Download ppt - Extreme Makeover -- Data Edition: Inside the Box

Extreme Makeover -- Data Edition: Extreme Makeover -- Data Edition: Inside the BoxInside the Box

Presentation at the CityMatch Conference, August 2007

Michael Kogan, Ph.D.U.S. Department of Health and Human Services

(DHHS)Health Resources and Services Administration

(HRSA)Maternal and Child Health Bureau (MCHB)

Director, Office of Data and Program Development

Presentation OutlinePresentation Outline Definition of ‘evidence’Definition of ‘evidence’ Discussion of evidence-based medicineDiscussion of evidence-based medicine Discussion of evidence-based public Discussion of evidence-based public

healthhealth How to use evidence-based approachesHow to use evidence-based approaches Evidence-based maternal and child healthEvidence-based maternal and child health

What is “Evidence”?What is “Evidence”?

Information that is collected in an orderly Information that is collected in an orderly way about a disease or its treatment. way about a disease or its treatment.

– CDC websiteCDC website

Are Evidence-Based Practices Are Evidence-Based Practices Applicable Only to the Health Applicable Only to the Health

Field?Field?

Evidence-Based BaseballEvidence-Based Baseball

Michael Lewis's book, Moneyball, Michael Lewis's book, Moneyball, documents the effective use of evidence-documents the effective use of evidence-based practices by Billy Beane, the based practices by Billy Beane, the general manager of the Oakland general manager of the Oakland Athletics. Lewis shows how Beane's Athletics. Lewis shows how Beane's reliance on theoretically relevant reliance on theoretically relevant statistics and on a scientific approach to statistics and on a scientific approach to baseball allowed him to achieve winning baseball allowed him to achieve winning seasons despite being burdened with seasons despite being burdened with severe budget constraints. severe budget constraints.

Evidence-Based BaseballEvidence-Based Baseball What predicts which amateur hitters What predicts which amateur hitters

make it to the big leagues and become make it to the big leagues and become successful players:successful players:– Ability to hit home-runs?Ability to hit home-runs?– Foot-speed?Foot-speed?– Fielding ability?Fielding ability?– Number of walks that a hitter drew?Number of walks that a hitter drew?


Answer: The number of walks that a Answer: The number of walks that a hitter drew, signifying his ability to hitter drew, signifying his ability to understand how to control the strike understand how to control the strike zone.zone.– Lewis, Moneyball, 2003.Lewis, Moneyball, 2003.


What is the biggest predictor of runs What is the biggest predictor of runs scored by a team over a season:scored by a team over a season:– Number of home-runs?Number of home-runs?– Team batting average?Team batting average?– On-base percentage?On-base percentage?– Number of steals?Number of steals?


Answer: On-base percentage.Answer: On-base percentage.– Lewis, Moneyball, 2003.Lewis, Moneyball, 2003.

What is “Evidence-Based What is “Evidence-Based Medicine”?Medicine”?

Health care practices that are based on Health care practices that are based on review of the current best evidence on review of the current best evidence on the effectiveness of a test, drug, surgery the effectiveness of a test, drug, surgery or other medical practice. or other medical practice.

Based on collecting and analyzing all of Based on collecting and analyzing all of the research studies that have been the research studies that have been conducted on a particular intervention.conducted on a particular intervention.

These reviews are called meta-analyses These reviews are called meta-analyses and systematic reviews.and systematic reviews.

Rise of Evidence-Based MedicineRise of Evidence-Based Medicine

First described in 1992First described in 1992 A new approach to teaching medicineA new approach to teaching medicine A “revolution” in medical practiceA “revolution” in medical practice Other “evidence-based” approaches: Other “evidence-based” approaches:

ethics, psychotherapy, occupational ethics, psychotherapy, occupational therapy, dentistry, nursing, and therapy, dentistry, nursing, and librarianshiplibrarianship

Factors Driving EBMFactors Driving EBM

Overwhelming size of the literatureOverwhelming size of the literature Inadequacy of textbooksInadequacy of textbooks Difficulty synthesizing evidence and Difficulty synthesizing evidence and

translating into practicetranslating into practice Increased number of randomized control Increased number of randomized control

trialstrials Available computerized databasesAvailable computerized databases Reproducible evidence strategiesReproducible evidence strategies

Steps of EBMSteps of EBM Convert the need for info. into an Convert the need for info. into an

answerable questionanswerable question Track down the best evidenceTrack down the best evidence Critically appraise that evidenceCritically appraise that evidence Integrate the appraisal with one’s clinical Integrate the appraisal with one’s clinical

expertise and the individual patientexpertise and the individual patient EvaluateEvaluate

Sackett DL. EBM: how to practice and teach EBM. Churchill Livingstone 2000

Differences between Medicine and Differences between Medicine and Public HealthPublic HealthPublic HealthPublic Health Medicine Medicine

