6
Current Costs, Funding, and Organizational Structures

The previous chapter describes the primary activities of poison control centers in the United States as well as the staffing, financial, and operational characteristics of these centers. The purpose of this chapter is to examine the costs and organizational structures of these centers in an effort to identify those characteristics that contribute to efficient operation and service delivery.

An earlier study of these factors was conducted in 1997 by Zuvekas et al. in response to a set of recommendations from the Poison Control Center Advisory Work Group (1996). The study’s purpose was to identify approaches to more efficient service delivery. The methods included six in-depth case studies examining the time and costs associated with poison control center activities and a written survey mailed to all 75 centers that posed a series of general questions regarding size, location, activities, and organizational affiliations. The results showed that the majority of staff time and expense, regardless of center size or penetrance, was associated with providing telephone advice to the public and health care professionals. Their analysis of costs is discussed later in this chapter (see potential economies of scale).

The major recommendations were based on the use of communication technology to link the centers, thereby more effectively distributing the calls across them and allowing for consolidation. It was estimated that 50 centers might be a target number based on the reasoning that some small centers might be easily combined; technology would allow more efficient communication; and funding by the states might be more easily



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Forging a Poison Prevention and Control System 6 Current Costs, Funding, and Organizational Structures The previous chapter describes the primary activities of poison control centers in the United States as well as the staffing, financial, and operational characteristics of these centers. The purpose of this chapter is to examine the costs and organizational structures of these centers in an effort to identify those characteristics that contribute to efficient operation and service delivery. An earlier study of these factors was conducted in 1997 by Zuvekas et al. in response to a set of recommendations from the Poison Control Center Advisory Work Group (1996). The study’s purpose was to identify approaches to more efficient service delivery. The methods included six in-depth case studies examining the time and costs associated with poison control center activities and a written survey mailed to all 75 centers that posed a series of general questions regarding size, location, activities, and organizational affiliations. The results showed that the majority of staff time and expense, regardless of center size or penetrance, was associated with providing telephone advice to the public and health care professionals. Their analysis of costs is discussed later in this chapter (see potential economies of scale). The major recommendations were based on the use of communication technology to link the centers, thereby more effectively distributing the calls across them and allowing for consolidation. It was estimated that 50 centers might be a target number based on the reasoning that some small centers might be easily combined; technology would allow more efficient communication; and funding by the states might be more easily

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Forging a Poison Prevention and Control System stabilized. No data were presented to directly support the recommendation for 50 poison prevention and control centers. Furthermore, no recommendations were presented regarding specific internal organizational structures, modes of operation, or the need to develop service quality measures. Finally, it was outside the scope of the study to compare the cost of poison control center service delivery with other delivery mechanisms such as emergency departments. The data and analysis presented in this chapter are an effort to further explore and clarify these issues. The first section of this chapter focuses on a review of the economic evaluations of services delivered by poison control centers and the direct and indirect cost savings gained by using them. The second section describes the staffing and operational characteristics of centers, evaluates their economies of scale, and compares their organizational characteristics that exhibit contrasting values on size and efficiency. In conducting these analyses, we used a variety of data sources, including the Toxic Exposure Surveillance System (TESS); nonaudited, self-reported survey data provided by the American Association of Poison Control Centers (AAPCC); statistical analysis of secondary data to explain variation in efficiency of poison control centers; and an analysis of qualitative interview data obtained from a sample of 10 poison control centers. These centers were a stratified, nonprobability sample based on cost per human exposure call handled in 2001, population served, and penetrance. COST-EFFECTIVENESS AND COST-BENEFIT ANALYSES While poison control centers perform a number of activities (see Chapter 5), as Phillips and colleagues state: “The primary benefit of poison control centers is that they provide advice that allows poisonings to be appropriately handled at home or triaged to a health care facility, thereby avoiding unnecessary visits to health care facilities or inappropriate and potentially harmful home treatments.” They also serve as a free resource for those without primary care or with limited access to primary care. In 2002, Watson et al. (2003), using TESS data, found that public calls to a poison control center were managed in a non-health-care facility—usually in the patient’s home (74 percent); were treated in a health care facility (23 percent); and were referred to a health care facility but the patient did not go (2 percent). Indeed, it is the benefits of this triage role, as well as better health outcomes from the center’s interfacing with emergency departments, that are the focus of the peer-reviewed literature on economic costs. A number of published studies provide cost-effectiveness and cost-

