An Introduction to Legal Epidemiology as a Tool to Study Public - - PowerPoint PPT Presentation

An Introduction to Legal Epidemiology as a Tool to Study Public Health Law

A Mini-Course for Public Health Practitioners and Academics

These course materials are for instructional use only and are not intended as a substitute for professional legal or other advice. While every effort has been made to verify the accuracy of these materials, legal authorities and requirements may vary from jurisdiction to jurisdiction. Always seek the advice of an attorney or other qualified professional with any questions you may have regarding a legal matter. The contents of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

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Substantive Due Process

Does the government have an appropriate justification for depriving someone of life, liberty, or property?

Today’s Faculty

PHLP’s Mission: To ad advan ance ce the und nders erstanding tanding an and us use of f la law w as a publ blic ic health th tool

Legal Epidemiology Competencies Addressed Today

Articulate the importance of legal epidemiology concepts to inform health, fiscal, administrative, legal, social, and political research and discourse Identify opportunities for legal mapping to inform the process, nature, and impact

• f policies and laws on public

health Identify opportunities for a legal evaluation study to address existing legal, health, or other issues Available at: https://www.cdc.gov/phlp/publications/to pic/resources/legalepimodel/index.html

Education

Clinical Interventions Long-lasting Protective Interventions Changing the Context to Make Individuals’ Default Decisions Easier

Socioeconomic Factors

Source: Friedman T.R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health, 100(4), 590-595.

Law that builds and maintains social, economic and physical worlds Law that defines structures Law that is an intervention tool

Consider the ways that law impacts health

Available at: www.cdc.gov/phlp/publications/topic/ vaccinations.html

State School Vaccination Exemption Laws

12

How do we know when laws (and policies) work?

1900 2010 1930s 1960s Smoking Rates WWII Education First Surgeon General’s Report Federal Cigarette Tax Doubles Policy Change Start Nonsmokers Rights Movement First Great American Smokeout

What do we mean by law?

Laws on the books Population health Changes in the environments

Logic Model of Public Health Law Research (Burris et.al. 2010)

Changes in behaviors Legal practices Lawmaking Law side of the evaluation equation

4

What do we mean by law (part 2)?

Logic Model of Public Health Law Program (CDC, 2014)

When do laws impact health?

Identify how laws (and policies) can target these complex public health issues # of days missed school Asthma Poverty Poor housing quality Addiction Overdose Over- Prescribing Pain - Prescribe Opioids Car Crash

Informational laws Infrastructural laws Interventional laws

What kinds of laws can improve health?

Scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population.

Legal Epidemiology

Foundational Principles

Scientific Systematic Transparent Replicable Precise Measurable

Legal practice applies the law; legal epidemiology measures it.

Counsel Legal etiology Legal prevention & control Policy surveillance Representation Research PUBLIC HEALTH LAW PRACTICE LEGAL EPIDEMIOLOGY

• Public Health Emergency Preparedness
• Tribal Public Health
• Health Information and Data
• Healthcare Quality
• Health Equity
• Global Public Health
• Vaccinations/Immunizations
• Environmental Health
• Birth Defects
• Aquatic Health
• Opioids
• and more…

Health Agencies Use Legal Epidemiology

Types of Legal Epidemiology Studies

LEGAL MAPPING LEGAL EVALUATION

Policy Surveillance Legal Assessments Exploratory Studies Explanatory Studies

Legal Mapping

A process for capturing important features of laws and policies, and for identifying how they vary across jurisdictions or institutions, and over time.

Policy Surveillance Legal Assessments

Collects data over time Creates longitudinal datasets Collects data at

• ne point in time

Creates cross- sectional datasets

Meet Wendy!

Her task: determine whether distracted driving laws have an effect on health

Wendy plans to measure the law and then measure its impacts on health

Wendy starts with policy surveillance

Across space: all US states and DC Over time: 1996– present day

Wendy assembles a team to tackle the process

1. Defining the scope 2. Conducting background research 3. Developing coding questions 4. Collecting the law 6. Coding the law 7. Publication and dissemination 8. Tracking and updating the law

Quality Control

5. Creating the legal text

Develop a clear statement

• f purpose

Investigate the legal landscape Identify key features of the law and any variations

Fundamental background research

2

Cull relevant, reliable secondary sources

Each day, more than

9 people…

Compile an initial sample of laws

 Regulated at state level  No preemption

Wendy discovers that distracted driving is a significant public health problem that is regulated at the state-level and preemption is not an issue.

Wendy learns that in 1996, Arizona became the first state to enact a distracted driving law.

Find salient features or variables in the law

Keep track of progress!

