OBJECTIVE: During the COVID-19 pandemic, the unemployment rate in the United States peaked at 14.8% in April 2020. We examined patterns in unemployment following this peak in counties with rapid increases in COVID-19 incidence. METHOD: We used CDC aggregate county data to identify counties with rapid increases in COVID-19 incidence (rapid riser counties) during July 1-October 31, 2020. We used a linear regression model with fixed effect to calculate the change of unemployment rate difference in these counties, stratified by the county's social vulnerability (an indicator compiled by CDC) in the two months before the rapid riser index month compared to the index month plus one month after the index month. RESULTS: Among the 585 (19% of U.S. counties) rapid riser counties identified, the unemployment rate gap between the most and least socially vulnerable counties widened by 0.40 percentage point (p<0.01) after experiencing a rapid rise in COVID-19 incidence. Driving the gap were counties with lower socioeconomic status, with a higher percentage of people in racial and ethnic minority groups, and with limited English proficiency. CONCLUSION: The widened unemployment gap after COVID-19 incidence rapid rise between the most and least socially vulnerable counties suggests that it may take longer for socially and economically disadvantaged communities to recover. Loss of income and benefits due to unemployment could hinder behaviors that prevent spread of COVID-19 (e.g., seeking healthcare) and could impede response efforts including testing and vaccination. Addressing the social needs within these vulnerable communities could help support public health response measures.

Persons from racial and ethnic minority groups are disproportionately affected by COVID-19, including experiencing increased risk for infection (1), hospitalization (2,3), and death (4,5). Using administrative discharge data, CDC assessed monthly trends in the proportion of hospitalized patients with COVID-19 among racial and ethnic groups in the United States during March-December 2020 by U.S. Census region. Cumulative and monthly age-adjusted COVID-19 proportionate hospitalization ratios (aPHRs) were calculated for racial and ethnic minority patients relative to non-Hispanic White patients. Within each of the four U.S. Census regions, the cumulative aPHR was highest for Hispanic or Latino patients (range = 2.7-3.9). Racial and ethnic disparities in COVID-19 hospitalization were largest during May-July 2020; the peak monthly aPHR among Hispanic or Latino patients was >9.0 in the West and Midwest, >6.0 in the South, and >3.0 in the Northeast. The aPHRs declined for most racial and ethnic groups during July-November 2020 but increased for some racial and ethnic groups in some regions during December. Disparities in COVID-19 hospitalization by race/ethnicity varied by region and became less pronounced over the course of the pandemic, as COVID-19 hospitalizations increased among non-Hispanic White persons. Identification of specific social determinants of health that contribute to geographic and temporal differences in racial and ethnic disparities at the local level can help guide tailored public health prevention strategies and equitable allocation of resources, including COVID-19 vaccination, to address COVID-19-related health disparities and can inform approaches to achieve greater health equity during future public health threats.

Objective: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid.Methods: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python.Results: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results.Conclusions: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

OBJECTIVE: The objective of this study was to assess the potential health and budgetary impacts of implementing a pharmacist-involved team-based hypertension management model in the United States. RESEARCH DESIGN: In 2017, we evaluated a pharmacist-involved team-based care intervention among 3 targeted groups using a microsimulation model designed to estimate cardiovascular event incidence and associated health care spending in a cross-section of individuals representative of the US population: implementing it among patients with (1) newly diagnosed hypertension, (2) persistently (>/=1 year) uncontrolled blood pressure (BP), or (3) treated, yet persistently uncontrolled BP-and report outcomes over 5 and 20 years. We describe the spending thresholds for each intervention strategy to achieve budget neutrality in 5 years from a payer's perspective. RESULTS: Offering this intervention could prevent 22.9-36.8 million person-years of uncontrolled BP and 77,200-230,900 heart attacks and strokes in 5 years (83.8-174.8 million and 393,200-922,900 in 20 years, respectively). Health and economic benefits strongly favored groups 2 and 3. Assuming an intervention cost of $525 per enrollee, the intervention generates 5-year budgetary cost-savings only for Medicare among groups 2 and 3. To achieve budget neutrality in 5 years across all groups, intervention costs per person need to be around $35 for Medicaid, $180 for private insurance, and $335 for Medicare enrollees. CONCLUSIONS: Adopting a pharmacist-involved team-based hypertension model could substantially improve BP control and cardiovascular outcomes in the United States. Net cost-savings among groups 2 and 3 make a compelling case for Medicare, but favorable economics may also be possible for private insurers, particularly if innovations could moderately lower the cost of delivering an effective intervention.

The American College of Preventive Medicine (ACPM) collaborated with the Centers for Disease Control and Prevention (CDC) in a cooperative 5-year agreement to improve population health through primary care and public health integration. As part of the last 2 years of the cooperative agreement, the CDC's 6|18 Initiative was identified as a critical project for ACPM to promote among its membership. Information on the CDC's 6|18 Initiative is available here: www.cdc.gov/sixeighteen/index.html. | | This paper reflects work done as part of the cooperative agreement between ACPM and CDC, with the intention of informing the preventive medicine community about the CDC's 6|18 Initiative, identifying physician barriers to adoption of the initiative, and providing examples from across the country of various 6|18 interventions implemented in the physician practice or healthcare setting. The purpose of this manuscript is to highlight existing physician practices related to the 6|18 Initiative, to increase physician awareness of the 6|18 Initiative, and to identify potential opportunities for ACPM physicians to incorporate elements of this initiative into their practice settings. This manuscript does not represent a policy statement from ACPM.