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Forging a Poison Prevention and Control System benefit analyses of various aspects of the poison control center system and some take account of the potential morbidity and mortality benefits.1 In many of these, the lack of necessary or appropriate data presents a challenge. Nonetheless, taken as a whole, this literature makes a convincing case that, at least in terms of treatment management guidance for the public, poison control centers save the health care system economic resources and save members of the public time, lost wages, and anxiety. Indeed, the literature supports the proposition that for every dollar spent on treatment management activities, multiple dollars are saved by the health care system as a whole. These studies do not examine the cost-effectiveness among poison control centers, but rather compare the centers with other health care providers such as emergency departments. The focus of the published literature on the economics of poison control centers also accords with the fact that treatment management guidance is the dominant activity of centers in terms of expenditures, representing on average some 70 percent of those expenditures (Zuvekas et al., 1997). Still, insofar as the peer-reviewed literature on economic costs has examined only their role in treatment management guidance responding to direct calls from the public, conclusions about the cost-effectiveness of other center activities are not available, including providing consultation for patients in intensive care units. One instructive study of the cost-effectiveness of poison control centers is King and Palmisano (1991). Louisiana discontinued its center during the late 1980s; King and colleagues analyzed a natural experiment based on the resultant experiences. The researchers compared various outcomes during the discontinuance of the center to the period just before the discontinuance, as well as to the outcomes in neighboring Alabama during the period of Louisiana’s discontinued service (a period during which the poison control center service in Alabama remained). During the discontinuance, it was estimated that self-referrals to the emergency department increased by a factor of more than fourfold and the number of home management cases declined to less than half. Before the closure of the Louisiana poison control center, the triage patterns in Alabama and Louisiana were nearly identical. During the closure, the rates of poison- 1   Cost-effectiveness analysis (CEA) captures the cost, per unit of specific outcome, of competing interventions. CEAs include cost per averted emergency department visit, cost per saved snail darter, and so forth. CEA is often the best way to rank competing interventions that would divide a rather fixed budgetary pie to achieve the same objectives. CEA is also valuable in ranking interventions whose outcomes are hard to value in monetary terms. Cost-utility analysis examines cost per unit of health outcome, operationalized as quality-adjusted life-years. Cost-benefit analysis assigns monetary values to all health and nonhealth outcomes.

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Forging a Poison Prevention and Control System ing self-referrals to the emergency department in Alabama did not increase. The projected incremental costs to Louisiana during the discontinuance of excess health care facilities visits were estimated at $1.4 million. This can be compared with the $400,000 in savings to the state from closing its center. In short, had the state spent the $400,000 to keep its poison control center open, it would have saved the system $1.4 million, for a net savings of $1 million. Phrased differently, this implies a savings to the health care system of more than $3 for every dollar invested in the center. This is an underestimate of the benefits of the poison control center insofar as it does not take into account a reduction in mortality and morbidity, or in anxiety and time to the public. Phillips et al. (1998) used the results of another “natural experiment” to examine cost savings of poison control centers. Between 1993 and 1994, a single county in California lost funding for its center. Public callers to the center received a recorded announcement advising them to dial 911 for poisoning exposures and information. If they called 911, they were patched into a neighboring poison control center to which they had prior direct access. An analysis was done of individuals who called the center during this interruption of service compared with a matched set who called subsequently after service was resumed. The outcomes during the period of blockage were substantially different than during the control period, even though the disruption did not involve lack of access to the center, but only patching into one through 911. Fourteen percent of callers with restricted access were treated in an inappropriate location (e.g., treated by an emergency department when they might have been managed at home), compared with 2 percent who had direct access to a poison control center. In a further analysis of the costs associated with the same blocked-caller episode, it was found that restricting access resulted in an additional $10.98 per case in net societal costs (all costs and benefits, including patient time and transportation and marginal costs for resources used as a result of the block) and an additional $33.14 per case in health care purchaser costs (Olson et al., 1999). Harrison et al. (1996), in one of the most thorough of the existing analyses, adopted a decision theoretic analysis to evaluate treatment management guidance for the public. In addition to secondary data on costs such as emergency department visits, ambulances, and other factors, Harrison and colleagues used data assembled from an expert panel of toxicologists to estimate probabilities of morbidity outcomes, mortality outcomes, and adverse treatment impacts of cases coming into an emergency department. Thus the researchers were able to consider not only differences in direct costs to the health care system, but also differences in morbidity and mortality due to the provision of poison control center

