Part III
Conclusions and Recommendations



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Forging a Poison Prevention and Control System Part III Conclusions and Recommendations

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Forging a Poison Prevention and Control System This page intentionally left blank.

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Forging a Poison Prevention and Control System 10 Conclusions and Recommendations The Institute of Medicine’s Committee on Poison Prevention and Control was charged by the Health Resources and Services Administration (HRSA) to consider a “systematic approach to understanding, stabilizing, and providing long-term support for poison prevention and control services in the United States” by reviewing the past and current approaches to the provision of these services in terms of: The scope of services provided, including consumer telephone consultation, technical assistance and/or hospital consultation for the care of patients with life-threatening poisonings, and education of the public and professionals; The coordination of poison control centers with other public health, emergency medical, and other emergency services; The strengths and weaknesses of various organizational structures for poison control centers and services, including a consideration of personnel needs; Approaches to providing the financial resources for poison prevention and control services; Methods for assuring consistent, high-quality services, including the certification of centers and methods of evaluation; and Current and future data systems and surveillance needs. This broad charge led the Committee to take a systems approach, viewing poison control centers within the public health and medical care systems, and reconsidering the organizational structure of poison control

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Forging a Poison Prevention and Control System centers to serve the needs of the nation. Addressing the charge also demanded that the Committee define clearly what is meant by a “poisoning.” Recognizing the controversies in the field and the fact that there is no universally agreed-upon definition, we adopted an operational definition, using the categories that are used by agencies and organizations that currently monitor the problem in the population. The Committee’s operational definition of poisoning subsumes “damaging physiological effects of ingestion, inhalation, or other exposure to a range of pharmaceuticals, illicit drugs, and chemicals, including pesticides, heavy metals, gases/ vapors, and common household substances, such as bleach and ammonia” (Centers for Disease Control and Prevention, 2004, p. 233). The Committee concluded, based on its research and discussions, that the current network of poison control centers does not constitute the complete “system” of poison prevention and control services needed by the nation in the 21st century. Such a system must provide the best prevention and patient care services for the diverse population of Americans who are exposed to hazardous substances and protect the nation from the threats associated with biological and chemical terrorist events and other public health emergencies. The Committee therefore based its report on a proposed Poison Prevention and Control System that included a network of poison control centers as a vital, but not exclusive, element. The Committee also concluded that in order to fulfill their pivotal role in the overall system, poison control centers must be more stable financially and better integrated and coordinated for performance of their public health roles. SCOPE OF CORE POISON PREVENTION AND CONTROL ACTIVITIES Poison control centers are the fundamental building blocks of the proposed Poison Prevention and Control System. A regional distribution of such centers will satisfy the need to distribute medical toxicological leadership across the United States to address the diversity of poison exposures and to provide firsthand consultation to hospitals and physicians. The interaction among regionally based centers will promote innovation and the sharing of best practices. Finally, a regionalized system should provide enough redundancy in skills and resources to meet surge needs and potential equipment failures. Therefore, the Committee carefully examined the activities, functions, performance, and organizational structures of current poison control centers. Based on the information and analyses provided in Chapters 5 through 9, a core set of activities was defined that constitutes the essential functions of the network of poison control centers within the larger system envisioned by the Committee.

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Forging a Poison Prevention and Control System Although these activities are already being carried out, it is essential to identify them as a set of core activities so that they become the basis for consistent funding under the aegis of the proposed expanded federal legislation. These activities are considered by the Committee to be core because (1) they represent critical components of current and future poison control efforts; (2) the structure of poison control centers and expertise of their staffs make them uniquely capable of performing these activities (i.e., there are no other organizations in the public health and health care arena that can perform these activities at the same level of excellence and cost); and (3) they provide an infrastructure to which other related activities can readily be added as required. The notion of core activities does not imply that poison control centers should confine their activities solely to these areas. The addition of other activities should be based on local capabilities and opportunities for funding. Examples include understanding clinical toxicology research or providing training for health care students who are not specifically focused on careers in medical or clinical toxicology. Recommendations 1. All poison control centers should perform a defined set of core activities supported by federal funding that is tied to the provision of these activities. The core activities include (1) manage telephone-based poison exposure and information calls; (2) prepare and respond to all-hazards emergency needs (especially biological or chemical terrorism or other mass exposure events); (3) capture, analyze, and report exposure data; (4) train poison control center staff, including specialists in poison information and poison information providers; (5) carry out continuous quality improvement; and (6) integrate their services into the public health system. In addition, a subset of poison control centers should train medical toxicologists; this is considered a core activity for only a subset of poison control centers because their involvement is necessary for the certification of this specialty. A subset of poison control centers should also assist in the training of pharmacists through clinical toxicology fellowships that prepare them for poison control center management positions. 2. Poison control centers should collaborate with state and local health departments to develop, disseminate, and evaluate public and professional education activities. Poison control centers alone cannot fulfill the need for public and professional education related to poisoning prevention and treatment and all-hazards response. Public health agencies already have the authorities, networks, and administrative mechanisms to carry out broad educational efforts, as they do for the prevention of other injuries and for other public health campaigns.

