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Using Childhood Adversity Data to Improve Adult Health

Posted By Anna Austin, Thursday, October 30, 2014
As a CDC/CSTE Applied Epidemiology fellow in the Injury and Violence Prevention branch at the North Carolina Division of Public Health, one project that has particularly developed my skills as an epidemiologist and public health professional relates to adverse childhood experiences (ACEs). ACEs are traumatic or stressful events experienced before age 18 and include eight categories of childhood abuse and household dysfunction, such as physical, sexual, and emotional abuse; adult substance abuse; and household domestic violence.

A growing body of evidence shows that these early experiences are common and can have long-lasting effects on mental and physical wellbeing. Findings from the original 1995-1997 ACE Study showed a strong, graded relationship between ACEs and several poor health outcomes in adulthood. As the number of ACEs a person experiences increase, what also increases are the risks of alcohol and drug abuse, obesity, suicidality, depression, intimate partner violence, heart disease, and a range of other poor health outcomes in adulthood. Data specific to ACEs among North Carolinians first became available in 2012 when questions about ACEs were included on the North Carolina Behavioral Risk Factor Surveillance System survey. My task was to analyze this data and create North Carolina’s first state report on the topic.

The findings from the state report mirror the findings of the original ACE study. ACEs were found to be common among North Carolinians: 58% reported at least one ACE and 22% reported three or more ACEs. Over a quarter of North Carolinians reported having grown up with an adult who was abusing alcohol or drugs, and one in 10 reported sexual abuse by an adult. In addition, ACEs were found to cluster among North Carolinians—if a person reported having experienced one ACE, it was highly likely that he/she had also experienced additional ACEs. Lastly, the results showed that the risk of smoking, binge drinking, and obesity as well as HIV-risk behaviors, poor physical and mental health, chronic obstructive pulmonary disease, cardiovascular disease, arthritis, depression, and disability in adulthood increased as the number of ACEs reported increased.

The finding that ACEs impact health outcomes in adulthood, long after the events have occurred, supports ACE prevention as an effective long-term strategy for population health and highlights the importance of a life-course perspective in such prevention efforts. The finding that ACEs impact a wide range of outcomes from social, emotional, and behavioral problems to chronic diseases presents an opportunity to foster collaboration among diverse stakeholders and suggests such collaboration will be important to successful ACE prevention. Increasing awareness of ACEs as a public health issue will be important in North Carolina for mobilization.

We are engaging stakeholders from across the state to support local prevention efforts. I presented the findings from the state report at the North Carolina Public Health Association Conference alongside colleagues from the Innovative Approaches Initiative in Buncombe County. This initiative is developing a toolkit and website to educate local primary care providers on ACEs, connect them to local resources, and provide referral options for affected children and families. I have also collaborated with Harry Herrick, a survey analyst at the North Carolina State Center for Health Statistics, to respond to requests for data regarding ACEs among special populations, such as current smokers and persons with disabilities. I am also currently working on a multi-state study of ACEs among persons who identify as gay, lesbian, and bisexual. Ideally, data from each of these studies will help inform programs and policies aimed at ACE prevention and the enhancement of current efforts. This project has proved invaluable to my experience as a fellow, and I am extremely grateful for the opportunities, support, and guidance my mentors and colleagues have provided throughout the process.

Anna Austin, MPH is the CDC/CSTE Applied Epidemiology Fellow at the North Carolina Division of Public Health. In addition to this project, Anna has linked prescription drug overdose data from multiple sources, served on the leadership team developing the 2015 North Carolina Suicide Prevention Plan, and written surveillance reports on motor vehicle crash-related injuries.
Would you like to host or be a CDC/CSTE Applied Epidemiology fellow? Find out how. To learn more about ACEs, take a look at the CDC Injury Prevention and Control page.

Are you a member with an important message to tell the CSTE community? Tell us about it!
Do you use social media? Stay tuned to CSTE on Facebook and Twitter for daily updates!