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Forging a Poison Prevention and Control System services. They did this in the context of four typical poison exposures (e.g., acute cough or cold preparation overdose in children younger than 13 years of age). For cough or cold preparation overdose, they concluded that when calls go through a poison control center first, the costs per case average $414 (in 1995 dollars), with a probability of .004 of morbidity and .000006 of mortality. In contrast, without a poison control center, the costs per case are $664, with a probability of .01 of morbidity and .00002 of mortality. The authors concluded that for cold preparation overdoses, and under the assumptions of their model, poison control centers lead to lower costs to the health care system and better outcomes in terms of morbidity and mortality. The cost savings result both from the centers triaging visits to the emergency departments and from the cost savings associated with better health outcomes for those cases going to the emergency departments that have already gone through the centers. These cost savings amount to an average of $250 per case ($664 minus $414). This compares with a cost per call to the poison control center in the $25-to-$30 range (Zuvekas et al., 1997). Applying the same methodology to acetaminophen overdoses, the cost savings are $343 per case. For antidepressant overdoses, the cost savings are estimated to be $347 per case. For a standard cleaning substance exposure in children, the cost savings are estimated to be an average of $297 per case. In each of these cases as well, each dollar of poison control center expenditure on treatment management guidance results in a cost savings to the health care system of $10 or more. This is a lower bound estimate insofar as it does not take into account the benefits of poison control centers in terms of time and anxiety to the public, nor to their substantial positive impact on morbidity and mortality outcomes. Miller and Lestina (1997) provided an analysis of cost savings from poison control centers that has been widely cited in legislation, congressional testimony, and many popular venues. It concluded that for every dollar invested in poison control centers, there are savings of about $6.50 to the health care system as a whole. While this magnitude of cost savings is not wildly different from other convincing analyses, there are significant limitations to the Miller and Lestina analysis. Miller and Lestina estimated that the total societal costs of poisonings would be reduced from $3,315 million if there were no poison control centers to $2,905 million if the whole population of the country had access to a center, a savings of $310 million. They compared this with the cost of centers, which they indicated to be between $60 and $80 million. These data form the basis of their conclusion that there is a 6.5-to-1 cost savings for each dollar invested in poison control centers. The $390 million in savings, an amount greater than Miller and

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Forging a Poison Prevention and Control System Lestina’s total estimate of net savings, comes from increased costs of hospitalization. One assumption that leads to these savings is problematic. This assumption concerns individuals who, had there been a poison control center, would have been treated at home but, absent a center, go to the emergency department. It is assumed that these individuals will have the same probability of hospitalization and the same hospitalization costs as experienced by the whole population of individuals who are hospitalized for poisoning. If this assumption is not valid, the resulting analysis will overestimate the savings attributable to poison control centers. On the other hand, there are some cost-saving features of poison control center systems not taken into account by Miller and Lestina. For example, Miller and Lestina used total center costs (e.g., including education), not costs associated with telephone-based case management. Also, better health outcomes for cases that did need to go to the emergency department (e.g., Harrison et al., 1996) were not taken into account. Thus, while the widely quoted figure from Miller and Lestina (1997) of a 6.5-to-1 cost savings for investments in poison control centers is not outside the bounds found in other studies, their methodology makes their particular conclusion problematic. All of the above analyses focus on tangible cost savings associated with poison control centers. In such analyses, intangible psychological benefits to the public of such centers are not considered. Yet parents and caregivers often experience lowered levels of anxiety if they are able to call the centers and be reassured, when warranted, that a trip an emergency department is not necessary, and they are subsequently advised about how to treat the situation at home. There is also the comfort of knowing that this service exists even if one does not use it. These intangible benefits are hard to quantify. One study that considers these psychological benefits is Phillips et al. (1997). The researchers asked individuals who had called a poison control center and members of the public what they would be willing to pay to have a center to which they could have access. A wide range of methodological concerns can be raised about hypothetical answers to willingness to pay that are given by members of the public without the benefit of deep reflection and thoughtful calculation of intangible and tangible benefits; nonetheless, the results are informative. For those who had called a poison control center, the average willingness to pay to have a center was $6 to $7 per month, or $72 to $84 per year; for members of the public, the results were an average of $2.55 per month, or about $30 per year. The willingness to pay these figures can be compared with the actual cost per person in service area of a treatment management guidance function, which Zuvekas et al. (1997) estimated to range from 22 to 58 cents per year. Thus, Phillips and colleagues (1997) found a difference of at least 50

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Forging a Poison Prevention and Control System to 1 between the lower estimate of willingness to pay and the upper estimate of cost incurred. Again, this provides additional evidence of the benefits of poison control centers compared with their cost. CURRENT COSTS, ORGANIZATION, AND STAFFING While the previous review of the existing literature suggests cost savings resulting from the activities of poison control centers, the samples on which many of these studies are based are limited and may not represent the population of centers as a whole. Furthermore, this literature does not attempt to account for potential variation in operating efficiency of centers or explain the sources of that variability. Below we analyze available data from AAPCC to address these issues. Because these data were collected for other purposes and are largely self-reported by the individual poison control centers, they are not ideally suited to such an analysis. However, given the paucity of research in the area of center operations and financial performance, even these limited data can provide valuable additional information and help inform recommendations relating to their size, structure, and consolidation. Results of these analyses may also highlight potentially important organizational or policy issues that require further investigation with better data and more rigorous research methods. Preliminary Characterization This section provides a description of the population of poison control centers in terms of their staffing, population served, revenue sources, and other operating characteristics. In 2001 (American Association of Poison Control Centers, 2002b) there were 65 poison control centers, located in 42 states plus the District of Columbia. The number of centers located in each state ranged from zero (Alaska, Idaho, Montana, Nevada, Rhode Island, South Dakota, and Vermont) to six (Texas).2 Regional distribution of poison control centers in the United States is depicted in Figure 6-1. The majority of centers are located in the South, while the remainder are distributed roughly evenly among the Northeast, Midwest, and West. Most poison control centers were certified by the AAPCC (N = 51; 78 percent). Descriptive data from the AAPCC survey administered to the poison control centers in 2001 shows the following characteristics (see Table 6-1 for the mean, range, and standard deviation of each characteristic3). 2   Data describing poison control center operations in 2002 were not available for analysis. 3   California is treated as one center because of the form in which the revenue and expense data were provided to the Committee.