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Forging a Poison Prevention and Control System COORDINATION OF POISON CONTROL CENTERS WITH OTHER PUBLIC HEALTH ENTITIES At the heart of the Committee’s proposal for a Poison Prevention and Control System is the integration of the current network of poison control centers into the broader public health system. As discussed in Chapter 9, the accountability for the establishment and maintenance of a population-based poison prevention and control system is currently diffuse, involving multiple levels of government. Although there are several programs or components within public health agencies that are relevant to poison prevention and control, some of which currently interact with the poison control centers, there is no clarity concerning the roles of each entity in the integrated system. This has resulted in inefficient interactions among federal, state, and local public health agencies and poison control centers that have limited their potential contributions to prevention of poisoning and promotion of health. To achieve the ultimate goal of preventing poisonings, as well as to improve the outcomes for those who are poisoned, the Committee envisions the need for a clear, single point of accountability at each level of government. The responsible agencies would assure the accomplishment of all the public health core functions or essential services as they relate to poison prevention and control. This does not mean that the responsible agencies would perform all the functions within their respective agencies. However, they would (1) take responsibility for developing the plan to accomplish the activities needed to assure that the system is in place, with a set of uniform standards across the country; (2) convene and work with the other agencies, including the existing poison control center network, to implement the plan; and (3) work in partnership to develop a set of performance standards for all components of the system. One possible model for the development of performance measures for a state-federal partnership is the Title V Maternal and Child Health (MCH) Block Grant, which is administered by states, and the federal grants for MCH activities, which are administered by the Maternal and Child Health Bureau in HRSA. This partnership has been in place for 5 years and has successfully developed and implemented performance criteria and data reporting mechanisms. Recommendations 3. The U.S. Department of Health and Human Services (DHHS) and the states should establish a Poison Prevention and Control System that integrates poison control centers with public health agencies, establishes performance measures, and holds all parties accountable for

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Forging a Poison Prevention and Control System protecting the public. At the federal level, the Secretary of Health and Human Services should designate the lead agency for this purpose; at the state level, the governor of each state should formally designate the appropriate lead (e.g., injury prevention directors from the public health entity). The Secretary of DHHS should assure integration of the existing regional network of poison control centers with the public health system. The Secretary of DHHS should create a single national repository of legislation, model prevention and education programs, website designs, and best practices material. Technical assistance should be provided for website design, content, navigation, and maintenance, maximizing the individual centers’ identity and contributions. Materials should be evaluated for quality and impact on intended audiences. For maximum effectiveness, their content should reflect the range of cultures and languages in the United States. The governor should assure that relevant all-hazards emergency preparedness and response activities are integrated with the Poison Prevention and Control System. 4. The Centers for Disease Control and Prevention, working with HRSA and the states, should continue to build an effective infrastructure for all-hazards emergency preparedness, including bioterrorism and chemical terrorism. A specific activity of this effort is to evaluate, through an objective structured review, the use of the Toxic Exposure Surveillance System as a source of case detection to all-hazards surveillance. STRENGTHS AND WEAKNESSES OF POISON CONTROL CENTER ORGANIZATIONAL STRUCTURES Early in its information gathering, the Committee weighed the options of conducting an in-depth analysis of all poison control centers or relying on existing survey data available from the American Association of Poison Control Centers (AAPCC) supplemented by case studies of a sample of centers varying with regard to size, cost, efficiency, and penetrance (number of human exposure calls per 1,000 population). The Committee’s assessment was that the existing data should be adequate to address the questions raised by HRSA about the organization and financing of the centers. However, as the analysis progressed, it became clear that the information available to the Committee was not sufficient to fully address this aspect of the charge. No data on service quality and outcomes had been systematically collected by the centers. Data on local variations in salaries and rent were not readily available. As a result, the Committee’s analysis presents preliminary findings that are useful in de-