Tags:  adverse childhood experiences  data  fellowship  member spotlight  substance abuse 

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Integrating our work with primary care

Posted By Katrina Hedberg, Thursday, August 7, 2014
Untitled Document
The landscape for both public health and the healthcare delivery system is changing for several reasons: the Affordable Care Act (ACA); efforts toward public health department accreditation; and requirements for community health assessments conducted by public health departments, hospitals, and accountable care organizations (ACOs). In Oregon, we use a coordinated care organization (CCO) model that envelopes a patient in medical, mental health, and dental care to provide care for the whole person.
For CCOs to be successful in achieving the triple aim of improved quality of care, improved population health, and lower costs, CCOs will need to focus on upstream prevention as well as improved care. CCOs are responsible for achieving metrics related to this triple aim, which should include receipt of clinical preventive services.
Public health epidemiologists can play an important role in helping to identify important metrics for CCOs and ACOs and to encourage these organizations to think about improving the health of the entire community in which their enrolled population lives. In addition, these organizations must work together with public health departments on community health assessments, as we have a role in determining the health status of our communities.
In Oregon, the Public Health Division is part of a larger agency, the Oregon Health Authority. The Office of Health Analytics, a separate division within the Oregon Health Authority, is responsible for analyzing healthcare service delivery data for Oregon’s CCOs. The Public Health Division is implementing an analytics tool that allows users to analyze public health data (e.g. birth, death, and reportable diseases) by not only the traditional state or county delineations but also by CCO service area. Looking at our data through different lenses and denominators helps us work with the CCOs to integrate healthcare and public health. Oregon also has a State Innovation Model grant from the Centers for Medicare and Medicaid Services, funds from which are being used to conduct a BRFSS-like survey of the Medicaid population to look at upstream health indicators.
Last year, CSTE Executive Director Jeff Engel and I attended a conference about the integration of public health and primary care for public health practitioners and clinicians. It was a good meeting, but epidemiologists were missing from the table. Coming away, we knew that epidemiologists have an important piece to inform the discussion, including data availability, metrics, and evaluation. Public health and healthcare systems have different definitions of ‘population health’—Epidemiologists generally think of their population as ‘everyone in a defined geographic location at a particular time,’ whereas healthcare systems hear this phrase to mean 'everyone enrolled or who received a service.' These realms are similar but slightly different, and these two definitions of the same word illustrate the difference. The epidemiologists' definition of population encompasses that of the healthcare system. We have to make sure we are using the same language and terms in order to work together to make our environment conducive to health as well.
From this meeting and these ideas, the Public Health and Primary Care Integration Subcommittee was born. It is clear CSTE can contribute to this new area for epidemiology and for public health. The subcommittee will have conversations that talk about, for example, the ways public health and healthcare use different terminology, what epidemiologists around the country are doing in this area, and how epidemiology can continue to have a seat at the table as health care transformation is implemented.
Katrina Hedberg - State Epidemiologist Oregon

Tags:  affordable care act  healthcare  member spotlight 

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Telling the Stories Behind the Data

