One Paper A Day: Reviewing population health paper "Variation In Health Outcomes: The Role Of Spending On Social Services, Public Health, And Health Care, 2000-09"

04 Aug 2021 Categorised under:  OPAD

TLDR

This is a 2016 population health paper that describes the impact of public health and social services on health outcomes. Link to paper can be found here.

Why should you be interested in this paper?

• If you are a public health practitioner, you might be interested in finding out how does public health impact healthcare outcomes despite not directly contributing to patient care itself.
• With limited resources, spending on healthcare has to be balanced between public health, social services and frontline healthcare services.

Key learning points

Methods

• Retrospective longitudinal study of the fifty states and the District of Columbia for the period 2000-09 (giving is 510 state year observation).
• Dependent variables: Eight measures of state-level health outcomes (e.g. asthma, mental health, activity limitations). Other health outcomes include state level mortality rates per 100,000 population for acute myocardial infarction, lung cancer, T2DM, post neonatal mortality rates.
• Independent variables: Spending on social services and public health relative to the spending on healthcare in each state.
• Ratios of descriptive analysis:
  • Both social services and public health spending are included jointly in the numerator of analysis in view of the fact that public health addresses social and environmental determinants of health for the population, as opposed to medical care delivered to individuals.
  • Ratio of social to health spending was calculated with the denominators: publicly funded health care spending (Medicare and Medicaid) and all public and private healthcare spending in the states.
• Covariates: Factors related to demographic characteristics, economics and the availbility of health care resources that might confound the association between state funding and health. These factors are adjusted for.
• Data analysis:
  • Descriptive statistics and graphs to characterise state-level variation in health outcomes, in the ratio of social to health spending, and in the component parts of the ratio.
  • To estiamte associations between the ratio of social of social spending and each of the eight healthcare outcomes, we fitted separate multivariate linear regression models for each health outcome as a function of the ratio of social to health spending in the state, using annual data for 2000-09 with spending variables lagged one and two years.
  • Models were also fitted with candidate covariates, including percentage of population, percentage white, unemployment rate,percentage of children living in single parent households, and number of primary care physicians and hospitals per 101,000 population.

Results

• State level variation in spending and outcomes
  • Average ratio of social to health spending in 2000-09 was 3.09 and the median was 3.02.
  • Mean share of state GDP devoted to healthcare spending was 14.1 percent while 12.2 percent was devoted to social services spending.
• Associations between spending and health outcomes
  • Primary and secondary multivariate analysis shows higer ratios of social to health spending were associated with significantly better outcomes for six out of eight healthcare outcomes.

Thoughts

• To understand the impact of this paper, we need to understand the definition of social services. They were defined as primary, secondary, and higher education; income supports such as cash assistance, general relief for low income or needs tested; beneficiaries of public welfare programs and supplemental nutritional assistance program funding; transportation and spending on sidewalks highways and mass transit systems, environment such as sanitation and programming; public safety, law enforcement and fire protection; housing such as aid for public or private housing and community development.
• Such social service spending might not be applicable to countries outside of US. For instance, in Singpoare, supplemental nutritional assistance programs are not common. This might place in question the external validity of the paper.
• It might also be much better for future studies of this nature to be more specific in the public health or social service intervention it is trying to study. It seems like the paper has a very broad conclusion that increases in public health or social spending correlates with improvements in healthcare outcomes.