Initial features

• bserved in the law

Device Prohibited Prohibited Behavior Age for Prohibition Driving Record Type of Driver Penalties

Features after narrowing the scope

Device Prohibited Prohibited Behavior Type of Driver Penalties

Wendy identifies the study variables

To confirm her choices, she must consult an expert.

1. Defining the scope 2. Conducting background research 3. Developing coding questions 4. Collecting the law 6. Coding the law 7. Publication and dissemination 8. Tracking and updating the law

Quality Control

5. Creating the legal text

2 4

Collecting the law

Collecting the law consists of recording important information about relevant laws for each jurisdiction in the project.

Always record:

 Legal citation  Effective date of law  The statutory history  The body of the law

Collecting the law

2 4

Always record:

 Legal citation  Effective date of law  The statutory history  The body of the law

Collecting the law

2 4

Record changes in the legal text over time

New Jersey Distracted Driving Law

N.J. Stat. § 39:4-97.3 Use of hands-free and hand-held wireless communication devices while driving; when permitted; penalty

2014 Version

• d. A person who violates this

section shall be fined as follows: (1) for a first offense, not less than $200 or more than $400; 2) for a second offense, not less than $400 or more than $600; and 3) for a third or subsequent

• ffense, not less than $600 or

more than $800.

2010 Version

• d. A person who violates this

section shall be fined $100.

 Legal citation  Effective date of law  The statutory history  The body of the law

Always record:

Collecting the law

2 4

 Legal citation  Effective date of law  The statutory history  The body of the law

Always record:

Collecting the law

2 4

1. Defining the scope 2. Conducting background research 3. Developing coding questions 4. Collecting the law 6. Coding the law 7. Publication and dissemination 8. Tracking and updating the law

Quality Control

5. Creating the legal text

Coding compares laws across jurisdictions and over time

2 6

Let’s try it!

Hea ealth Care Worker (H (HCW) Vaccination Leg egal Mapping Activity

• You are assisting the National Center for Immunization and Respiratory

Diseases (NCIRD) with an ongoing examination of state immunization laws for healthcare workers (HCW) and patients and their impact on public health. You have conducted a preliminary scan of science, laws, and policy related to state immunization laws for HCW and have found some sample laws.

• You must examine 4 different provisions related to pertussis vaccinations.

Please look over the following laws and assess whether they are relevant to the

• assessment. If not, please explain your reasoning. For all relevant laws, please

code them based on the given criteria.

Coding questions

• 1. Does state law establish requirements for pertussis vaccinations in

the healthcare setting?

• 2. Does the law apply to patients or HCW?
• 3. Does the law specify a type of facility?
• 4. Does the law require a facility to take action?
• 5. Does the law provide an exemption?

Question Code

• 1. Does the law establish requirements for pertussis vaccination in

the healthcare setting? Y/N/AB/NM/NS

• 2. Does the law apply to specific patients or HCW?

No – all patients or HCW Age-specific Location-specific Relationship-specific

• 3. Does the law specify a type of facility?

Hospital (all or specific?) Long-term care facility (all or specific?) Ambulatory surgical center Outpatient setting Renal dialysis Other

• 4. Does the law require the facility to take action?

Assess/Offer/Ensure/None

• 5. Does the law provide an exemption for a patient?

None/Medical/Religious/ Philosophical

Neb ebraska: Neb

• eb. Rev. St.
• St. § 71

71-467. Gen eneral acu cute hosp spital; em employees; inf influenza vaccinations; tetanus-diphtheria-pertussis vaccine; duties; rec record:

(1) Each general acute hospital shall take all of the following actions in accordance with the guidelines of the Centers for Disease Control and Prevention of the United States Public Health Service of the United States Department of Health and Human Services as the guidelines existed on January 1, 2013:

(a) Annually offer onsite influenza vaccinations to all hospital employees; (b) Offer to all hospital employees a single dose of tetanus-diphtheria-pertussis vaccine if they have not previously received such vaccine and regardless of the time since their most recent vaccination with such vaccine; and (c) Require all hospital employees to be vaccinated against influenza, tetanus, diphtheria, and pertussis, except that an employee may elect not to be vaccinated.

(2) The hospital shall keep a record of which hospital employees receive the annual vaccination against influenza and a single dose of tetanus-diphtheria-pertussis vaccine and which hospital employees do not receive such vaccinations.

Question Code

• 1. Does the law establish requirements for pertussis vaccination in

the healthcare setting? Y/N/AB/NM/NS

• 2. Does the law apply to specific patients or HCW?

No – all patients or HCW Age-specific Location-specific Relationship-specific

• 3. Does the law specify a type of facility?