Posted By Robert Harrison and Laura Styles, Thursday, July 31, 2014
Untitled Document
As epidemiologists, we view and interpret a lot of data. It's our responsibility to take action on the surveillance we conduct. Public health professionals understand that each case, each dot on a map, each block on an epi curve represents an ill patient, a person who has died, or a worker who has been injured. To us, charts and tables and summary reports tell an important story, but for others, we have to make it more personal to make an impact.
The Fatality Assessment and Control Evaluation (FACE) program is a case-based investigation program for the prevention of work-related injuries and illnesses. When workplace fatalities for landscape services increased in California and nationally from 2010 to 2012, we wanted to look closer. Data from the Census of Fatal Occupational Injuries (CFOI) confirmed that tree trimmers' fatality rate is twice the national average for worker fatalities. There is also a high incidence of workplace injury in this industry, although not all workers report these injuries or receive medical treatment.
At the California Department of Public Health, Occupational Health Branch, we have created videos about worker safety and health issues in addition to fact sheets, fatality alerts and investigation reports. These videos are a new strategy in the California FACE program’s prevention effort – written findings and prevention recommendations are brought to life with video re-creations, photos from the investigation, interviews with co-workers and family members, and clear explanations of how these tragedies can be prevented.
One such video, "Preventing Palm Tree Trimmer Fatalities," tells the story of Roberto, a 35-year-old tree trimmer, who died of suffocation when the palm fronds he was cutting fell on him. The video also explains proper equipment and climbing techniques that prevent this type of hazard. We see these workers every day around our neighborhoods, and they perform one of the most dangerous jobs in the U.S. They often don't have adequate training, and several deaths due to falls, suffocation, and other causes have occurred in California and elsewhere.
Click here to view the video, Preventing Palm Tree Trimmer Fatalities.
The California FACE video uses digital storytelling techniques to create a different kind of narrative to communicate public health data and messages. The key messages for the video are conveyed through real people and a real story; the video shows the devastating impact of not using proper palm trimming equipment or climbing techniques on the job. We listened to those affected by this issue so we could tell their story respectfully. This approach makes occupational health personal and local for viewers and the public, in order to encourage safety and prevent deaths.
A lot of planning went in to creating the video itself. We created a storyboard as a roadmap for the video with planned narration, video, and photos. Production partners included the Los Angeles County Fire Department, and tree climbing and safety professionals. We sought to balance the emotional and the factual, the problem and the solution, and to create a compelling video that could be used in trainings and would tell Roberto’s story.
We have found this and our other workplace safety videos on YouTube to be an effective medium to reach our target audiences and make our surveillance data come alive for maximum public health impact. We hope you can use our experience to weave together data and narrative to tell an important story for your program.
Laura Styles is the California FACE Program Manager, and Robert Harrison is the Chief of the Occupational Health Surveillance and Evaluation Program at the California Department of Public Health, Occupational Health Branch.

Tags:  collaboration  data  member spotlight  occupational health 

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Epidemiology methods – Our common link

Posted By Matt Thomas, Thursday, July 24, 2014
Untitled Document
As an epidemiologist for the tobacco program and formerly with the healthcare associated infections program at the Vermont Department of Health, I’ve been exposed to several different types of public health practice within applied epidemiology. Every program area has one thing in common—each relies on the same epidemiology and surveillance concepts and methods. These methods provide a foundation that ties all of our work together.

I’m finding in my career that epidemiologist are often in situations in which they may not have enough time or resources to fully utilize their training in epidemiology methods. This might be due to the pressures to quickly provide the public and partners with data or the need to have epidemiologist play a role in a variety of other functions (e.g., disease control, program evaluation, performance measurement, or informatics). The epidemiologist may have a supporting role in all of these activities, but that role shouldn’t be at the expense of the practice of epidemiology methods. While providing data to the public and partners is an essential function of an applied epidemiologist, that data is produced as a result of epidemiology and statistical methods. Placing a priority on that final product without prioritizing methods can lead to less reliable data. The Epidemiology Methods Subcommittee was formed to address these issues.
The Epidemiology Methods Subcommittee gives us the opportunity to highlight why epidemiological methods are integral to public health. The subcommittee focuses on both providing methodological content and building capacity to better allow epidemiologists to practice their skills.
So far, this new subcommittee has begun a series of webinars, each of which focuses on a different topic pertinent to applied epidemiologists. These webinars allow us to listen to our colleagues talk about epidemiology methods in-depth so we can use them in our day-to-day work. For example, one webinar looked at analyzing public health data using census tract-level poverty. Another discussed data analysis in small jurisdictions. Continuing to learn new methods and improve our skills allows us to enhance public health.
Going forward the subcommittee will take on projects related to improving how health departments function as a system in addition to professional development about epidemiology methods. In many settings, improving the organizational setting may be a necessary step that allows epidemiologists to practice the novel methods they learn from the webinars.
I have often heard from leaders in epidemiology that we need to advocate for our role in the public health landscape, especially in an ever-tightening funding climate. The Epidemiology Methods Subcommittee can be a forum for us to improve our skills, promote the value of these skills to our partners, and advocate for the ability to use these methods to their fullest.
I’d like to see this cross-disciplinary group of epidemiologists continue to come together to learn about new topics and ways to promote and advocate for their value. We’re still in our formative stage as a subcommittee, and we could use your participation to shape it into what you want it to be. What do you want help with? What issues are you dealing with in your health department? What have you found success in that you can share?
Matt Thomas, PhD is an epidemiologist at the Vermont Department of Health and the chair of the Epidemiology Methods Subcommittee.

