Structuring a Framework for Public Health Performance-based Budgeting

Barriers to Recovery and Recommendations for Change: The Pennsylvania Consensus Conference on Psychiatry's Role

W IIEN President John Kennedy congratulated spacemaster John Glenn for his probe into the great unknown, the President said, is the new ocean and we must sail on Medical care administration is our new ocean and we must sail on it. So far, we in public health have probed about as much of our new ocean as the astronauts have of theirs. Why is this? Old hands in public health will recall lhow in their trainiing days their professors anid mentors carefully admonished them to steer clear of medical care. They warned that if one opened thlat door even a crack the city fatlhers would flood him with so many clinical responsibilities that all his fine-laid plans for the 'basic six of public health would languish in dusty pigeonholes. Ouir preoccupation with the sacred six lhas tend(led to insulate us from a full appreciation oL g,reat chlanges that have been occurring in the field of personal lhealtlh services. Until the beginning of this century, personal health services in America required almost no administrative kniow-lhow. It was pretty much a matter of a doctor on one end of a stethoscope and a patient on the other. Hospitals were the end of the line, and prepaid medical service was hardly known ouitside the merchlant marine. All t.hat is changed. Personal health services have become an extremely complex interrelationship of contributions to patient care by a wide spectrum of professional disciplines under a bewildering variety of conditions and settings. Haldeman has *observed that governmellts characteristically participate in the provision of personal health services before they develop public health controls. This is particularly true of underdeveloped areas. Our country was no exception. Benjamin Franklin got that first grant-in-aid to build the first lhospital in the colonies a hundred years before Shattuck dreamed up the idea of a State health department. The nature of our national development., witl its rapidly expanding frontier and almiost completely decentralized form of gover,nmient responsibility, limited these early sall ies inito mlledical care to a minor facet of ouir health cafre growth. From t.he middle of the 19tlh centuiry until the Great Depression, puiblic lhealtlh was the predominant group activity in health care. With mi nor exceptions, programs were beamed at all the people: sanitate all the environment; protect all the water, all the milk, all the food; vaccinate all the people; record all the births, all the deaths. As late as 1952, Smillie could wrvite in his textbook on preventive medicine anll puiblic health, Only in recent years have we gaine(d the concept that a healthy individual is a community asset. Contrariwise, a sick individual, or a man wlho dies prematurely, represents a community liability. The change in emplhasis that is occurring in Dr. Wright is senior research officer, office of human resources and social development, research and evaluation stagf, Agency for International Development. This article is adapted from an address before the American College of Preventive Medicine, October 18, 1962, Miami Beach, Fla.

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. In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. 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. 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. Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.

Until now, much of the work on machine learning and health has focused on processes inside the hospital or clinic. However, this represents only a narrow set of tasks and challenges related to health; there is greater potential for impact by leveraging machine learning in health tasks more broadly. In this Perspective we aim to highlight potential opportunities and challenges for machine learning within a holistic view of health and its influences. To do so, we build on research in population and public health that focuses on the mechanisms between different cultural, social and environmental factors and their effect on the health of individuals and communities. We present a brief introduction to research in these fields, data sources and types of tasks, and use these to identify settings where machine learning is relevant and can contribute to new knowledge. Given the key foci of health equity and disparities within public and population health, we juxtapose these topics with the machine learning subfield of algorithmic fairness to highlight specific opportunities where machine learning, public and population health may synergize to achieve health equity. Algorithmic solutions to improve treatment are starting to transform health care. Mhasawade and colleagues discuss in this Perspective how machine learning applications in population and public health can extend beyond clinical practice. While working with general health data comes with its own challenges, most notably ensuring algorithmic fairness in the face of existing health disparities, the area provides new kinds of data and questions for the machine learning community.

Advances in community and public health are needed to address contemporary health needs, particularly poor health outcomes related to the social determinants of health and inequity. Nurses are ideally placed to promote meaningful advances in community and public health, collectively referred to as population health. Nurse educators can promote a deeper understanding of core population health concepts by threading these concepts throughout the academic nursing curricula in addition to standalone population or public health courses. Strategies for incorporating population health concepts in a variety of courses can be conceptualized through the themes emphasizing context, honoring community voices, cultivating community connection, and fostering leadership in social responsibility. Nurse educators with expertise in population health can serve as a resource for faculty as these strategies are implemented. Teaching population health provides exciting opportunities for innovative approaches to facilitate students to link their practice to wider social contexts. Further steps to strengthen the public and community health workforce will still be needed to meet population health needs.

