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FEASIBILITY OF LINKING CORE FUNCTION-RELATED
PERFORMANCE MEASURES AND COMMUNITY HEALTH OUTCOMES Kevin D. Hutchison
R.N., M.S. Bernard J. Turnock
M.D., M.P.H. Center for Public
Health Practice Division of Community
Health Sciences School of Public
Health University of
Illinois at Chicago Chicago, Illinois November 1999 (DISCUSSION DRAFT) This study was commissioned by Public Health Futures
Illinois with funding from the Illinois Department of Public Health and the
Robert Wood Johnson Foundation as part of the Turning Point:
Collaborating for a New Century in Public Health initiative. TITLE Feasibility
of Linking Core Function-related Performance Measures and Community Health
Outcomes BACKGROUND
The
Illinois Turning Point initiative, Public Health Futures Illinois, is a
collaborative effort to redefine the public health system in Illinois and
expand the universe of strategic partners with a shared vision for public
health in the 21st century. In this project, the Illinois state partnership has
established objectives within five broad categories: §
Establishing a sustainable participatory process §
Developing a public health improvement plan §
Redefining the relationship of state and local
health departments §
Integrating the medial and public health systems §
Analyzing mutual and complementary data needs,
developing coordinated information systems, and promoting the epidemiologic
approach to strategic planning and policy development One of the
key elements of Public Health Futures Illinois is the development of
partnerships that share responsibility and accountability for improved
community health. This is facilitated by establishing and evaluating strategies
for monitoring performance of the redefined public health system, including its
impact on the health of communities (Illinois Department of Public Health,
1997). Central to the performance monitoring system is the ability to assess
the effectiveness of public health practice and to relate public health
practices to important community health outcomes. This study explores ways in
which the Illinois model for community public health practice may be used as a
framework for assessing the performance within a redefined public health
system. PURPOSE
The Illinois Project for Local Assessment of Need (IPLAN),
established in 1993, provides a structured framework for governmental public
health agencies to link with community partners in a community health
assessment and planning process. Within the IPLAN framework, community health priorities
and quantifiable performance indicators are developed, facilitating examination
of the relationship between performance of core function-related practices and
community health outcomes. This study uses core function-related performance
measures that have been applied to local health jurisdictions in Illinois in
two previous studies during the 1990s in order to examine the relationships
between local public health performance and community health outcomes for
selected priority health problems. The study also examines the perceived impact
of selected events and changes in public health policies and systems on the
ability of local health jurisdictions to carry out core public health functions
and practices as defined by the Institute of Medicine (IOM) and Public Health
Practice Program Office (PHPPO) of the Centers for Disease Control and
Prevention. (Institute of Medicine, 1988; CDC-PHPPO,1991). Ultimately, this
feasibility study seeks to determine if this evaluation strategy is appropriate
and feasible for assessing the impact of interventions developed through Public
Health Futures Illinois. APPROACH Prior to the initiation of Public Health Future Illinois,
UIC School of Public Health investigators conducted several studies of core
function-related performance in jurisdictions served by Illinois local health
departments. A baseline study was completed in 1992 and a follow up study was
performed in 1994 (Turnock, Handler, Hall, and Lenihan, 1995). The latter study
also assessed the impact of specific initiatives and events that occurred
between 1992 and 1994 on local public health practice performance patterns. Key
among those initiatives was the performance of community needs assessments and
development of community health priorities and action plans. Additional
research on the core function-related performance in local health jurisdictions
across the nation has further refined the measures that are used to evaluate
local pubic health practice performance (Turnock, Handler, and Miller,1998).
This study builds upon these earlier studies to examine current core
function-related performance effectiveness and community health outcomes in
Illinois local health jurisdictions. The strategies of this project included multiple facets: 1.
A
statewide re-survey of local health jurisdictions to track core
function-related performance for 26 performance measures. Survey results are
compared to previous studies conducted in 1992 and 1994 to examine core
function-related performance changes in Illinois local health jurisdictions
over a 7-year time period. 2.
