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Volume 361:843-845
August 27, 2009

Number 9
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H1N1 Influenza, Public Health Preparedness, and Health Care Reform
Nicole Lurie, M.D., M.S.P.H.
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In December 2009, the Department of Health and Human Services will
present to Congress its first-ever national health security strategy,
outlining high-priority activities and areas of investment for
strengthening the capability of the United States to prepare for,
respond to, and recover from large-scale public health emergencies.
Fortunately, the strategy is being developed in parallel with a
national debate over health care reform, since national health
security will not be achievable without key elements of reform. These
elements include an effective focus on prevention and wellness,
universal access to needed care, widespread deployment of health
information technology, changes in the organization of and payment for
care, and research on comparative effectiveness.
A hazard equation that informs many approaches to preparedness makes
it clear that risk can be reduced by mitigating vulnerabilities and
hazards and increasing resilience.1 People who are vulnerable because
they are poor or have underlying health conditions suffer
disproportionately in nearly all emergencies.1 The people hit hardest
by Hurricane Katrina, for instance, were those with the highest burden
of chronic disease, many of whom could not be evacuated because they
had physical disabilities or required ongoing care.2 Responders were
caught off guard by the extent of the population's needs. Although
many lessons from Katrina were heeded after Hurricane Ike in 2008, a
high prevalence of obesity among Ike's victims strained the systems
responsible for evacuation and provision of shelter. As a result, some
relief organizations now require morbidly obese people to be served in
special-needs shelters, a requirement that puts a strain on those
resources as well. But if the investments in prevention and wellness
that are envisioned in a reformed health care system — including
payment for preventive care, aggressive secondary prevention, and
population-level interventions to prevent chronic disease and its
complications — achieve their aims, they will increase the
population's resilience by reducing key vulnerabilities, including
those associated with obesity, chronic diseases, and illnesses that
are preventable with vaccines.

Early detection of a new infectious disease — and potentially the
survival of those who are infected — requires that sick people have
access to the health care system and receive early treatment. Delays
in seeking care can lead to delays in the recognition and control of
an epidemic and in the treatment of patients. Indeed, experts have
hypothesized that one reason the mortality associated with the current
epidemic of swine-origin influenza A (H1N1) virus (S-OIV) was so high
in Mexico is that many people delayed seeking care, in part because of
its cost.3 In the United States, lack of health insurance is a key
reason for delays in seeking care; health care reform that results in
universal coverage would facilitate earlier detection of new diseases,
enable disease-control efforts to be instituted, and alleviate the
population's vulnerability that is attributable to delayed care.
During a large-scale health emergency, emergency care must be
available to seriously ill or injured patients. Without substantial
changes in policies and procedures, overcrowded emergency departments
and inefficient hospitals will struggle to handle a surge of patients
who are acutely ill, as well as those who are worried but only mildly
ill. The emergency departments in New York City experienced
overcrowding in the spring of 2009 because of H1N1 influenza. Yet
studies repeatedly suggest that one half to two thirds of emergency
department visits are potentially avoidable if there is timely access
to high-quality primary care.4 In some cities, the lack of
communication between emergency transportation systems and hospitals
means that patients are taken to emergency departments that are too
busy or too poorly equipped to care for them. Implementing the
recommendations of the Institute of Medicine for revamping the
emergency medical services system as part of health care reform will
be critical to alleviating overcrowding in emergency departments,
improving turnover time, and enhancing the capacity of emergency
departments to handle a surge of acutely ill or injured patients.