Gunshot wounds place an enormous burden on clinicians, the health care system, and society at large. As described by Brown et al. (2) in this issue (see pp. 149-153), approximately one quarter of all the orthopaedic admissions to their hospital resulted from gunshot wounds. In addition, patients with these injuries used more orthopaedic trauma resources than did patients with any other single diagnosis. Although the article primarily describes the impact of these injuries on the orthopaedic surgical service, Brown et al. note that other health care resources also are consumed by these patients. In their study, 26% of the gun-injured patients required admission to the intensive care unit. Also important to note is that the effect of firearm-related injury goes well beyond the immediate acute care setting. The loss of productivity and disability resulting from such injuries is staggering (6). The burden these injuries impose and their far-reaching consequences make a strong argument for prevention. Fully 59% of the patients required what Brown et al. refer to as "free care." Of course, as Brown et al. point out, such care is anything but free; the costs are borne by all of us. Brown et al. also note that more than 80% of the care for these patients is paid with government funds. Louisiana, where the study was based, has recently experienced a crisis in government-sponsored health care funding, brought on in part by changes in the Medicaid program. These changes have particularly affected Louisiana and have led to lay-offs and service cutbacks throughout the state public health system. Firearm injuries further strain the already stressed public health care system in Louisiana. Although this article focuses on the experience of a single trauma center, firearm-related injury is a problem throughout the United States and affects all demographic groups. During 1994, there were more than 38,500 firearm-related deaths nationwide (7) and an estimated additional 90,000-100,000 nonfatal injuries due to firearms (unpublished data, National Center for Injury Prevention and Control [NCIPC]). During the same year, injuries from firearms were the ninth leading cause of death overall and ranked fourth in terms of years of potential life lost (unpublished data, NCIPC). The toll of these injuries is particularly great on young people. For individuals between the ages of fifteen and twenty-four, firearm-related injuries were the second leading cause of death (unpublished data, NCIPC). The mean age of patients in the study was twenty-seven years; this is consistent with national trends and highlights the disproportionate impact of these injuries on our youth. Given the scope of the problem and the desire for prevention, the public health community has begun applying public health principles to address firearm-related injury. The public health approach is a scientific, multidisciplinary, four-step process that has been used successfully in the past to eradicate smallpox and to reduce the number of deaths due to motor vehicle crashes. The first step is defining the problem; this includes describing the magnitude and determining "who, where, when, and how." The second step is identifying the causes of the problem. Of particular importance are those risk factors that can be modified. The third step is developing prevention strategies based on information obtained from the first and second steps and testing them for effectiveness. The final step is implementing proven interventions on a widespread basis. With regard to firearm-related injury, we have made progress toward achieving the first two steps, but we still have much more to learn and to do. This article underscores the need for improved collection of basic data about injuries from firearms to fulfill the first step of the public health approach. Except for information about deaths obtained from vital statistics records, data about nonfatal firearm-related injuries are not readily available. Unlike other public health problems, such as measles or acquired immunodeficiency syndrome (AIDS), there is currently no national, systematic data collection regarding nonfatal firearm-related injuries. Special studies, such as the one described in this article, must be undertaken simply to describe the magnitude of the problem. Brown et al. used information available from their trauma registry but needed to supplement this information with data from additional sources in order to obtain a more complete picture of the problem. Efforts are currently under way to improve firearm-related injury surveillance. The Centers for Disease Control and Prevention has provided seven states with funds to develop systems for collecting data on firearm-related injury. These projects will help us better understand the best methods to collect such data and the extent of both nonfatal and fatal injuries from firearms, and they will give us insight into the causes and circumstances of these injuries. The surveillance systems developed by these states use data collected from numerous sources, such as emergency departments, police departments, and ballistics laboratories (1,3). In addition to allowing us to describe and monitor public health problems, ongoing, systematic data collection also helps us identify opportunities for prevention and evaluate the effectiveness of prevention strategies. At a time when we are seeking to reduce health care costs, firearm-related injuries offer a rich area for prevention and cost savings. Areas of potential intervention are as varied as the underlying causes and factors that contribute to the problem. These underlying factors are numerous and complex. They include issues surrounding the firearms themselves, as well as societal factors, such as poverty, discrimination, the cultural acceptance of violence, and the lack of opportunities for education and employment. Because these causes are so varied, no single solution for prevention is likely to be completely effective, but many different approaches may work. Various prevention strategies have been proposed, but we are still in the early stages with respect to our knowledge about their feasibility and effectiveness. Strategies that address some of the individual and societal factors include economic development programs, mentoring programs for youth, improvements in the educational systems, and programs that teach conflict resolution techniques. Although these strategies may seem beyond the scope of an individual physician, opportunities for intervention exist even in the acute care setting. Counseling in the acute care setting represents a "teachable moment" that is often overlooked. Patients who are recovering from a violent injury are often in the right state of mind to address the reasons why the violent injury occurred and to explore how the injury could have been avoided (4,5). Given the burden of these injuries, orthopaedists have a strong incentive to partner with social service agencies to advocate for the development of such programs at their institutions. Clinicians also can work with local public health agencies to design and implement prevention programs. If we focus our collective efforts on this problem and work effectively toward prevention, victims of firearm-related injuries need not fill our hospitals and deplete our communities.

