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Public Health - Seattle & King County

WA PBRN research projects, 2009-2012

The two year start-up funds supported the development of a network infrastructure. In addition, the WA PBRN has either completed or is in process of conducting the following research studies:

Multi-Network Practice and Outcomes
LHD Communicable Disease Outbreak Response
Evidence-based Practice under Pressure: Local Public Health Decisions Made During a Financial Crisis
Local Public Health Performance in H1N1 Mass Vaccination
QI Project to Improve Workforce Diversity
Public Health Activities and Services Tracking (PHAST) Study on Retrospective Data Compilation and Transformation
Local Health Department Workforce Cuts: The Impact on Health Disparities and Workforce Diversity


Multi-Network Practice and Outcomes Variation Examination Study (MPROVE)
Funder: RWJF
Grant type: Robert Wood Johnson Foundation Practice-Based Research Network in Public Health
Amount: $43,552
Duration: April 2012 – October 2013
PI: Barry Kling, Chelan-Douglas Health Department

Specific aims:

  • Collect comrnunity-level measures of public health service delivery in the domains of chronic disease prevention, cornmunicable disease control, and environmental health protection in all of Washington's 36 local public health jurisdictions, building upon an existing, statewide inventory of local public health services rnaintained by members of the project team.

  • Link service delivery measures with related data available from the state health department, recording detailed measures of local public health expenditures and community-level disease surveillance data, in order to support analyses of the relationships among spending, service delivery, and health outcomes.

  • Data from this project will be pooled with measures collected by the other five participating PBRNs in order to identify factors that influence geographic variation in public health service delivery and to detect service-outcome relationships that present opportunities for health improvement.

Translation plan:

  • Findings will be disseminated through a workshop, a policy brief and joumal article, and a decision support tool developed for state and national public health audiences.
LHD Communicable Disease Outbreak Response
Funder: RWJF
Grant type: Small Scale PHSSR Research Project
Amount: Part of initial Research Implementation Award from RWJF (total of $90,000 for 2 years, no special amount for Communicable Disease study)
Duration: Nov-10
PI: Jeff Duchin, Hanne Thiede, Public Health — Seattle & King County

Research questions:

  1. To conduct a descriptive study of the differences in approaches to communicable disease investigations for a select list of diseases across Washington State jurisdictions.
  2. What are the characteristics of systems with most efficient and timely practices?

Preliminary findings:

Our findings demonstrate that there are significant variations in investigation and control practices for several notifiable diseases that we evaluated across Washington LHJs in spite of national and state guidelines. Variation in practice may result from differences in interpretation of recommendations, the perception that guidance is not practical or relevant in local circumstances, or that guidelines are not supported by adequate data.

More description of findings:

Health officers from 30 (86%) of the 35 Washington LHJs responded to the survey. These LHJs represent 96% of the state's population. The respondents varied in their recommendations about rabies post-exposure prophylaxis (PEP) for adults sleeping in a room where a bat was present (no PEP =47%, PEP =43% and not sure =10%) while the majority 987%) would recommend PEP for a child under those circumstances. Most (63%) would recommend PEP for a provoked bite by a raccoon that acted aggressive but only 30% would do so if the raccoon acted normal. LHJs differed in their investigation of hepatitis C cases. One-third investigated all reported cases, half investigated possible acute cases, 3% investigated all chronic cases, and 20% investigated a proportion of chronic cases. There was also variability with regard to follow-up of non-household close contacts of pertussis cases. Eight percent would follow up with kindergarten classroom contacts, 80% with healthcare workers at facilities where the pertussis case sought care, 53% with high school classroom contacts, and 20% with workplace contacts who were not pregnant. There were differences in recommendations for when restaurant food handlers with non-Typhi salmonella infection should return to work. Forty-three percent said after two consecutive negative stool cultures 24 hours apart, 23% said when a person no longer has diarrhea, and 17% said that both these conditions should be met.

