Health Services Research Commons^™

Disasters And Impacts In Appalachian Kentucky: A Behavioral Health Analysis, Walter David Mathews Phd, Joseph M. Clark, Amy S. Potts

Journal of Appalachian Health

Introduction: Major disasters continue to occur in Appalachian Kentucky with devastating consequences. A major disaster, defined by the Federal Emergency Management Agency (FEMA) as an event too large for a community to manage without outside help, involves emergency responders from the local, state, and federal disaster agencies, plus national volunteers.

Purpose: This paper reports on recent disasters in eight southeast Kentucky counties, the changing nature of these disasters, and the behavioral health impact on the people affected.

Methods: In this large-scale disaster survey in the Appalachian counties in Southeast Kentucky, over 3,500 people were asked about their recent disaster experiences …

Ensuring Equitable Application Of Interventions To Vulnerable Subpopulations In The Kentucky Consortium For Accountable Health Communities (Kc-Ahc), Jing Li, Jessica M. Clouser, Akosua Adu, Aiko Weverka, Nikita Vundi, Terry D. Stratton, Mark V. Williams

Journal of Appalachian Health

Introduction: The Centers for Medicare and Medicaid Services (CMS) has funded the Accountable Health Communities (AHC) model to test whether systematically identifying and addressing the health-related social needs (HRSNs) of individuals would impact healthcare utilization and total cost of care for Medicare and Medicaid beneficiaries. Toward this effort, AHCs implement screening, referral, and community navigation services in their local areas. There are 28 CMS-funded AHCs nationwide, including the Kentucky Consortium for Accountable Health Communities (KC-AHC).

Purpsoe: This study aims to assess the equity of KC-AHC model activities in three vulnerable sub-populations: dual enrollees, disabled individuals, and women.

Methods: Twenty-eight primary …

The Appalachian Gap In Preventable Hospitalizations: Are We Seeing Any Progress?, Rachel Hogg-Graham, Juan Lang, Teresa M. Waters

Journal of Appalachian Health

Introduction: Previous studies have documented geographic variation in preventable hospitalizations between rural and urban areas, but much less is known about preventable hospitalization patterns between heterogeneous rural areas. Unique challenges related to access of care and poverty may put the rural Appalachian Region at risk for higher rates of preventable hospitalizations.

Purpose: This study examines whether within-rural differences in Kentucky’s preventable hospitalization rates exist and how these differences may be changing over time.

Methods: Longitudinal and geographic trends in county-level preventable hospitalization rates were examined using Kentucky hospital discharge data from 2016 to 2019. Regression models were run to determine …

Association Between Insurer Connectivity In Appalachian Population Health Networks And Preventable Hospitalizations: Evidence From Kentucky, Rachel Hogg-Graham, Kelsey R. Gatton, Rick Ingram, Glen P. Mays

Journal of Appalachian Health

Introduction: Addressing complex health and social needs requires cross-sector collaboration to deliver medical, social, and population health services at the community level. Capacity in community health and social services networks may be constrained in regions like Appalachia due to the combined effects of rurality and persistently poor health and social outcomes. One way that cross-sector networks serving low-resource communities can expand their capacity is by engaging partners, like health insurers, who can leverage resources from outside the local area.

Purpose: This study examines insurer connectivity in cross-sector networks across Kentucky’s geographic regions and the association between connectivity and the probability …

Patient Engagement In Patient Portals In Appalachia V. Surrounding U.S. Census Regions: An Analysis Of Hints (Health Information National Trends Survey) Data, 2017–2020, Heather Lea Tudor, Rick Ingram, Sarah Wackerbarth

Journal of Appalachian Health

Introduction: Those living in the Appalachian Region face a greater number of significant health disparities than residents of other areas of the U.S. Patient portals can decrease disparities, increase health literacy, and improve health outcomes.

Purpose: This study explores if those living in the Appalachian Region are offered access to and use their patient portals differently than those in the surrounding U.S. Census regions. Additionally, the study aims to determine if there was a difference in reported reasons for the non-use of patient portals.

Methods: A secondary analysis was completed using data from the National Cancer Institute's Health Information National …

A Better Life: Factors That Help And Hinder Entry And Retention In Mat From The Perspective Of People In Recovery, Adam D. Baus, Martha Carter, Jennifer Boyd, Erin Mcmullen, Trey Bennett, Alexandra Persily, Danielle M. Davidov, Christa Lilly

Journal of Appalachian Health

Introduction: Opioid addiction and opioid-related overdoses and deaths are serious public health problems nationally and in West Virginia, in particular. Medication-assisted treatment (MAT) is an effective yet underutilized treatment for opioid use disorder (OUD).

