Public Health in the Emergency Department: Surveillance, Screening, and Intervention—Funding and Sustainability
This work is the output from a consensus workshop conducted during the May 2009 Academic Emergency Medicine Consensus Conference in New Orleans, LA: “Public Health In the ED: Surveillance, Screening, and Intervention.”
Workshop attendees were as follows: Chris Carpenter, Esther Choo, Ted Christopher, Eileen Couture, Linda Degutis, William G. Fernandez, Fred Harchelroad, Jeremy Hess, Jon Mark Hirshon, Nancy Kerr, Barbara Kirrane, Robert Lipton, Rika Maeshiro, Douglas McLachlan, Michael Mello, Mary Murphy, David Orban, Lori Post, Mandy Roberts, Richard Rothman, Richard Sattin, and Robert Woolard.
Address for correspondence and reprints: Robert Woolard, MD; e-mail: email@example.com.
This article summarizes the work and discussions of the funding and sustainability work group at the 2009 Academic Emergency Medicine consensus conference “Public Health in the ED: Surveillance, Screening, and Intervention.” The funding and sustainability session participants were asked to address the following overarching question: “What are the opportunities and what is needed to encourage academic emergency medicine (EM) to take advantage of the opportunities for funding available for public health research initiatives and build stronger academic programs focusing on public health within EM?” Prior to the session, members of the group reviewed research funding for EM in public health, as well as the priorities of federal agencies and foundations. Recommendations for actions by EM summarize the findings of workshop.
Emergency medicine’s (EM) academic involvement in “public health” was last catalogued by the Public Health Interest Group (PHIG) of the Society for Academic Emergency Medicine (SAEM) in 2005.1 Almost 100 individual investigators participating in public health research projects were identified in the survey. Healthy People 20102 lists 28 public health focus areas, and the PHIG 2005 survey responses also reflected a wide array of interests, projects, and programs in EM involving 15 of the 28 HP2010 focus areas with 66 projects under way. Active areas of investigation included health policy (16 projects); alcohol, tobacco, and other drugs (12 projects); injury prevention and intimate partner violence (12 projects); human immunodeficiency virus (HIV), sexually transmitted infections (STI), and infectious diseases (five projects); and mental health (three projects), which are the focus areas of funding reviewed in this article. Of the projects reported, over 82% had external funding. Source of funding included 50% federal or state (18% NIH funded), and 36% privately funded. Some projects were funded from multiple sources. Very few were industry sponsored.1
Funding and sustaining surveillance, screening, and intervention research projects and public health programs, especially those that deliver clinical preventive services in the ED, was the focus of one of the breakout sessions at the 2009 Academic Emergency Medicine consensus conference. The overarching question that was asked of the participants was “What are the opportunities and what is needed to encourage academic EM to take advantage of the opportunities for funding available for public health research initiatives and build stronger academic programs focusing on public health within EM?” In the session, we discussed academic department development and health policy advocacy as they relate to creating a milieu to encourage funding and sustaining public health initiatives in EM. Obtaining research funding is competitive, and sustaining public health programs is difficult for many faculty, departments, and institutions. Our recommendations focus on creating an awareness of opportunities and enhancing the status of public health activities within EM academia. We recognize and incorporate in our recommendations that funded programs and funding sources (past, present, and future) change over time, frequently in response to perceptions of public needs. Creating and sustaining academic projects and programs often requires a series of initial submissions and subsequent resubmissions of well-written and highly informed proposals submitted in response to program announcements from a variety of agencies and foundations. This document does not provide a comprehensive review of funding sources. We do provide links to several websites for searching for funding opportunities. As a result of discussion during the session, we agreed on specific recommendations that favor the further development of public health initiatives within academic EM and should encourage EM academic activity in public health.
Brief summary of funding for public health research in em
Over the past 20 years, EM researchers have developed a history of funding in public health–related areas. EM researchers have received funding to study injury, interpersonal violence, substance misuse, HIV/STI testing, health policy, and more recently, mental health issues. Within each of these focus areas, EM researchers have developed specific expertise and have begun to build research programs that are having an impact on the health of the community. Projects with a public health focus range from ED-based interventions to community-based interventions and from policy analysis to program evaluation. In addition, funding is available for program implementation and evaluation, as well as education. The mix of funders includes federal agencies, national foundations, state and local agencies, community foundations, health care institutions and foundations, conversion foundations, and industry. Table 1 provides examples of funding priorities and funding announcements that have provided opportunities for EM researchers. A more detailed description of agency priorities is provided in the paper by D’Onofrio et al.3
CDC Research Priorities Relevant to EM
|Assess and identify strategies and model practices for the integration of public health and clinical response systems during public health emergencies.|
|Optimize local and regional operational strategies for information exchange, decision-making, and command and control and define the optimal roles and functions for persons involved in managing public health emergencies.|
|Develop and integrate systems to detect, report, and investigate illness and injury associated with intentional and unintentional emergent health threats.|
|Identify specific risk factors associated with fatal and nonfatal injuries and develop and evaluate interventions for reducing such injuries.|
|Develop and evaluate the efficacy, effectiveness, and economic efficiency of interventions to prevent and reduce the consequences of interpersonal violence, suicidal behavior, and unintentional injury.|
|Determine and evaluate how the components of trauma systems, including disability and rehabilitation services, improve short- and long-term health outcomes and costs for the acutely injured.|
|Identify the relationships among different forms of violence and other public health problems and evaluate integrative strategies to address them. Identify the causes, consequences, and costs of intentional and unintentional injuries and assess the efficacy, effectiveness, and economic efficiency of interventions to prevent injuries and mitigate consequences.|
A critical component of increased funding of EM-based public health research is the review of applications submitted by EM researchers. As EM is a relatively young field, particularly on an academic level, there are not as many senior researchers in EM to fill the ranks of review panels examining EM-based proposals. Review panel members from other specialty areas and other fields often do not understand the nature of the ED environment or its unique characteristics and constraints. This, sometimes in combination with limited knowledge or understanding of public health, leads to a lack of understanding of the importance of a specific application or the degree to which the proposed project is innovative in the field of EM. Notably, however, more senior investigators have been invited to serve on a number of review panels (e.g. CDC, NIAID, NHLBI, SAMHSA) and have had important visible roles to play in the review process.