Hospital (all or specific?) Long-term care facility (all or specific?) Ambulatory surgical center Outpatient setting Renal dialysis Other

• 4. Does the law require the facility to take action?

Assess/Offer/Ensure/None

• 5. Does the law provide an exemption for a patient?

None/Medical/Religious/ Philosophical

New York: McK cKinney's Public He Health La Law § 2805 2805-h. Im Immunizations

• 3. Immunizations against influenza and Bordetella pertussis; neonatal intensive care units.

(a) It shall be the duty of each general hospital (i) with a neonatal intensive care unit to offer, annually between September first and April first, to every parent or person in parental relation who is reasonably anticipated to be a caregiver in the household of a newborn being treated in the neonatal intensive care unit vaccination against influenza virus; and (ii) having a newborn nursery or providing obstetric services to offer to every parent, person in parental relation or other person who is reasonably anticipated to be a caregiver of a newborn being treated in such hospital vaccination against Bordetella pertussis (whooping cough). If the parent or person in parental relation wishes to be vaccinated, the hospital shall provide the person with the

• vaccination. If the parent or person in parental relation declines the hospital offer or wishes to defer

vaccination, the hospital shall provide information on where such person may be vaccinated. Such general hospital need not offer the vaccination to parents and persons in parental relation who have already received such vaccine or for whom it is medically inappropriate. (b) Each general hospital shall adopt a policy for implementing this subdivision, documenting the offer of vaccine administration.

Question Code

• 1. Does the law establish requirements for pertussis vaccination in

the healthcare setting? Y/N/AB/NM/NS

• 2. Does the law apply to specific patients or HCW?

No – all patients or HCW Age-specific Location-specific Relationship-specific

• 3. Does the law specify a type of facility?

Hospital (all or specific?) Long-term care facility (all or specific?) Ambulatory surgical center Outpatient setting Renal dialysis Other

• 4. Does the law require the facility to take action?

Assess/Offer/Ensure/None

• 5. Does the law provide an exemption for a patient?

None/Medical/Religious/ Philosophical

Il Illinois Compiled St Statutes 225 IL ILCS 10/4 /4.6 .6. Pro rofessions, Occu cupations, and Business Oper erations; He Health; Child ild Care re Act ct of f 1969; ; Vaccination req requirements for r em employees No person may be employed by a child care facility that cares for children ages 6 and under unless that person shows proof of having received: (i) one dose of the Tdap (tetanus, diphtheria, and pertussis) vaccine; and (ii) 2 doses of the measles, mumps, and rubella (MMR) vaccine or shows proof of immunity to MMR.

Question Code

• 1. Does the law establish requirements for pertussis vaccination in

the healthcare setting? Y/N/AB/NM/NS

• 2. Does the law apply to specific patients or HCW?

No – all patients or HCW Age-specific Location-specific Relationship-specific

• 3. Does the law specify a type of facility?

Hospital (all or specific?) Long-term care facility (all or specific?) Ambulatory surgical center Outpatient setting Renal dialysis Other

• 4. Does the law require the facility to take action?

Assess/Offer/Ensure/None

• 5. Does the law provide an exemption for a patient?

None/Medical/Religious/ Philosophical

Calif lifornia Code Regs. Titl itle 8. . Ind Industrial Relations; Div ivision 1. . Dep epartment of f Ind Industrial Relations; Chapter 4. . Div ivision of f Ind Industrial Sa Safety; Su Subchapter r 7. . General Ind Industry ry Sa Safety Ord rder ers; Gro roup 16. . Control of f Ha Hazardous Su Substances; Art rticle 109. . Ha Hazardous Su Substances and Pro rocesses; § 5199. Aer erosol Tra ransmissible Dise iseases.

(a) Scope and Application. (1) Scope. This section applies to work in the following facilities, service categories, or operations: (A) Each of the following health care facilities, services, or operations:

• 1. Hospitals
• 2. Skilled nursing facilities
• 3. Clinics, medical offices, and other outpatient medical facilities
• 4. Facilities where high hazard procedures, as defined in subsection (b), are performed
• 5. Home health care
• 6. Long term health care facilities and hospices
• 7. Medical outreach services
• 8. Paramedic and emergency medical services including these services when provided by

firefighters and other emergency responders

• 9. Medical transport

(B) Facilities, services, or operations that are designated to receive persons arriving from the scene of an uncontrolled release of hazardous substances involving biological agents, as defined in Section 5192, Hazardous Waste Operations and Emergency Response, of these orders. (C) Police services, provided during transport or detention of persons reasonably anticipated to be cases or suspected cases of aerosol transmissible diseases; and police services provided in conjunction with health care or public health operations. (D) Public health services, such as communicable disease contact tracing