Tags:  epidemiology  member spotlight  professional development 

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Alaska’s New Vaccine Assessment Law

Posted By Joe McLaughlin, Thursday, July 17, 2014

In June 2014, Alaska Senate Bill 169, which authorized the formation of a statewide vaccine assessment account, was signed into law. The intent of this new law is to preserve universal access to state-distributed vaccines for children and to provide state-distributed vaccine for covered adults.

Effective January 1, 2015, the vaccine assessment account will be forward-funded through vaccine payments from payers (e.g., private and public health care insurers, health benefit plans, and third-party administrators), and will be overseen by an independent vaccine assessment council. Payers will be assessed based on their proportionate share of the overall vaccine costs. The Alaska Immunization Program will then use the account funds to purchase vaccines at a discounted rate from a bulk contract and distribute pediatric and adult vaccines to health care providers statewide.  

Although many other states have already created similar vaccine financing solutions, below are some of the distinctive features of the Alaska law that might benefit policy makers in other states who would like to pursue similar legislation in the future.

  • Adult Vaccines: Alaska’s new law allows assessments for both pediatric and adult vaccines. State-distributed vaccine will be available to providers for all children and adults who are covered by participating payers. Most other states that have similar programs only allow for the purchase of pediatric vaccines. 

  • The Model: The two primary models under consideration for the Alaska assessment are the “covered lives” model (e.g., Idaho) and the “dosage-based assessment” model (e.g., Washington). Alaska’s new law is not prescriptive in terms of which model should be used; rather, it allows Alaska’s Vaccine Assessment Council the flexibility to make this determination.

  • Phase-in Period:  Under procedures approved by the DHSS Commissioner, an assessable entity will be able to opt-out of the program during a 3-year phase-in period. The effective dates will likely be on January 1 each year during 2015–2017.

  • Mandatory Participation: The law mandates participation—after the 3-year phase-in period—from all assessable entities, to the extent participation in the program is authorized by law. This includes Employee Retirement Income Security Law (ERISA) plans and publicly funded coverage like Medicare, Medicaid, and TRICARE. While publicly-funded healthcare benefit plans are included in the law’s definition of a health care insurer, it is currently unclear whether this law can require these entities to participate in the assessment program after the 3-year phase-in period, as federal law might prohibit such a mandate for at least some of the plans. Any federal plans that cannot be required to participate might still be able to opt-in to the assessment; those that are not able or willing to opt-in will need to continue directly purchasing vaccine for those clients not covered in the assessment by another payer.

  • Provider Opt-in: Providers will receive, at no cost, state-supplied vaccine purchased with vaccine assessment funds. Unique to the Alaska model, providers who care for uninsured adults can benefit from the state’s bulk purchasing power by opting-in to the program at any time. This provision offers providers a more cost-effective way to fund vaccines for their uninsured adult patients. 

  • Pharmacists: Pharmacists with a collaborating physician licensed in Alaska will be able to receive state-distributed vaccine for all children and adults who are covered by participating payers. Pharmacists can receive state distributed vaccine for uninsured adults if they opt-in to the program. 

  • Alaska’s Vaccine Assessment Council Responsibilities: The Alaska Vaccine Assessment Council will be established within the Alaska Department of Health and Social Services. Responsibilities of the Council include determining 1) the method for calculating the assessment amount; 2) the method for determining proportional costs to payers; 3) procedures for collecting and depositing assessment fees; 4) procedures for collecting data, which includes at a minimum the number of covered individuals and vaccine usage; and 5) developing a system for crediting overpayments. The council will consist of eight members appointed by the DHSS Commissioner; all members will serve without compensation for up to two 3-year terms.

The Alaska Immunization Program is committed to working with providers to make as much state-supplied vaccine available to Alaskans as possible in an equitable fashion.  More information about this Law is available at www.epi.alaska.gov under the “Spotlights” section, “Vaccine Assessment Account FAQ” link.

Joe McLaughlin is the State Epidemiologist of Alaska and CSTE President-Elect.