BACKGROUND: Public health officials must frequently demonstrate the quality and value of public health services, especially during challenging fiscal climates. One of the ways that public health quality and accountability have been demonstrated is through the use of accreditation and standard setting initiatives. OBJECTIVE: The objective of this analysis was to identify existing alignment opportunities between standards established by the Public Health Accreditation Board (PHAB) and the Centers for Disease Control and Prevention's (CDC's) public health preparedness (PHP) capabilities in order to optimize and leverage the connections for state and local public health professionals. DESIGN: During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP capabilities and the PHAB standards. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities) and the PHAB Standards and Measures, Version 1.0 (PHAB Standards) as its source documents. To help illustrate the results of the crosswalk, alignment was also depicted through a network graph to transform the results into a visual depiction of the linkages between PHP capabilities and PHAB standards. RESULTS: The most direct links to emergency preparedness were found in PHAB Domains 2 and 5. Opportunities for improved alignment were found throughout the standard documents, particularly in PHAB Domains 3, 8, and 11. The most direct links to accreditation were found in PHP capabilities 1, 2, 3, and 4. CONCLUSIONS: The results highlight the synergy between the infrastructure and foundational elements represented by accreditation and targeted programmatic activities supported by preparedness funding.

OBJECTIVE: Identify lessons about the public health emergency preparedness system from after action report/improvement plans (AAR/IPs) authored by state and local health departments following the 2009 H1N1 influenza pandemic. DESIGN: Potentially generalizable findings were collected during a workshop attended by representatives from the Centers for Disease Control and Prevention (CDC), state and local public health departments, and other organizations that prepared 2009 H1N1AAR/IPs. PARTICIPANTS: Workshop participants included state and local health department personnel who had submitted AAR/IPs to the CDC for review. MEASURES: Workshop participants were asked to consider the question: What did you hear from other jurisdictions that resonated with your own experience and could be a generalized finding? RESULTS: Workshop discussions revealed potential lessons concerning: (1) situational awareness during the initial response; (2) resource mobilization and legal authority; (3) the complexity of vaccine distribution and administration; (4) balancing emergency response and routine operations; (5) communication and coordination among the many independent actors in the public health system; and (6) incident management in a long-duration incident. CONCLUSIONS: The response to the 2009 H1N1 influenza pandemic provides an opportunity to learn about the public health system's emergency response capabilities and to identify ways to improve preparedness for future events. Perhaps the most important lessons from the 2009 H1N1 response reveal the complexity of coordinating actions among the many different actors, institutions, sectors, and disciplines involved in the public health system. While the response to the pandemic engendered creative "on the spot" solutions, continued effort is needed to better understand and manage the identified challenges.

OBJECTIVE: To identify the extent to which the Homeland Security Exercise and Evaluation Program's (HSEEP) After Action Report/Improvement Plan (AAR/IP) template was followed by public health entities and facilitated the identification of detailed corrective actions and continuous improvement. DESIGN: Data were drawn from the US H1N1 Public Health Emergency Response (PHER) federal grant awardees (n = 62). After action report/improvement plan text was examined to identify the presence of AAR/IP HSEEP elements and characterized as "minimally complete," "partially complete," or "complete." Corrective actions (CA) and recommendations within the IP focusing on performance deficits were coded as specific, measurable, and time-bound, and whether they were associated with a problem that met root cause criteria and whether the CA/recommendation was intended to address or fix the root cause. MAIN OUTCOME MEASURES: A total of 2619 CA/recommendations were identified. More than half (n = 1480, 57%) addressed root causes. Corrective actions/recommendations associated with complete AARs more frequently addressed root cause (58% vs 51%, chi = 9.1, P < 0.003) and were more specific (34% vs 23%, chi = 32.3, P < 0.0001), measurable (30% vs 18%, chi = 37.9, P < 0.0001), and time-bound (38% vs 15%, chi = 115.5, P < 0.0001) than partially complete AARs. The same pattern was not observed with completeness of IPs. Corrective actions and recommendations were similarly specific and measurable. Recommendations significantly addressed root cause more than CAs. CONCLUSIONS: Our analysis indicates a possible lack of awardee distinction between CA and recommendations in AARs. As HSEEP adapts to align with the 2011 National Preparedness Goal and National Preparedness System, future HSEEP documents should emphasize the importance of root cause analysis as a required element within AAR documents and templates in the exercise and real incident environment, as well as the need for specific and measurable CAs.

OBJECTIVE: To analyze key variations in the after action report/improvement plan (AAR/IP) process used by state and local health departments following the 2009 H1N1 pandemic and identify ideas for improving that process. DESIGN: Workshop participants discussed their AAR findings and the methods used to prepare their reports and implications for improving the AAR/IP process in future events. PARTICIPANTS: Workshop participants included state and local health department personnel who had submitted AAR/IPs to the Centers for Disease Control and Prevention (CDC) for review. MEASURES: Workshop participants were asked to consider the question: On the basis of what you heard in this workshop, what would you do differently if you could redo your 2009 H1N1 AAR/IP? RESULTS: Workshop discussions revealed wide differences in the participants' understanding of the intended uses and users of the AAR/IPs, their scope, timing, and format, and the use of external consultants in their preparation, and on the strengths and weaknesses of various approaches. The AAR/IPs also varied in the extent to which they sought to identify root causes and the methods they used to do so. CONCLUSIONS: The AAR/IPs can be useful for both accountability and quality improvement, but these objectives require different foci and methodological approaches. Notably, the AAR/IPs can also be used as an opportunity to hold health departments accountable for conducting root cause analyses and making the improvements that follow from them. Federal agencies requiring the AAR/IPs should clarify the purpose and issues of scope and timing; develop training materials and exemplary cases of effective AAR/IPs, particularly of root cause analysis applied to public health emergency preparedness, professional guidelines, and standards for consultants; and consider developing a peer model for preparing AAR/IPs.