A key challenge for schools throughout the COVID-19 pandemic was finding ways to monitor and prevent COVID-19 cases. While diagnostic testing and connecting students and their families to appropriate resources to mitigate the spread of COVID-19 were recommended, few schools had scalable infrastructure, including information technology systems, to implement these types of measures. This study tested a new approach to COVID-19 testing (SCALE-UP Counts) in school settings that used automated bidirectional text messages provided to the school community that alerted parents of students to COVID-19 testing options and guidance on when to test. The SCALE-UP Counts trial was designed as a Sequential Multiple Assignment Randomized Trial and final analyses compared results from parents who received intensive, fully automated, bidirectional text messaging about COVID-19 testing or usual care (control; fully automated unidirectional text messaging about COVID-19 testing), unblinded interventions. From the 16 selected schools, we enrolled all eligible participants who did not opt out of the study. The study provided schools from both arms of the trial with free at-home COVID-19 test kits. The primary outcome was the proportion of parents whose households tested for COVID-19, and the secondary outcome was the number of missed school days. The study asked parents to respond to self-report measures on testing outcomes and missed school days through web-based questionnaires. The study included 7122 parents of students from 16 schools, half of which were title 1 schools; 2588 were randomized to usual care or control and 4534 to bidirectional text messaging. The SCALE-UP Counts intervention led to increased self-reported testing when compared with the control condition (22.8% vs 13.5%, relative testing rate=1.64, 95% CI 1.31-2.02; P<.001). There was no observed difference in missed school days between the study arms (0.43 per month vs 0.28 in usual care, relative missed days rate=1.55, 95% CI 0.98-2.45; P=.06). SCALE-UP Counts worked closely with schools and the state's public health system to implement and test a scalable health information technology approach that delivered automated text messages to students' parents around COVID-19 testing and provided access to free at-home test kits. Such an approach can help facilitate COVID-19 testing among school communities, including those that provide education and resources to students and their families from racial or ethnic minorities and with low socioeconomic status. Similar health information technology approaches could be used to increase ease of access to testing, reduce testing burden, and provide tailored information on health measures in school communities for a variety of illnesses or public health concerns. ClinicalTrials.gov NCT05112900; http://clinicaltrials.gov/ct2/show/NCT05112900.

Public Health in Resource Poor Settings

The goal of this American Heart Association Guide for Improving Cardiovascular Health at the Community Level (AHA Community Guide) is to provide a comprehensive inventory of evidence-based goals, strategies, and recommendations for cardiovascular disease (CVD) and stroke prevention that can be implemented on a community level. This guide advances the 2003 AHA Community Guide1 and the 2005 AHA statement on guidance for implementation2 by incorporating new evidence for community interventions gained over the past decade, expanding the target audience to include a broader range of community advocates, aligning with the concepts and terminology of the AHA 2020 Impact Goals, and recognizing the contributions of new public and private sector programs involving community interventions. In recent years, expanding arrays of programs and policies have been implemented in increasingly diverse communities to provide tools, strategies, and other best practices to potentially reduce the incidence of initial and recurrent cardiovascular events. The AHA Community Guide complements the AHA statement entitled “Population Approaches to Improve Diet, Physical Activity, and Smoking Habits”3 and supports the AHA 2020 goal4 to “improve the cardiovascular health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.” The present AHA Community Guide supports the AHA 2020 goal by identifying exemplary regional or national programs that encourage cardiovascular health behaviors and health factors (formerly addressing risk behaviors and risk factors) from which communities might acquire proven strategies, expertise, and technical assistance for improving cardiovascular health. The AHA Community Guide seeks to prevent the onset of disease (primary prevention) and to maintain optimal cardiovascular health (primordial prevention) among broader segments of the population. Prior research indicates that using public health strategies such as sodium reduction in processed foods to lower blood pressure,5–8 tobacco laws to promote smoking cessation,9–11 and modification of …