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Forging a Poison Prevention and Control System fining the information needed for a full-scale, definitive study of organizational efficiency and effectiveness. As noted in Chapter 6, a number of published studies provide cost-effectiveness and cost-benefit analyses of various aspects of the poison control center system and some take account of the potential reduction in morbidity and mortality as benefits. In many of these studies the lack of 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. The Committee found no studies that compare cost-effectiveness of service delivery models among poison control centers. Also noted in Chapter 6, the Committee found a wide range of service delivery models, organizational structures, and financing arrangements among poison control centers that successfully deliver core services. Although an earlier study conducted on six poison control centers suggested possible economies of scale for service areas of 2 million people or more, the Committee found little conclusive evidence from its own analysis that economies of scale operate with respect to size of population served and poison control center costs. Costs were best predicted by variables related to staffing patterns and wage rates rather than hardware expenses, population served, or funding source. More complete data are needed to further explore this important concern. The Committee’s qualitative analysis of 10 poison control centers indicated that the more efficient centers had lower staff turnover rates with fewer concerns about salaries and were more likely to (1) participate in partnerships or joint ventures in the community, (2) have written strategic plans specific to the poison control center, and (3) be organizationally affiliated with a private institution. Furthermore, the more efficient centers were less likely to cite problems related to complex reporting and accountability and problems of balancing core poison control functions with other activities such as research and bioterrorism response and preparedness. These results provide some indications of desirable (e.g., written strategic plans and participation in joint ventures) and undesirable organizational characteristics. It is important to note that these analyses were based solely on population served, cost per human exposure call, and penetrance. The existing data are insufficient for the development of either contractual specifications or performance measures for a new Poison Prevention and Control System. The Committee suggests new data-gathering efforts to obtain original financial and performance data from existing poison control centers. These data are needed to guide future public funding of core activities.

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Forging a Poison Prevention and Control System Recommendation 5. HRSA should commission a systematic management review focusing on organizational determinants of cost, quality, and staffing of poison control centers as the foundation for the future funding of this program. This analysis should include the following elements: The development of new indicators of quality and impact of poison control center services. The implications of different organizational structures and funding accountabilities on service quality and impact. The role of center size and governance in poison control center service quality and impact. The impact of regional differences on poison control center operational cost. How staffing patterns, recruitment, and retention of poison control center staff affect cost, quality, and impact of poison control centers. An economic evaluation of poison control centers to determine whether economies of scale exist among them. FINANCIAL SUPPORT FOR THE POISON PREVENTION AND CONTROL SYSTEM Poison Control Centers As noted in Chapter 6, poison control centers are currently funded by a patchwork of sources (including federal, state, institutional, and private) that are subject to budget cuts and changing priorities every year. Across the states there are 29 separate funding sources: 6 percent of total poison control center funding comes from federal and state Medicaid programs, 3 percent from federal block grants, and 8 percent from other federal programs, for a total of 17 percent from federally associated programs. Approximately 44 percent of total funding comes from states, with many different approaches to state funding, ranging from line-item appropriation to state-funded universities to telephone surcharges. Hospitals represent 15 percent of total funding (either as host institutions or network members), another 3 percent of funding comes from a wide range of donations and grant sources, and 20 percent comes from myriad other sources. Because of the lack of consistent, reliable funding sources, poison control centers report that significant time is spent in raising revenues and that there has been substantial instability in funding. As financial pressures on state governments and health systems have risen, the willingness of traditional funders to continue to provide revenues has dimin-

