Not Only How Much But How: The Importance Of Diversifying Funding Streams In A Reimagined Public Health System.

Revenue diversification may be a synergistic strategy for transforming public health, yet few national or trend data are available. This study quantified and identified patterns in revenue diversification in public health before and during the COVID-19 pandemic. We used National Association of County and City Health Officials' National Profile of Local Health Departments study data for 2013, 2016, 2019, and 2022 to calculate a yearly diversification index for local health departments. Respondents' revenue portfolios changed fairly little between 2016 and 2022. Compared with less-diversified local health departments, well-diversified departments reported a balanced portfolio with local, state, federal, and clinical sources of revenue and higher per capita revenues. Less-diversified local health departments relied heavily on local sources and saw lower revenues. The COVID-19 period exacerbated these differences, with less-diversified departments seeing little revenue growth from 2019 to 2022. Revenue portfolios are an underexamined aspect of the public health system, and this study suggests that some organizations may be under financial strain by not having diverse revenue portfolios. Practitioners have ways of enhancing diversification, and policy attention is needed to incentivize and support revenue diversification to enhance the financial resilience and sustainability of local health departments.

Association Between Community Social Vulnerability and Preventable Hospitalizations.

Preventable hospitalizations are common and costly events that burden patients and our health care system. While research suggests that these events are strongly linked to ambulatory care access, emerging evidence suggests they may also be sensitive to a patient's social, environmental, and economic conditions. This study examines the association between variations in social vulnerability and preventable hospitalization rates. We conducted a cross-sectional analysis of county-level preventable hospitalization rates for 33 states linked with data from the 2020 Social Vulnerability Index (SVI). Preventable hospitalizations were 40% higher in the most vulnerable counties compared with the least vulnerable. Adjusted regression results confirm the strong relationship between social vulnerability and preventable hospitalizations. Our results suggest wide variation in community-level preventable hospitalization rates, with robust evidence that variation is strongly related to a community's social vulnerability. The human toll, societal cost, and preventability of these hospitalizations make understanding and mitigating these inequities a national priority.

Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications.

The financing of public health systems and services relies on a complex and fragmented web of partners and funding priorities. Both underfunding and "dys-funding" contribute to preventable mortality, increases in disease frequency and severity, and hindered social and economic growth. These issues were both illuminated and magnified by the COVID-19 pandemic and associated responses. Further complicating issues is the difficulty in constructing adequate estimates of current public health resources and necessary resources. Each of these challenges inhibits the delivery of necessary services, leads to inequitable access and resourcing, contributes to resource volatility, and presents other deleterious outcomes. However, actions may be taken to defragment complex funding paradigms toward more flexible spending, to modernize and standardize data systems, and to assure equitable and sustainable public health investments.

Associations between physician practice models and health information exchange.

OBJECTIVES: The interaction between emerging physician practice models and the use of health information exchange (HIE) remains understudied. We examined associations between the use of emerging practice models and the use of HIE. We also examined barriers to HIE adoption among physicians who were not utilizing HIE. STUDY DESIGN: Survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3312, or 17.9% of all practicing physicians). METHODS: Primary outcomes were physician-reported HIE use for patient care summaries and for laboratory results. Secondary outcomes were 5 common HIE barriers among non-HIE users. The primary predictor was physician practice model: accountable care organization (ACO), clinically integrated network (CIN), or integrated delivery network (IDN) vs traditional care delivery model. Covariates included physician specialty, age, gender, and county of practice. RESULTS: Compared with physicians in traditional care delivery models, physicians in ACOs, CINs, or IDNs had significantly higher odds of using HIE to share both patient care summaries (P < .01) and laboratory results (P < .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. CONCLUSIONS: Providers in an emerging practice model are more likely to use HIE than those in a traditional care delivery model. However, nuances in these associations suggest a persistence of previously identified HIE gaps, and the barriers cited provide guidance for increasing HIE use among different practice types.

Staffing Up and Sustaining the Public Health Workforce.

OBJECTIVES: Estimate the number of full-time equivalents (FTEs) needed to fully implement Foundational Public Health Services (FPHS) at the state and local levels in the United States. METHODS: Current and full implementation cost estimation data from 168 local health departments (LHDs), as well as data from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, were utilized to estimate current and "full implementation" staffing modes to estimate the workforce gap. RESULTS: The US state and local governmental public health workforce needs at least 80 000 additional FTEs to deliver core FPHS in a post-COVID-19 landscape. LHDs require approximately 54 000 more FTEs, and states health agency central offices require approximately 26 000 more. CONCLUSIONS: Governmental public health needs tens of thousands of more FTEs, on top of replacements for those leaving or retiring, to fully implement core FPHS. IMPLICATIONS FOR POLICY AND PRACTICE: Transitioning a COVID-related surge in staffing to a permanent workforce requires substantial and sustained investment from federal and state governments to deliver even the bare minimum of public health services.

