RAND gives Cities Readiness Initiative good marks

Jun 7, 2012 (CIDRAP News) – A federal program designed to prepare communities to quickly distribute medications to the population to blunt a bioterrorist attack generally seems to be working well and making an impact, but there's room for improvement, according to a new report from the RAND Corp.

The assessment says the metropolitan areas and other units participating in the Cities Readiness Initiative (CRI) generally score well on performance capacity, but they could benefit from staging larger drills that more closely mimic real emergencies, among other steps.

The CRI is a Centers for Disease Control and Prevention (CDC) program that was born in 2004. Its goal is to equip metropolitan areas to provide life-saving medications to their populations in the event of a major bioterrorist attack, natural disease outbreak, or other health emergency.

The program currently includes 72 of the nation's largest urban areas along with various "planning jurisdictions," such as health departments and groups of cities within those areas, according to the report. All told, the program covers about 57% of the US population.

The CDC hired RAND in 2010 to assess (1) the capability of CRI communities to meet the program goal of delivering medical countermeasures within 48 hours, and (2) whether the program has actually improved communities' capability to meet that goal.

The study relied primarily on the CDC's existing CRI data collected over the years, including data from a standardized written assessment tool called the Technical Assistance Review (TAR) and self-reported data from program drills. The authors supplemented these sources by interviewing stakeholders in a few of the participating jurisdictions.

The CDC has conducted TARs on state health departments and on local jurisdictions within the participating metro areas, the report explains.

As of 2009-10, all the state health departments had overall TAR scores of at least 79%, the threshold of acceptability, and the average state score was 94%, the report says. "Although performance was strong across all functional areas, performance was somewhat lower in three particularly critical areas: coordination and guidance for dispensing, security, and distribution," it adds.

The TAR scores for local jurisdictions were aggregated to give a score for each federally defined Metropolitan Statistical Area (MSA). The average MSA scored 86% on the TARs, with a median of 89%, the RAND analysts found.

They found that local scores varied more than state scores and that local performance "was lower in the critical areas of training, exercise, and evaluation; security; and dispensing." MSAs in higher-scoring states with centralized public health systems performed better on the TAR than those in lower-scoring states with less centralization.

RAND also found that TAR scores have improved consistently for both states and MSAs. The median for states rose from 85% in 2006-07 to 95% in 2009-10, while the MSA median climbed from 52 to 89 over the same period.

There is also anecdotal evidence that the CRI has improved responses to real incidents, the investigators found. For example, three sites said preparations for rapid dispensing helped them set up vaccination clinics during the 2009 flu pandemic.

"The fact that greater 'exposure' to CRI is associated with considerable increases in TAR scores is consistent with CRI having an effect on preparedness," the report states. "However, the absence of data from a representative comparison group makes it difficult to rule out the possibility that other factors drove the increases. Thus, the findings must be regarded as suggestive but not conclusive."

As for test exercises, participating units conducted 1,364 drills in 2008-09 and 1,422 in 2009-10, but few have run large-scale exercises, the report says. For example, in 2009-10, only 32% of exercises that tested medication dispensing involved 500 clients or more.

Conducting larger exercises is one of the report's five recommendations. It says that larger drills, such as ones involving a jurisdiction's entire point-of-dispensing volunteer list, would lead to more realistic assessments of capabilities.

In other recommendations, the report suggests that the CDC should:

  • Try to validate TAR scores, ie, determine whether they reflect real differences in communities' preparedness.
  • Improve performance feedback to jurisdictions and develop better tools to help them improve.
  • Consider encouraging states to collect more data on non-CRI communities to permit systematic comparisons between CRI and non-CRI areas.
  • Assess the program's cost-effectiveness.

See also:

RAND report access page

Report summary

Full text of report (76 pages)

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