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Forging a Poison Prevention and Control System ished, leaving many centers facing great uncertainty, budget pressures, and cutbacks. Initial efforts to stabilize the delivery of poison center services to the public and health care professionals were provided by the Poison Control Center Enhancement and Awareness Act of 2002; however, the funds appropriated through this legislation have not been sufficient. In 2001, AAPCC reported $104 million in total funding for poison control centers. In a separate analysis the Committee estimated a similar amount by multiplying the cost per human exposure call by call volume (see Chapter 6). The Committee concludes that the most effective approach to stabilization is through federal funding of approximately $100 million to support the core activities. This funding could reduce or replace the support for core activities provided by many of the current funding sources; however, it would not reduce the need for state and local funding to support non-core services. Recommendation 6. Congress should amend the current Poison Control Center Enhancement and Awareness Act to provide sufficient funding to support the proposed Poison Prevention and Control System with its national network of regional poison control centers. Support for the core activities at the current level of service is estimated to require more than $100 million annually. Extension of services to include the growing all-hazards emergency needs (especially biological or chemical terrorism) and enhancements to current surveillance and data collection activities will require additional support and should be supplemented as appropriate to such mandates. The funding could be channeled either through a direct federal grant or a federal-state matching process. Performance measures for poison control center services must be specified and monitored by the funding agencies involved. Separate funding will be required to support activities performed at the federal and state levels. State and Local Infrastructure For the Poison Prevention and Control System to be implemented and continuously improved in the most effective manner, resources must be made available to carry out the mandate. Public health initiatives with a clear mandate and resources available to both federal and state agencies are the most successful. In addition to the funds required by each poison control center to implement the core activities, the Committee estimates an amount roughly on the magnitude of $30 million to assure that all the essential services of public health related to poisoning could be accom-

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Forging a Poison Prevention and Control System plished. This estimate includes approximately $10 million in the form of grants to each state to support a poison prevention coordinator’s office whose responsibilities would include coordination of public education efforts and a plan for their evaluation, and $20 million for federal-level activities, including (1) development and maintenance of quality assurance and improvement mechanisms for every component of the Poison Prevention and Control System; (2) training activities for health providers outside the poison control centers who require training in toxicology, such as emergency department workers and emergency medical technicians; (3) a clearinghouse for primary prevention materials and resources; and (4) research and the translation of research and evaluation studies into best practices and regulatory changes. Federal estimates are based on similar public health programs funded by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration. Recommendation 7. Congress should amend existing public health legislation to fund a state and local infrastructure to support an integrated Poison Prevention and Control System. The Committee at this time is not able to provide a precise estimate of the required level of support for such a federal and state program. The Committee recommends that the Secretary of Health and Human Services should develop a budget proposal to support the costs of training, research, data archiving and reporting, quality assurance, and public education (including state-level coordination of prevention education and the creation of a central repository of best model programs). This amount is in addition to the $100 million needed to support poison control core services. ASSURE HIGH-QUALITY POISON CONTROL CENTER SERVICE Certification of poison control centers is currently the responsibility of AAPCC, and the centers are required to join this organization to become certified. A more accepted model for certification of health care professionals or programs is for it to be the responsibility of an independent agency, rather than an organization in which the applicants are paying members. (For example, medical toxicologists are certified by a board that is a member of the American Board of Medical Specialties rather than by a toxicology organization.) With the continued development of poison control centers and their increased integration into the public health system, alternative certification processes will offer advantages over the current system, including greater independence of the process from the partici-

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Forging a Poison Prevention and Control System pants, wider input from the health care community, and wider recognition of the skills and contributions of poison control centers and their personnel. Recommendation 8. A fully external, independent body should be responsible for certification of poison control centers and specialists in poison information. This body should be separate from the professional organizations representing them. NATIONAL DATA SYSTEM AND SURVEILLANCE NEEDS A Uniform Definition of Poisoning Among the most important functions of the Poison Prevention and Control System will be the collection and provision of poison exposure and surveillance data to the nation’s health authorities. The Committee’s analysis focused on existing data resources, including national surveys, which have been designed at least in part for epidemiological tracking purposes, or can be readily exploited for such purposes. Although electronic medical records systems may hold promise for augmenting existing data and surveillance resources in the future, they were not included because of issues of sensitivity, specificity, data access, data coding, scope of use, and data requirements as they pertain to surveillance for poisonings. The Committee found many barriers to the effective operation of a comprehensive data and surveillance system and to the provision and utilization of the information by agencies at the federal, state, and local levels (details of this analysis are presented in Chapter 7). The steps to ameliorate this situation are complex, but there is a pressing need for change. The Committee recommends that these be addressed at the same time that the legislative, financing, and organizational reforms are being implemented. Recommendation 9. The Secretary of Health and Human Services should instruct key agencies to convene an expert panel to develop a definition of poisoning that can be used in surveillance activities (including the Toxic Exposure Surveillance System) and ongoing data collection studies. Furthermore: The Secretary should ask the World Health Organization to review and reform the International Classification of Diseases codes for poisoning,