Joe McLaughlin

Tags:  Alaska  immunization  Law  member spotlight  Vaccine 

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Increasing informatics capacity

Posted By Lauren Reeves, Thursday, July 10, 2014
Updated: Thursday, July 10, 2014
“People are the most important; the systems are secondary.” Joe Gibson, Director of Epidemiology at the Marion County Public Health Department in Indiana, understands the importance of having capable people for public health and informatics capacity. He views epidemiology as decision support: getting the right information to the right people at the right time, to improve decisions affecting the health of the community. The belief in this process is underscored by Joe’s support of public health informatics training. Joe is a mentor in the Applied Public Health Informatics Fellowship program, which provides on-the-job training to recent graduates in order to increase public health informatics capacity. 

The Fellow working in Marion County under Joe’s mentorship is Crystal Clay, a graduate student in the School of Informatics and Computing at Indiana University Purdue University in Indianapolis. Crystal has enjoyed her time as an APHIF Fellow, because she’s received more experience with informatics and has been able to learn about public health informaticians and public health practitioners. “I’ve learned a lot about the value of effective communication, a vital skill for public health informaticians,” Crystal adds. “Effectively engaging stakeholders is especially important in informatics, which involves interacting with a diverse workforce.” She says the mentorship model of the fellowship was extremely helpful in understanding the health department culture, the agency’s structure and dynamics, and completing projects. 

Crystal has worked on several projects as a Fellow. One has dealt with Meaningful Use compliance, working with health department providers to teach them how to use the electronic prescribing system, and to adapt the system to the provider’s needs. “I created a training document and facilitated several training sessions to help providers improve care and ensure compliance,” she says.. “Marion County will continue to benefit from the progress Crystal has made,” Joe says. “She has made considerable progress on important informatics projects for our health department.”

Joe and Crystal both emphasize the role of informatics in public health and the role that business process analysis plays. Business process analysis helps get public health program staff to understand data and information as well as the technical side. Clearer business processes can streamline how public health works, making it more effective. Joe says that “public health increasingly needs rapid access to information. Both developing good information systems and paying attention to processes are important parts of achieving that.”

Perhaps the biggest indicator of the program’s success is the future. Joe says “I’d definitely continue a relationship with APHIF. The fellowship helps us train informaticians with great technical and public health skills.” Crystal, too, is looking towards the future and is interested in staying in public health. She also would like to serve as a mentor one day. “Mentors have played a monumental role in my success. It’s my desire to contribute to the development of other aspiring public health informaticians.”

Crystal Clay

For more information about the Applied Public Health Informatics Fellowship and other training programs offered by CSTE, including how to apply to be a mentor or a fellow, please visit www.aphif.org

Tags:  informatics  member spotlight  workforce development 

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Position Statement Process Helps HAI Programs and Engages a CSTE Member

