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The Association in State Health Outcomes by Provider Type Difference in Association Between State-Level Health Outcomes for Direct Patient Care FTEs and.

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Presentation on theme: "The Association in State Health Outcomes by Provider Type Difference in Association Between State-Level Health Outcomes for Direct Patient Care FTEs and."— Presentation transcript:

1 The Association in State Health Outcomes by Provider Type Difference in Association Between State-Level Health Outcomes for Direct Patient Care FTEs and Population Based FTEs Robin Pendley, DrPH, MPH, CPH Assistant Professor, ETSU Department of Health Services Management and Policy October 29, 2012

2 Efforts to Enumerate Public Health Workforce 1920- APHA/USPH S 83 Municipal Health Depts. 1923 US Treasury/Public Health Service- 100 Largest Cities Health Depts. 1933 Mountin expenditures, full time workers, part- time, per- capita expenditures nursing, physicians 1933-1946- US Public Health Service personnel and public expenditures local agencies 1945 Emerson Report-LHDs benchmarks for services/staffing patterns 1947-1964- DHEW yearly reporting of local public health per capita expenditures

3 Efforts to Enumerate PH Workforce 1970-1995 ASTHO Reporting System- state/local expenditures 1976 Health Professionals Education Assistance Act 1978 Health Services Research, Health Statistics, and Health Technology Act 1980 USDHHS Public Health Service 1988 IOM Report, Future of Public Health 1990 NACCHO Profile 1992-1995 PH>Impact- health status 1996-97 NACCHO profile

4 Efforts to Enumerate PH Workforce 1999- 2000- NACCHO Infrastruct ure survey 2000 HRSA Public Health Workforce Enumeration 2002 IOM report, The Future of Public Health in the 21 st century 2003 IOM report, Who Will Keep the Public Healthy? 2010/2011 ACA 2010-2012 Enumeration

5 Crawford et al Research Agenda 1 Workforce size and composition Workforce diversity Workforce effectiveness and health impact Recruitment, Retention, and Separation Worker pay, promotion, and job satisfaction Demand for public health workforce Education, training, and credentialing Public health workforce policy

6 Relevant studies Mays 2011-increased spending in public health decreases preventable deaths including infant mortality, diabetes, cardiovascular disease, and cancer 2 Erwin 2010-examined changes in local health department resources with AHR state-level outcomes. Increases in staff significantly associated with decreases in CVD mortality 3

7 Recent PHSSR Agenda What factors influence the supply of, demand for, and geographic and organizational distribution of workers with the public health workforce? How does the size and composition of the public health workforce affect the volume, mix, quality, and outcomes of public health strategies delivered at local, state, and national levels?

8 Purpose To examine the relationship between workforce, provision of services, and provider type (population-based/clinical) for state health agencies and state level health outcomes This will not only be the first attempt to examine state health agencies workforce data and health outcomes at the state level but will be among the first to explore Association of State and Territorial Health Officials (ASTHO) data

9 Inputs Workforce Funding Governance State Health Agency Structure Outputs Clinical and Population -Based Services Outcomes Improved Health

10 Methods Cross-sectional study of secondary data (ASTHO 2010, AHR 2010, Census 2010) Descriptive Statistics Bivariate Analyses (p-value less than 0.20) Multiple Imputation, Multivariate Analyses- Linear Regression, Linear Contrast-Research Question 3

11 Potential Control Variables State health department structure Capacity variables (governance classification, role of state health agencies, does your state have a board of health, Enforcement/adjudicatory powers, expenditures, state health official authority, qualifications, salary Demographic characteristics-age of population, race, ethnicity

12 Description of FTEs FTEs n Mean (SD) Median (Q1, Q3) Min, Max Skewness 48 2177.55 (2,944.75) 1280.05 (476.75, 2,651.00) 199.00, 15,364.00 3.07 FTEs/Population per 100,000 n Mean (SD) Median (Q1, Q3) Min, Max Skewness 48 49.72 (53.76) 31.00 (18.03, 65.54) 5.41, 263.47 2.38 Direct Patient Care FTES/Population per 100,000 (Physician, Public Health Nurse, Nutritionist) n Mean (SD) Median (Q1, Q3) Min, Max Skewness 36 7.46 (9.34) 2.90 (0.86, 13.42) 0.27, 45.10 2.18 Population-based FTES/Population per 100,000 n Mean (SD) Median (Q1, Q3) Min, Max Skewness 30 8.37 (5.68) 7.80 (3.12, 11.65) 0.79, 21.94 0.85

13 Occupational Classifications of FTEs Occupational Classification Total current FTE Administrative or clerical Personnel n Mean (SD) Median (Q1, Q3) Min, Max Skewness 44 415.93 (670.44) 153.00 (87.01, 25396.50) 21.00, 3197.00 3.18 Public health nurse n Mean (SD) Median (Q1, Q3) Min, Max Skewness 43 256.31 (422.39) 79.00 (21.00, 374.70) 1.00, 2190.00 3.05 Environmental health worker n Mean (SD) Median (Q1, Q3) Min, Max Skewness 40 144.18 (68.90) 183.52 (27.25, 181.75) 2.00, 677.00 1.75