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Forging a Poison Prevention and Control System FIGURE 6-1 Geographic distribution of poison control centers. Population Served and Call Volume Figure 6-2 shows the distribution of population size served across all poison control centers. As can be seen from the figure, the size ranges from 634,000 to nearly 35 million. Because the largest poison control center is California’s, which operates as a four-region poison control system, average population size served by centers may be highly skewed; therefore, the median population served of 3.8 million is probably a better indicator of the average for all poison control centers. Centers handle three types of calls: human exposure, information, and animal exposure. Total call volume for human exposure and information calls combined averaged 55,687 per center in 2001, although there was great variability from center to center (range 4,716 to 300,321). Staffing The majority of poison control centers (92 percent) had 24-hour staffing by specialists in poison information (SPIs). Compared with SPIs and certified specialists in poison information (CSPIs), poison information providers (PIPs) made up a small proportion of the center staff (8 percent on average, range 0 to 67 percent). PIPs tend to have different backgrounds and have less training than SPIs or CSPIs. They are typically drawn from

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Forging a Poison Prevention and Control System TABLE 6-1 General Characteristics of Poison Control Centers   N Median Mean Standard Deviation Minimum Maximum Population Served 62 3,765,293 4,593,562 4,492,049 634,448 34,501,130 Calls: Human poison exposure calls 62 31,514 37,155 31,125 3,150 230,438 Information calls 62 11,928 16,569 13,066 1,491 62,003 Animal poison exposure calls 62 1,043 1,850 2,380 0 12,118 Nonexposure calls 62 89 117.7 97.23 0 450.0 All calls 62 47,272 55,687 41,767 4,716 300,321 Human exposure calls: % total calls 62 68.5% 66% 11.2% 37.7% 88.% Penetrance: Human exposure calls per 1,000 population 62 8.291 8.611 2.502 4.946 16.79 Staffing: Managing director full-time equivalents (FTEs) 61 1.00 0.971 0.455 0 3.500 FTEs of medical director funded 62 .50 0.667 0.498 0 3.150 FTEs of medical director 62 .60 0.751 0.559 0.0125 3.500 FTEs: Administrative staff 62 2.00 2.100 1.976 0 10.73 Health educator FTEs 62 1.00 1.151 1.048 0 7.500 Total PIP and CSPI/ SPI FTEs 62 9.85 10.94 7.511 0 55.90 Total PIP FTEs 62 0 1.060 2.366 0 14.50 Total CSPI plus SPI FTEs 62 9.30 9.877 5.915 0 41.40 FTEs: SPI plus CSPI : % total FTE 61 100.0% 91.8% 15.5% 33.3% 100.0% Expenses: Total expenses 61 1.2E6 1.38E6 968,595 116,579 6.89E6 Personnel expenses 61 1.0E6 1.1E6 775,509 101,579 5.7E6 All nonpersonnel expenses 61 181,071 276.431 254,894 15,000 1.05E6 Expenses per 1,000 population 61 303.2 336.8 131.9 82.76 723.8