Purpose: Research examining factors that help individuals succeed in MAT has been conducted from provider and program perspectives, but little research has been conducted from the perspective of those in recovery.

Methods: This study, co-developed with individuals in recovery, took place in West Virginia-based MAT programs using an exploratory sequential mixed methods approach. The survey was open February through August 2021. Data were analyzed late 2021 …

Covid-19 Pandemic Impact On Essential Public Health Services And Online Health Communication—Appalachian Kentucky, March–December 2020, Margaret A. Riggs, Kenny Ortiz-Jurado, Keith Klein

Journal of Appalachian Health

Introduction: The COVID-19 pandemic posed many challenges for local health departments (LHDs). This study examines how stay-at-home orders impacted the provision of essential public health services and subsequent increased use of online health communication by LHDs for rural populations in Appalachian Kentucky during the first year of the COVID-19 pandemic.

Methods: A survey to gather information about provision of essential public health services was administered to five LHDs representing 13 counties between June 2020 and December 2020. Additionally, demographic and health-outcome data from LHD, state health department, and CDC websites were reviewed, alongside health communications posted on LHD social media …

Changes In Adolescent Birth Rates Within Appalachian Subregions And Non-Appalachian Counties In The United States, 2012–2018, Nathan Hale, Kathleen Tatro, Sylvester Olubolu Orimaye, Michael Smith, Michael Meit, Kate E. Beatty, Amal Khoury

Journal of Appalachian Health

Background: Adolescent births are associated with numerous challenges. While adolescent birth rates have declined across the U.S., disparities persist and little is known about the extent to which broader declines are seen within Appalachia.

Purpose: The purpose of this study was to examine the extent to which adolescent birth rates have declined across the subregions of Appalachia relative to non-Appalachia.

Methods: We conducted a retrospective study of adolescent birth rates between 2012 and 2018 using county-level vital records data. Differences were examined across the subregions of Appalachia and among non-Appalachian counties. Multiple regression models were used to examine changes in …

Access To Health Care In Appalachia: Perception And Reality, Michele Morrone, Cory E. Cronin, Kristin Schuller, Shannon E. Nicks

Journal of Appalachian Health

Introduction: Health disparities such as cancer and diabetes are well documented in Appalachia. These disparities contribute to health status, and by many indicators, Appalachian people are less healthy than those who live in other parts of the country. Access to health care is one factor that contributes to health disparities. Access to care is complex and involves both intrinsic and extrinsic aspects, including satisfaction with quality of care. This research sought to compare Appalachian to non-Appalachian communities in terms of perceptions of access to care.

Methods: We implemented a statewide survey to quantify perceptions of multiple components of …

Loss Of Obstetric Services In Rural Appalachia: A Qualitative Study Of Community Perceptions, Caroline R. Efird, David Dry, Rachel F. Seidman

Journal of Appalachian Health

Background: As rural hospitals across the United States increasingly downsize or close, the availability of inpatient obstetric services continues to decline in rural areas. In rural Appalachia, the termination of obstetric services threatens to exacerbate the existing risk of adverse birth outcomes for women and infants, yet less is known about how the cessation of these services affects the broader community.

Purpose: The purpose of this paper is to explain how the loss of local obstetric services affects perceptions of healthcare among multi-generational residents of a remote, rural Appalachian community in western North Carolina.

Methods: An interdisciplinary team of researchers …

Leveraging Electronic Health Records Data For Enhanced Colorectal Cancer Screening Efforts, Adam D. Baus, Lauren E. Wright, Stephenie Kennedy-Rea, Mary E. Conn, Susan Eason, Dannell Boatman, Cecil Pollard, Andrea Calkins, Divya Gadde

Journal of Appalachian Health

Introduction: Colorectal cancer is the third most common type of cancer in the United States for men and women combined. While the current threat of disease nationally is significant, the majority of colorectal cancer cases and deaths could be prevented through established screening tests and guidelines. Within the Appalachian region and West Virginia in particular, colorectal cancer is a significant public health problem. A more systematic, comprehensive approach to preventing and controlling cancer is essential.

Methods: Through the West Virginia Program to Increase Colorectal Cancer Screening, primary care systems across the state received data-informed practice facilitation designed to increase screening …

Qualitative Analysis Of Maternal Barriers And Perceptions To Participation In A Federal Supplemental Nutrition Program In Rural Appalachian North Carolina, Sydeena E. Isaacs, Lenka H. Shriver, Lauren Haldeman

Journal of Appalachian Health

Background: Little is known about barriers to and perceptions of participation in the in Women, Infants, and Children (WIC) program in rural Appalachia.