Posted By Lauren Reeves, Thursday, June 5, 2014
Untitled Document
At the 2013 Annual Conference, CSTE passed position statement 13-ID-02, “Healthcare-associated infections data presentation and reporting standardization.” Although individual states have regulations on how healthcare-associated infection (HAI) data are displayed and shared, position statement author Andrea Alvarez, of the Virginia Department of Health’s HAI program, felt it was important to have a standardized approach and model for HAI data analysis, reporting, and presentation. The position statement highlighted the need for guidelines about the public reporting of HAI data. An HAI data analysis and presentation standardization workgroup was formed in 2013 after the position statement was approved.
After participating in the HAI subcommittee for several years and understanding the importance of data presentation issues in her daily work as an HAI program coordinator, Alvarez felt strongly about pursuing a position statement. “I knew why this position statement was needed, and I had strong support from other HAI subcommittee members and the CSTE staff,” Alvarez said. “The structure of the position statement template and the valuable insights of my colleagues helped the statement come together relatively easily.”
Below are some of the details of the process that Alvarez and other authors go through to submit a position statement.
Position statements document policy issues that affect public health and CSTE members. They can make a general policy statement or call for placing a health condition under standardized surveillance. Any active CSTE member can identify an issue of importance and submit it as a position statement for consideration by the relevant Steering Committee and then the CSTE membership. Templates for different types of position statements help authors write in a consistent format, especially when calling for standardized surveillance.
Many position statement authors begin thinking about, discussing, and writing their position statement well before the deadline, but position statements must be submitted 10 weeks before the June business meeting. After the submission deadline, position statements are posted on the CSTE website so that members can read and consider them before discussions at the Annual Conference. Informal discussion webinars take place several weeks before the conference to provide a forum for discussion—this year they’ll take place on June 10, 12, and 17. Infectious disease position statements are discussed at informal roundtables at the Annual Conference on Monday afternoon and Tuesday morning.
At the Annual Conference, CSTE members are encouraged to attend formal discussions scheduled by Steering Committee where each position statement is formally presented, discussed by CSTE members, and voted on. Position statements that are approved by the Steering Committees are then brought to the business meeting for final approval. At this meeting, representatives from each state and territory vote on the position statements.
After approval
Approved position statements become CSTE policy and are posted on the position statement archive. The author is responsible for tracking the position statement during the following year and reporting back on its status and impact.
Impact of 13-ID-02 on public health
Per the position statement’s desired actions to be taken, the HAI data analysis and presentation standardization workgroup was formed following the position statement’s approval. It is a multidisciplinary group of CDC and CSTE epidemiologists and HAI coordinators, communications specialists, and representatives from consumer groups. “We’re developing a toolkit to describe best practices and to recommend methods of presenting HAI data analyses,” Alvarez says. The toolkit’s introduction and methods section will provide guidance to HAI coordinators on the structure and content of their state HAI data reports. The toolkit will also contain two report templates (one targeted to healthcare consumers and the other to healthcare professionals that contains more technical information) that demonstrate the use of these best practices and provide several considerations for the display of HAI data. The toolkit aims to improve stakeholders’ capacity to understand and use HAI data and consumers’ ability to make informed choices about their healthcare.
“The position statement created this workgroup, which has had important discussions about ways to analyze and report HAI data. The toolkit we’re putting together will help us in public health, those working in healthcare facilities, and hopefully healthcare consumers as well.” Alvarez says that this outcome of the position statement has “helped me grow as a public health professional by affording me the opportunity to lead a national workgroup in close partnership with Lindsey Weiner, an epidemiologist from CDC. The process has helped me understand CSTE better and has definitely helped me get more out of my participation with CSTE and the HAI subcommittee.”
Andrea Alvarez, MPH is the Healthcare-Associated Infections Program Coordinator at the Virginia Department of Health. Nicole Bryan, MPH is the Associate Research Analyst and the HAI lead at the CSTE National Office.
For more information about position statements, please visit the position statement overview page. Individual CSTE National Office staff can help you with specific questions.

Tags:  HAI  member spotlight  position statement 

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Synergy across chronic disease programs: An example from the Colorado Department of Public Health and Environment

Posted By Sara Ramey, Thursday, May 1, 2014
Untitled Document
Collaboration, integration, synergy, collective impact… whatever you call it, working with key public health partners can make efficient use of limited resources while increasing quality and reach of public health programs. Integration of chronic disease programs in public health departments has allowed for cross-cutting work on common risk factors and at-risk populations, including health care system changes, across programs that typically have worked in isolated silos.

The Colorado Department of Public Health and Environment’s (CDPHE) pathway to increased chronic disease integration started with organizational structure changes – centralization of epidemiology, evaluation, fiscal, and communication services. Soon thereafter, CDC selected Colorado and three other states to pilot combined chronic disease funding streams. CDPHE formed an integrated chronic disease leadership team, and the efforts of work units – newly organized along functional lines, including community-clinical linkages, health systems change, environmental approaches, and law and policy development – were increasingly evidence-based, executed at an enhanced level, and informed by science and data.
As part of the health systems change efforts, the Colorado Colorectal Cancer Control Program promoted colorectal cancer prevention and control efforts statewide by providing population-based strategies to increase screening rates and addressing the U.S. Preventive Services Task Force (USPSTF) recommended screening modalities through health systems change efforts. Through development of colorectal cancer screening policies, procedures, and protocols; client and provider-oriented reminder and recall systems; and staff training on USPSTF screening guidelines, this cancer program’s activities resulted in increased colorectal screening rates from 10 to 48 percent and from 16 to 29 percent in two Federally Qualified Health Centers (FQHCs).