Investments in interoperable health information technology (HIT) form
one of the cornerstones of health care reform. After Hurricane
Katrina, the lack of access to medical records was a major impediment
to caring for most displaced, chronically ill persons; the records of
those who received care through the Department of Veterans Affairs,
however, were accessible anywhere in the country. Portable,
interoperable HIT will be essential for efficiently and safely caring
for displaced populations during a health emergency.
With appropriate planning and standards, HIT can also play a key role
in detecting and monitoring disease outbreaks. Routine, automated
reporting of diagnoses to health departments by primary care
practices, emergency departments, and laboratories can provide early
evidence of an impending epidemic. Such monitoring has proved useful
in determining whether a report of a single case might be accompanied
by spikes in the use of health care services, signaling that many
people are ill. Such a system was used recently by the New York City
health department and others to determine whether large numbers of
people were ill when a cluster of cases of H1N1 influenza was
identified in a school and to monitor the epidemic.

A key challenge facing public health officials who are planning
responses to a potentially more severe H1N1 influenza epidemic this
fall is finding a way to quickly link information regarding who is
vaccinated to information about the subsequent use of health care
services by these people. Such linking will be essential for detecting
and interpreting reports of adverse events after vaccination and
determining the effectiveness of vaccines in preventing illness.
Whereas some countries with universal health care systems can readily
gather and use such information, the fact that not all Americans are
accounted for in our system and the lack of HIT make it impossible to
do so in most of the United States.
In the event of a large-scale health emergency such as an influenza
pandemic, the health care system will experience unprecedented demand.
Although much care can be provided outside hospital settings,
intensive-care resources will be in particularly short supply.
Determining how to retain — and pay for — the capacity to "surge" in
such an event is a critical aspect of health preparedness; it is
particularly challenging, however, because one way to achieve the
cost-containment goal of health care reform is to shift care from
expensive inpatient settings to less expensive outpatient settings.
New approaches, including self-triage guidelines, remote monitoring
devices, and telemedicine, support such shifts in the delivery of
care. Research suggests that building excess emergency-department and
inpatient capacity as a sort of insurance policy may not be a sound
approach and will only increase health care expenditures: if capacity
is there, it will be used for other, nonemergency care. Unfortunately,
we have not yet found the right payment policies to ensure that
hospitals will be able to defer elective procedures and discharge
patients who are less severely ill in order to make space for those
who are more acutely ill.

Currently, we are far from allocating our resources with maximum
efficiency, even in the absence of a large-scale emergency. For
example, real-time electronic reporting of available bed capacity is
not widespread, despite several years of investment in hospital
preparedness. Hospitals still have patients who might be better served
with a less intensive level of care, remote monitoring and telehealth
technologies are not yet widely deployed, and our surveillance systems
are lacking in timeliness and coverage.
Finally, the scientific basis for the real-world application of
preparedness measures is underdeveloped. For example, are some modes
of public communication in a health emergency or some
social-distancing strategies to prevent the spread of disease better
than others? Comparative-effectiveness research, a cornerstone of the
Obama administration's approach to health care reform, will be
essential for gathering evidence to support particular preparedness
measures and for ensuring the creation of a maximally efficient
system.

In summary, a U.S. health security strategy will need to build on, and
take full advantage of, core components of a reformed health care
system. With the right approach, reform could facilitate vast
improvements in our ability to respond to and recover from large-scale
health emergencies.
No potential conflict of interest relevant to this article was
reported.

Source Information
From RAND Health, Arlington, VA. After writing this article, Dr. Lurie
was named Assistant Secretary for Preparedness and Response,
Department of Health and Human Services.

References
1.  Keim ME, Giannone P. Disaster preparedness. In: Cittone GR, ed.
  Disaster medicine. St. Louis: Mosby, 2006:164-73. 

2.  Kessler RC, Hurricane Katrina Community Advisory Group.
  Hurricane Katrina's impact on the care of survivors with chronic
  medical conditions. J Gen Intern Med 2007;22:1225-1230. CrossRefWeb
  of ScienceMedline
3.  Lacey M, Malkin E. First flu death provides clues to Mexico
  toll. New York Times. April 30, 2009.

4.  Oster A, Bindman AB. Emergency department visits for ambulatory
  care sensitive conditions: insights into preventable
  hospitalizations. Med Care 2003;41:198-207. CrossRefWeb of
  ScienceMedline
This Article

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