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Forging a Poison Prevention and Control System thereby addressing the discrepancies and complexities identified in the current classification. The Secretary should require agencies that sponsor existing surveillance and data collection instruments to use a common definition of poisoning that allows comparability across data collection efforts. The National Center for Health Statistics (NCHS) should review the methodology of its existing surveys to maximize the value of their survey data for poison prevention and control. Other agencies collecting health-related data at the federal level outside NCHS, and at the state level, should enhance their surveys or surveillance data systems to better gather and interpret data related to poisoning injury and risk factors. Privacy Barriers to Data Collection New patient protections provided by the Health Insurance Portability and Accountability Act and state privacy regulations have placed substantial limitations on sharing health care data. This situation is exacerbated by the fact that there are many misconceptions among health care professionals regarding the conditions under which such data are available. Recommendation 10. DHHS should undertake a targeted education effort to improve health provider awareness of poisoning data collection as it relates to the Health Insurance Portability and Accountability Act (HIPAA) and state privacy regulations to mitigate their unintended chilling effect on poison control center consultation, including follow-up. DHHS should review and resolve the negative impact of HIPAA and state privacy regulations on poison control center functions, including toxicology consultations and outcomes evaluation. Availability of TESS Data The Toxic Exposure Surveillance System is a proprietary data and surveillance system owned by AAPCC. Using funding from the CDC, AAPCC recently developed the capability to provide real-time surveillance through TESS based on input from the poison control centers. The Committee recognizes that this system was established and has been significantly strengthened through the initiative of AAPCC. However, there is now enough evidence to suggest that a private system cannot meet the national need for timely data in this area. Despite federal funding, the

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Forging a Poison Prevention and Control System computer code for TESS is owned by a private company, further complicating its use and distribution. Recommendation 11. The Director of the Centers for Disease Control and Prevention should ensure that exposure surveillance data generated by the poison control centers and currently reported in the Toxic Exposure Surveillance System are available to all appropriate local, state, and federal public health units and to the poison control centers on a “real-time” basis at no additional cost to these users. These data should also be publicly accessible with oversight mechanisms and privacy guarantees and at a cost consistent with other major public use systems such as those currently managed by the National Center for Health Statistics. Research Needs The Committee made an attempt, within the constraints of the available literature and data systems, to document the magnitude of the poisoning problem and its cost, in terms of health care outcomes, to the nation. The results of this analysis are provided in Chapter 3. We concluded that despite limitations in the data, poisoning is a far greater problem than has been generally recognized and it deserves a higher level of scrutiny and support. The Committee has provided rough estimates that at best need to be refined to become the basis of policy. Therefore, as a first step, the Committee recommends a baseline assessment of the magnitude and cost of poisoning. Furthermore, the Committee found a dearth of research on poisoning and poison control center operations and encourages funding of research in this area. Recommendation 12. Federally funded research should be provided for (1) studies on the epidemiology of poisoning, (2) the prevention and treatment of poisoning and drug overdose, (3) health services access and delivery, (4) strategies to improve regulations and facilitate researchers’ input into regulatory procedures, and (5) the cost efficiency of the new Poison Prevention and Control System on population-based outcomes for general and specific poisonings. CDC should take the lead in marshalling the relevant data pertaining to the epidemiology of poisoning. It should produce a comprehensive report estimating the national incidence of poisoning morbidity and mortality, exploiting its existing data sources. Within the centers, the National

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Forging a Poison Prevention and Control System Center for Injury Prevention and Control (NCIPC) could lead this effort, coordinating data needs with NCHS. Data sources should include TESS, the National Health Interview Survey, the National Electronic Injury Surveillance System, the Drug Abuse Warning Network, MedWatch, and others. The Agency for Healthcare Research and Quality (AHRQ) and CDC should be directed to undertake a rigorous economic analysis of the overall direct and indirect health care costs of poisoning and drug overdose. The Secretary of Health and Human Services should encourage funding by appropriate agencies, such as CDC and the Consumer Product Safety Commission, to ensure the needed flow of information from toxicology researchers in poison control centers on prevention problems and strategies to regulators and to encourage the study and development of new regulatory strategies and initiatives to reduce poisonings. Researchers should be funded through grants from appropriate institutes such as the National Institutes of Health, the National Library of Medicine, AHRQ, and CDC/NCIPC, to study prevention and treatment of poisonings and drug overdose, health service access and delivery, and the cost efficiency and clinical impact of the Poison Prevention and Control System.