Building upon its pilot integration and health systems change efforts, CDPHE is now using funding from CDC’s new collaborative chronic disease grant, “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health” (a.k.a. “1305,” a nickname based on the RFA number) to increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level. Part of CDPHE’s approach to this strategy is to combine efforts and resources across four grant programs: the Colorado Colorectal Cancer Control Program (CO CRCCP), the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program, and “1305.” Synergy!

To leverage promotion of screening for chronic diseases and related risk factors, CDPHE staff across these previously siloed programs revised the baseline assessment methodology to align measures with National Qualify Forum (NQF) standards and statistically validated the methods for establishing baseline cancer, cardiovascular, diabetes and tobacco screening rates among patient populations. In the near future, staff will establish comprehensive baseline screening rates in selected pilot FQHCs and will then conduct clinic site visits to:

  • Review the comprehensive baseline screening rates (cancer, cardiovascular, diabetes, and tobacco)
  • Determine concordance between chart audit findings and existing electronic health record reports
  • Evaluate existing clinic policies, procedures, and protocols
  • Collaborate with clinic staff to develop action plans for quality improvement measures to increase preventive screening rates. These health system change efforts are based on The Guide to Community Preventive Services (The Community Guide) and How to Increase CRC Screening Rates in Practice: A Primary Care Clinicians’ Evidence-Based Toolbox and Guide
By working collaboratively and combining chronic disease grant funding, we will maximize our efforts in the promotion of health system change to institutionalize and monitor aggregated/standardized quality measures and increase screening rates for chronic diseases such as cancer, cardiovascular disease, and diabetes in Federally Qualified Health Centers in Colorado. CDPHE staff have been able to determine the best way to integrate chronic disease programs and which strategies to implement and how based on data, evidence, and target populations. All states benefit from hearing what colleagues in other states are doing and what initiatives are making a difference. We welcome continued related discussion and sharing of experiences, challenges, and successes.
Renee Calanan
Chronic Disease and Oral Health Epidemiologist
Colorado Department of Public Health and Environment

Tags:  chronic disease  collaboration  member spotlight 

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Influenza Data Management and Epidemiological Analysis course

Posted By Sara Ramey, Thursday, April 24, 2014
Untitled Document
A team of four CSTE members and staff traveled to Athens, Greece to facilitate and lecture at the CSTE-CDC Influenza Data Management and Epidemiological Analysis Course. Rachelle Boulton from the Utah Department of Health, Janet Hamilton from the Florida Department of Health, Dennis Perrotta, former State Epidemiologist from Texas, and Jennifer Lemmings from CSTE, joined staff from CDC and the World Health Organization European Office in a data management training course for influenza surveillance data managers/epidemiologists in the European Region. Influenza surveillance staff from Albania, Armenia, Bosnia and Herzegovina, Bulgaria, Croatia, Georgia, Kosovo, Kyrgyzstan, Macedonia, Moldova, Montenegro, Serbia, and the Ukraine participated in this 5 day course. Lectures were provided in English and translated to Russian for participants as needed.

The course was designed to help surveillance data managers establish, maintain, and improve influenza surveillance systems by teaching Influenza data managers and staff roles and responsibilities, minimum data requirements for influenza surveillance, quality assurance, quality control (standardized data entry, methods for checking accuracy and consistency of data), basic data analysis, data interpretation, and reporting. Some of the lectures focused on very specific details of data management methods, such as setting up tables in Microsoft Excel, while others encouraged discussion of general concepts such as deciding on which type of baseline to choose for their data.
There was a wide range of capabilities among the participants with some having advanced knowledge and experience and others a more basic understanding of influenza surveillance data management concepts and tools. Participants especially enjoyed the hands-on work using their most recent 12 months of seasonal influenza surveillance data. These data were usually counts of influenza-like illness (ILI) or Severe Acute Respiratory Illness (SARI). CSTE members and staff each provided several lectures and individual attention to participants as they worked case studies and group activities in data management and epidemiological analysis. On the last day of training, each country provided a short presentation using their influenza data and the methods learned during the training in a mock effort to convince their Minister of Health that influenza surveillance was of vital importance and should be continued.
Dennis Perrotta
CSTE Consultant