We read with interest the brief by Keane, Marx, and Ricci, summarizing the National Association of County and City Health Officials (NACCHO) study of privatization in local health departments.1 In 1996, the sale of our community’s public hospital to a for-profit corporation privatized most medical services for the poor. At that time, local political events forced the separation of our community’s indigent care programs from other public health functions, and our local health department stopped providing most personal health services and immunizations.2 Our community is attempting to understand the effects of privatization on some of the health care activities that were privatized in 1996. The City of Amarillo Department of Public Health has recently assessed childhood immunization rates and compared them with historic rates before privatization of our immunization programs. Vaccination coverage in local children, as defined and measured in the Texas Immunization Survey, increased from 70% in 1996 to 72% in 2000. During this same period of time, Texas coverage increased from 68% to 70%.3 Thus, it appears that childhood immunization rates after privatization increased in our community by the same margin as in the rest of the state. We are interested in the experience of other local health departments in assessing the effects of the privatization of health care activities that they previously performed. We urge NACCHO and other national leaders in public health to develop recommendations for communities attempting to understand the effects of privatization of health care activities that were previously publicly delivered.

The Deregulatory State Lawrence O. Gostin (bio) Public health can be achieved only through collective action. Individuals acting alone cannot protect themselves from work hazards, unsafe or ineffective vaccines and pharmaceuticals, impure food and water, a polluted environment, or epidemics. Only a well-regulated society can secure the essential conditions for health. Yet in this country, successive administrations have eroded health and safety protections. The consequences include deaths in the mining industry, lead in toys, industrial solvents in toothpaste, harmful bacteria in peanut butter and spinach, and unsafe and ineffective pharmaceuticals (such as COX-2 inhibitors and non-statin cholesterol medications). The "Deregulatory State" is a result of a conservative campaign that has created and reinforced deep-seated concerns about overbearing government. The political dialogue used to describe agency action is pejorative and effective: "big government," "centralized," "top-down," and "bureaucratic." This antigovernment narrative has set the terms of the debate about the role of government in protecting the public from market excesses and failures. The Deregulatory State takes many subtle forms, including self-policing, so that industry discloses and corrects its own safety violations; incapacitating, so that agencies are starved of expertise and resources; devolving, so that residual regulation is focused at the local level; preempting, so that the federal government denies states the authority to protect their citizens; and privatizing, so that government functions are conducted by "for-profit" or voluntary entities. In this column, I will focus on two broad categories of deregulation: federal preemption and privatization. Regulatory Vacuums through Preemption Congress has the power to preempt, or supersede, public health regulation at the state level, even if the state is acting squarely within its police powers. Federal preemption may seem like an arcane doctrine, but it has powerful consequences for the public's health and safety. The Supreme Court's preemption decisions can effectively foreclose meaningful state regulation and prevent people from turning to the courts for legal redress.1 Preemption has had antiregulatory effects on issues ranging from tobacco control to occupational health and safety, motor vehicle safety, and employer health care plans. From 2001 to 2006, Congress enacted twenty-seven statutes that preempt state health, safety, and environmental policies, demonstrating the potential breadth of federal power to override state public health safeguards.2 The Bush administration has vigorously advocated preemption to invalidate state public health efforts in both amicus curiae briefs and preambles to agency rules. On February 20, 2008, the Roberts Court handed the administration a victory in two major preemption cases. In Rowe v. New Hampshire Motor Transport Association, the Court held that a federal transportation statute preempted Maine's laws designed to prevent minors from buying cigarettes on the Internet.3 In Riegel v. Medtronic, Inc., the Court ruled that manufacturers are immune from tort liability for medical devices, such as implantable defibrillators or heart pumps, that received premarket approval and meet Food and Drug Administration specifications.4 The Court just heard another FDA preemption case on whether tort liability can be based on fraud for misrepresenting or withholding information from the agency during the approval process. And next term, the Court will decide whether FDA drug approval preempts personal injury suits. In effect, the executive and judicial branches are dismantling a long-standing civil justice safety net for consumers and patients who suffer from industry misconduct left unchecked by federal and state regulations. Outside the courtroom, multiple agencies charged with protecting public health, safety, and the environment have systematically pushed for preemption through administrative rulemaking. Federal agencies have inserted preemptory language in preambles to rules governing everything from seatbelt placement (this from the National Highway Traffic and Safety Administration) and mattress flammability (the Consumer Product Safety Commission) to drug labeling (the FDA) and railroad safety (the Railroad Administration). This troubling trend is made all the more worrisome by the administration's failure to provide an opportunity for public comment on the preemption language in rule preambles. This sweeping preemption of state regulation and tort actions has created regulatory vacuums. Instead of advocating devolution or otherwise supporting state authority to protect the public's health, the federal government has consistently derailed state regulation. At the same time, it has dismantled federal...

