Impact of State Stroke Systems of Care Laws on Stroke Outcomes.

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

How State Scope-of-Practice Policies Impact NP Care.

Three projects examine the effect of NP practice acts on access to health care.

Translating Workforce Development Policy Interventions for Community Health Workers: Application of a Policy Research Continuum.

CONTEXT: There is a need for knowledge translation to advance health equity in the prevention and control of cardiovascular disease and type 2 diabetes. One recommended strategy is engaging community health workers (CHWs) to have a central role in related interventions. Despite strong evidence of effectiveness for CHWs, there is limited information examining the impact of state CHW policy interventions. This article describes the application of a policy research continuum to enhance knowledge translation of CHW workforce development policy in the United States. METHODS: During 2016-2019, a team of public health researchers and practitioners applied the policy research continuum, a multiphased systematic assessment approach that incorporates legal epidemiology to enhance knowledge translation of CHW workforce development policy interventions in the United States. The continuum consists of 5 discrete, yet interconnected, phases including early evidence assessments, policy surveillance, implementation studies, policy ratings, and impact studies. RESULTS: Application of the first 3 phases of the continuum demonstrated (1) how CHW workforce development policy interventions are linked to strong evidence bases, (2) whether existing state CHW laws are evidence-informed, and (3) how different state approaches were implemented. DISCUSSION: As a knowledge translation tool, the continuum enhances dissemination of timely, useful information to inform decision making and supports the effective implementation and scale-up of science-based policy interventions. When fully implemented, it assists public health practitioners in examining the utility of different policy intervention approaches, the effects of adaptation, and the linkages between policy interventions and more distal public health outcomes.

Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care.

OBJECTIVE: Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN: This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS: As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION: The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.

Mapping and Analysis of US State and Urban Local Sodium Reduction Laws.

CONTEXT: Excessive sodium consumption contributes to high blood pressure, which is a risk factor for cardiovascular disease. OBJECTIVES: To (1) identify state and urban local laws addressing adult or general population sodium consumption in foods and beverages and (2) align findings to a previously published evidence classification review, the Centers for Disease Control and Prevention Sodium Quality and Impact of Component (QuIC) evidence assessment. DESIGN: Systematic collection of sodium reduction laws from all 50 states, the 20 most populous counties in the United States, and the 20 most populous cities in the United States, including Washington, District of Columbia, effective on January 1, 2019. Relevant laws were assigned to 1 or more of 6 interventions: (1) provision of sodium information in restaurants or at point of purchase; (2) consumer incentives to purchase lower sodium foods; and provision of lower sodium offerings in (3) workplaces, (4) vending machines, (5) institutional meal services, and (6) grocery, corner, and convenience stores. The researchers used Westlaw, local policy databases or city Web sites, and general nutrition policy databases to identify relevant laws. RESULTS: Thirty-nine sodium reduction laws and 10 state laws preempting localities from enacting sodium reduction laws were identified. Sodium reduction laws were more common in local jurisdictions and in the Western United States. Sodium reduction laws addressing meal services (n = 17), workplaces (n = 12), labeling (n = 13), and vending machines (n = 11) were more common, while those addressing grocery stores (n = 2) or consumer incentives (n = 6) were less common. Laws with high QuIC evidence classifications were generally more common than laws with low QuIC evidence classifications. CONCLUSIONS: The distribution of sodium laws in the US differed by region, QuIC classification, and jurisdiction type, indicating influence from public health and nonpublic health factors. Ongoing research is warranted to determine how the strength of public health evidence evolves over time and how those changes correlate with uptake of sodium reduction law.

Exploring new technologies in biomedical research.

The Health Law, Policy & Ethics Project at Emory University School of Law and the Human Toxicology Project Consortium of the Humane Society of the United States co-sponsored a symposium on October 23, 2017, to showcase innovations using human-based in silico and in vitro models for drug and device discovery. The goal of the symposium was to introduce researchers and students to exciting new tools and possible future careers that will increase understanding of disease and improve the search for effective therapeutics, while reducing reliance on animal testing. The symposium concluded with a discussion between scientists and lawyers about the legal regulation of new biomedical research technologies.

An Overview of State Policies Supporting Worksite Health Promotion Programs.

PURPOSE: Worksite health promotion (WHP) programs can reduce the occurrence of cardiovascular disease risk factors. State law can encourage employers and employer-provided insurance companies to offer comprehensive WHP programs. This research examines state law authorizing WHP programs. DESIGN: Quantitative content analysis. SETTING: Worksites or workplaces. SUBJECTS: United States (and the District of Columbia). INTERVENTION: State law in effect in 2013 authorizing WHP programs. MEASURES: Frequency and distribution of states with WHP laws. ANALYSIS: To determine the content of the laws for analysis and coding, we identified 18 policy elements, 12 from the Centers for Disease Control and Prevention's Worksite Health ScoreCard (HSC) and 6 additional supportive WHP strategies. We used these strategies as key words to search for laws authorizing WHP programs or select WHP elements. We calculated the number and type of WHP elements for each state with WHP laws and selected two case examples from states with comprehensive WHP laws. RESULTS: Twenty-four states authorized onsite WHP programs, 29 authorized WHP through employer-provided insurance plans, and 18 authorized both. Seven states had a comprehensive WHP strategy, addressing 8 or more of 12 HSC elements. The most common HSC elements were weight management, tobacco cessation, and physical activity. CONCLUSION: Most states had laws encouraging the adoption of WHP programs. Massachusetts and Maine are implementing comprehensive WHP laws but studies evaluating their health impact are needed.