Primary Focus Primary Focus PopulationsPopulations Individuals Individuals

Emphasis Emphasis PreventionPrevention DiagnosisDiagnosis

Health PromotionHealth Promotion TreatmentTreatment

Whole CommunityWhole Community Whole PatientWhole Patient

Paradigm Paradigm Interventions Interventions aimed at aimed at Environment, Environment, Human Behavior Human Behavior and Lifestyle, and and Lifestyle, and Medical CareMedical Care

Medical CareMedical Care

Differences between Medicine and Differences between Medicine and Public Health (continued)Public Health (continued)

Public HealthPublic Health Medicine Medicine Organizational Organizational Lines of Lines of SpecializationSpecialization

Analytical Analytical (Epidemiology)(Epidemiology)

Organ (Cardiology)Organ (Cardiology)

Setting and Setting and Population Population

(Occupational Health)(Occupational Health)

Patient Group Patient Group (Pediatrics) (Pediatrics)

Substantive Health Substantive Health Problem (Nutrition)Problem (Nutrition)

Etiology, Etiology, Pathophysiology Pathophysiology (Oncology, Infectious (Oncology, Infectious

Disease)Disease) Skills in Assessment, Skills in Assessment, Policy Development, Policy Development, and Assurance and Assurance

Technical Skill Technical Skill

(Radiology)(Radiology)

Development of Evidence Based Development of Evidence Based Public HealthPublic Health

Jenicek (1997) published a review Jenicek (1997) published a review discussing epidemiology, EBM, EBPHdiscussing epidemiology, EBM, EBPH

Epidemiology described as the foundation Epidemiology described as the foundation of both EBM and EBPHof both EBM and EBPH

EBPH unique in using complex EBPH unique in using complex interventions with multiple community interventions with multiple community and societal issuesand societal issues

Jenicek M. J Epidemiol 1997;7:187-Jenicek M. J Epidemiol 1997;7:187-9797

Definition of EBPH (1)Definition of EBPH (1)

““EBPH is the conscientious, EBPH is the conscientious, explicitexplicit, and , and judiciousjudicious use of current use of current best evidencebest evidence in in making decisions about the care of making decisions about the care of communities and populations in the communities and populations in the domain of health protection, disease domain of health protection, disease prevention, health maintenance and prevention, health maintenance and improvement.”improvement.”

Jenicek (1997)Jenicek (1997)

Definition of EBPH (2)Definition of EBPH (2)

Evidence-based public health is defined Evidence-based public health is defined as the development, implementation, as the development, implementation, and evaluation of effective programs and and evaluation of effective programs and policies in public health through policies in public health through application of principles of scientific application of principles of scientific reasoning, including systematic uses of reasoning, including systematic uses of data and information systems, and data and information systems, and appropriate use of behavioral science appropriate use of behavioral science theory and program planning models.theory and program planning models.

Brownson, et al, 2003Brownson, et al, 2003

Brownson RC. J Public Health ManaBrownson RC. J Public Health Manag Pract 1999;5:86-87g Pract 1999;5:86-87

Steps of EBPHSteps of EBPH Develop an initial statement of the issueDevelop an initial statement of the issue Search the scientific literature and Search the scientific literature and

organize informationorganize information Quantify the issue using sources of Quantify the issue using sources of

existing dataexisting data Develop and prioritize program options; Develop and prioritize program options;

implement interventionsimplement interventions Evaluate the program or policyEvaluate the program or policy

Steps to Searching the Public Health Steps to Searching the Public Health LiteratureLiterature

Determine the public health problem and Determine the public health problem and define the question.define the question.

Select information sources.Select information sources. Identify key concepts and terms.Identify key concepts and terms. Conduct the search in subject-appropriate Conduct the search in subject-appropriate

databases.databases. Select documents for review.Select documents for review. Abstract relevant information.Abstract relevant information. Summarize and apply the literature Summarize and apply the literature

review.review. Brownson, et al. 2003.Brownson, et al. 2003.

Evaluating the Quality and Methods Evaluating the Quality and Methods of Public Health Research Resultsof Public Health Research Results

What are the results?What are the results?– Were the results similar from study to study?Were the results similar from study to study?– What are the overall results of the review?What are the overall results of the review?– How precise were the results?How precise were the results?– Can a causal association be inferred?Can a causal association be inferred?

Are the results valid?Are the results valid?– Did the review explicitly address the PH question?Did the review explicitly address the PH question?– Was the search exhaustive?Was the search exhaustive?– Were the primary studies of high methodological Were the primary studies of high methodological

quality?quality? How can the results be applied to PH practice?How can the results be applied to PH practice?

– How can the results be interpreted and applied?How can the results be interpreted and applied?– Were all the important PH outcomes considered?Were all the important PH outcomes considered?– Are the benefits worth the costs and potential risks?Are the benefits worth the costs and potential risks?