The federal appropriations process provides funding for federal agencies and stipulates the amount of funding each agency receives. The dollar amounts are based on budgets presented by the agencies, as well as the priorities that are set by Congress for the appropriations process. Many groups and organizations lobby for particular areas of research or programs to receive higher levels of funding, and these are often negotiated in the context of the appropriations. Some institutions and investigators propose earmarks, which are written into the appropriations for a particular institution or program and do not undergo the more rigorous peer review of applications that are open to the field at large. For this reason, earmarks are controversial, and there are academic institutions that do not allow their faculty to participate in efforts to obtain earmarks.
To successfully incorporate public health concepts into research projects in EM, an understanding of public health issues and their impact on EM is necessary. We reviewed medical school curricula, residency curricula, and websites offering EM continuing medical education (CME) for public health content to determine the extent to which public health issues (especially alcohol, tobacco, and other drug use) are a priority within academic EM training. Some public health issues do not play a prominent role in EM training, while others are emerging as a focus in EM. Knowledge of HIV and STIs are included as core components of the American Board of Emergency Medicine (ABEM) training curriculum.4 Understanding principles and practice of the diagnosis of these conditions is considered fundamental for trainees. Trainee education includes classic teaching regarding modes of infectious disease transmission and findings from recent ED-specific studies demonstrating that there is a large reservoir of HIV/STI-infected individuals in whom there are no apparent clinical signs of symptoms.5,6 Explicit but limited attention is given to the concepts of screening and associated interventions in the leading EM texts.
The EM medical student curriculum contains no lectures on public health areas.7 The EM residency core curriculum contains over 700 suggested topics for lectures, and only 16 relate to public health issues. Four relate to substance use: drug dependence, drug intoxication and withdrawal, substance abuse, and drug seeking. Individual schools of medicine may provide curricula focused on public health, and a number of medical schools provide students with an option to earn a Master of Public Health (MPH) degree jointly with their medical degree.
A review of the American College of Emergency Physicians (ACEP) CME course offerings for practicing emergency physicians for April 2009 through March 2010 reveals only one course title of 156 that directly relates to a public health topic. The most frequent CME course topics are Spanish, ultrasound, airway, life support, pediatrics, and review of EM. Other online CME sources for EM, such as CMEdownloads.com, have very little public health content. CMEdownloads.com, when queried for lectures on injury prevention, HIV, STI, intimate partner violence, mental health, alcohol, and substance use, responded with “no titles available.” Among a multitude of offerings, ACEP does list one online program on alcohol intervention, one on ED crowding, and a 9-hour series on injury prevention.8,9 ACEP has also hosted a 2-hour CME program on HIV testing.
Emergency medicine review courses usually do not cover public health topics because reviews often focus on ABEM exam preparation. ABEM does not list public health topics as content areas for the certification exam. One of the 18 ABEM content areas, psychobehavioral disorders, overlaps with public health. The written exam draws only 3%, or approximately 10 questions of over 300, from this content area. However, ABEM-required lifetime learning articles (LLSA 2004–2009) contain more public health content, with 7 of 96 articles relating to public health; all except one are contained in psychobehavioral content for 2008.10
Education of trainees in public health concepts, both at medical schools and in residency training programs, has been successfully accomplished in some institutions. Injury prevention has been successfully integrated into some medical school curricula, and in several schools this has been led by EM faculty.10 The Association of American Medical Colleges and the CDC funded grants to EM faculty for the development of public health curricula within residency training that include injury prevention topics.10 Pilot funding from state health departments has funded brief educational programs for HIV testing in EDs. Others have also defined core competencies for injury and violence prevention that could be incorporated into medical school and graduate medical education.
A few academic EM departments have utilized departmental and philanthropic funding to develop non-Accreditation Council for Graduate Medical Education (ACGME) fellowship programs for EM resident graduates (e.g. Brown, Emory, UC Irvine) to develop future injury prevention researchers within the specialty.