Purpose: To gain a deeper understanding of maternal barriers and perceptions related to WIC participation in rural Appalachia

Methods: Pregnant women and mothers were recruited in-person and via flyers from WIC offices in three counties in Appalachian North Carolina. Four semi-structured focus groups were conducted between May to July 2018. Each focus group was approximately 60 minutes long and included open-ended questions about the overall WIC experience in rural Appalachia. Focus groups were audio-recorded, transcribed verbatim, and …

Using Electronic Health Record Data To Improve Community Health Assessment, Brian E. Dixon, Jian "Frank" Zou, Karen F. Comer, Marc Rosenman, Jennifer L. Craig, P Gibson

Frontiers in Public Health Services and Systems Research

Background: Community health assessments assist health departments in identifying health needs as well as disparities, and they enable linking of needs with available interventions. Electronic health record (EHR) systems possess growing volumes of clinical and administrative data, making them a valuable source of data for ongoing community health assessment.

Purpose: To produce population health indicators using data from EHR systems that could be combined and visually displayed alongside social determinants data, and to provide data sets at geographic levels smaller than a county.

Methods: Data from multiple EHR systems used by major health systems covering >90% of the population in …

Local Health Departments’ Involvement In Hospitals’ Implementation Plans, Simone Singh, Erik Carlton

Frontiers in Public Health Services and Systems Research

Background: More than half of all local health departments (LHDs) in the U.S. are involved in collaborations with nonprofit hospitals on a community health needs assessment (CHNA), yet little is known about the role that LHDs play in hospitals’ implementation plans.

Purpose: This study aims to explore the current state of hospital–LHD collaborations around the implementation plan using data from a survey of LHDs across the country.

Methods: The study sample included 457 LHDs that completed both the 2015 Forces of Change survey and the 2013 Profile survey conducted by the National Association of County and City Health Officials. Univariate …

Multi-Sectoral Partnerships And Patient-Engagement Strategies In Accountable Care Organizations, Margae Knox, Hector P. Rodriguez, Stephen M. Shortell

Frontiers in Public Health Services and Systems Research

Background: Patient-engagement strategies are increasingly recognized for enriching traditional medical care and improving population health. Accountable Care Organizations (ACOs) may be well positioned to leverage multi-sector organizational partnerships to improve the reach of their patient-engagement strategies, particularly given incentives to meet cost, quality and population health goals. Little is currently known about the relation of multi-sector partnerships and patient engagement in ACOs.

Purpose: To examine the relation of patient-engagement strategies and breadth of multi-sectoral organizational partnerships in 71 primary care practices affiliated with one of two ACOs.

Methods: Clinical and administrative leaders from each practice were surveyed. Questions assessed practice …

Using Process Mining To Assess The Fidelity Of A Home Visiting Program, Riyad Haq, Sofia Campos Vidal Pires, Julie M. Kapp, Sara Schlemper, Eduardo J. Simoes

Frontiers in Public Health Services and Systems Research

Background: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is a federal public health initiative which supports at-risk families through evidence-based programs and promising approaches for pregnant women, and childhood development for children aged 0 to 5. These public health program funding mechanisms commonly include process evaluation mandates.

Purpose: The use of process mining was explored as a methodology to assess the fidelity of the MIECHV programs’ actual workflow to that of their intended models.

Methods: Research Electronic Data Capture (REDCap) data files that were populated with program process data elements from the local implementing agencies were …

Injury-Related Infant Deaths: A State Analysis Of A Public Health, Health Care, Policy Network, Sharla Smith, Xi Zhu, Mary Aitken

Frontiers in Public Health Services and Systems Research

Introduction: This research examines a state-level public health, health care, and policy network focused on efforts to reduce unintentional childhood injuries. The network is composed of 12 organizations: four public health, four health care, and four policy.

Methods: A 23-item survey was administered to the 12 organizations between January and June 2015. Analyses were conducted using HyperResearch and UCInet 6.

Results: More organizations worked together on assessment and planning efforts that identify and quantify the nature of at-risk infants in the community and strategies for reducing injury-related infant deaths. The Injury Prevention Center, the most central organization, interacted most frequently …

A Tool To Cost Environmental Health Services In North Carolina Local Health Departments, Nancy L. Winterbauer, Simone Singh, Ashley Tucker, Lisa M. Harrison

Frontiers in Public Health Services and Systems Research

Introduction: The cost of providing a basic set of public health services necessary not been well-described. Recent work suggests public health practitioners are unlikely to have the empirically-based financing information necessary to make informed decisions regarding practice. The purpose of this paper is to describe the development of a costing tool used to collect primary data on the number of services provided, staff employed, and costs incurred for two types of mandated environmental health services: food and lodging inspections and onsite water services.

