be sensitive to community conditions. We used geo-linked electronic health records from 2016 of African American patients of a network of federally qualified health centers in Philadelphia, PA to examine cross-sectional associations between characteristics of patients' residential neighborhoods and hypertension and diabetes control (n = 1061 and n = 2633, respectively). Hypertension and diabetes control were defined to align with the Health Resources and Services Administration (HRSA) Uniform Data System (UDS) reporting requirements for HRSA-funded health centers. We examined associations with nine measures of neighborhood socioeconomic status (poverty, education, deprivation index), social environment (violent crime, perceived safety and social capital, racial segregation), and built environment (land-use mix, intersection density). In demographics-adjusted log-binomial regression models accounting for neighborhood-level clustering, poor diabetes and hypertension control were more common in highly segregated neighborhoods (i.e., high proportion of African American residents relative to the mean for Philadelphia; prevalence ratio = 1.27 [1.02-1.57] for diabetes, 1.22 [1.12-1.33] for hypertension) and less common in more walkable neighborhoods (i.e., higher retail land use). Neighborhood deprivation was also weakly associated with poor hypertension control. An important consideration in making geographic information actionable for providers is understanding how specific community-level determinants affect the patient population beyond individual-level determinants.

The Impact of Law on Syndromic Disease Surveillance Implementation.

CONTEXT: Legal environments influence how health information technologies are implemented in public health practice settings. Syndromic disease surveillance (SyS) is a relatively new approach to surveillance that depends heavily on health information technologies to achieve rapid awareness of disease trends. Evidence suggests that legal concerns have impeded the optimization of SyS. OBJECTIVES: To (1) understand the legal environments in which SyS is implemented, (2) determine the perceived legal basis for SyS, and (3) identify perceived legal barriers and facilitators to SyS implementation. DESIGN: Multisite case study in which 35 key informant interviews and 5 focus groups were conducted with 75 SyS stakeholders. Interviews and focus groups were audio recorded, transcribed, and analyzed by 3 coders using thematic content analysis. Legal documents were reviewed. SETTING: Seven jurisdictions (5 states, 1 county, and 1 city) that were purposively selected on the basis of SyS capacity and legal environment. PARTICIPANTS: Health department directors, SyS system administrators, legal counsel, and hospital personnel. RESULTS: Federal (eg, HIPAA) and state (eg, notifiable disease reporting) laws that authorize traditional public health surveillance were perceived as providing a legal basis for SyS. Financial incentives for hospitals to satisfy Meaningful Use regulations have eased concerns about the legality of SyS and increased the number of hospitals reporting SyS data. Legal issues were perceived as barriers to BioSense 2.0 (the federal SyS program) participation but were surmountable. CONCLUSION: Major legal reforms are not needed to promote more widespread use of SyS. The current legal environment is perceived by health department and hospital officials as providing a firm basis for SyS practice. This is a shift from how law was perceived when SyS adoption began and has policy implications because it indicates that major legal reforms are not needed to promote more widespread use of the technology. Beyond SyS, our study suggests that federal monetary incentives can ameliorate legal concerns regarding novel health information technologies.

Public Health and the Pope's Visit to Philadelphia, 2015.

Pope Francis visited Philadelphia for 2 days during September 2015. Preparedness functions managed by the Philadelphia Department of Public Health (PDPH) were similar to those of other mass gatherings but also required accommodation of special security arrangements and the location of public events in central areas of the city. Public health planning involved collaborations with multiple city, state, and federal agencies and neighboring jurisdictions. PDPH preparations encompassed incident command procedures, contingency planning, disease surveillance and prevention, food safety, vector control, BioWatch air sampling, volunteer management for first-aid services, and continuity of operations. These were based on, or informed by, existing emergency plans and prior experiences in responding to public health crises, supporting large public events, managing regional preparedness exercises, engaging Medical Reserve Corps volunteers, and executing routine functions. Although the papal visit concluded without the occurrence of a substantial public health or healthcare emergency, lessons learned have and will continue to improve coordination with partner agencies in planning and executing large-scale events, as well as managing regional disease surveillance procedures and medical volunteer engagement. Another area identified for improvement concerns enhancing the role of local health departments in planning for responses to possible BioWatch alerts.