14 Research Question Is the association between state-level health outcomes and direct patient care FTEs different than the association between state-level health outcomes and population-based FTEs? H 0 : There is no difference in association between state-level health outcomes and direct patient care FTEs and association between population-based FTEs and state-level health outcomes adjusting for potential control variables. H a : There is a difference in association between state-level health outcomes and direct patient care FTEs and association between population-based FTEs and state-level health outcomes adjusting for potential control variables

15 Direct Patient Care Job Classification (Clinical) Population-Based Job Classification (Non-clinical) Physician Public health nurse Nutritionist Environmental health worker Epidemiologist/statistician Health educator Public health information specialist Laboratory worker

16 Linear Contrast Test of Equality 1 OutcomeEst β Transformed Population FTE Est β Transformed Direct Care FTE SEBeta1SEBeta2CorrB1B2zp Obesity-0.960.720.860.53-0.59-1.340.18 Smoking-0.550.510.880.54-0.6-0.830.41 Binge Drinking 0.89-0.841.230.48-0.591.110.27 Occupational1.190.020.460.33-0.571.650.10 Infectious0.140.581.391.08-0.63-0.20.84 Air Pollution-0.47-0.180.710.34-0.6-0.310.76 Immunization0.75-0.380.490.35-0.561.530.13

17 Linear Contrast Test of Equality 2 OutcomeEst β Transformed Population FTE Est β Transformed Direct Care FTE SEBeta1SEBeta2CorrB1B2zp Preventable Hospitalizations -0.930.664.262.15-0.48-0.280.78 Early Prenatal Care 0.80-0.502.921.51-0.600.320.75 Premature Death -52.7292309165-0.47-0.830.40 Poor Physical Health -0.050.010.110.06-0.26-0.400.69 Geographic Disparity 0.460.121.240.69-0.580.200.84

18 Linear Contrast Test of Equality 3 OutcomeEst β Transformed Population FTE Est β Transformed Direct Care FTE SEBeta1SEBeta2CorrB1B2zp Infant Mortality -0.130.320.210.14-0.58-1.400.16 Cancer Deaths -3.932.556.302.63-0.54-0.810.42 CVD Deaths -4.040.987.805.76-0.62-0.410.68 Teen Birth Rate -6.745.781.761.2-0.62-4.67<0.01 Recent Dental Visit 1.86-1.620.900.55-0.442.800.01 Stroke-0.120.180.090.05-0.59-2.330.02

19 Linear Contrast Test of Equality 4 OutcomeEst β Transformed Population FTE Est β Transformed Direct Care FTE SEBeta1SEBeta2CorrB1B2zp High Cholesterol 1.30-0.340.560.30-0.562.120.03 Heart Attack 0.060.100.200.10-0.62-0.130.89 Cardiac Heart Disease 0.21-0.080.150.12-0.541.230.22 Diabetes-0.470.390.290.19-0.62-1.950.06 Low Birth Weight 0.58-0.130.200.10-0.552.610.01 Preterm Birth 0.250.100.350.22-0.590.280.78

20 Conclusion Significant differences in association between health outcomes and population based FTEs and association between health outcomes and direct care FTEs

21 Areas for Future Research Evidence linking public health workforce to health outcomes is relatively sparse Comparison of Beck’s NACCHO/CHSI 2010 Cross-sectional/Longitudinal ASTHO/Commonwealth Report State Scorecard, AHRQ National Healthcare Disparities Report Repeating Erwin’s study for 2010 NPHPSP for State

22 References 1. Crawford, C.A.G., et al., Perspectives on Public Health Workforce Research. Journal of Public Health Management and Practice, 2009: p. S5- S15. 2. Mays, G.P. and S.A. Smith, Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths. Health Affairs, 2011. 3. Erwin, P.C., et al., The Association of Changes in Local Health Department Resources With Changes in State-Level Health Outcomes. Am J Public Health, 2011. 101(4): p. 609-615.

23 Bivariate Screening State/Territorial Laboratory Services- Cholesterol Screening Performed by state/territ orial public health agency Performed by local health dept. led by a state/territ orial employee Performed by local health dept. led by a local employee Performed by a not- for profit entity Performed by a for- profit entity Performed by another state/territ orial agency High Cholesterol T p- value -1.95 0.06 -0.75 0.46 0.64 0.52 0.45 0.65 1.70 0.10 1.06 0.29

24 Pearson’s Correlation Transformed FTE per Population Transformed Direct Care FTE per Population Transformed Population FTE per Population Prevalence of Binge Drinking (Percent of population) Pearson Correlation -0.20-0.240.12 N48.0036.0030.00 Air Pollution (Micrograms of fine particles per cubic meter) Pearson Correlation -0.38-0.17-0.26 N48.0036.0030.00 Preterm Birth (Percent of births under 37 weeks gestation) Pearson Correlation 0.290.320.13 N48.0036.0030.00

25 ANOVA of Governance and Health Outcomes ANOVAdfFSig. Prevalence of Binge Drinking 491.140.36 Immunization Coverage 491.210.32 Preventable Hospitalizations 490.370.89 Early Prenatal Care481.170.34 Premature Death491.700.15 Teen Birth Rate492.200.06 Low Birth Weight492.160.07 Preterm Birth492.140.07

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