Methods: The tool was iteratively reviewed, revised, and piloted with local health department (LHD) environmental health and …

Tuberculosis And Local Health Department Expenditures On Tuberculosis Services, Michelle P. Yip, Betty Bekemeier

Frontiers in Public Health Services and Systems Research

Background: Although tuberculosis (TB) morbidity and mortality have decreased in recent decades, challenges exist regarding disproportionate distributions of TB among specific populations and geographic areas. Inconsistent local health department (LHD) funding for TB programs poses difficulties for LHDs to sustain resources and personnel that predisposes communities to risks of future outbreaks of TB and drug-resistant TB diseases.

Purpose: This study examined relationships between annual TB incidence rates and LHD expenditures on TB-related services to elucidate potential impacts of TB incidence on LHD TB spending.

Methods: This dataset included county-level TB incidence data with comparable, annual (2000–2010) TB-related service expenditures for …

Local Health Department Clinical Service Delivery Along The Urban/Rural Continuum, Kate E. Beatty, Nathan Hale, Michael Meit, Paula Masters, Amal Khoury

Frontiers in Public Health Services and Systems Research

Background: Engagement in the core public health functions and ten essential services remains the standard for measuring local health department (LHD) performance; their role as providers of clinical services remains uncertain, particularly in rural and underserved communities.

Purpose: To examine the role of LHDs as clinical service providers and how this role varies among rural and nonrural communities.

Methods: The 2013 National Association of County and City Health Officials (NACCHO) Profile was used to examine the geographic distribution of clinical service provision among LHDs. LHDs were coded as urban, large rural, or small rural based on Rural/Urban Commuting …

Accounting For Indirect Costs In Public Health Cost Analyses, Melanie D. Whittington, Adam Atherly, Lisa Vanraemdonck

Frontiers in Public Health Services and Systems Research

Background. There is a gap in research regarding the resources needed to deliver public health activities, which inhibits informed decision making around investments in public health and the allocation of funds among activities. When conducting cost analyses in public health, it is important to include costs from all cost components, including personnel, non-personnel, and indirect costs. However, defining, identifying, and measuring indirect costs is challenging and can impede studies of this type. Purpose. The purpose of this pilot study is to create a catalog of the methodologies public health researchers have used to account for indirect costs. Methods. We surveyed …

Assessment Of Quality Improvement In Ontario Public Health Units, Madelyn P. Law, J. Ross Graham, Erica Bridge

Frontiers in Public Health Services and Systems Research

Background: Quality Improvement (QI) approaches are used extensively in healthcare settings and increasingly in public health. However, the proliferation of QI in Canadian public health settings is unknown.

Purpose: The purpose of this study was to (a) assess the QI maturity in Ontario local public health units in Canada, and (b) to determine the relevance of the QI Maturity Tool in a Canadian setting

Methods: The QI Maturity Tool (Version 5) was used to conduct a cross-sectional assessment of the QI maturity of 36 local public health units in Ontario, Canada. After tool items were reviewed for relevance, individuals most …

Local Health Departments’ Costs Of Providing Environmental Health Services, Simone Singh, Nancy L. Winterbauer, Ashley Tucker, Lisa Macon Harrison

Frontiers in Public Health Services and Systems Research

Background: A detailed understanding of the costs that local health departments (LHDs) incur in the provision of public health services plays an important role in their efforts to provide services in an effective and efficient manner. However, surprisingly little evidence exists about the key cost components that LHDs incur in the provision of services.

Purpose: The purpose of this report was to provide empirical estimates of LHDs’ cost structure.

Methods: Using cost information for 2012 from 15 LHDs in North Carolina for two public health services—food and lodging and onsite water—this report first presents estimates of the total costs per …

Use Of Facebook By Local Health Departments: Usage, Public Health Themes, And Maintenance, Rakhi Trivedi, Gulzar H. Shah, Ankit Bangar

Frontiers in Public Health Services and Systems Research

Background: Recent research shows that social media offer unprecedented opportunities for communications with stakeholders in public health and other industries.

Purpose: This study examines the manner in which U.S. local health departments (LHDs) use Facebook. Public health program themes discussed on Facebook profiles of LHDs were analyzed and ranked by the frequency of mentions on Facebook.