Racial/Ethnic Disparities in the Use of Lethal Force by US Police, 2010-2014.

OBJECTIVES: To update previous examinations of racial/ethnic disparities in the use of lethal force by US police. METHODS: I examined online national vital statistics data for deaths assigned an underlying cause of "legal intervention" (International Classification of Diseases, 10th Revision, external-cause-of-injury codes Y35.0-Y35.7, excluding Y35.5 [legal execution]) for the 5-year period 2010 to 2014. RESULTS: Death certificates identified 2285 legal intervention deaths (1.5 per million population per year) from 2010 to 2014. Among males aged 10 years or older, who represented 96% of these deaths, the mortality rate among non-Hispanic Black and Hispanic individuals was 2.8 and 1.7 times higher, respectively, than that among White individuals. CONCLUSIONS: Substantial racial/ethnic disparities in legal intervention deaths remain an ongoing problem in the United States.

Prevalence and correlates of local health department activities to address mental health in the United States.

Mental health has been recognized as a public health priority for nearly a century. Little is known, however, about what local health departments (LHDs) do to address the mental health needs of the populations they serve. Using data from the 2013 National Profile of Local Health Departments - a nationally representative survey of LHDs in the United States (N=505) - we characterized LHDs' engagement in eight mental health activities, factors associated with engagement, and estimated the proportion of the U.S. population residing in jurisdictions where these activities were performed. We used Handler's framework of the measurement of public health systems to select variables and examined associations between LHD characteristics and engagement in mental health activities using bivariate analyses and multilevel, multivariate logistic regression. Assessing gaps in access to mental healthcare services (39.3%) and implementing strategies to improve access to mental healthcare services (32.8%) were the most common mental health activities performed. LHDs that provided mental healthcare services were significantly more likely to perform population-based mental illness prevention activities (adjusted odds ratio: 7.1; 95% CI: 5.1, 10.0) and engage in policy/advocacy activities to address mental health (AOR: 3.9; 95% CI: 2.7, 5.6). Our study suggests that many LHDs are engaged in activities to address mental health, ranging from healthcare services to population-based interventions, and that LHDs that provide healthcare services are more likely than others to perform mental health activities. These findings have implications as LHDs reconsider their roles in the era of the Patient Protection and Affordable Care Act and LHD accreditation.

Emergency codes: a study of hospital attitudes and practices.

Many hospitals use color codes to denote internal (i.e. patient respiratory distress), or external (i.e. natural disasters) emergencies, via public announcement systems. Variations in the codes used by different hospitals can create confusion among providers who may practice in more than one hospital. This study sought to understand emergency code practices in the Delaware Valley region, assess patient and provider knowledge of codes at one hospital in that region, and patient and provider preferences for emergency code standardization and format. Anonymous electronic surveys on procedural knowledge and perspectives of emergency codes were disseminated to hospital staff and patients located at a large regional hospital. Phone interviews were conducted with hospital administration at the regional hospital and other hospitals within a 50-mile radius. The author's research indicates that standardization would be accepted by patients and providers and its lack is considered a barrier to providing high quality care.

Prevalence, Disparities, and Trends in Obesity and Severe Obesity Among Students in the School District of Philadelphia, Pennsylvania, 2006-2013.

INTRODUCTION: Recent analyses suggest that increases in rates of childhood obesity have plateaued nationally and may be decreasing among certain populations and communities, including Philadelphia, Pennsylvania. We examined 7 years of data, including 3 years not previously reported, to assess recent trends in major demographic groups. METHODS: We analyzed nurse-measured data from the School District of Philadelphia for school years 2006-07 through 2012-13 to assess trends in obesity (body mass index [BMI] ≥95th percentile) and severe obesity (BMI ≥120% of the 95th percentile) among all children aged 5 to 18 years for whom measurements were recorded. RESULTS: Over 7 school years, the prevalence of childhood obesity declined from 21.7% to 20.3% (P = .01); the prevalence of severe obesity declined from 8.5% to 7.3% (P < .001). Declines were larger among boys than among girls and among African Americans and Asians than among non-Hispanic whites and Hispanics. Over the final 3 years of study, the prevalence of obesity continued to decrease significantly among boys (including African Americans and Asians) but increased significantly among Hispanic girls and girls in grades kindergarten through 5. At the end of the study period, Hispanics had the highest prevalence of obesity among boys (25.9%) and girls (23.0%). The prevalence of severe obesity continued to trend downward in boys and decrease significantly among girls (including African American girls) but remained highest among Hispanic boys (10.1%) and African American girls (8.3%). CONCLUSION: The prevalence of obesity and severe obesity continued to decline among children in Philadelphia, but in some groups initial reductions were reversed in the later period. Further monitoring, community engagement, and targeted interventions are needed to address childhood obesity in urban communities.

