Assessing local public health capacity and performance in diabetes prevention and control

Deborah Porterfield, MD MPHUniversity of North Carolina-Chapel Hill and RTI InternationalAcademyHealth PHSR Interest Group6.07

Problem statement: Local public health and chronic disease Available evidence suggests that chronic disease

activities in local health departments (LHDs) lag behind the historically important issues of control of infectious diseases, maternal and child health, and environmental health. (NACCHO, 2006)

In order to improve LHD performance in chronic disease, we must first describe current practice, and develop valid measures of performance

Measuring diabetes prevention and control in North Carolina LHDs Diabetes as a model chronic disease for study

State Diabetes Prevention and Control Program Provides technical assistance and funding to LHDs

(Diabetes Today)

Objectives1. Measure capacity of NC LHDs to conduct

diabetes prevention and control activities.

2. Measure levels of performance in diabetes related prevention and control services and programs in NC LHDs.

3. Assess characteristics of local health departments and their jurisdictions (communities) that may be associated with higher performance.

4. Examine differences in capacity and performance between LHDs that have received training and funds through a specific federal and state program, Diabetes Today, and those who have not, in order to assess if participation has increased capacity and performance.

Survey administration

Mailed survey Participants: All local health departments in

North Carolina (n=85) Instrument adapted from the Local Public

Health System Performance Assessment 10 Essential Services Additional diabetes-specific questions

Measuring “capacity” and “performance” Capacity defined as FTEs in diabetes

prevention or control

Performance defined as self-reported provision of program or service 33 yes/no questions combined into a 10 point

index, one point for each Essential Service

Based on model of public health performance by Handler, et al (2001)

Other characteristics of LHD and community under categories of “Macro Context”, “Structural Capacity”, and “LHD Mission”

Main predictors of interest: History of Diabetes Today (or Project IDEAL) funding; Mission statement; estimates of need Size of LHD considered to be a confounder Accreditation status not considered as confounder

Secondary data sources

County-specific sociodemographic and medical care data Diabetes Prevention and Control Program, DPH NC Health Professions Data system US Census NC Community Health Center Association

Profile survey of the National Association of City and County Health Officers (NACCHO)

Data Analysis

Univariate descriptions Bivariate analyses to examine relationship

between performance and LHD or jurisdiction characteristics T-tests and Spearman correlation coefficients

Limited multiple linear regression modeling the effect of confounding assessed one variable

at a time

Results

100% response 2 mailings, reminder postcards, phone follow up

LHD characteristics

Number of FTEs (median) 80 (IQR 51-128)

Expenditures, million (median) $ 4.81 (IQR 2.95-8.0)

Accredited 31%

Diabetes Today funding 35%

Project IDEAL funding 4%

Full time medical director 20%

DM or chronic disease in mission 18.9%

Characteristics of LHD jurisdictionsSingle-county 93%

Population >100k 31%

Urban 47%% population below poverty (mean) 14% (sd 4.2)

Any C/MHC or free clinic 71%

Physician/100k ratio (median) 62.0 (IQR 47.8-89.0)

Est. diabetes prevalence (mean) 9.1% (sd 0.93)

Capacity: FTEs

Prevention FTEs (median) 0.05 (IQR 0-0.5)

Control FTEs (median) 0.1 (IQR 0-0.5)

40% have no FTEs devoted to prevention or control

Performance by Essential Service No.

questionsMedian (IQR)

ES1 Monitor health 6 0.5 (0.33-0.83)

ES2 Diagnose, investigate 3 0.33 (0.33-0.67)

ES3 Inform, educate 4 0.75 (0.5-1)

ES4 Mobilize partnerships 2 0.5 (0-1)

ES5 Develop policies, plans 3 0 (0-0.33)

ES6 Enforce laws 1 0 (0-0)

ES7 Link persons 7 0.43 (0.14-0.71)

ES8 Assure competent workforce 3 0.33 (0-0.33)

ES9 Evaluate 2 0 (0-0)

ES10 Conduct research 2 0.5 (0-0.5)

Performance index

Mean 3.5 (range 0-9.2; sd 1.9)0

.05

.1.1

5.2

.25

Den

sity

0 2 4 6 8 10Total essential services

Associations between index and LHD characteristics

R* or Mean index PNumber of FTEs 0.349 0.003Expenditures, in millions 0.363 0.002Accredited Yes 4.30 0.025 No 3.23Diabetes Today funding Yes 4.08 0.030 No 3.15Project Ideal funding Yes 6.70 0.002 No 3.36

Associations between index and jurisdiction characteristics

R* or Mean index P

Population>100k

Yes 4.26 0.010

No 3.13

Regression models

To understand the association between Diabetes Today funding and performance index

Controlling for population size did not change the association between DT funding and the performance index.

Conclusions

Limited capacity (FTEs)

Variation in performance of Essential Services Surveillance, health education, linking to

services HIGH Research, evaluation, policy LOW Specific questions with notable results:

Assessment of availability of clinical care or diabetes education LOW

Community based screening HIGH

Total performance not higher in areas with greater need (prevalence of diabetes, availability of primary care)

Funding from state health department or foundation and the size of the LHD are associated with performance

Limitations

Self-report Types, numbers of respondents

Item validity and reliability Measuring capacity and performance

Cross-sectional design Generalizability Other characteristics of LHD not measured

Implications

Although some NC LHDs are able to provide diabetes services and programs with limited resources, the findings suggest the opportunity to enhance local public health practice through targeted funding

Specific findings can influence technical assistance provided by the state DPCP to LHDs

Acknowledgments The NC Association of Local Health Directors Health Promotion

Committee: Curtis Dickson and Beth Lovette

NC Division of Public Health: Janet Reaves, RN, MPH; Marcus Plescia, MD, MPH

UNC School of Public Health and the NC Institute for Public Health: Ed Baker, MD, MPH; Mary Davis, DrPH, MSPH; Bob Konrad, PhD;

Bryan Weiner, PhD

Data for this study were obtained from the 2005 National Profile of Local Health Departments, a project supported through a cooperative agreement between the National Association of County and City Health Officials and the Centers for Disease Control and Prevention (U50/CCU302718).

Work funded by the Pfizer Scholars Grants in Public Health

Deborah Porterfield, MD, MPHDepartment of Social MedicineUNC Chapel Hill School of Medicineporterfi@email.unc.edu919/843-6596