Ongoing Congressional debates concerning the spreading Zika virus provide the latest reminder about our national uncertainties in preparing for and responding to large-scale health emergencies. Storms, fires, industrial accidents, and infrastructure failures like the recent Flint water crisis add to the constellation of emergencies and "near misses" that threaten health and safety somewhere in the U.S. nearly every day.
These events qualify as emergencies partly because of the uncertainties surrounding their locations, severity, and timing. Adding to the uncertainty, emergency preparedness is a responsibility shared by many different actors in government and the private sector, making it difficult to assess the collective strength of efforts to protect American communities from adverse health consequences. Uncertain risks combined with uncertain protections make for serious policy disagreements about the sufficiency of the nation's preparedness activities and investments.
For these reasons, the Centers for Disease Control and Prevention (CDC) created the National Health Security Preparedness Index in 2013 to offer a clearer view of the health protections in place for the nation as a whole and for each U.S. state. Much like an economic index is used to detect general patterns and trends in a complex economy, the Preparedness Index aggregates data from many sources to characterize the overall strength of the national preparedness system, and to track how this strength varies across the U.S. and changes over time.
The newly revised and enhanced 2016 release of the Index, now supported by the Robert Wood Johnson Foundation, combines data from more than 130 individual measures over a three-year period. The latest results reveal that preparedness is improving overall, but protections remain uneven across the U.S., and they are losing strength in some critical areas.
Five Important Lessons from the 2016 Index
1. Steady National Improvement
The U.S. consistently improved its ability to prepare for and respond to disasters and other large-scale health emergencies over each of the last three years, with the national Preparedness Index reaching its highest level of 6.7 out of 10 in 2015 (Figure 1). This result represents a 1.8 percent improvement from the previous year, and a 3.6 percent improvement from 2013.
Figure 1: Preparedness levels improved by an average of 3.6 percent between 2013 and 2015. Individual state trends ranged from a 9.1 percent improvement to a 3.5 percent decline.
2. Wide Geographic Variation in Preparedness
The nation's health protections are not distributed evenly across the U.S., with a gap of 36 percent between the states with the highest and lowest preparedness levels in 2015. Maryland achieved the nation's highest overall preparedness level of 7.6 in 2015, 14 percent higher than the national average.
A total of 18 states achieved preparedness levels that significantly exceeded the national average in 2015, with many of these leading states located along the Eastern seaboard or clustered in the Upper Midwest and Southwestern U.S. (Figure 2). Conversely, 16 states lagged significantly below the national preparedness level in 2015, including clusters of states in the Deep South and Mountain West regions. Some states with comparatively low levels of preparedness are located in geographic regions that face elevated risks of disasters, such as growing wildfire risks across the West and perennial storm and flood risks in the Gulf states. These findings indicate a need for focused improvements in high-risk and low-resource areas.
Figure 2: Preparedness improved in most states during 2013-15, but significant geographic differences remain. Gaps in the Deep South and Mountain West are particularly large.
Note: Relative size of the circles in each state reflects the percentage change in preparedness levels for each state between 2013 and 2015. Yellow circles indicate positive change. Pink circles represent negative changes.
Most states are moving in the right direction, with preparedness levels trending upward for all but four states in the Index results from 2013 to 2015. Most of these improvements were relatively modest, but five states experienced large gains in preparedness of more than 7.5 percent (one standard deviation), indicating a statistically meaningful change. Ohio achieved the largest improvement of any state over this period, with a 9.1 percent gain that brought the state in line with the national preparedness level by 2015.
A total of five states achieved gains in preparedness during 2013-15 that significantly outpaced the improvements of the nation as a whole. Conversely, five states that were significantly above the national preparedness level in 2013 fell significantly below this level by 2015. States that have improved and fallen behind in preparedness during recent years offer valuable laboratories for learning about specific practices and policies that can strengthen health protections and resiliency across the nation as a whole.
3. Significant Strengths and Gains in Preparedness
The nation's greatest strength in preparedness lies in incident and information management, the ability to follow a standardized approach in managing the response to emergency events. Strong incident management can lead to faster response times, fewer errors, and more efficient use of resources.
Preparedness in this domain reached 8.4 in 2015, significantly higher than any other area monitored in the Index (Figure 3). These results reflect years of national focus on training government agencies, health professionals, and community leaders in the incident command system and in practicing these skills regularly through exercises, drills, and real events. National capabilities in health security surveillance are also relatively strong and trending upward since 2013, indicating a robust ability to detect health threats and identify where and how they spread across the U.S.