Defining information needs for public health systems and services research.

BACKGROUND: People who lead or manage public health agencies have multiple needs for information in order to do their jobs effectively. In seeking to investigate "what works" in public health practice, investigators in the field of public health systems and services research (PHSSR) have largely overlapping information needs but often require a greater detail, specificity, or comprehensiveness than is routinely available in public health data systems. PHSSR DATA NEEDS MEETING: On April 24, 2014, the PHSSR Center of the University of Kentucky and AcademyHealth convened a 1-day meeting of public health practitioners and PHSSR investigators to identify PHSSR information needs. Meeting participants considered data needs for three PHSSR domains: the organization of public health agencies and services, the use of rapidly evolving health information technologies, and the financing and economic evaluation of public health activities. FUTURE DATA NEEDS: Identifying data needs in these and other PHSSR domains requires clarification of research questions, consideration of research methods, a balance of imagination and practicality, and investments to extend the information captured in existing administrative, financial, and population health monitoring systems.

Resource and cost adjustment in the design of allocation funding formulas in public health programs.

CONTEXT: Multiple federal public health programs use funding formulas to allocate funds to states. OBJECTIVE: To characterize the effects of adjusting formula-based allocations for differences among states in the cost of implementing programs, the potential for generating in-state resources, and income disparities, which might be associated with disease risk. SETTING: Fifty US states and the District of Columbia. INTERVENTION: Formula-based funding allocations to states for 4 representative federal public health programs were adjusted using indicators of cost (average salaries), potential within-state revenues (per-capita income, the Federal Medical Assistance Percentage, per-capita aggregate home values), and income disparities (Theil index). MAIN OUTCOME: Percentage of allocation shifted by adjustment, the number of states and the percentage of US population living in states with a more than 20% increase or decrease in funding, maximum percentage increase or decrease in funding. RESULTS: Each adjustor had a comparable impact on allocations across the 4 program allocations examined. Approximately 2% to 8% of total allocations were shifted, with adjustments for variations in income disparity and housing values having the least and greatest effects, respectively. The salary cost and per-capita income adjustors were inversely correlated and had offsetting effects on allocations. With the exception of the housing values adjustment, fewer than 10 states had more than 20% increases or decreases in allocations, and less than 10% of the US population lived in such states. CONCLUSIONS: Selection of adjustors for formula-based funding allocations should consider the impacts of different adjustments, correlations between adjustors and other data elements in funding formulas, and the relationship of formula inputs to program objectives.

Funding formulas for public health allocations: federal and state strategies.

Public health funding formulas have received less scrutiny than those used in other government sectors, particularly health services and public health insurance. We surveyed states about their use of funding formulas for specific public health activities; sources of funding; formula attributes; formula development; and assessments of political and policy considerations. Results show that the use of funding formulas is positively correlated with the number of local health departments and with the percentage of public health funding provided by the federal government. States use a variety of allocative strategies but most commonly employ a "base-plus" distribution. Resulting distributions are more disproportionate than per capita or per-person-in-poverty allotments, an effect that increases as the proportion of total funding dedicated to equal minimum allotments increases.

Reference allocations and use of a disparity measure to inform the design of allocation funding formulas in public health programs.