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Forging a Poison Prevention and Control System   N Median Mean Standard Deviation Minimum Maximum Expenses per human exposure calla 61 37.18 39.98 13.54 13.72 76.78 Expenses per call (all) 61 24.83 26.31 8.509 9.222 54.00 Personnel expenses per 1,000 population 61 257.1 272.8 112.7 70.60 605.0 Personnel expenses per human exposure call 61 30.81 32.15 11.08 11.71 65.29 Personnel expenses all calls 61 20.82 21.23 7.124 7.868 42.09 Nonpersonnel expenses per 1,000 population 61 55.82 63.99 39.64 3.303 183.7 Nonpersonnel expenses per human exposure call 61 7.11 7.834 5.076 0.661 23.20 Nonpersonnel expenses all calls 61 4.52 5.083 3.256 0.454 15.83 Total revenue 61 1.2E6 1.4E6 1.02E6 116,579 7.07E6 aIncludes industry calls which represent less than 1 percent. SOURCE: American Association of Poison Control Centers, 2001 Survey (2002a). non-health-services backgrounds and, like SPIs, they are not certified in poison information. One poison control center (North Dakota) had neither SPIs nor PIPs, although they did field 4,641 calls from a population of 634,448. The median number of health educator full-time equivalents (FTEs) was 1 (mean 1.1, range 0 to 7.5); 4 centers (6 percent) had no health educators; and 17 (29 percent) had more than one health educator FTE. There was usually a managing director (average FTE 0.97, median 1.0, range 0 to 2) and a medical director (average funded medical director FTE 0.67, median 0.5, range 0 to 3.1). In nine poison control centers (14 percent), the managing director was also the medical director. Two poison control centers had no managing director and four had no medical director. While most (77 percent) poison control centers had one or more administrative staff FTEs (mean 2.1, range 0 to 10.7), seven centers (11 percent) had none. The median number of FTEs for administrative staff was two.

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Forging a Poison Prevention and Control System FIGURE 6-2 Population served at poison control centers in 2001 (N = 62).

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Forging a Poison Prevention and Control System Centers serving smaller populations reported declines in service all related to the inability to fund activities—either a direct loss of funding (e.g., loss of grant) or discontinuation of services due to unacceptably high costs (e.g., decision to discontinue accepting drug information calls). Two of these centers also reduced education activities, in one case an unfilled fellowship position and in another a decrease in professional education. Centers serving larger populations, while also experiencing declines due to funding issues, also reported declines in service due to other factors—two of these centers reported declines in exposure calls as a percentage of all calls, while three others reported declines in overall call volume. Also mentioned were decreases in industry contracts, professional or resident training, and other types of calls (animal exposures, drug decoding, pesticide calls). One center turned down requests for various services due to lack of staff. Declines in service are somewhat different between higher- and lower-cost centers. Three higher-cost centers experienced declines in professional education or fellowship training, while one lower-cost center suffered a decrease in resident training. Two lower-cost centers indicated declines in industry or other contracts. Both types of centers, however, mentioned declines in call volumes, with one higher-cost and two lower-cost centers reporting declines in general call volume, and one of each type of center reporting decreases in exposure calls as a percentage of all calls, drug information calls, and other types of calls (e.g., animal exposures). The decreases in information and other calls are largely a function of the centers’ termination of these services. Interorganizational Relationships Five respondents indicated that their centers have joined some type of coalition or collaboration with other centers in the past 4 years. These formal arrangements include state poison center networks and regional consortia. Four respondents mentioned informal collaborative arrangements—such as data sharing or call coverage—that their centers have with another center or centers. Six centers have entered into partnership or joint venture arrangements with other organizations. These vary, and include partnerships to provide education and outreach services, multicenter research projects, and joint programs with other hospital or university departments. None of the centers indicated that they have been involved in a merger. (However, at least three of the centers mention in other parts of the survey that they have expanded their service areas in the past 10 years because other centers have closed.) Of the five centers joining some sort of coalition or other formal collaboration with other centers in the past 4 years, four were centers serving

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Forging a Poison Prevention and Control System larger populations. Of the four centers mentioning informal collaborative arrangements, two were centers serving larger and two smaller populations. Only one center serving a smaller population has entered into a partnership or other joint venture arrangement with another organization, compared with five of the large-population centers. Two higher-cost centers have entered into a partnership or other joint venture arrangement with another organization compared with four of the lower-cost centers. Most centers provide services to other providers, the majority of which are related to professional education. A few centers provide data collection services for other providers. One regional center provides bilingual services to the rest of its state and to another state. Both large- and small-population centers are equally likely to provide services to other providers. Centers serving smaller populations have more shared staff and shared databases than centers serving larger populations. Both higher- and lower-cost centers are equally likely to provide services to other providers. Centers with higher costs have more shared staff and shared information technology (including databases) than centers with low costs, but neither type of center reported extensive sharing of administrative support or other services. Few centers share administrative support services, information technology, or staffing with another center or organization; one center shares these with another service of the hospital in which it was based, while another two share education personnel with other hospitals. One center shares its bilingual staff, as described above. Two centers share information technology, some staff, and call volume with other poison control centers in their state. Two other centers share only databases for joint research projects, and three others mention providing occasional coverage for another center or handing off patients to a nearby center. Referrals in and out of the centers vary considerably. While one center indicated it receives “minimal” referrals from other providers, another said 58 percent of its clients are so referred. Most centers indicate a percentage closer to 15 to 20 percent. Similarly, most centers refer about 15 to 20 percent of their clients to outside providers, usually hospitals, for evaluation, treatment, and monitoring; this percentage ranges from 7.5 percent to 30 to 40 percent. There seems to be no clear difference in the estimated number of referrals between types of centers in either referrals to the poison control center or referrals from the center to other providers. Centers serving smaller populations tend to fall at the higher end of the distribution in terms of referrals out to other health care providers, but there are some centers serving larger populations with similar figures. However, centers with lower costs tend to have a somewhat lower percentage