The authors of this paper identify risks to health and other factors that determinethe need for health care services among children and adolescents. They documentservice utilization patterns in the areas of well-child care and immunizations, acuteambulatory care and hospital services, and injury prevention. They also acknowledgethe special health care needs of adolescents and of children with chronic illnesses.It appears that neither the traditional personal health service delivery system nor thepublic health system alone can effectively provide all of the health services childrenneed. Collaboration between public health and personal health service providers isessential to future efforts to improve the health of children and adolescents. Recom-mendations include development of community-based preventive care programs inall parts of the country, extension of current traditional primary care capabilities,assurance of access to primary care services, enhancement of public health activities,expansion of specialized adolescent health programs, and coordination of a com-prehensive set of medical and other services for children with chronic illness andtheir families. The authors conclude that, to be effective, future health systemreforms must be implemented through a coordinated program of care rather thanthrough competing systems of services.

Introduction: Public health is a crucial aspect of maintaining the well-being and health of the community. The ever-growing demands of the modern world have resulted in a growing emphasis on public health to address the needs of the people in society. In the present era, the focus has shifted towards more advanced technologies like Chatbots. This essay will explore the importance of Chatbots in revolutionizing public health. What are Chatbots? A Chatbot is a computer program that uses artificial intelligence (AI) to simulate human conversation. It utilizes natural language processing (NLP) to recognize words and provide responses to queries. Chatbots can be programmed to interact with humans, answer questions, provide recommendations, and even offer assistance in various areas of public health. The Importance of Chatbots in Public Health: 1. Supporting Mental Health: Chatbots can be used to support mental health in various ways. They can be used to provide emotional support to individuals going through mental health issues. Chatbots can also direct individuals to professional help services, providing reassurance and guidance. The ability of chatbots to be available around the clock makes them an excellent resource to anyone experiencing distress. 2. Providing Personalized Health Solutions: Chatbots have the capacity to provide personalized health solutions tailored to individual needs. They can provide recommendations and guidance to people who are looking to improve their health status. Additionally, chatbots can also recommend lifestyle modifications, healthy eating habits, and medication management. 3. Improving Timeliness of Information: Chatbots can be programmed to deliver timely health information, such as disease outbreaks and epidemics. They can also provide real-time updates to help prevent the spread of disease. The prompt dissemination of information can save lives by keeping people informed and prepared. 4. Enhancing Efficiency: Chatbots can be integrated with health management systems to improve efficiency in the delivery of health services. They can be used to automate the appointment booking process, thus reducing wait times and streamlining service delivery. Chatbots can also assist in scheduling appointments, ensuring that patients receive timely treatment. 5. Cost-Effective Solution: Chatbots are a cost-effective solution to the growing demand for public health services. They can operate around the clock, providing assistance to a vast number of people with minimal operational costs. Chatbots can reduce the need for face-to-face consultations, which can be costly and time-consuming. Drawbacks of Chatbots in Public Health: 1. Limited Capacity: Chatbots may have limitations in handling complex healthcare services that require a sophisticated response from a human health professional. 2. Privacy and Security: Chatbots may not always be secure, raising concerns about privacy concerns for sensitive patient information. 3. Limited Human Connection: Chatbots cannot replace the human connection aspect of healthcare, especially during difficult times when emotions are running high. Conclusion: Chatbots have revolutionized public health by providing accessible, cost-effective, and personalized healthcare services. However, the potential drawbacks of limitations in handling complex healthcare tasks, privacy concerns and a lack of human connection highlight the need for careful integration of chatbots in the public's health landscape. While the integration of chatbots in public health care delivery will continue to grow, the need for monitoring and refinement will evolve with the technology's evolution. Chatbots are a valuable addition in the delivery of public health services, which need to be continuously fine-tuned to respond appropriately to the population's health needs.

The EU Response to COVID-19: From Reactive Policies to Strategic Decision-Making.

Public Health Finance