The Art of Translating Research Into Policy

1. The Art of Translating Research Into Policy Joseph W. Thompson, MD, MPH Surgeon General, State of Arkansas Director, Arkansas Center for Health Improvement Associate Professor, UAMS Colleges of Medicine and Public Health 2008 National Network of Public Health Institutes

2. Arkansas Center for Health Improvement Mission: Improving health through evidence-based health policy research, program development, and public issue advocacy Core Values: Initiative, Trust, Commitment, and Innovation

3. ACHI’s Scope of Work ACHI Scope of Work Health Policy & System Integration Health Promotion & Disease Prevention Health Care Finance Access to Needed Quality Care

4. A Model for Health Policy Development Opportunity Principals for Decisions Empirical Assessment Education Program Development Political Discourse J. Thompson et al, Society for Public Health Education July 2004;5(3)57-63. Implementation

5. ACHI Health Policy Board: Decision Support Document Identified issue Proposed solution • Identified areas • of need: • Health care financing • Health promotion/ disease prevention • Access to quality care Empirical evidence • Proposed tools • to create solutions: • Executive • Legislative • Judicial • Private Consensus process • Empirical evidence: • Scientific studies • Program evaluations • Secondary data analyses • Primary data analyses • Trusted sources • for consensus guidelines • (including but not limited to): • U.S. Community Preventive Services Task Force • Arkansas Health Insurance Roundtable • Institute of Medicine • National Quality Forum ACHI HPB decision • On-going ACHI staff activities: • Proactive • Identify needs • Develop proposals • Engage collaborative partners • Develop methods to improve policy development • Responsive • Respond to external requests for information/analyses • Respond to external requests for proposal development • Monitoring • Scan for opportunities and vulnerabilities • Tracking health indicators • Defensive • Raise awareness of potential threats • ACHI Health Policy Board • decision making process considerations: • Impact assessment (Arkansas health impact and ACHI’s ability to effect change) • Support, oppose, or remain silent • Level of engagement (see table below) • Specific to a topic (e.g., fluoridation) or an action (e.g., support a specific House bill)

6. Preparedness Awareness Policymakers Ownership Environment Support Their problems Their needs Engagement Trustworthy Credible Interpreter Source Policy process Agenda Options / alternatives Information Credible Useful Appropriate Balanced Policy Window Immediate Future Created Agendas, Alternatives and Public Policies J. Kingdon - Framework for Policy Environment

7. Be Strategic

8. Arkansas Center for Health Improvement (1999 Public challenge to elected leadership) Four Principles for Tobacco Settlement Decisions • All funds should be used to improve and optimize the health of Arkansans. • Funds should be spent on long-term investments that improve the health of Arkansans. • Future tobacco-related illness and health care costs in Arkansas should be minimized through this opportunity. • Funds should be invested in solutions that work effectively and efficiently in Arkansas.

9. Tobacco Settlement Initiated Act - 2000 • Staged political process • ~ $60m / year • $$ in perpetuity • All new health programs • External evaluation in place • No changes in 4 sessions • Thompson et al, Health Affairs 2004;23(1)

10. Empiric Information in Graphical Format

11. Patchwork quilt of Arkansas health insurance coverage ~520,000

12. ARHealthNet – Program Details • Partnership between small businesses, state, and federal government • Premiums subsidized for employees / spouses with incomes <200% FPL • Targeted to Arkansas employers not currently offering health insurance • 1115 Waiver program with potential to expand coverage to as many as 80K uninsured Arkansans • Commitment to incorporate health promotion and disease prevention

13. Constructively Educate

14. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1998, 2006 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2006 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

15. Cardiac Pathway Tobacco / Obesity / Physical inactivity High cholesterol / Limited blood flow Coronary artery blockage Heart Attack Cardiac disability Cardiac death

16. Show them the $$

17. AR State Employees Self-Reported Risks HRA Respondents Eligible to Incur Claims (N=43,461) No Risks 11% P 10% O20% O+P9% Physically Inactive 21% Obese 32% C+O+P1% C+O2% C+P1.5% Daily Cigarette Users12% C7% O = Obese P = Physically Inactive C = Daily Cigarette Use Other Risks 39%