Continuation
of a longitudinal examination of 10 core function-related performance measures
applied to local health jurisdictions nationally in a 1993 study and in
Illinois in the 1994 study. 3.
A
comparison of Illinois local health jurisdiction performance on 20 core
function-related measures with a 1995 national study. 4.
An
examination of relationships between local health jurisdiction core
function-related performance and outcomes of priority community health problems
as identified in the 1993 IPLAN. 5.
An
examination of the perceived impact of various events and initiatives on the
ability of local health jurisdictions to carry out public health core functions
and practices. METHODOLOGY A survey instrument developed by investigators at the
UIC-SPH in 1992 served as the framework for the survey instrument used in this
study. The original survey instrument included queries that addressed 26 core
function-related practice measures. This instrument was used in previous studies
of Illinois local health jurisdictions conducted in 1992 and 1994 and a
national study undertaken in 1993 (Turnock, Handler, Dyal, and Christenson,
1994). The survey instrument used in the current study retained these same 26
questions allowing for a longitudinal comparison on self-reported performance
of core function-related practices within local health jurisdictions. The survey instrument was expanded to include questions
pertaining to 20 core function-related practice measures that were jointly developed
by investigators from UIC-SPH and the University of North Carolina School of
Public Health in a 1995 national study (Turnock, Handler, and Miller,1998).
Inclusion of these questions, while similar to the 26 core function practice
measures, allowed for a direct comparison of practice performance of Illinois
local health jurisdictions in 1999 with the 1995 national study. The survey instrument included a section with questions
rating the impact of various events on the ability to carry out public health
core functions and practices. Four of the impact events were included in an
earlier study. Response to these events allowed for examination of the
influence of these events over the seven-year time frame. Three additional
events that emerged since 1994 were included in this study to examine their
impact on performance. A final section of the survey instrument asked
respondents to provide investigators information about their age, gender,
education, professional discipline, years of public health experience, and
specialized public health training. This information allows for examination of
possible relationships between the characteristics of the public health
administrator work force and practice performance of local health jurisdictions
(See Appendices A and B). A second major component of the methodology was the
utilization of county-specific health outcome data included in the IPLAN
database maintained by the Illinois Department of Public Health. In the initial
round of IPLAN implementation, local health jurisdictions throughout Illinois
carried out community health assessments and identified priority health
problems. Community health plans were developed providing local health
jurisdictions with strategies for interventions and actions to address the priority
health problems. The most frequently identified priority health problems among
Illinois local health jurisdictions in 1993 were coronary heart disease,
stroke, lung cancer, infant mortality and deaths from motor vehicle accidents.
Utilizing information from the IPLAN data set, an examination of the health
outcomes for these priority problems was conducted. Aggregate crude death rates
were calculated for each of these priority problems for 1990-1992. This time
period essentially represents a baseline rate prior to the initiation of
community health plans. Aggregate crude mortality rates for the years 1995-97
were also computed for each of these priority problems. Comparisons of changes
in crude death rates between these time periods were linked to core
function-related performance within the local health jurisdictions that
selected these priority problems in their IPLAN. The top 20% of local health
jurisdictions in terms of core function-related performance scores were
identified, as were the lowest 20%. Health outcomes for the five priority
problems were examined for both the high and low performing local health
jurisdictions, and for jurisdictions that met a previously used definition of
effectiveness. Health outcomes were also examined for jurisdictions that
identified these problems as priorities and compared with outcomes in
jurisdictions that did not cite these as priorities. These comparisons are used
to assess the feasibility of various measurement designs that link practice
performance to actual health outcomes. SURVEY RESPONSE The survey instrument was sent to 90 certified local health
departments throughout Illinois in January 1999. A follow-up survey was sent