Research Funding Sustainability
Sustaining funding over the long term is a challenge for academic departments and programs in EM, much as it is for any professional specialty. First, there needs to be a receptive and supportive environment within the institution where the EM department is based. Without a strong culture supporting research, it is difficult to successfully seek external support. Funding is affected by the economy, competing priorities, and prior successes. Funding is also critical to academic progress and promotion in many institutions. To maintain and grow funding, the capacity for research needs to increase, including the number of individuals involved in externally funded research. This includes research training for faculty, so that they can develop independent research portfolios, as well as collaborations with other EM academics and collaborations outside of EM. The National Institutes of Health provides mechanisms for research training through research fellowship training grants (T and F awards), as well as career mentored grants (K awards). Another critical program for building public health research capacity in EM is the Robert Wood Johnson Clinical Scholars program, which currently exists at four institutions (University of California at Los Angeles, University of Michigan, University of Pennsylvania, and Yale University) and includes a community-based research component. Several emergency physicians have completed this program and have developed career paths in EM research related to public health.
Emergency medicine research fellowships, as well as fellowships in other subspecialty areas of EM, also offer the opportunity to engage in public health research. Several EM research fellowships include injury prevention as an area of concentration, and many pediatric EM fellowships offer research opportunities in injury prevention.
Project/Program Sustainability Once Funding Is Completed
The development and design of public health research needs to include plans for translation and dissemination to the broader community. One of the primary issues with many funded research and program projects is that once the funding is gone, the interventions also disappear, regardless of their efficacy. For some interventions, policy change is necessary. This may include initiating reimbursement for a particular intervention, such as screening and brief intervention, or regulatory requirements imposed by oversight agencies, such as the Joint Commission requirement for screening for intimate partner violence.11
Em’s role (organizational and individual) in influencing the research agenda and funding streams
As previously stated, EM faculty have played and continue to play a role in the development of research agendas and clinical programs for funders. The identification of public health issues linked to EM can be documented not only through research projects, but through the use of data obtained from various systems that obtain emergency department data, as well as community-based data. Using these data sets can be beneficial in identifying public health issues in EM. A discussion of these data systems is beyond the scope of this paper and is addressed in the article in this issue by Hirshon et al.12 In addition, reviewing information on agency and foundation websites will provide information about funding priorities and funding availability (information is listed in Data Supplement S1, available as supporting information in the online version of this paper).
Once the issues have been identified, the key action steps include advocacy with federal agencies, foundations, and state and local funders with a public health focus. This advocacy can drive the research agendas of federal agencies, and the level of funding for the research that is needed. EM faculty, as well as professional organizations, need to be involved in these efforts, both on an individual level and as members of broader coalitions that will work to increase research funding for public health issues. EM needs to be proactive in creating partnerships with others who have similar areas of interest (public health community, law enforcement, criminal justice system, etc.) and may take the lead in developing focus areas for research based on data and practice experience.
Based on the background information and discussion at the working group session, we make the following recommendations for increasing funding of EM research in public health issues, sustaining funding of research in this area, and ensuring the sustainability of successful programs and projects.
1. Departments of EM should develop and include public health surveillance, screening, and intervention research projects and programs as a part of their academic programs and practice.
2. Academic EM programs can be most effective in addressing public health problems by partnering with the community in focusing on local problems, addressing local needs, conducting research to establish evidence for potential solutions, and implementing evidence-based programs. Program implementation should include developing materials and training programs to disseminate and translate best practices from academia into the community, such as SBIRT (screening, brief intervention, and referral for treatment) for alcohol misuse.
3. At a national level, EM should take a leadership role in promoting the public’s health by advocating for research and program initiatives addressing surveillance, screening, and intervention for alcohol and other drug misuse, injury prevention, intimate partner violence, HIV and STIs, and mental health disorders, as well as the policy implications of these initiatives including reimbursement, education, and regulation.
Emergency medicine needs to work collaboratively with public health to define the critical research linkage between public health and EM and to describe and improve the health of the public seeking emergency care and the health services delivered by EM. The positive impact that EM has on the health of the public is undervalued and often unrealized. The potential for EM to deliver a more substantial and longer-lasting health benefits should be explored. We need to do this in light of the data that we collect, our practice experience, and our linkage with the community we serve. Public health encompasses a much broader range of issues and topics than discussed in this article. In essence, academic departments and community EDs need to answer the question “what is the relationship between emergency care and the health of the public, and what can EM do to improve the health of the public we serve?” Answering these questions will create a genuine public health research focus for EM.
To continue the growth of EM research in public health, EM needs to be present in the discussion and persistent in its efforts to address public health issues. This includes advocacy for research funding and program initiatives by individuals and professional organizations, as well as documentation and dissemination of clinical program initiatives and research results. As faculty create and expand research programs in public health and disseminate their research findings, the importance of public health research in EM will become even more visible.
The authors thank the following for their assistance with the paper: Katie Chung for serving as a scribe during the AEMCC conference session, Erin Reutenauer for editing and Web search assistance, and Adolph Ulloa, MD.