Brownson, et al. 2003.Brownson, et al. 2003.

How are Decisions Usually Made?How are Decisions Usually Made?

Decisions on policies and programs are Decisions on policies and programs are often made based on:often made based on:– Personal experiencePersonal experience– What we learned in formal trainingWhat we learned in formal training– What we heard at a conferenceWhat we heard at a conference– What a funding agency required/ suggested What a funding agency required/ suggested – What others are doing What others are doing

Evidence and Public Health Decision Evidence and Public Health Decision MakingMaking

Good newsGood news– Strong evidence on the effect of many Strong evidence on the effect of many

policies/ programs aimed to improve public policies/ programs aimed to improve public healthhealth

– Major efforts underway to assess the body Major efforts underway to assess the body of evidence for wide range of public health of evidence for wide range of public health interventions interventions

What Works to Improve the Public’s What Works to Improve the Public’s Health?Health?

Bad newsBad news– Many public health professionals are Many public health professionals are

unaware of this evidenceunaware of this evidence– Some who are aware don’t use it Some who are aware don’t use it – Many existing disease control programs Many existing disease control programs

have interventions with insufficient have interventions with insufficient evidence –while others use interventions evidence –while others use interventions with strong evidence of effectivenesswith strong evidence of effectiveness

– Lack of use of effective interventions can Lack of use of effective interventions can adversely affect fulfilling mission and adversely affect fulfilling mission and getting public supportgetting public support

Barriers Facing Evidence-Based Barriers Facing Evidence-Based Public HealthPublic Health

““Evidence-based research tells you what Evidence-based research tells you what you should do, not what you can do … you should do, not what you can do … What a lot of us are facing is no matter What a lot of us are facing is no matter how much evidence you have, you just how much evidence you have, you just don’t have enough resources.”don’t have enough resources.”– A Title V Director (interviewed for an A Title V Director (interviewed for an

evaluation study)evaluation study)

Evidence-Based Maternal and Child Evidence-Based Maternal and Child HealthHealth

True or False:True or False: The more prenatal care a woman The more prenatal care a woman

receives, the better her birth outcomes?receives, the better her birth outcomes?


FALSE:FALSE: If a woman receives MORE than the If a woman receives MORE than the

recommended amount of care, she is recommended amount of care, she is more likely to have worse birth outcomes.more likely to have worse birth outcomes.


True or false:True or false: For women who are experiencing For women who are experiencing

problems with their pregnancy, bed rest problems with their pregnancy, bed rest is effective in preventing preterm labor.is effective in preventing preterm labor.


FALSE:FALSE: Obstetric practices for which there is little Obstetric practices for which there is little

evidence of effectiveness in preventing or evidence of effectiveness in preventing or treating preterm labor include bed rest.treating preterm labor include bed rest.– Goldenberg, Obstetrics and Gynecology, Goldenberg, Obstetrics and Gynecology,

20022002

ResourcesResources Medline search Medline search

(http://www.ncbi.nlm.nih.gov/sites/entrez)(http://www.ncbi.nlm.nih.gov/sites/entrez) Cochrane Collaboration (www.cochrane.org)Cochrane Collaboration (www.cochrane.org) Task Force on Community Preventive Services Task Force on Community Preventive Services

(http://www.thecommunityguide.org/)(http://www.thecommunityguide.org/) National Guideline Clearinghouse National Guideline Clearinghouse

(http://www.guideline.gov/) (http://www.guideline.gov/) The Institute of Medicine (www.iom.edu)The Institute of Medicine (www.iom.edu) Evidence-Based Practice for Public Health Evidence-Based Practice for Public Health

(http://library.umassmed.edu/ebpph/)(http://library.umassmed.edu/ebpph/) Best Practices at the Local Level Best Practices at the Local Level

(http://archive.naccho.org/modelPractices/)(http://archive.naccho.org/modelPractices/)

ResourcesResources

Promising Practices Network for Children Promising Practices Network for Children (http://promisingpractices.net/programs_o(http://promisingpractices.net/programs_outcome.asp)utcome.asp)

AcknowledgmentsAcknowledgments

Jonathan Fielding, MD, Los Angeles County Jonathan Fielding, MD, Los Angeles County Dept. of Health ServicesDept. of Health Services

Neal Kohatsu, MD, University of IowaNeal Kohatsu, MD, University of IowaHarvey Fineberg, MD, Harvard UniversityHarvey Fineberg, MD, Harvard University

Contact InformationContact Information

Michael Kogan, Ph.D.Michael Kogan, Ph.D.HRSA/MCHBHRSA/MCHBDirector, Office of Data and Program Director, Office of Data and Program

DevelopmentDevelopment5600 Fishers Lane, Room 18-415600 Fishers Lane, Room 18-41Rockville, MD 20857Rockville, MD [email protected]@hrsa.gov