Tags:  infectious disease  influenza  meeting summary  member spotlight 

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Recreational Marijuana and the role of the Colorado Department of Public Health and Environment

Posted By Sara Ramey, Thursday, April 3, 2014
Untitled Document
It started with a public vote on November 6, 2012 – the citizens of Colorado decided by a vote of 55% to 45% to legalize marijuana. This set the wheels in motion to develop a regulatory system for the production, sale, and use of marijuana. An implementation task force was established in December of 2012 to hash out the major issues. This task force grappled with issues surrounding legalization including taxation, cultivation, laboratory testing processes, and public health. By March of 2013, this task force produced recommendations that Colorado legislators turned into law by June of 2013. In just 18 months, the first set of comprehensive laws regulating marijuana in a way similar to alcohol was produced.

From a public health standpoint, Colorado is fortunate that marijuana legislation took advantage of the last 50 years of public health research on reducing tobacco use. The legislation included specific requirements to limit youth access and prevent the normalization of marijuana use. This legislation also established a specific role for the Colorado Department of Public Health and Environment (CDPHE). CDPHE was charged with monitoring changes in drug use patterns and health effects. In addition, CDPHE was charged with setting up a panel of healthcare professionals with expertise in “cannabinoid physiology” to conduct literature reviews to make science-based recommendations for policies protecting consumers and the public. In addition to the duties outlined above, CDPHE played a role in establishing laboratory testing procedures, food safety recommendations for the manufacture of marijuana-infused edible products, waste disposal requirements and prevention messaging.
In the fall of 2013, before the official legalization of marijuana, there was an “outbreak” of synthetic marijuana users presenting at emergency rooms in the Denver area with severe adverse reactions. In less than a month, there were 263 reported emergency room visits which was far greater than the normal volume. The description of this outbreak has been published elsewhere. But, more important for CDPHE were the lessons learned that could be applied to potential events associated with legal marijuana. This “outbreak” quickly brought home the point that our surveillance infrastructure was not prepared for an event related to a toxic exposure disseminated over a large geographic area. Specific lessons learned included the insensitivity of poison center call data to indicate a problem for an illicit substance, the lack of an established network of emergency room case reporters, and our inexperience in utilizing atypical disease surveillance intelligence sources such as law enforcement.

Legal marijuana activity at CDPHE began in earnest in January of 2014 as implementation funding became available. Between January and March of 2014, the CDPHE internal marijuana steering committee grew from four to 22 members, as the public health considerations of legal marijuana became clear. It has become clear that legal marijuana affects nearly every division in our organization from injury prevention, to foodborne disease investigation, to regulation of health facilities. It also has become clear that there are numerous issues that need to be addressed in new ways due to the legalization of marijuana including surveillance for acute health effects from contaminated marijuana products, safety of edible marijuana products, accidental poisonings of young children from edible products, youth prevention, use among pregnant and breastfeeding women, marijuana disposal issues, marijuana lab testing issues, substance abuse prevention, injury and impaired driving prevention, and occupational health and safety issues among growers – just to name a few.

We have just begun to develop our surveillance program. In order to monitor the prevalence of marijuana use, we have added questions to the major population-based surveys in Colorado including the Behavioral Risk Factor Surveillance System (BRFSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), and the Child Health Survey (CHS). We have also started analyzing hospital discharge and emergency department data to evaluate baseline levels of marijuana-related trauma and morbidity. Procedures for foodborne illness investigations are being modified to include the consumption of marijuana. Finally, we have been working to shore up the weaknesses in our surveillance infrastructure by developing a more extensive network of case reporters from emergency rooms, law enforcement, medical toxicologists, and the poison center.

We are still learning about the potential public health implications of legal marijuana and look forward to reporting the actual outcome data as it becomes available. In the meantime, those who would like a head start if legal marijuana comes to their state can follow our progress and public outreach at www.colorado.gov/marijuana.
Mike Van Dyke, Ph.D., CIH
Chief, Environmental Epidemiology, Occupational Health, and Toxicology Section
Colorado Department of Public Health and Environment

Tags:  marijuana  member spotlight  surveillance 

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