Translation plan:

Residents in Washington State receive different advice and services related to important public health conditions depending on where they reside in the state. Training regarding implementation of recently revised notifiable disease regulations and standardization of investigation and control activities may be useful. Additional research should be undertaken to explore the reasons for variability in practice and to determine whether these differences extend to other public health activities and services.

Presentations and reports:

Publications:

Evidence-based Practice under Pressure: Local Public Health Decisions Made During a Financial Crisis
Funder: RWJF
Grant type: Research Implementation Award
Amount: $150,000
Duration: Feb. 2010 - Aug. 2011
PI: Betty Bekemeier, University of Washington School of Nursing; Anthony Chen, Tacoma-Pierce County Health District

Research questions:

  1. Describe the variation in cuts made by WA LHD leaders to their programs, operations, and core activities in response to the current dramatic fiscal conditions, forcing LHD service and system changes in WA.
  2. Identify factors that influence the adoption, implementation, and maintenance of evidence-based public health practices for disease prevention during a fiscal crisis.
  3. Identify commonalities between decisions made regarding LHD service and system changes and disparities in the adoption and implementation of evidence-based practices across public health settings and based on the racial, ethnic, and socioeconomic composition of the populations served.

Preliminary findings, major themes:

  1. Evidence-based practice is not commonly referred to;
  2. varied notions of 'core' PH activities;
  3. prioritization is not systematic.

Discussion:

There are gaps b/t practice & research (e.g., differences in 'relevant' data/evidence, EB practices not used in prioritization; Barriers to use of evidence (language & knowledge issues, realities of practice); Inefficiencies in decision-making (leaders desire knowing 'best' strategies, but little sharing & uptake re strategies in use)

More description of findings:

Evidence-based practice: No systematic use of programmatic evidence or data for decision-making; strong interest in evaluation, but few resources; 'immeasurable' outcomes; data are hard to come by and use; expert opinion is highly regarded; Core PH activities: Perceptions of fundamental public health services a) vary across LHDs, differ b/t LHD leader perceptions & national discussions; Crosswalk with 10 essential services; types of fundamentals: CD control; population-focused, MCH, "safety-net". Prioritization: Limited prioritization needed - mandates & categorical funding trump real decision making; Factors directing priorities: a) Population-versus individual-focused, b) Current human resources/ workforce, c) community values, d) BOH input, e) agency history.

Translation plan: Recs:

  1. Policy: Need policy to support and/or fund evidence-based practices in decision-making,
  2. Research: Examine mandated/funded services; identify effective prioritization strategies & decision tools,
  3. Practice: Use peer networks to disseminate systematic strategies

Additional Funding Needs that PBRN could Support: Some possibilities for additional research????

Publications, Presentations and Report:

Local Public Health Performance in H1N1 Mass Vaccination
Funder: WSDOH, PHEPR,TPCHD
Grant type: Addition to PHSKC emergency preparedness contract with WSDOH?
Amount: $200,000 (Phase I)
Duration: Phase I - Completed July 2010
PI: Anthony Chen, Tacoma-Pierce County Health District and Hanne Thiede, Public Health — Seattle & King County

Research questions:

  1. How do H1N1 planning and implementation practices vary by LHJ or region? What was the real time experience with H1N1? How did planning differ from implementation? How is this experience applicable to general pandemic preparedness?
  2. What community mitigation practices involving schools, day cares and other institutions were put in place? How did LHJs and regions work with these institutions?
  3. What is the nature of community engagement around H1N1, and how do practices and experiences vary? What actually happened?
  4. What best practices are identified that could be applied in WA state during a future influenza pandemic or other emergency public health scenario?

Preliminary findings:

Gaps in practice identified in report issued by PBRN. Changes suggested to COOP and Child Profile. Assessing and Comparing H1N1 Planning and Implementation Activities across Washington State. July 2010.

More description of findings:

The intial study described H1N1 mass vaccination planning and implementation activities at four different points of the fall 2009 outbreak (the "second wave"): pre-outbreak, early outbreak, late outbreak and post-outbreak.The DOH is in a position to address these issues by focusing on:

  • Child Profile. As the existing statewide immunization registry, it has the potential to be the solution to track and report administered vaccine. If operational and technical obstacles that prevented its widespread use in this pandemic can be addressed and corrected, it will be ready for future infectious disease emergencies. It may also play a future role in engaging pharmacy and other non-traditional vaccine providers in the provision of routine immunizations.