March 1999. (See Appendix B.). The survey instrument was completed and returned by 75
local health departments for an 83% response rate. Respondents included 61
single county health departments, 7 multi-county health departments
(representing 20 counties), 4 municipal health departments, and 3 public health
districts. All respondents represented IDPH certified local health agencies
pursuant to Illinois Code 600. The
responses were grouped according to population served in order to allow
analysis of results based upon size (Table 1). Table 1 Local Health
Jurisdiction Respondents by Jurisdiction Population
Information as to the gender, age, years of experience,
educational background, and specialized public health training was also
collected. Characteristics of the local health department administrator
workforce provide a basis for examination of possible relationships of the
local public health leadership and core function-related performance. (Table 2)
Table 2 Characteristics of Local Public Health Agency Respondents
RESULTS
This study
examined various aspects of core function-related performance. Comparison of Performance
of 26 Core Function-related Performance Measures in Illinois Local Health
Jurisdictions, 1992-1999
Longitudinal examination of core function-related
performance was undertaken utilizing 26 performance measures developed by
UIC-SPH researchers. Survey data from 1992, 1994, and 1999 were examined to
evaluate changes in self-reported performance. A comparison of responses from
the 3 surveys reveals some changes during the study period. Although the median
performance score changed little from 1994 to 1999 (84.6% and 82.6%
respectively), there were changes in performance for several measures. Mean
scores for assessment measures
decreased somewhat except for the use of behavioral risk factor survey
information, which increased from 67.6% in 1994 to 72.0% in 1999. All 3 of the
measures for the practice of analyze
showed declines between 1994 and 1999. Core function measures for analysis of determinants of health problems
decreased from 84.5% to 74.7%; population
at risk decreased from 83.1% to 66.7%; and adequacy of existing resources decreased from 87.3% to 73.3%.
Measures for the advocate
practice generally increased in 1999 compared to 1994. Notably, meets with health related organizations
increased from 64.8% to 80.0% and public
review of mission and role increased from 57.7% to 70.7%. Measures for the
core function-related practice plan
decreased overall, but agency strategic
plan is linked to community heath action plan decreased from 66.2% to
40.0%. Conversely, the manage practice score for strategy for securing funding increased from
42.3% to 65.3%. Additionally, the performance measures for the implement increased with agency providing or assuring services for
each priority health need
increased from 66.2% to 82.7%. (Table 3) Comparison of
Performance of 10 Public Health Practice Performance Measures in Local Health
Jurisdictions in Illinois, 1999, and U.S., 1995. A second aspect of this study was
an examination of the mean performance for measures of 10 public health
practices defined by the CDC Public Health Practice Program Office. (Appendix
C) This part of the study had two components. The first was a longitudinal
examination of performance of these practices in Illinois local health
jurisdictions in 1992, 1994 and 1999. The 26 core function-related performance
measures examined separately above were grouped by practice allowing for the
computation of a mean score for each practice. These mean scores were then
compared to track changes occurring from 1992 to 1999. The mean
practice scores for Assess, Investigate,
Advocate, Manage, Evaluate, and Inform/Educate
did not appreciably change between 1994 and 1999. There was a decline in the Analyze practice from a 1994 score of
85.0% to a 1999 score of 71.5%. The score for Advocate increased somewhat from 70.8% to 79.3%. The score for Plan in 1994 was 79.3%; in 1999, it was
66.7%, a notable decrease. The 1999 score for Implement (90.0%) was higher than the 1994 score of 78.2%. (Table
4) The second component of the examination of 10 public health practices was
directed at a comparison of mean scores for the various practices in the 1999
Illinois survey with scores from two national studies conducted in 1993 and
1995. The mean scores for Illinois local health jurisdictions were notably
higher in six of the ten practices: Assess,
Analyze, Prioritize, Plan, Manage, and Evaluate.
Illinois local health jurisdiction scores were somewhat higher in all of the
remaining practices compared to then national mean scores in both 1993 and
1995. Illinois mean scores from 1992 were generally comparable to the 1993
national mean scores. (Table 5) Table 3 Percent of Illinois Local Health Jurisdictions Performing Selected Measures, 1992, 1994, and 1999
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