• r screening programs that are reasonably anticipated to be provided to

cases or suspected cases of aerosol transmissible diseases, and public health services rendered in health care facilities or in connection with the provision of health care. [. . . ]

[Sa [Same tit title and ch chapter as s pre revious cit citation] ] Art rticle 109. . Ha Hazard rdous Su Substances and Pro rocesses; Aer erosol Tra ransmissible Dise iseases; Appendix E: : Aer erosol Tra ransmissible Dise isease Vaccination Recommendations for r Su Susceptible He Health Care re Workers (M (Mandatory)

Vaccine Schedule Influenza One dose annually Measles Two doses Mumps Two doses Rubella One dose Tetanus, Diptheria, and Acellular One dose, booster as recommended Pertussis (Tdap) Varicella-zoster (VZV) Two doses

Source: California Department of Public Health, Immunization Branch Immunity should be determined in consultation with Epidemiology and Prevention of Vaccine-Preventable Diseases.

This database is current through 9/15/17

1. Defining the scope 2. Conducting background research 3. Developing coding questions 4. Collecting the law 6. Coding the law 7. Publication and dissemination 8. Tracking and updating the law

Quality Control

5. Creating the legal text

Tracking and updating legal data

Check periodically for new laws or updates to existing laws included in the project, to maintain the dataset

DISTRACTED DRIVING LAW

2 8

Leveraging policy surveillance

In policy surveillance projects, researchers must code every amendment or newly enacted law over time. This allows researchers to create a legal dataset that can be used in legal evaluations.

Quantitative Qualitative

Compares datasets from law and health Uses policy surveillance

2006 1996 2006

Identifies discrete impacts Uses cross-sectional data

Using Legal Mapping Findings for Legal Evaluation

We study law as a natural experiment

Changes in laws or systems provide evaluation opportunities No controls or treatment groups Results can facilitate diffusion of effective strategies

TREATMENT GROUP

REDUCTION IN CAR CRASHES/TRAFFIC FATALITIES

CONTROL GROUP

Quasi-Experimental Research Design

Check Data Sources

LEGAL OUTCOME

Example: The state Example: Number of traffic fatalities 5

Wendy found some useful data sources

Legal data

Policy surveillance Legal assessments Data.cdc.gov CDC’s STATE system LawAtlas.org Pdaps.org

Public health data

Surveillance data State or local costs System performance Program data

and designs a legal evaluation

Legal evaluation

• pportunities

Get to know legal data through summary and descriptive statistics Analyze trends (e.g., difference- in-difference or interrupted time series analyses) Interpret results and relationships Discuss statistical significance, limitations, and results

Remember: translate data effectively

What can policy surveillance achieve?

Policy Surveillance Guides Research

R² = 0.3335

5 10 15 20 25 30 35 40 50 100 150 200 TOTAL LAWS RELATING TO HIES AND HIOS AS OF JAN. 2014 (SIM STATES) % CHANGE IN THE NUMBER OF NON-FEDERAL ACUTE CARE HOSPITALS THAT ELECTRONICALLY EXCHANGED HEALTH …

R² = 0.1102

5 10 15 20 25 30 35 20 40 60 80 100 LAWS RELATED TO HIT OVERSIGHT BY STATE AS OF JAN. 2014 PERCENT OF ELIGIBLE STAGE 2 HOSPITALS’ ELECTRONIC REPORTING OF LABORATORY RESULTS, SYNDROMIC SURVEILLANCE AND …

Policy Surveillance Informs Agencies

State Ebola protocols. (August 19, 2016.) In Public Health Law Program. Retrieved June 6, 2017, from https://www.cdc.gov/phlp/publications/topic/ebola.html

… and Informs Stakeholders

Buzzell, J., Klaes, G., & Penn, M. (2014). Public health preparedness: An examination of legal language authorizing responses to incidents involving contamination with radioactive

• material. Atlanta, GA: Centers for Disease Control and Prevention, Office for State, Tribal, Local, and Territorial Support.

Policy Surveillance Tracks Progress

Behavioral therapy rates before and after implementation of a prior authorization policy for ADHD medications in Illinois

Data source: Medicaid Analytic Extract Files

Polar Graph on State School Vaccination Exemptions Law

www.cdc.gov/phlp/publications/topic/v accinations.html

… and Indicates Gaps and Future Priorities

Policy Surveillance Guides Best Practices

What We Discussed

How does law affect health? What is legal epidemiology? What is policy surveillance? How is it used in practice?

Thank you!

Tara Ramanathan, JD, MPH Team Lead for Research and Translation Public Health Law Program Center for State, Tribal, Local and Territorial Support (proposed) Centers for Disease Control and Prevention irt2@cdc.gov

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