The Art of Translating Research Into Policy Joseph W. Thompson, MD, MPH Surgeon General, State of Arkansas Director, Arkansas Center for Health Improvement Associate Professor, UAMS Colleges of Medicine and Public Health 2008 National Network of Public Health Institutes

Arkansas Center for Health Improvement Mission: Improving health through evidence-based health policy research, program development, and public issue advocacy Core Values: Initiative, Trust, Commitment, and Innovation

Health Care Finance Access to Needed Quality Care Health Policy & System Integration Health Promotion & Disease Prevention ACHI Scope of Work ACHI’s Scope of Work

A Model for Health Policy Development Opportunity Principals for Decisions Empirical Assessment Education Program Development Political Discourse Implementation J. Thompson et al, Society for Public Health Education July 2004;5(3)57-63.

Identified areas of need: Health care financing Health promotion/ disease prevention Access to quality care Proposed tools to create solutions: Executive Legislative Judicial Private Empirical evidence: Scientific studies Program evaluations Secondary data analyses Primary data analyses Trusted sources for consensus guidelines (including but not limited to): U.S. Community Preventive Services Task Force Arkansas Health Insurance Roundtable Institute of Medicine National Quality Forum ACHI Health Policy Board decision making process considerations: Impact assessment (Arkansas health impact and ACHI’s ability to effect change) Support, oppose, or remain silent Level of engagement (see table below) Specific to a topic (e.g., fluoridation) or an action (e.g., support a specific House bill) Identified issue Proposed solution Empirical evidence Consensus process ACHI HPB decision ACHI Health Policy Board: Decision Support Document Level of engagement Support proposalNeutralOppose proposal Policy position— Position statement— Letter of support—Letter of opposition Board testimony— Public support—Public opposition On-going ACHI staff activities: Proactive Identify needs Develop proposals Engage collaborative partners Develop methods to improve policy development Responsive Respond to external requests for information/analyses Respond to external requests for proposal development Monitoring Scan for opportunities and vulnerabilities Tracking health indicators Defensive Raise awareness of potential threats

Agendas, Alternatives and Public Policies J. Kingdon - Framework for Policy Environment Preparedness Awareness –Policymakers –Ownership –Environment Support –Their problems –Their needs Engagement –Trustworthy –Credible –Interpreter –Source Policy process Agenda Options / alternatives Information –Credible –Useful –Appropriate –Balanced Policy Window –Immediate –Future –Created

Be Strategic

Arkansas Center for Health Improvement ( 1999 Public challenge to elected leadership) Four Principles for Tobacco Settlement Decisions –All funds should be used to improve and optimize the health of Arkansans. –Funds should be spent on long-term investments that improve the health of Arkansans. –Future tobacco-related illness and health care costs in Arkansas should be minimized through this opportunity. –Funds should be invested in solutions that work effectively and efficiently in Arkansas.

Tobacco Settlement Initiated Act Staged political process ~ $60m / year $$ in perpetuity All new health programs External evaluation in place No changes in 4 sessions Thompson et al, Health Affairs 2004;23(1)

Empiric Information in Graphical Format

Patchwork quilt of Arkansas health insurance coverage ~520,000

ARHealthNet – Program Details Partnership between small businesses, state, and federal government Premiums subsidized for employees / spouses with incomes <200% FPL Targeted to Arkansas employers not currently offering health insurance 1115 Waiver program with potential to expand coverage to as many as 80K uninsured Arkansans Commitment to incorporate health promotion and disease prevention

Constructively Educate

1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2006 (*BMI 30, or about 30 lbs. overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Cardiac Pathway Cardiac death Cardiac disability Heart Attack Coronary artery blockage High cholesterol / Limited blood flow Tobacco / Obesity / Physical inactivity

Show them the $$

Obese 32% Daily Cigarette Users 12% Physically Inactive 21% No Risks 11% O+P 9% C+P 1.5% C+O 2% C+O+P 1% HRA Respondents Eligible to Incur Claims (N=43,461) O =Obese P =Physically Inactive C =Daily Cigarette Use C 7% O 20% P 10% AR State Employees Self-Reported Risks Other Risks 39%