Figure 3: National preparedness levels trended upward in most functional areas during 2013-15, except in environmental health and in health care delivery.
Note: Vertical lines indicate confidence intervals.
The largest gains in preparedness occurred in an area of persistent weakness for the nation as a whole, that of community planning and engagement. Historically, the U.S. has experienced uneven success with developing supportive relationships among government agencies, community organizations, and individual residents and developing shared plans for responding to emergencies.
Research shows that relationships connecting people and organizations together can make communities more resilient to disasters; however, this domain stood out as the nation's weakest area of preparedness in the 2013 Index. The latest Index results, however, show that preparedness in this domain has improved 8.4 percent since 2013, more than any other domain monitored in the Index. If maintained over time, these improvements will protect more people from adverse health consequences when disasters occur.
4. Troublesome Losses and Gaps in Preparedness
Index results show that the nation has lost some ground in its ability to monitor environmental hazards and maintain the security and safety of water and food supplies in recent years. Preparedness levels for environmental and occupational health fell by 4.5 percent between 2013 and 2015 (Figure 4).
These losses pose challenges for the nation in detecting and responding to environmental risks on a timely basis, as exemplified by events like the recent water contamination crises in Michigan and West Virginia. Projected increases in the frequency and intensity of environmental health emergencies suggest that this area of preparedness needs focused attention.
Figure 4: Changes in preparedness levels since 2013 have varied widely across domains and states.
The largest differences in preparedness from state to state also occur in the environmental and occupational health domain. The leading state achieved a preparedness level 2.9 times higher than the lowest state in 2013, and this gap widened to 3.4 by 2015 (Figure 5). Gaps between the highest and lowest states also exceeded 2.0 for community planning and engagement and for health care delivery. Large differences in preparedness across states can weaken national preparedness by limiting the ability of state, federal, and local stakeholders to work together and share information and resources.
These preparedness gaps are particularly troubling because they leave some communities more vulnerable to disasters and emergencies than others, contributing to inequities in population health and well-being. These findings suggest a need for sustained national efforts focused not only on improving preparedness levels overall, but also on closing gaps in preparedness across states and communities.
Figure 5: Gaps in preparedness between the highest and lowest states are large and persistent, and they have increased in environmental health and in health care delivery
5. Preparedness vs. Everyday Performance
A long-standing area of policy uncertainty concerns the extent to which emergency preparedness activities complement or compete with the everyday performance of health care and public health delivery systems. If preparedness strengthens the quality and efficiency of routine health care and public health operations, and vice-versa, then the case for investing time and money in preparedness becomes clearer.
On the other hand, preparedness activities may impose added demands and costs on health care providers that detract from routine operations, as argued by some critics of new health care emergency preparedness standards proposed by the Centers for Medicare and Medicaid Services (CMS). The Preparedness Index provides a starting point for examining these relationships because its metrics can be easily linked and analyzed together with comparable measures of health system performance.
For example, when we examine performance measures from the Commonwealth Fund's 2015 State Health System Scorecard, we see that they track closely with state preparedness levels in the Index (Figure 6). Overall, 35 percent of the variation in preparedness levels across states is explained by differences in health system performance, with measures of access being most strongly related to preparedness.
Figure 6: Health system performance measures track closely with state preparedness levels, indicating complementary relationships.
Similarly, Preparedness Index results track closely with composite measures of public health system performance from the United Health Foundation's America's Health Rankings (Figure 7). Public health measures explain about 28 percent of the variation in preparedness levels across states, with measures of health determinants like smoking and physical activity being most strongly related to preparedness. Collectively, these relationships suggest that efforts to improve routine health care and public health delivery may generate added benefits in the form of readiness for emergencies.
Figure 7: Public health performance measures track closely with state preparedness levels.
Strengthening Preparedness by Reducing Uncertainty
The revised and improved National Health Security Preparedness Index does not eliminate all of the uncertainties facing the U.S. as we contemplate the next emergency, but it does offer some useful navigational assistance. Public health officials, health system administrators, community organizations, and policymakers can use the Index results at multiple levels of specificity to identify where things stand and where they are headed. Users can drill down into each of the Index's 6 domains, 19 subdomains, and 134 individual measures to learn more about the constellation of activities and actors that contribute to preparedness across the U.S.
No index is without uncertainty, but a useful index extracts information from multiple imperfect sources to offer a clearer representation of location and direction. In the policy spheres of emergency preparedness, this information should help to bring disparate viewpoints closer together and reveal viable pathways for progress.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/28PZAsd
No comments:
Post a Comment