18. Average Annual Total Costs (Med + Rx) Average cost for all HRA respondents eligible to incur claims $3,097 Physically Inactive Obese Average cost for those with any of the three risk factors $3,427 Average cost for those with no risks $2,382 Daily Cigarette Users

19. Average Annual Total Cost for State Employees by Risk Factor No Risks $2,382 P $3,169 O $3,441 O+P $4,158 Obese $3,679 Physically Inactive $3,643 C+O+P $4,432 C+O $3,529 C+P $3,257 Daily Cigarette Users$3,081 C $2,690 O =Obese P = Physically Inactive C = Daily Cigarette Use

20. Annual Average Total* Costs Linked to Obesity Total difference $1,297 (54%) *Includes medical (inpatient and outpatient) and pharmacy costs for 18-84 year old state employees.

21. Data Driving Policy • ~26% of annual total costs associated with one or more of three risk factors—obesity, physical inactivity, or daily cigarette smoking. • Paradigm shift of Board recognizing current costs associated with failed past prevention • Incorporation of new benefits: • Evidence-based preventive clinical services • Tobacco counseling and pharmaceutical coverage • Three-tiered obesity benefit • Tiered health insurance premiums for risk • Legislative authorization provides up to 3 extra vacation days after health improvements -Jaster et al, Am Journal of Preventive Medicine (under review)

22. Make It Personal

23. Quality of diabetes care (HbA1c) among Employer Healthcare Coalition providers* *PCPs w/ largest # of eligible diabetic participants aged 18–75 yr Data source: ACHI analysis of EHC data (unpublished results). ACHI, 2005.

24. Use Innovative Strategies & Find Non-Traditional Partners

25. 84th General Assembly Act 1220 of 2003 An act to create a Child Health Advisory Committee; to coordinate statewide efforts to combat childhood obesity and related illnesses and to improve the health of the next generation of Arkansans; Goals: • Change the environment within which children go to school and learn health habits every day • Engage the community to support parents and build a system that encourages health • Enhance awareness of child and adolescent obesity to mobilize resources and establish support structures

26. Act 1220 Requirements • Establishment of an Arkansas Child Health Advisory Committee • Vending machine content and access changes • Physical activity / education requirements • Requirement of professional education for all cafeteria workers • Public disclosure of “pouring contracts” • Establishment of local parent advisory committees for all schools • Confidential child health report delivered annually to parents with body mass index (BMI) assessment - Ryan et al, Health Affairs July/August 2006;25(4):

27. Demonstrate That Change Can Happen – Share Success

28. Percentage of students classified as overweight or at risk for overweight by Arkansas public school district (’05–’06) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.

29. 22.0 21.5 25 21.0 AR grades 7-12 20.5 Avg N=150,881 AR grades K-6 Avg N=212,011 20 20.0 AR grades K-6 19.5 03-04 N=981 AR grades 7-12 03-04 N=2,159 19.0 15 2004 2005 2006 2007 10 US 12-19 yr 5 US 6-11 yr 0 1963-65 1971-74 1988-94 01-02 04 06 1966-70 1976-80 99-00 03-04 05 07 National and Arkansas Childhood Obesity Trends Thompson et al, Morbidity and Mortality Weekly Reports January 2006; 55(1)

30. Challenge to the Institutes

31. In Summary: • Be Strategic • Empirical Information in Graphical Form • Constructively Educate • Show Them The Money • Make It Personal • Use Innovative Strategies & Non-traditional Partners • Demonstrate That Change Can Happen / Share Successes

32. Translation of knowledge into policy • Integration of research skills and empirical information into relevant queries • Environmental awareness of political processes, structures, and issues • Personal “risk-tolerance” for non-traditional roles and undertakings • Relationship development with decision-makers – supporter, informant, advisor • Engage, Engage, Engage!!!!

35. Arkansas Surgeon General (Act 384) Governor may appoint a SG of Arkansas to: • Serve as a cabinet level advisor to the Gov. • Review, assess, and develop health policy options for the state across state agencies • Review and analyze legislative proposals under consideration • Provide policy options and position statements for the Governor and senior state agency officials • Raise awareness of healthcare and health issues to advance the state population’s health