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David J. Dausey, Nicole Lurie, and Alexis Diamond, Public Health Response To Urgent Case Reports, Health Affairs Web Exclusive, August 30, 2005 [Abstract] [PDF] [HTML Version][Supplemental Exhibit 1] [Reprints & Permissions]

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The Responses Lag the Resources

Annalynn Skipper PhD   ( 31 August 2005 )

Errors and Distortions in RAND Report

Patrick M. Libbey   ( 31 August 2005 )

Re: Errors and Distortions in RAND Report

David J. Dausey, Nicole Lurie   ( 8 September 2005 )

What Are the True Implications of the RAND Report?

Ron Bialek   ( 8 September 2005 )

The Effects of False Alarms on Local Health Department Responsiveness

Timothy R. Cote, John Davies-Cole   ( 10 November 2005 )

The Responses Lag the Resources 31 August 2005
Annalynn Skipper PhD, Principal AS Consulting and Training Send comment to journal: Re: The Responses Lag the Resources annalynn_skipper{at}comcast.com Annalynn Skipper PhD	Even the most cursory reading of this study raises the question: Where is the bioterrorism money being spent? One argument could be that it is not being spent at the local level, where both the public and the health reside. An investigation of the allocations seems to be in order. I am more concerned that when that investigation is completed, another exercise in scrutiny will have to be undertaken. That exercise will be to call local public health departments to account for the sizable resources that they have recieved and that have been misspent. The failure of public health departments to investigate and integrate the most fundamental interactive communications tools into their service offerings is indicative of a combination of hubris and arrogance that does not serve the public well. In an era of electronic revolution, when one can check on the shipment of a book and recieve hourly updates, something more is wanting from these stewards of public health and their use of public funds.
Errors and Distortions in RAND Report 31 August 2005
Patrick M. Libbey, Executive Director National Association of County and City Health Officials Send comment to journal: Re: Errors and Distortions in RAND Report plibbey{at}naccho.org Patrick M. Libbey	This article is rife with negative bias in the reporting of results, and it provides no data that support any valid conclusions about preparedness of local public health departments. The authors chose to highlight negative findings and downplay or omit equally pertinent facts, a tactic that makes for good headlines but does a disservice to the field. Among the errors and distortions in the study are the following: (1) The authors erroneously state at the outset that the CDC issued guidance to agencies in 2003 recommending response to urgent case reports within 30 minutes, the benchmark they used in their test. Such guidance was in fact provided only in May 2005 to accompany funds that have not yet been released. (2) The authors chose to quote two inappropriate responses, while providing no similarly graphic detail on the other 141 responses. (3) The authors acknowledge that they were not testing a random sample of health departments, omitting that their nonrandom sample of 19 was drawn from a universe of more than 2800 local health departments. (4) The authors state at the outset that gaps exist in response times in 19 communities, but mention only in passing that 91% of the calls they made were in fact returned within 30 minutes. We consider that a good record. The National Association of County and City Health Officials fully supports the development of performance measures, and the authors’ work is important in that regard. However, it is essential for all readers to remember that local health departments must undertake dozens of preparedness activities with limited and ever-shrinking federal assistance. The most current CDC requirements include 65 “critical tasks” that state and local health departments must undertake, of which maintenance of systems to receive disease reports 24/7 is just one.
Re: Errors and Distortions in RAND Report 8 September 2005
David J. Dausey, Associate Policy Researcher RAND Corporation, Nicole Lurie Send comment to journal: Re: Re: Errors and Distortions in RAND Report dausey{at}rand.org David J. Dausey, et al.	Mr. Libbey alleges four areas of “errors and distortions” in our report. Regarding the CDC guidance, we downloaded the guidance referenced in our paper from the CDC Web site in early 2003. That guidance has now been replaced with guidance calling for an even faster response time. Mr. Libbey was also concerned that we chose to quote two inappropriate responses while not providing detail on other responses. Unfortunately, there are not existing appropriateness criteria with which to judge the adequacy of response. While many of the responses we received were quite concerning, we chose two that were clearly inappropriate in order to avoid any question about those in the gray zone. We also noted that “several action officers asked relevant questions about the location of the patient and about clinical details.” It is not possible to evaluate the performance of a health department based on a single call, which is why we placed multiple calls to each health department to evaluate performance. Although most calls did in fact get answered, only two health departments reliably answered all calls with warm transfers within 30 minutes, while three health departments did not respond to any of the first five calls. The remaining health departments fell somewhere in between. Our report was never intended to be an exhaustive study of public health preparedness in the United States. Rather, it was designed to test a specific aspect of preparedness to prove that measurement is possible and improvement is necessary. Our other work has demonstrated that health departments have made progress in the past several years in improving public health preparedness and public health infrastructure (see http://www.rand.org/publications/TR/TR239/index.html). What is sorely lacking are performance measures that allow us to support and measure that improvement over time. We hope that research like that described in our paper will continue to move the field in this direction.
What Are the True Implications of the RAND Report? 8 September 2005