  • Continuity of Operations. While plans exist and have been exercised for public health emergencies, the prolonged nature of this incident dramatically exceeded the duration of any exercise or past incident. It revealed the need to develop flexible plans that can mobilize additional staff as needed and conduct regular public health duties alongside emergency activities - so-called a "graduated continuity of operations plan."

Translation plan:

Starting Phase II Now:

  1. Describe best practices for graduated COOP (review AARs, PBRN report, national documents) and write report with recommendations. Look at several models. Include survey of what worked and didn't work in last COOP during H1N1 (Ken Back has sent preliminary questions).
  2. Write draft guidance for how to do a graduated COOP, including convening experts and/or consultants.
  3. Engage several LHJs to pilot the guidance and write graduated COOPs.
  4. Further pilot the graduated COOPs in an exercise.
  5. Evaluate the exercise and suggest revisions.

Additional funding needs that PBRN could support:

Once best practices are identified and captured in 'graduated COOP' document, and pilot tested in emergency response exercises, PBRN role in evaluation in future emergency response. Child Profile: No role for PBRN.

Presentations and reports:

QI Project to Improve Workforce Diversity
Funder: RWJF
Grant type: Quick Strike
Amount: $25,000
Duration: April - Oct 2011
PI: Nadine Chan, Public Health — Seattle & King County
Research questions:

What is the impact of a quality improvement initiative to implement innovative hiring practices aimed at changing a system that favors some candidates over others?

Preliminary findings:

Translation plan:

Recommendations to help our LHD meet and exceed mandates for diversity of workforce/leadership will be made to the County for adoption in 2012. Study findings will inform policy discussions to improve diversity in the public health sector as we work to find efficient and effective ways to eliminate health inequities. This study would contribute to the broader workforce research agenda to understand the impact of a diverse workforce on population health inequities. With additional funding, we could include evaluation of data from a comparison LHJ to control for threats to validity due to concurrent historic events. Recommendations based on study findings are scheduled for presentation to the LHD Executive Team Leadership and County ESJI Team in December 2011 and first quarter of 2012. Recommended hiring policy changes will be adopted in 2012. We will disseminate findings through our PBRN to other LHDs and agencies who have expressed interest in improving workforce/leadership diversity in their organizations. We will also prepare a manuscript for submission to a peer-reviewed journal and present findings at conferences as appropriate.

More description of findings:

Additional funding needs that PBRN could support:

Public Health Activities and Services Tracking (PHAST) Study on Retrospective Data Compilation and Transformation

Presentations and reports:

Local Health Department Workforce Cuts: The Impact on Health Disparities and Workforce Diversity
Funder: RWJF
Grant type: Practice-Based Research Network in Public Health – Administrative Supplement
Amount: $99,999
Duration: Oct 2011 – Sept 2012
PI: Tracy Hilliard, Public Health — Seattle & King County ; Betty Bekemeier, University of Washington School of Nursing; Anthony Chen, Tacoma-Pierce County Health District

Specific aims:

  1. Describe descriptively the variation in workforce cuts made by WA Local Health Departments (LHDs) in response to current fiscal conditions, and the relationship between these cuts and service and system changes.
  2. Investigate the impact of WA LHD workforce cuts on LHDs’ capacity to address health disparities.
  3. Investigate the impact of WA LHD workforce cuts on LHD’s workforce diversity.

Translation plan:

Based on the study findings, steps will be taken in collaboration with practitioners, policy makers, educators, and researchers to address how to maximize population health, while addressing health disparities and LHD’s workforce diversity in the context of limited resources. These implications will be disseminated nationally via a journal article published by the research team in a practice-based journal such as the Journal of Public Health Management and Practice. In addition, abstracts will be submitted to present study findings, with an emphasis on implications for translation into practice, to audiences at national public health conferences.