The Opportunity Cost of COVID for Public Health Practice: COVID-19 Pandemic Response Work and Lost Foundational Areas of Public Health Work.

This article has been temporarily removed by the publisher, Wolters Kluwer, due to a data quality issue. We regret any confusion this may have caused. This article will be published once production is complete on the Public Health Workforce Interest and Needs Survey supplemental issue. CONTEXT: There is little empirical evidence regarding the magnitude of the COVID-19 response across the public health workforce and the extent to which other public health programs were called upon to contribute to the response, potentially leading to less work being done in other public health programs during the COVID-19 pandemic. OBJECTIVES: To assess the composition of the workforce that contributed to the COVID-19 pandemic response during 2020-2022. DESIGN: A large, cross-sectional, nationally representative survey of the state and local public health agency workforce through the Public Health Workforce Interest and Needs Survey (PH WINS). SETTING: Nearly all state health agency-central offices (SHA-COs) and Big City Health Coalition (BCHC) member public health departments as well as a nationally representative sample of other local health departments (LHDs) with more than 25 staff members and serving more than 25 000 people participated in fall 2021. PARTICIPANTS: A sample of all individuals working at each SHA-CO or LHD as part-time or full-time employees, contractors, or other employee types was used. A total of 44 732 responses (35% of eligible respondents) were received. MAIN OUTCOME MEASURE: Main outcomes included the proportion of full-time equivalent (FTE) effort devoted to COVID-19 response work by quarter (Q) from Q1 2020 through Q1 2022. Predictors of interest included individual- and agency-level demographics, most notably an individual's self-reported public health program area. RESULTS: Staffing and hiring for the COVID-19 pandemic response was an ongoing effort that began in 2020 and lasted through 2022. During the pandemic, all public health program areas contributed at least 20% of their workforce time to COVID-19 response, peaking at 47-83% of the staff time, depending on the program area. CONCLUSIONS: There was a considerable public health opportunity cost to the public health systems' large and prolonged COVID-19 response. Persistent understaffing in the public health system remains an important issue.

Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults.

Greater investment in the social determinants of health (SDOH) is positively associated with improved health outcomes of both individuals and their communities, which in turn may help to bend the health care cost curve and reduce health care spending. The purpose of this study was to examine the relationship between local governments' spending on the SDOH and the health care costs of privately insured nonelderly adults. Annual spending by local governments on the SDOH for the years 2007-2017 was obtained from the Census of Governments. Annual health care costs for privately insured nonelderly adults for the years 2013-2017 was obtained from the Health Care Cost Institute. Bivariate and multivariate regression analyses were performed to examine the association between county-level local governments' per capita spending on the SDOH and the per member health care costs of privately insured adults living in these counties controlling for community characteristics. All analyses were conducted in 2021. For near-elderly adults ages 55-64, health care costs were significantly higher in counties with the lowest levels of local governmental spending on the SDOH. For adults ages 18-54, in contrast, health care costs were unrelated to local governmental spending. Investments of local governments in the SDOH may have rather limited potential to yield meaningful savings in health care costs for privately insured nonelderly adults at the population level, especially once such investments exceed a minimum threshold.

Past local government health spending was not correlated with COVID-19 control in US counties.

CONTEXT: Wide variation in state and county health spending prior to 2020 enables tests of whether historically better state and locally funded counties achieved faster control over COVID-19 in the first 6 months of the pandemic in the Unites States prior to federal supplemental funding. OBJECTIVE: We used time-to-event and generalized linear models to examine the association between pre-pandemic state-level public health spending, county-level non-hospital health spending, and effective COVID-19 control at the county level. We include 2,775 counties that reported 10 or more COVID-19 cases between January 22, 2020, and July 19, 2020, in the analysis. MAIN OUTCOME MEASURE: Control of COVID-19 was defined by: (i) elapsed time in days between the 10th case and the day of peak incidence of a county's local epidemic, among counties that bent their case curves, and (ii) doubling time of case counts within the first 30 days of a county's local epidemic for all counties that reported 10 or more cases. RESULTS: Only 26% of eligible counties had bent their case curve in the first 6 months of the pandemic. Government health spending at the county level was not associated with better COVID-19 control in terms of either a shorter time to peak in survival analyses, or doubling time in generalized linear models. State-level public spending on hazard preparation and response was associated with a shorter time to peak among counties that were able to bend their case incidence curves. CONCLUSIONS: Increasing resource availability for public health in local jurisdictions without thoughtful attention to bolstering the foundational capabilities inside health departments is unlikely to be sufficient to prepare the country for future outbreaks or other public health emergencies.

Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report.

CONTEXT: Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure. OBJECTIVES: This review examines the influence of the Finance report's 10 recommendations on public health policy and practice. DESIGN: This review utilized peer-reviewed and gray literature published since 2012. ELIGIBILITY CRITERIA: Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community. RESULTS: Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts. DISCUSSION: Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending. CONCLUSIONS: The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine's 2012 Report.

OBJECTIVE: The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." DESIGN: Qualitative study involving key informant interviews. SETTING AND PARTICIPANTS: Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. MAIN OUTCOME MEASURES: Qualitative feedback about changes to public health finance since the report. RESULTS: Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. CONCLUSIONS: Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. IMPLICATIONS FOR POLICY AND PRACTICE: Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.

Accuracy of Case-Based Seroprevalence of SARS-CoV-2 Antibodies in Maricopa County, Arizona.

We conducted a community seroprevalence survey in Arizona, from September 12 to October 1, 2020, to determine the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the seroprevalence estimate to predict SARS-CoV-2 infections in the jurisdiction by applying the adjusted seroprevalence to the county's population. The estimated community seroprevalence of SARS-CoV-2 infections was 4.3 times greater (95% confidence interval = 2.2, 7.5) than the number of reported cases. Field surveys with representative sampling provide data that may help fill in gaps in traditional public health reporting. (Am J Public Health. 2022;112(1):38-42. https://doi.org/10.2105/AJPH.2021.306568).

An efficient, localised approach for the simulation of elastic blood vessels using the lattice Boltzmann method.

Many numerical studies of blood flow impose a rigid wall assumption due to the simplicity of its implementation compared to a full coupling with a solid mechanics model. In this paper, we present a localised method for incorporating the effects of elastic walls into blood flow simulations using the lattice Boltzmann method implemented by the open-source code HemeLB. We demonstrate that our approach is able to more accurately capture the flow behaviour expected in elastic walled vessels than ones with rigid walls. Furthermore, we show that this can be achieved with no loss of computational performance and remains strongly scalable on high performance computers. We finally illustrate that our approach captures the same trends in wall shear stress distribution as those observed in studies using a rigorous coupling between fluid dynamics and solid mechanics models to solve flow in personalised vascular geometries. These results demonstrate that our model can be used to efficiently and effectively represent flows in elastic blood vessels.

High fidelity blood flow in a patient-specific arteriovenous fistula.

An arteriovenous fistula, created by artificially connecting segments of a patient's vasculature, is the preferred way to gain access to the bloodstream for kidney dialysis. The increasing power and availability of supercomputing infrastructure means that it is becoming more realistic to use simulations to help identify the best type and location of a fistula for a specific patient. We describe a 3D fistula model that uses the lattice Boltzmann method to simultaneously resolve blood flow in patient-specific arteries and veins. The simulations conducted here, comprising vasculatures of the whole forearm, demonstrate qualified validation against clinical data. Ongoing research to further encompass complex biophysics on realistic time scales will permit the use of human-scale physiological models for basic and clinical medicine.

Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: A systematic review and meta-analysis.

BACKGROUND: Pre-term or full-term childbirth can be experienced as physically or psychologically traumatic. Cumulative and trans-generational effects of traumatic stress on both psychological and physical health indicate the ethical requirement to investigate appropriate preventative treatment for stress symptoms in women following a routine traumatic experience such as childbirth. OBJECTIVE: The objective of this review was to investigate the effectiveness of early psychological interventions in reducing or preventing post-traumatic stress symptoms and post-traumatic stress disorder in post-partum women within twelve weeks of a traumatic birth. METHODS: Randomised controlled trials and pilot studies of psychological interventions preventing or reducing post-traumatic stress symptoms or PTSD, that included women who had experienced a traumatic birth, were identified in a search of Cochrane Central Register of Randomised Controlled Trials, MEDLINE, Embase, Psychinfo, PILOTS, CINAHL and Proquest Dissertations databases. One author performed database searches, verified results with a subject librarian, extracted study details and data. Five authors appraised extracted data and agreed upon risk of bias. Analysis was completed with Rev Man 5 software and quality of findings were rated according to Grading of Recommendation, Assessment, Development, and Evaluation. RESULTS: Eleven studies were identified that evaluated the effectiveness of a range of early psychological interventions. There was firm evidence to suggest that midwifery or clinician led early psychological interventions administered within 72 hours following traumatic childbirth are more effective than usual care in reducing traumatic stress symptoms in women at 4-6 weeks. Further studies of high methodological quality that include longer follow up of 6-12 months are required in order to substantiate the evidence of the effectiveness of specific face to face and online early psychological intervention modalities in preventing the effects of stress symptoms and PTSD in women following a traumatic birth before introduction to routine care and practice. PROSPERO REGISTRATION: CRD42020202576, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=202576.