Funding formulas are commonly used by federal agencies to allocate program funds to states. As one approach to evaluating differences in allocations resulting from alternative formula calculations, we propose the use of a measure derived from the Gini index to summarize differences in allocations relative to 2 referent allocations: one based on equal per-capita funding across states and another based on equal funding per person living in poverty, which we define as the "proportionality of allocation" (PA). These referents reflect underlying values that often shape formula-based allocations for public health programs. The size of state populations serves as a general proxy for the amount of funding needed to support programs across states. While the size of state populations living in poverty is correlated with overall population size, allocations based on states' shares of the national population living in poverty reflect variations in funding need shaped by the association between poverty and multiple adverse health outcomes. The PA measure is a summary of the degree of dispersion in state-specific allocations relative to the referent allocations and provides a quick assessment of the impact of selecting alternative funding formula designs. We illustrate the PA values by adjusting a sample allocation, using various measures of the salary costs and in-state wealth, which might modulate states' needs for federal funding.

Lessons learned from the 2007 to 2009 Haemophilus influenzae type B vaccine shortage: implications for future vaccine shortages and public health preparedness.

OBJECTIVE: To understand immunization programs' experience managing the 2007 to 2009 Haemophilus influenzae type B (Hib) vaccine shortage and identify ways in which the US immunization system can be improved to assist in responses to future shortages of routine vaccines and large-scale public health emergencies. METHODS: An Internet-based survey was conducted from July 2009 to October 2009 among the 64 city, state, and territorial immunization program managers (IPMs). RESULTS: Fifty-eight percent (37 of the 64) of IPMs responded. Forty percent of responding IPMs indicated not having enough Hib vaccine within their Vaccines for Children program to fulfill the temporary 3-dose recommendation issued in December 2007 in response to the Hib vaccine shortage. While 73% of IPMs indicated success in monitoring provider inventory and 68% indicated success in monitoring doses administered during the shortage, fewer than half indicated success in monitoring providers' compliance with shortage-specific recommendations regarding Hib vaccine. Forty-six percent of IPMs used their immunization information system (IIS) to monitor provider compliance with recommendations regarding Hib vaccine use, and of these, nearly 60% reported success in monitoring provider compliance with recommendations compared with 35% of IPMs who did not use their IIS in this way. Forty-two percent of IPMs felt that the Centers for Disease Control and Prevention (CDC) was successful in determining stockpiled vaccine allocations to their program, and 56% felt that the CDC was successful in communicating its rationale for their immunization program's Hib allocation during the shortage. CONCLUSIONS: Experiences from the 2007 to 2009 Hib vaccine shortage offer insights on how the US immunization system and system-wide response to vaccine shortages can be improved. Results from this survey suggest that improving vaccine transfer between jurisdictions and using IIS to track provider compliance with shortage recommendations are 2 ways that can help the US immunization system respond to future vaccine shortages and large-scale public health emergencies like influenza pandemics.

Multicomponent interventions to enhance influenza vaccine delivery to adolescents.

OBJECTIVE: To compare school- versus provider-based approaches to improving influenza vaccination coverage among adolescents in rural Georgia. METHODS: We used a nonrandomized, 3-armed design: (1) a middle- and high school-based influenza vaccination intervention in 1 county; (2) a provider-based influenza vaccination intervention in a second county; and (3) a standard-of-care condition in a third county. Interventions also included distribution of an educational brochure, school presentations, and community-based outreach to enhance vaccine knowledge and awareness among adolescents and their parents. RESULTS: During the 2008-2009 influenza season, 70 (19%) of 370 students were vaccinated in the school-based county and 110 (15%) of 736 students were vaccinated in the provider-based county, compared with 71 (8%) of 889 students in the standard-of-care county (risk ratio [RR](school): 2.4 [95% confidence interval (CI): 1.7-3.2]; RR(provider): 1.9 [95% CI: 1.4-2.5]). During 2009-2010, seasonal influenza vaccination coverage was 114 (30.4%) of 375 of students in the school-based county, 122 (16.9%) of 663 of students in the provider-based county, and 131 (15.2%) of 861 students in the standard-of-care county (RR(school): 2.3 [95% CI: 1.9-2.9]; RR(provider): 1.2 [95% CI: 0.97-1.5]). CONCLUSIONS: Special efforts to promote influenza vaccination among rural, predominantly black students were associated with increased vaccination coverage. The school-based influenza vaccination intervention was associated with the highest levels of vaccination coverage. This study revealed the efficacy of school-based influenza education to improve vaccination rates among adolescents.