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Forging a Poison Prevention and Control System of referrals to other health care providers (7.5 percent to 19 percent of calls, versus 11 percent to 35 percent of calls for higher-cost centers). Quality Improvement and Assurance All programs surveyed use some kind of written procedures for handling telephone calls. These procedures are of two types. Most of the centers have written policies or administrative procedures for handling calls that address topics such as how to answer the phone, what information to collect from callers, and other general triage guidelines. Most of the centers also have guidelines addressing evaluation and treatment of specific exposures. One center has a library of about 200 management guidelines on hand, not only for its own use, but to fax to treatment facilities. All but one center practice case management as defined in the survey. This includes conducting a comprehensive assessment of clients’ needs at intake, making referrals for services, following up on referrals to make sure that clients received services, and contacting clients periodically to check on their progress. Most centers indicate that they do this kind of case management at minimum for anyone they refer to a hospital for treatment; however, some also follow up with less serious exposures. All centers have a formal written quality assurance plan, with two indicating they are in the process of revision. Quality assurance activities focus on two areas, customer service and appropriateness of treatment. Many centers assess this through review of telephone calls, either recordings or transcripts. Some do this for a random selection of all calls, while a few also target specific categories of calls for review (e.g., those clients referred to hospitals, deaths). Some centers also have daily or twice-daily reviews of currently active cases. In most instances, these reviews are done by senior personnel, and in particular the medical director; however, a few centers also involve other staff in quality reviews, including specialists in poison information, as a part of their ongoing training. Two centers have mission and vision statements related to quality improvement. Finally, staff in all centers undergo at least in-house, in-service training related to their jobs, with some centers conducting such training on an ongoing basis. In terms of more formal training, 25 to 100 percent of centers’ staffs have participated in formal continuing education or inservice training during the past year. There are no discernable differences between high- and low-population areas and higher- and lower-cost centers regarding quality assurance activities.

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Forging a Poison Prevention and Control System Research and Training FTEs devoted to research vary from zero to six, with higher numbers devoted to research at sites that have fellowship programs. FTEs devoted to staff training are difficult for respondents to estimate, given that none of the centers have dedicated personnel for this task. Instead, responsibility for training tends to be shared among senior staff and, sometimes, more experienced SPIs. Estimates range from 0.1 to 1 FTE. The estimated length of SPI training varies from 8 weeks to 12 months, with the most common length of approximately 3 months. Respondents note that it can take from 6 months to 2 years for new hires to come fully up to speed. Few of the sites have funding for poison control center research, and those that do have grant funding. Not surprisingly, research funding is generally considered insufficient. Similarly, there is little dedicated funding for training, except for some fellowships (and these funds do not necessarily come through the center). A few centers have limited travel funds or small grant funds for training, but none consider them sufficient. Staff-training FTEs also appear to be roughly equal, again with those centers having fellowship programs reporting additional FTEs. Almost none of the sites have funding for poison control center research or staff training, so this does not vary by type of center. The exception is three centers serving high populations that have fellowship funding; two of these centers are higher cost and one is lower cost. Neither research nor staff training funding was considered sufficient by any of the centers. Future Organizational Challenges General Three centers have a formal written strategic plan and one is in the process of developing such a plan. Four centers are included under the strategic plan of the organization (usually a hospital) of which they are a part. Two of these either also have their own plan, or are included under the plan of the state poison control network. Two centers do not have a strategic plan of their own, but have written objectives or a mission and vision statement specific to the center. The most often mentioned organizational challenge the poison control centers face is staff recruitment and retention, particularly for SPIs. Respondents complain of difficulty in finding qualified staff to hire, not only because of competition from better paying jobs, but also because of problems finding people with the right mix of skills. Some respondents also describe organizational challenges arising from the complex, multidisciplinary nature and structure of some of these centers. For example, a center may be part of a hospital affiliated with a university whose staff and fellows have appointments in a number of