County health outcomes linkage to county spending on social services, building infrastructure, and law and order.

Will counties that reallocate money from law enforcement to social services improve subsequent markers of population wellbeing? In this study, we measure the association between county government spending across multiple sectors and Life Expectancy at Birth (LEB) in the U.S. using data from the U.S. Census Bureau. We constructed a Structural Equation Model to determine whether social expenditure, building infrastructure, and spending on law and order were positively or negatively associated with LEB three-years after initial spending. The analysis compared data between 2002-05 and 2007-10 and was stratified for urban and rural counties. In rural counties, a one-standard-deviation increase in social spending increased subsequent LEB by 0.58 (SE 0.16) and 0.36 (SE 0.16) years in 2005 and 2010, respectively. In urban counties, a one-standard-deviation increase in building infrastructure spending increased subsequent LEB by 1.14 (SE 0.51) and 1.05 (SE 0.49) years in 2005 and 2010, respectively. In 2002, a one-standard-deviation increase in law and order spending significantly decreased subsequent life expectancy, 2.2 (SE 1.27) and 0.46 (SE 0.13) years in urban and rural counties, respectively. Similarly, investments in building infrastructure for urban counties and social services for rural counties were associated with subsequently higher life expectancy three years later after initial investments.

Association Between K-12 School Mask Policies and School-Associated COVID-19 Outbreaks - Maricopa and Pima Counties, Arizona, July-August 2021.

CDC recommends universal indoor masking by students, staff members, faculty, and visitors in kindergarten through grade 12 (K-12) schools, regardless of vaccination status, to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Schools in Maricopa and Pima Counties, which account for >75% of Arizona's population (2), resumed in-person learning for the 2021-22 academic year during late July through early August 2021. In mid-July, county-wide 7-day case rates were 161 and 105 per 100,000 persons in Maricopa and Pima Counties, respectively, and 47.6% of Maricopa County residents and 59.2% of Pima County residents had received at least 1 dose of a COVID-19 vaccine. School districts in both counties implemented variable mask policies at the start of the 2021-22 academic year (Table). The association between school mask policies and school-associated COVID-19 outbreaks in K-12 public noncharter schools open for in-person learning in Maricopa and Pima Counties during July 15-August 31, 2021, was evaluated.

US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19.

The COVID-19 pandemic has prompted concern about the integrity of the US public health infrastructure. Federal, state, and local governments spend $93 billion annually on public health in the US, but most of this spending is at the state level. Thus, shoring up gaps in public health preparedness and response requires an understanding of state spending. We present state spending trends in eight categories of public health activity from 2008 through 2018. We obtained data from the Census Bureau for all states except California and coded the data by public health category. Although overall national health expenditures grew by 4.3 percent in this period, state governmental public health spending saw no statistically significant growth between 2008 and 2018 except in injury prevention. Moreover, state spending levels on public health were not restored after cuts experienced during the Great Recession, leaving states ill equipped to respond to COVID-19 and other emerging health needs.

Towards blood flow in the virtual human: efficient self-coupling of HemeLB.

Many scientific and medical researchers are working towards the creation of a virtual human-a personalized digital copy of an individual-that will assist in a patient's diagnosis, treatment and recovery. The complex nature of living systems means that the development of this remains a major challenge. We describe progress in enabling the HemeLB lattice Boltzmann code to simulate 3D macroscopic blood flow on a full human scale. Significant developments in memory management and load balancing allow near linear scaling performance of the code on hundreds of thousands of computer cores. Integral to the construction of a virtual human, we also outline the implementation of a self-coupling strategy for HemeLB. This allows simultaneous simulation of arterial and venous vascular trees based on human-specific geometries.