Do State Community Health Worker Laws Align with Best Available Evidence?

Community health workers (CHWs) are expected to improve patient care and population health while reducing health care costs. Law is a tool states are using to build a supportive infrastructure for the CHW workforce. This study assessed the extent existing state law pertaining to the CHW workforce aligned with best available evidence. We used the previously developed Quality and Impact of Component (QuIC) Evidence Assessment method to identify and prioritize those components that could comprise an evidence-informed CHW policy at the state level. We next assessed the extent codified statutes and regulations in effect as of December 31, 2014 for the 50 states and D.C. included the components identified in the evidence assessment. Fourteen components of an evidence-informed CHW policy were identified; eight had best, three had promising, and three had emerging evidence bases. Codified law in 18 states (35.3 % of 51) pertained to the CHW workforce. Fifteen of these 18 states authorized at least one of the 14 components from the evidence assessment (maximum: nine components, median: 2.5). The most frequently authorized component was a defined scope of practice for CHWs (authorized by eight states) followed by a standard core competency curriculum and inclusion of CHWs in multidisciplinary health care teams (each authorized by six states). States could consider the components presented in this article when developing new or strengthening existing law.

Collaborative drug therapy management: case studies of three community-based models of care.

Collaborative drug therapy management agreements are a strategy for expanding the role of pharmacists in team-based care with other providers. However, these agreements have not been widely implemented. This study describes the features of existing provider-pharmacist collaborative drug therapy management practices and identifies the facilitators and barriers to implementing such services in community settings. We conducted in-depth, qualitative interviews in 2012 in a federally qualified health center, an independent pharmacy, and a retail pharmacy chain. Facilitators included 1) ensuring pharmacists were adequately trained; 2) obtaining stakeholder (eg, physician) buy-in; and 3) leveraging academic partners. Barriers included 1) lack of pharmacist compensation; 2) hesitation among providers to trust pharmacists; 3) lack of time and resources; and 4) existing informal collaborations that resulted in reduced interest in formal agreements. The models described in this study could be used to strengthen clinical-community linkages through team-based care, particularly for chronic disease prevention and management.

Appraising the evidence for public health policy components using the quality and impact of component evidence assessment.

An essential strategy expected to reduce the global burden of chronic and cardiovascular disease is evidence-based policy. However, it is often unknown what specific components should constitute an evidence-based policy intervention. We have developed an expedient method to appraise and compare the strengths of the evidence bases suggesting that individual components of a policy intervention will contribute to the positive public health impact of that intervention. Using a new definition of "best available evidence," the Quality and Impact of Component (QuIC) Evidence Assessment analyzes dimensions of evidence quality and evidence of public health impact to categorize multiple policy component evidence bases along a continuum of "emerging," "promising impact," "promising quality," and "best." QuIC was recently applied to components from 2 policy interventions to prevent and improve the outcomes of cardiovascular disease: public-access defibrillation and community health workers. Results illustrate QuIC's utility in international policy practice and research.

Improving stroke outcomes in rural areas through telestroke programs: an examination of barriers, facilitators, and state policies.

INTRODUCTION: Every year in the United States more than 600,000 ischemic stroke patients do not receive proven, effective stroke treatment or may not be medically eligible to receive the one medication endorsed by the U.S. Food and Drug Administration for acute ischemic stroke. The lack of treatment is due partly to shortages of neurological experts in rural and underserved areas. Telestroke programs can improve stroke care for stroke patients in rural and underserved settings by using interactive telecommunication technology that connects centrally located neurological experts to rural healthcare facilities. Many states have enacted policies and practices that facilitate telestroke access. MATERIALS AND METHODS: We reviewed statutes and regulations in all 50 states that affect the adoption of telemedicine programs and describe examples of state-implemented programs in two states with policies that encourage telestroke use. RESULTS AND DISCUSSION: This review presents evidence of the value and effectiveness of telestroke programs, as well as an explanation of common barriers and facilitators of telestroke, including licensing and credentialing rules, reimbursement issues, and liability concerns. Most states have adopted policies that affect the adoption of telestroke programs. Georgia and South Carolina are examples of states implementing stroke policies using a telestroke model to treat stroke patients in rural areas.

A summary of public access defibrillation laws, United States, 2010.

INTRODUCTION: On average, less than 8% of people who experience an out-of-hospital cardiac arrest survive. However, death from sudden cardiac arrest is preventable if a bystander quickly retrieves and applies an automated external defibrillator (AED). Public access defibrillation (PAD) policies have been enacted to create programs that increase the public availability of these devices. The objective of this study was to describe each state's legal requirements for recommended PAD program elements. METHODS: We reviewed state laws and described the extent to which 13 PAD program elements are mandated in each state. RESULTS: No jurisdiction requires all 13 PAD program elements, 18% require at least 10 elements, and 31% require 3 or fewer elements. All jurisdictions provide some level of immunity to AED users, 60% require PAD maintenance, 59% require emergency medical service notification, 55% impose training requirements, and 41% require medical oversight. Few jurisdictions require a quality improvement process. CONCLUSION: PAD programs in many states are at risk of failure because critical elements such as maintenance, medical oversight, emergency medical service notification, and continuous quality improvement are not required. Policy makers should consider strengthening PAD policies by enacting laws that can reduce the time from collapse to shock, such as requiring the strategic placement of AEDs in high-risk locations or mandatory PAD registries that are coordinated with local EMS and dispatch centers. Further research is needed to identify the most effective PAD policies for increasing AED use by lay persons and improving survival rates.