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Forging a Poison Prevention and Control System different departments and schools, and whose funding comes from multiple sources (e.g., the hospital, the university, the state department of health, and grants). In circumstances such as these, it can be difficult for the center to function as an autonomous, “cohesive” organizational entity. One respondent noted that the result can be delays in addressing important issues. Related to this, some respondents point to the difficult balance between “core” functions (e.g., answering calls) and other activities that are important, but perhaps not considered central to the poison control center mission (e.g., research). In most cases, these are viewed as tasks that centers are well placed and well suited to do, such as bioterrorism and emergency preparedness. Some respondents express the opinion that poison control centers have been overlooked and should be more involved in these “noncore” issues. However, they also recognize the difficulties of coordinating multiple missions, given the realities of multiple, separate funding streams and already fragmented organizational structures. Several respondents note problems related to HIPAA and the difficulty convincing provider organizations that they can share routine patient-level follow-up data with the center. This has hampered toxicosurveillance efforts and research efforts. Finally, one respondent notes the language and cultural barriers that need to be addressed as the number of linguistic minorities in the United States continues to grow. These groups’ utilization of poison control center services is low; yet, they are at perhaps a higher risk than the English-speaking population. This is because of the younger average age of some of these populations and the fact that they may have difficulty reading packaging in English. Larger versus smaller populations More centers serving larger populations have a formal written strategic plan, are in the process of developing one, or have written objectives or a mission and vision statement specific to the center (five centers). Only one center serving a smaller population indicated having a formal strategic plan specific to its center. Two of each type of center are included under the strategic plan of the larger organization of which they are a part. Staff recruitment and retention is a pressing organizational challenge for many centers serving larger populations, but it is a challenge for all centers serving smaller populations. Interestingly, low-population centers are as likely as high-population centers to describe organizational challenges arising from the complex, multidisciplinary nature and structure of their organizations. They are also as likely to report difficulties in balancing “core” poison control functions and other functions, such as research and bioterrorism response and preparedness. Overall, the chal-

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Forging a Poison Prevention and Control System lenges poison control centers face seem to be similar, no matter the size of the population they serve. Lower- versus higher-cost centers More lower-cost centers have a formal written strategic plan, are in the process of developing one, or have written objectives or a mission and vision statement specific to their center (five centers). Only one high-cost center indicated having a formal strategic plan specific to its center. Three high-cost centers are included under the strategic plan of the larger organization of which they are a part, as is one lower-cost center. Staff recruitment and retention is a pressing organizational challenge for most centers, and this does not differ by type of center. Higher-cost centers are much more likely than lower-cost centers to describe organizational challenges arising from the complex, multidisciplinary nature and structure of their organizations. They are also more likely to experience difficulties in balancing “core” poison control functions and other functions, such as research and bioterrorism response and preparedness. SUMMARY Many of the studies on examining the costs and effectiveness of poison control centers lack the necessary or appropriate data needed to reach strong conclusions, particularly regarding effectiveness. Nonetheless, taken as a whole, this literature makes a convincing case that, at least in terms of treatment management guidance for the public, poison control centers save the health care system economic resources and save members of the public time, lost wages, and anxiety. These studies, however, do not examine the cost-effectiveness among poison control centers, but rather compare them with other health care providers such as emergency departments. There is wide variation among poison control centers on a number of operational characteristics, including total costs, personnel costs, and nonpersonnel costs per (1) population served, (2) total calls, and (3) human exposure calls. There is little conclusive evidence that economies of scale operate with respect to size of population served and poison control center costs, particularly for centers serving populations of 2 million or more. Costs are best predicted by variables related to staffing patterns and wage rates rather than hardware expenses or funding source. Regarding staff time, higher-cost centers estimate fewer hours spent weekly on all poison control center activities, whether direct client response or not. However, the two types of centers do not differ greatly on total number of FTEs employed. Centers with higher costs have more shared staff and shared information technology (including databases)

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Forging a Poison Prevention and Control System than centers with low costs, but neither type of center engages in extensive sharing of administrative support or other services. Centers serving smaller populations employ, on average, fewer professional education and public health education FTEs. They also have more shared staff and shared databases than centers serving larger populations. In the area of quality assurance and planning, there was little variation in quality assurance activities among centers, with virtually all engaging in them. The staff of all centers undergo at least in-house, in-service training related to their job. Only two centers (both high cost) have no strategic plan; the eight others either have their own formal written strategic plan or objectives, or are included under the strategic plan of the organization of which they are a part. Regarding affiliation and interorganizational relationships, four out of five higher-cost centers described themselves as public not-for-profits, while four out of five lower-cost centers are private not-for-profits. Centers serving larger populations and lower-cost centers described themselves as more likely to have joined a coalition, other formal collaboration, partnership, or other joint venture. Centers serving smaller populations all experienced declines in service related to the inability to fund activities. Declines in service are somewhat different between higher- and lower-cost centers. Three higher-cost centers reported declines in professional education or fellowship training, while one lower-cost center experienced a decrease in resident training. Both types of centers, however, mentioned declines in call volumes. The most often-mentioned organizational challenge the poison control centers face is staff recruitment and retention, particularly for SPIs. Lower-cost centers, all of which serve larger populations, are much less likely to mention low pay as contributing to turnover rates. Higher-cost centers are much more likely than lower-cost centers to describe organizational challenges arising from the complex reporting and conflicting accountabilities of their organizations. Higher-cost centers are more likely to experience difficulties in balancing “core” poison control functions and other functions, such as research and bioterrorism response and preparedness.

