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, CPHAssistant Professor, ETSU

Department of Health Services Management and Policy

October 29, 2012

Efforts to Enumerate Public Health Workforce

1920-APHA/

USPHS 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

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

Efforts to Enumerate PH Workforce

1999-2000-

NACCHO Infrastructure survey

2000 HRSA Public Health

Workforce Enumeration

2002 IOM

report, The

Future of Public

Health in the 21st century

2003 IOM report, Who Will Keep the

Public Healthy?

2010/2011 ACA

2010-2012 Enumeration

Crawford et al Research Agenda1

• 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

Relevant studies

• Mays 2011-increased spending in public health decreases preventable deaths including infant mortality, diabetes, cardiovascular disease, and cancer2

• Erwin 2010-examined changes in local health department resources with AHR state-level outcomes. Increases in staff significantly associated with decreases in CVD mortality3

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?

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

InputsWorkfor

ceFundingGoverna

nceState

Health Agency Structur

e

Outputs

Clinical and

Population-

BasedService

s

Outcomes

Improved Health

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

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

Description of FTEsFTEs n

Mean (SD)Median (Q1, Q3)Min, MaxSkewness

482177.55 (2,944.75)1280.05 (476.75, 2,651.00)199.00, 15,364.003.07

FTEs/Population per 100,000 nMean (SD)Median (Q1, Q3)Min, MaxSkewness

4849.72 (53.76)31.00 (18.03, 65.54)5.41, 263.472.38

Direct Patient Care FTES/Population per 100,000(Physician, Public Health Nurse, Nutritionist)

nMean (SD)Median (Q1, Q3)Min, MaxSkewness

367.46 (9.34)2.90 (0.86, 13.42)0.27, 45.102.18

Population-based FTES/Population per 100,000

nMean (SD)Median (Q1, Q3)Min, MaxSkewness

308.37 (5.68)7.80 (3.12, 11.65)0.79, 21.940.85

Occupational Classifications of FTEsOccupational Classification

Total current FTE

Administrative or clerical Personnel

nMean (SD)Median (Q1, Q3)Min, MaxSkewness

44415.93 (670.44)153.00 (87.01, 25396.50)21.00, 3197.003.18

Public health nurse nMean (SD)Median (Q1, Q3)Min, MaxSkewness

43256.31 (422.39)79.00 (21.00, 374.70)1.00, 2190.003.05

Environmental health worker

nMean (SD)Median (Q1, Q3)Min, MaxSkewness

40144.18 (68.90)183.52(27.25, 181.75)2.00, 677.001.75

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?

• H0: 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.

• Ha: 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

Direct Patient Care Job Classification (Clinical)

Population-Based Job Classification (Non-clinical)

PhysicianPublic health nurseNutritionist

Environmental health workerEpidemiologist/statisticianHealth educatorPublic health information specialistLaboratory worker

Linear Contrast Test of Equality 1Outcome Est β

Transformed Population

FTE

Est βTransformed

Direct Care FTE

SEBeta1 SEBeta2CorrB1B2 z p

Obesity -0.96 0.72 0.86 0.53 -0.59 -1.34 0.18

Smoking -0.55 0.51 0.88 0.54 -0.6 -0.83 0.41

Binge Drinking

0.89 -0.84 1.23 0.48 -0.59 1.11 0.27

Occupational 1.19 0.02 0.46 0.33 -0.57 1.65 0.10

Infectious 0.14 0.58 1.39 1.08 -0.63 -0.2 0.84

Air Pollution -0.47 -0.18 0.71 0.34 -0.6 -0.31 0.76

Immunization 0.75 -0.38 0.49 0.35 -0.56 1.53 0.13

Linear Contrast Test of Equality 2Outcome Est β

Transformed Population

FTE

Est βTransformed

Direct Care FTE

SEBeta1 SEBeta2 CorrB1B2 z p

Preventable Hospitalizations

-0.93 0.66 4.26 2.15 -0.48 -0.28 0.78

Early Prenatal Care

0.80 -0.50 2.92 1.51 -0.60 0.32 0.75

Premature Death

-52.7 292 309 165 -0.47 -0.83 0.40

Poor Physical Health

-0.05 0.01 0.11 0.06 -0.26 -0.40 0.69

Geographic Disparity

0.46 0.12 1.24 0.69 -0.58 0.20 0.84

Linear Contrast Test of Equality 3Outcome Est β

Transformed Population

FTE

Est βTransformed

Direct Care FTE

SEBeta1 SEBeta2 CorrB1B2 z p

Infant Mortality

-0.13 0.32 0.21 0.14 -0.58 -1.40 0.16

Cancer Deaths

-3.93 2.55 6.30 2.63 -0.54 -0.81 0.42

CVD Deaths

-4.04 0.98 7.80 5.76 -0.62 -0.41 0.68

Teen Birth Rate

-6.74 5.78 1.76 1.2 -0.62 -4.67 <0.01

Recent Dental Visit

1.86 -1.62 0.90 0.55 -0.44 2.80 0.01

Stroke -0.12 0.18 0.09 0.05 -0.59 -2.33 0.02

Linear Contrast Test of Equality 4Outcome Est β

Transformed Population

FTE

Est βTransformed

Direct Care FTE

SEBeta1 SEBeta2 CorrB1B2 z p

High Cholesterol

1.30 -0.34 0.56 0.30 -0.56 2.12 0.03

Heart Attack

0.06 0.10 0.20 0.10 -0.62 -0.13 0.89

Cardiac Heart Disease

0.21 -0.08 0.15 0.12 -0.54 1.23 0.22

Diabetes -0.47 0.39 0.29 0.19 -0.62 -1.95 0.06

Low Birth Weight

0.58 -0.13 0.20 0.10 -0.55 2.61 0.01

Preterm Birth

0.25 0.10 0.35 0.22 -0.59 0.28 0.78

Conclusion

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

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

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.

Bivariate ScreeningState/Territorial Laboratory Services-Cholesterol Screening

Performed by state/territorial public health agency

Performed by local health dept.led by a state/territorial 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/territorial agency

High Cholesterol

Tp-value

-1.950.06

-0.750.46

0.640.52

0.450.65

1.700.10

1.060.29

Pearson’s CorrelationTransformed

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 -0.24 0.12

N 48.00 36.00 30.00

Air Pollution (Micrograms of fine particles per cubic meter)

Pearson Correlation

-0.38 -0.17 -0.26

N 48.00 36.00 30.00

Preterm Birth (Percent of births under 37 weeks gestation)

Pearson Correlation

0.29 0.32 0.13

N 48.00 36.00 30.00

ANOVA of Governance and Health Outcomes

ANOVA df F Sig.

Prevalence of Binge Drinking

49 1.14 0.36

Immunization Coverage

49 1.21 0.32

Preventable Hospitalizations

49 0.37 0.89

Early Prenatal Care 48 1.17 0.34

Premature Death 49 1.70 0.15

Teen Birth Rate 49 2.20 0.06

Low Birth Weight 49 2.16 0.07

Preterm Birth 49 2.14 0.07