Methods: LHDs included in the study were those indicating use of Facebook in the 2010 National Profile of Local Health Departments. Using the list from the profile study, the primary data from LHDs’ public Facebook profiles were collected over a period of 4 months. …

Applying Failure Modes And Effects Analysis To Public Health Models: The Breathe Easy At Home Program, Johnna S. Murphy, Margaret Reid, Amanda Ali, Laura Harrington, Megan Sandel

Frontiers in Public Health Services and Systems Research

Failure Modes and Effects Analysis (FMEA) is a structured process used to identify and prioritize risks by ranking them based on severity, occurrence, and detectability. Historically, FMEA has been used within industries, including automotive and health care. This project explored the adaption of the FMEA template to a small public health program designed to improve asthma outcomes. The Breathe Easy at Home (BEAH) program is a multi-sector partnership that uses a web-based system to link clinical sites with housing code inspections and enforcement for patients with asthma.

In July and August 2014, an FMEA was conducted to uncover risks within …

Economic Evaluation Of Fungal Meningitis Outbreak Response In New River Valley: Local Health Department Perspective, Kaja M. Abbas, Nargesalsadat Dorratoltaj, Margaret L. O’Dell, Paige Bordwine, Thomas M. Kerkering, Kerry J. Redican

Frontiers in Public Health Services and Systems Research

Background: The multi-state fungal meningitis outbreak started in September 2012 in Tennessee. The cause of the outbreak was injection of contaminated lots of methylprednisolone acetate used in epidural spinal injections. Roanoke and New River Valley were the epicenter of this outbreak in Virginia, with two clinical centers having administered the contaminated injections to their patients. New River Health District, in coordination with hospitals, and state and federal agencies, deployed its resources to control the local impact of the outbreak.

Purpose: The objective of this study was to conduct an economic evaluation of the fungal meningitis outbreak response in New River …

High-Risk Travel Distance And Number Of Primary Care Visits In A North Carolina Medicaid Population, Justin Allred, Christopher Duffrin, Jason Brinkley, John Jones

Frontiers in Public Health Services and Systems Research

Background: With nearly 20% of the U.S. population in rural areas, a lack of access to primary care may cause rural residents to forego recommended preventive care procedures, and suffer higher morbidity rates than their urban counterparts.

Methods: Medicaid billing data from 2009 to 2011 were analyzed to calculate the distance and duration that a Medicaid patient population had to travel when seeking primary care in the 29 rural counties of eastern North Carolina. Primary care codes were analyzed to detect any differences in access patterns for various complexity levels of physician visits. Data were also used to evaluate health …

A Cost Analysis Of The 1-2-3 Pap Intervention, Kristina M. Rabarison, Rui Li, Connie L. Bish, Robin C. Vanderpool, Richard A. Crosby, Mehran S. Massoudi

Frontiers in Public Health Services and Systems Research

Background: Cervical cancer places a substantial economic burden on our healthcare system. The three-dose human papillomavirus (HPV) vaccine series is a cost-effective intervention to prevent HPV infection and resultant cervical cancer. Despite its efficacy, completion rates are low in young women aged 18 through 26 years. 1-2-3 Pap is a video intervention tested and proven to increase HPV vaccination completion rates.

Purpose: To provide the full scope of available evidence for 1-2-3 Pap, this study adds economic evidence to the intervention’s efficacy. This study tested the economies of scale hypothesis that the cost of 1-2-3 Pap intervention per number of …

Preliminary Evaluation Of The Disease Surveillance System During Influenza Outbreaks Of Pandemic Scale, Eric Meisheri, Diana M. Prieto, Peter Holvenstot, Richard Vanenk

Frontiers in Public Health Services and Systems Research

In the United States it is currently unknown whether the influenza surveillance system is capable of producing timely and accurate data for case estimation during an outbreak of pandemic scale. This simulation provides a preliminary evaluation of the surveillance system’s ability to collect data and produce timely and accurate trends of cases confirmed with an influenza virus. For the evaluation, a computer-based simulation of the data-collection process was used, which was validated with real demographic and epidemiologic information. The results were analyzed to determine the most significant behavioral and operational factors influencing the data collection and to propose the exploration …

Answering The Call To Integrate: Simple Strategies From Public Health And Healthcare Executives In One Urban County, Erik L. Carlton, Paul C. Erwin

Frontiers in Public Health Services and Systems Research

Background: As the Affordable Care Act transforms the practice of both public health and health care, it also provides opportunity for both to become more closely linked through improved integration and collaboration. Yet, while public health agencies are increasingly called to work with healthcare partners to address population health needs, both public health leaders and their healthcare counterparts may not be well equipped to answer that call. Although recent studies have begun exploring the collaborative strategies and capacity of public health system partners, there is still much to learn. The purpose of this study was to identify, through the perspective …