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Forging a Poison Prevention and Control System Appendix 6-A Poison Control and Prevention Organizational Interview Questions GENERAL In what year was your Center established? Please describe the current organizational structure of your poison control center, including: size, functional divisions/units, administrative support. Do have an organizational chart that you would be willing to send us? Describe the governance of your center. Does it have a formally designated board (is it a separate 501(c)(3)? A steering committee? Who sits on the board and how is board composition/membership determined? Describe how your center has changed organizationally over the past 10 years and what has precipitated those changes. How has your center changed functionally (e.g., services provided) over the past 10 years and what has precipitated those changes? STAFFING Did your poison control center receive support services from volunteers during the most recent complete fiscal year? Describe the extent of turnover in center staff over the past 5 years. What categories of personnel are most likely to experience turnover and why? How many consultants or independent contractors, either part-time or full-time, are used to provide poison control and prevention services at your center? During a typical week, what is the total number of hours that your staff, including consultants, independent contractors, and administrative staff, work at all activities for your poison control center? What is the total number of hours per week spent by these staff members conducting services other than direct client response, but relating to poison control and prevention? These services may include, for example, outreach activities, community collaboratives, or prevention workshops. INTERORGANIZATIONAL RELATIONS In the last 4 years has your center done any of the following: Joined a coalition or association with other centers? Formed a partnership or en-

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Forging a Poison Prevention and Control System tered into a joint venture with other groups or organizations? Merged with another poison control center or organization? What types of services does your poison control center provide to other provider organizations: data analysis, education, consulting, client referrals, other? Does your poison control center share any services with another poison control center or organization: administrative support services (clerical), information technology, staffing, other? In the most recent complete fiscal year, about what percentage of your poison control center’s clients were referred by other provider organizations or individual providers? Of your poison control center’s clients, what percentage are referred to outside providers for additional treatment or services? What are the major services/treatments for which your clients are referred? SERVICES AND ACTIVITIES What specific services does your center provide and to what markets or groups (e.g., handling exposure calls, handling nonexposure calls, research, education, professional training, residency training, contract data collection, outreach activities, or prevention workshops)? How many staff FTEs (or staff hours per week) were assigned to each of these activities/services during the most recent fiscal year? Which of the activities/services you listed have experienced the most growth in the past 3 years (top 2)? Which of the activities you listed have experienced the most declines in the past 3 years (top 2)? AFFILIATION Is your poison control center private for-profit, private not-for-profit, or public not-for-profit? Is your poison control center part of a larger organization (through ownership or affiliation)? Which of the following describe the organization or type of facility that your poison control center is part of? Is it a hospital, an emergency department, a unit of county government, a network or consortium of providers, center, or some other kind of organization? Does the organization that your poison control center is part of have to approve major management decisions such as those involving programs, services, staffing, or finances? Describe the reporting/accountability relationship between your center and the entity with which your center is affiliated.

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Forging a Poison Prevention and Control System Of all the hours worked by all of your poison control center’s employees each week (including consultants and independent contractors), what percent of total staff hours are typically devoted to nontreatment activities such as administrative work, supervision, hiring or program development, or clerical and support services, such as accounting, billing, and other record-keeping activities? QUALITY IMPROVEMENT AND ASSURANCE Does your poison control center use standard, written procedures that indicate steps to follow in dealing with clients—these may be termed “practice guidelines,” “protocols,” or “critical pathways”? Does your poison control center use case management? Case management can consist of several different activities. Considering current poison control center clients who receive case management, for about what percent does the case manager: b1. … conduct a comprehensive assessment of clients’ needs at intake? b2. … make referrals for clients to receive various services? b3. … follow up referrals to make sure clients receive services? b4. … contact clients periodically to check on their progress? Does your poison control center have a formal written quality assurance plan? During the most recent fiscal year, what percent of your center’s staff underwent in-service training or took continuing education related to their jobs in the center? RESEARCH AND TRAINING How many staff FTEs are assigned to research activities that focus on (a) poison control center service delivery or (2) the use poison control center data (e.g., poison control center case data or comparisons of treatments conducted through the poison control center)? How many staff FTEs are assigned to staff training (SPI and PIP) and how long does it take to complete the training? How many staff FTEs are assigned to medical toxicology fellowship training? Is there funding specifically for poison control center research and is it sufficient? Is there funding specifically for staff training and toxicology fellowship training and is it sufficient?

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Forging a Poison Prevention and Control System FUTURE Does your poison control center have a formal written strategic plan, or is the center a part of a larger unit/organization with such a strategic plan? Other than sustainable funding, what are the most pressing organizational challenges faced by your center currently? What are those challenges likely to be in the future?