Ron Bialek, President Public Health Foundation Send comment to journal: Re: What Are the True Implications of the RAND Report? rbialek{at}phf.org Ron Bialek	Patrick Libbey noted flaws in the study design and results reported in this article. These flaws indeed exist. However, there are several valid and important observations reflected in this article, such as the following: (1) local public health agencies (LPHAs) are the first line of defense during outbreaks (2) the federal government has developed guidelines and some standards for LPHA preparedness, but has developed “almost no objective measures” (3) tools and methods for determining and improving performance in the area of preparedness have not been made available to LPHAs (4) much has been learned in the health care arena about quality measurement and performance improvement that can be applied to public health (5) “strengthening the public health system is essential” The importance of the public health system to our nation’s health security and increasing expectations the public and policymakers have for a high level of performance and accountability are evident. As implied by this article, this reality makes the development and integration of performance measurement and improvement practices in public health exceedingly important. To date, much of the preparedness investment in public health has required public health agencies to respond to ever changing and, in many instances, ill-conceived guidelines and standards. Virtually no funding has been permitted for or attention paid to increasing the ability of our nation’s public health agencies to integrate performance management and improvement processes into their activities – - processes to help agencies manage for results. Indeed, funds have been provided for different pieces of the system, but as with an airline, if the plane doesn’t arrive safely and on time, does the performance of the individual units -- pilots, flight attendants, maintenance workers, ticket agents, and others -- really matter? As standards and measures become increasingly important for demonstrating performance and holding agencies accountable, we must be certain that we are measuring the right things and that our nation’s public health agencies are provided with the resources, training, and tools to develop fully integrated performance management and improvement systems. Exploring ways to adapt successful performance improvement strategies from the health care and manufacturing sectors, and providing the necessary funding to the public health community for building its capacity in this essential area, certainly would be a good place to start. Our nation’s health security depends on it.
The Effects of False Alarms on Local Health Department Responsiveness 10 November 2005
Timothy R. Cote, Senior Federal Advisor CDC assignee to DC DOH, John Davies-Cole Send comment to journal: Re: The Effects of False Alarms on Local Health Department Responsiveness tim.cote{at}dc.gov Timothy R. Cote, et al.	The article by Dausey and colleagues, which reported a study of responses by local public health agencies (LHDAs) to faux emergencies, should be taken in the context of increasing numbers of false alarms to LHDAs. Over the past six months the District of Columbia Department of Health (DC DOH) delivered emergency chemoprophylaxis measures for hundreds of postal works in response to an anthrax alarm later shown to be generated by laboratory error (1), initiated an investigation at 2:30 a.m. when a cluster of five students simultaneously developed rashes that were later shown to be hypersensitivity reactions, and, most recently, responded to false biosensor alarms for Francisella tularensis, the organism that causes tularemia (2). Nationally, health departments have similarly responded to false biosensor alarms (3) and false “signals” from newly deployed syndromic surveillance systems (4). These activities depict a public health system energetically responding to many alarms that are ultimately found to be non-threats. To this system, Dausey and colleagues added their six to ten calls to each LHDA about a faux urgent case. In reporting the response times measured, Dausey and colleagues’ choice of statistics directs the reader toward their conclusion that responsiveness by LPHAs is uneven at best. They present the longest period before calls were returned and the mean time until calls were returned. This choice skews the results toward outlying values; median time to response would have been a better measure. The authors' data can be alternatively read to show that all but 5 of 143 calls were returned, only one of the calls was returned more than 12 hours after it was made, and the vast majority of calls were returned within two hours. We laude Dausey and colleagues' efforts to directly measure responsiveness, a critical component of bioterrorism preparedness (5). However, given that most LPHAs are already overburdened with important, “real-world” investigations that usually resolve as false alarms, we are concerned that their system employing additional false alarms might be unnecessarily burdensome. As an alternative, we suggest that responsiveness could be more usefully assessed through periodic audits of the times elapsed between registering relevant calls to the central call center (most LPHAs employ one for off-hours) until documented response by the relevant party (such as the physician or nurse on call). Although such audits could require more formalized telephone logs than currently exist at LPHA’s, they would provide data more useful to local corrective actions. As importantly, a system of internal audits would not add to the increasingly abundant false alarms that already consume significant local public health resources. REFERENCES 1. Hardeman B, Calhoun T, Faggett W, Gonzalez G, Sidbury G, Pane G, Adams S, Blair R, Coté T. Anthrax scare 2005, Washington DC: Operational issues in Chemoprophylaxis. Ann Emerg Med, in press. 2. Center for Infectious Disease Research and Policy (CIDRAP) Web site, http://www.cidrap.umn.edu/cidrap/content/bt/tularemia/news/oct0305tularemia.html, accessed October 13, 2005. 3. Houston Department of Health and Human Services, Officials Following Up on Bacteria Detection, Press Release, October 9, 2003, found online at http://www.ci.houston.tx.us/departme/health/bacteria%20detection.htm. See also Eric Berger, Suspicious Bacteria Detected: Security Monitors Spot Germ; Terrorism Discounted, Houston Chronicle, October 10, 2003, p. A27, and Robert Roos, Signs of Tularemia Agent Detected in Houston Air, CIDRAP News, October 10, 2003. 4. Reingold A. If syndromic surveillance is the answer, what is the question? Biosecurity and Bioterrorism, 2003, 1 (2):77-81. 5. US Centers for Disease Control and Prevention, Improving Surveillance Infrastructure for Terrorism Detection: The Eight-Cities Project Resource Materials, 7 April 2004, www.cdc.gov/epo/dhphsi/8city.htm.