Namvar Zohoori, MD, MPH, PhD Chronic Disease Director, Associate Director for Science, Arkansas Department of Health. Associate Professor, Department

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1 Namvar Zohoori, MD, MPH, PhD Chronic Disease Director, Associate Director for Science, Arkansas Department of Health. Associate Professor, Department of Epidemiology, U. Of Arkansas for Medical Sciences, FWB College of Public Health. Board of Directors, National Association of Chronic Disease Directors

2 Many thanks for input from scores of individuals across the country, through National Association of Chronic Directors Cardiovascular Health Council Many state health department personnel: Program managers Epidemiologists Consultants

3 Clients at the state level Data availability issues Incidence Prevalence Clinical Level of availability Others Data linkage issues Between diseases Between stages of care Between diseases and risk factors

4 State-level data use issues Targeting of interventions Tracking and evaluation Local empowerment Systems change Methodological issues

5 State Health Departments Users of data Also expected to be providers of data Our clients Programs Funders Researchers Communities Providers Coalitions Legislators All our partners in the PH system

6 Incidence data Generally lacking for many diseases and their early stages Prevalence data Also not generally, reliably or uniformly available to all states for many diseases Clinical data Measures of awareness, treatment, compliance, control ED data not available in many states Self-management behavior Use of preventive services Outpatient treatments, including counseling Level and availability of cardiac, pulmonary, stroke and TBI rehabilitation services

7 Other data needs Productivity measures (missed days, disability) True cost of acute events (out of hospital charges) Effectiveness and safety of treatments Pre-hospital and in-hospital delays Specific procedures performed, and discharge status of patients receiving them

8 State HDSP Program Priority Areas Increase control of high blood pressure and high cholesterol Increase knowledge of signs & symptoms Improve emergency response Improve quality of care Eliminate health disparities (race, ethnicity, gender, geography, or SES) Healthy People and CDC Indicators Adapted from a talk by Sara Huston

9 All states have: Self-reported cholesterol screening (BRFSS) Self-reported diagnosed hypertension and high cholesterol (BRFSS) Self-reported hypertension treatment (BRFSS) Some states have: Measured BP & blood lipids (AR, KS, OK, WA): one-time! Claims data: EMR, Medicaid, Medicare databases Gaps/Issues: No surveillance of measured BP or lipids, and their control Limited data on validity of self-reports Limited data on systems, policies, and supportive environments (worksite, communities, health care settings) Adapted from a talk by Sara Huston

10 All states have: Knowledge of stroke and heart attack symptoms (BRFSS) Gaps/Issues: No ideal way to measure knowledge, no consensus on the best way, this is just one method Education campaigns may not match ability of surveillance system Limited data on systems, policies, and supportive environments Adapted from a talk by Sara Huston

11 All states have: Self-reported intention to call 911 for stroke (BRFSS) Place of death (mortality data pre-transport) Some states have: EMS response data Arrival mode to ED and other ED data (ED data) Policies, systems of EMS and dispatch (statespecific efforts) Gaps/Issues: Limited availability of EMS, ED, registry/qi data Limited data on systems, policies, and supportive environments Adapted from a talk by Sara Huston

12 All states have: Use of Rehab and Aspirin post MI or stroke (BRFSS) Place of death (mortality data) Some states have: Hospital readiness to treat CVD events (state-specific efforts) EMS care data (EMS data) ED procedures, discharge status (ED data) Hospital discharge data Registry/QI data (Coverdell, Get With the Guidelines) Rehab policies, systems data (state-specific efforts) Gaps/Issues: No incidence data Limited availability of EMS, ED, hospital dx, registry/qi data Limited data on rehab, or post-event secondary prevention Limited data on systems, policies, env. supportive of quality of care Adapted from a talk by Sara Huston

13 % states (50+DC) with unfettered access to state data system Mortality: 72.5% Hospital discharge: 80.4% Cancer registry: 82.4% Medicaid: 35.3% Medicare: 5.9% BRFSS: 86.3% YRBS: 64.7% Emergency Dept: 41.2% EMS: 33.3% Adapted from a talk by Sara Huston

14 Small-area data Averages hide huge disparities Most requests made of State Health Departments are for local and community-level data

15 Zohoori, Pulley and Jones, 2008

16 Zohoori, Pulley and Jones, 2008

17 Zohoori, Pulley and Jones, 2008

18 Prevalence of adult hypertension: 48% 55% higher than self-reported BRFSS data Blacks >> Whites Prevalence of adult prehypertension: 28% Whites >> Blacks Higher in younger adults Hypertension awareness: 75% Treatment of hypertension: 67% Younger adults << Older adults Younger men least likely (among age-gender groups) Black men least likely (among race-gender groups) Control of treated hypertension: 59% Higher in White Women and Black Men Control of all hypertension: 39% Youngest adults less likely Men << Women Younger men least likely (among age-gender groups) Zohoori, Pulley and Jones, 2008

19 Between different chronic diseases Co-morbidities (CVD and PD not always available together) Between different stages of care EMS, ED, Hopsital, Rehab and death Currently very difficult to link these Important to identify gaps in care continuum Between diseases and their risk factors Ability to correlate and GIS map Risk factors Social determinants of health Resources for prevention and treatment

20 Targeting of interventions Breakdown by state-level geography or SES Identifying and tracking difficult populations Targeting interventions, education Tracking and evaluation Directory of resources targeted to at-risk populations Tracking and evaluation of success of interventions and programs Ability to track success of current CDC and HP indicators Tracking trends across time and space

21 Local empowerment Increase community awareness and minority participation Improve grant-writing opportunities Increase local use of data Local systems change Making the case with local and national policymakers for additional targeted resources and manpower, eg more doctors, more facilities, more preventive programs, etc.

22 Registries All-payer registries Chronic disease registries But, registries collect data only on those who present themselves to the healthcare system

23 BRFSS Expand to include more measures Add concurrent ancillary environmental surveys Increase funding to allow states to survey difficult populations NHANES Oversampling of specific states on a rotating basis for states state-level data 10 states per year Each state would have data every 5 years Could be done for a limited set of measures (eg blood pressure, cholesterol, glucose/hba1c)

24 Increase surveillance capacity at state level Annual surveillance institute and training Funding for state health examination surveys Funding for independent state-level surveys, but using common protocols and definitions, with a core set of indicators Alternatively, an extension of NHANES but done by states using NHANES protocols for consistency Importance of standardization across states

25 Funding issues Always an issue at the state level Ideally, additional surveillance efforts should not end up costing states more Where is the biggest bang? Already aware of level of burden of diseases at a macro level. What s needed is Data on reach and coverage of services Data on effectiveness of approaches Data for evaluation purposes Data for local action

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