Average Annual Total Costs (Med + Rx) Average cost for all HRA respondents eligible to incur claims $3,097 Average cost for those with no risks $2,382 Average cost for those with any of the three risk factors $3,427 Obese Daily Cigarette Users Physically Inactive

Obese $3,679 Daily Cigarette Users $3,081 Physically Inactive $3,643 No Risks $2,382 O+P $4,158 C+P $3,257 C+O $3,529 C+O+P $4,432 C $2,690 O $3,441 P $3,169 Average Annual Total Cost for State Employees by Risk Factor O =Obese P =Physically Inactive C =Daily Cigarette Use

Annual Average Total * Costs Linked to Obesity *Includes medical (inpatient and outpatient) and pharmacy costs for year old state employees. Total difference $1,297 (54%)

Data Driving Policy ~26% of annual total costs associated with one or more of three risk factors—obesity, physical inactivity, or daily cigarette smoking. Paradigm shift of Board recognizing current costs associated with failed past prevention Incorporation of new benefits: –Evidence-based preventive clinical services –Tobacco counseling and pharmaceutical coverage –Three-tiered obesity benefit Tiered health insurance premiums for risk Legislative authorization provides up to 3 extra vacation days after health improvements -Jaster et al, Am Journal of Preventive Medicine (under review)

Make It Personal

Quality of diabetes care (HbA1c) among Employer Healthcare Coalition providers* *PCPs w/ largest # of eligible diabetic participants aged 18–75 yr Data source: ACHI analysis of EHC data (unpublished results). ACHI, 2005.

Use Innovative Strategies & Find Non-Traditional Partners

84th General Assembly Act 1220 of 2003 Goals: Change the environment within which children go to school and learn health habits every day Engage the community to support parents and build a system that encourages health Enhance awareness of child and adolescent obesity to mobilize resources and establish support structures An act to create a Child Health Advisory Committee; to coordinate statewide efforts to combat childhood obesity and related illnesses and to improve the health of the next generation of Arkansans;

Act 1220 Requirements 1.Establishment of an Arkansas Child Health Advisory Committee 2.Vending machine content and access changes 3.Physical activity / education requirements 4.Requirement of professional education for all cafeteria workers 5.Public disclosure of “pouring contracts” 6.Establishment of local parent advisory committees for all schools 7.Confidential child health report delivered annually to parents with body mass index (BMI) assessment - Ryan et al, Health Affairs July/August 2006;25(4):

Demonstrate That Change Can Happen – Share Success

Percentage of students classified as overweight or at risk for overweight by Arkansas public school district (’05–’06) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.

National and Arkansas Childhood Obesity Trends N=2, N= US 6-11 yr US yr Avg N=150,881 Avg N=212,011 AR grades K-6 AR grades AR grades K-6 AR grades 7-12 Thompson et al, Morbidity and Mortality Weekly Reports January 2006; 55(1)

Challenge to the Institutes

In Summary: Be Strategic Empirical Information in Graphical Form Constructively Educate Show Them The Money Make It Personal Use Innovative Strategies & Non-traditional Partners Demonstrate That Change Can Happen / Share Successes

Translation of knowledge into policy Integration of research skills and empirical information into relevant queries Environmental awareness of political processes, structures, and issues Personal “risk-tolerance” for non- traditional roles and undertakings Relationship development with decision- makers – supporter, informant, advisor Engage, Engage, Engage!!!!

Arkansas Surgeon General (Act 384) Governor may appoint a SG of Arkansas to: Serve as a cabinet level advisor to the Gov. Review, assess, and develop health policy options for the state across state agencies Review and analyze legislative proposals under consideration Provide policy options and position statements for the Governor and senior state agency officials Raise awareness of healthcare and health issues to advance the state population’s health