CDC Panel: Community Guides and US Preventive Services Task
Force
Theresa Ann Sipe, PhD, MPH, RN Statistician
The Guide to Community Preventive ServicesNational Center for Health Marketing
Centers for Disease Control and Prevention
Overview1. What is the Guide to Community Preventive
Services (Community Guide)? Is it credible? Relevant to the issues I face?
2. What are key challenges to disseminating evidence-based information and translating it into action?
3. How does the Community Guide aim for: Credibility Dissemination of its recommendations?
4. What are implications for nursing?
The Community Guide is: Systematic reviews of the
available evidence
Formulated by a team of renowned researchers, public health practitioners, representatives of health organizations
Concise, carefully-considered recommendations for policy and practice
Identification of research gaps
The Clinical Guide and Community Guide Are Complementary
The Clinical and Community Guides Are Complementary
Individual levelClinical settingsDelivered by healthcare providers Screening, Counseling, etc.
Group level Health system changes Insurance/benefits coverage Access to/provision of servicesCommunity, population-based Informational (Group Education, Media) Behavioral, Social Environmental & Policy Change
Community Guide(TFCPS
Recommendations)
Clinical Guide (USPSTF
Recommendations)
Community Guide (CG) TopicsThe EnvironmentSocial Environment
SettingsWorksites
Schools
Risk Behaviors Specific ConditionsTobacco Use
Alcohol Abuse/Misuse
Other Substance Abuse
Poor Nutrition
Inadequate Physical Activity
Unhealthy Sexual Behaviors
Vaccine-Preventable Disease
Pregnancy Outcomes
Violence
Motor Vehicle Injuries
Depression
Cancer
Diabetes
Oral Health
Obesity
Community Guide Accomplishments >200 systematic review findings
completed
“Family of Products” Book
• First book published in January 2005
www.thecommunityguide.org, Oxford Press
Publications Web site
www.thecommunityguide.org
Community Guide: How is it Used?
To inform decision making around:
Practice
Policy making
Research
Research Funding
Community Guide: Intended Users Public Health Practitioners
Program planning, grant guidance, focus for research funding goals
Healthcare Providers System-level interventions for effective clinical
services delivery Group based interventions to prevent/reduce
Employers Healthy worksite interventions, benefit plan
design/selection Community-based Organizations
Program planning, grant guidance, focus for research funding goals
Legislators & Policy Makers Broad policies, targeted laws, educational
system requirements, community-wide interventions
Researchers Conduct research on “insufficient evidence”
findings, other research gaps Funders
Develop requests for proposals, fund studies of identified research gaps
[The General Public – a secondary audience]
Community Guide: Intended Users (cont’d)
Bottleneck in Translating Health Research into Action
There is insufficient recognition of the complexities inherent in putting health research findings into practice across diverse communities, settings, and situations
“I want you to quit smoking and lose 35 pounds. Then I want you to come back and
tell me how the hell you did it.”
“I want you to quit smoking and lose 35 pounds. Then I want you to come back and tell me how the hell you did it.”
Bottleneck: Research Must Meet the Diversity of Practice Needs
If research is to guide practice, it must consider internal and external validity Internal:
• Are we measuring what we purport to measure? External:
• How applicable is this to real-world settings, situations?
• Generalizability • Adaptaptability
– Locally appropriate and affordable – Special populations, underserved areas, low
SES/education
Application Gaps Accessibility gap
Do I have the same resources as the experimenters?
Credibility gap How different is their situation of practice from
mine?
Expectations gap Is it really necessary for me to strive for such
lofty goals in my practice?– Lancaster B. Closing the gap between
research and practice. Health Educ Q 1992;19:408-411
Addressing the Bottleneck: #1
“If we want more evidence-based practice, then we need more practice-based evidence”
– Lawrence W. Green
Lesson for systematic reviews: Consider external validity alongside internal
validity
The Typical Approach to Dissemination of Evidence:
A Push Model
Systematic Review of the
Scientific Evidence
By researchers
Practice, PolicyDissemination
Knowledge to Action Continuum
Participationand Collaboration
Participationand Collaboration
DisseminationDissemination
Planning, AssessingUptake and Quality
Planning, AssessingUptake and Quality
Identify Research-Practice Gaps
Identify Research-Practice Gaps
How to MeasureEffects
How to MeasureEffects
TranslationTranslation
Public Health Research&
Systematic Reviews of Research
Surveillance & Evaluation
Monitoring, NeedsAssessment
ActionPractice, Policy
Lawrence W. Green, DrPH & Shawna L. Mercer, MSc, PhD
Addressing the Bottleneck: #2
Actively engaging those who will be users in the systematic review and dissemination processes, it is more likely the findings and recommendations will be relevant to their needs
Participatory Research is…
“Systematic inquiry With the collaboration of those affected by
the issue being studied For the purposes of education and taking
action or effecting social change”
Green, et al., 1995
Study of Participatory Research in Health Promotion.
Whose Participation Should be Sought in the Systematic Review
Process? Who is to be affected by the research
results? Who are the intended users? Practitioners Policy makers Professional organizations Nongovernmental organizations Health departments Employers Representatives of minority or special
populations
The CG Seeks to Answer Key Questions about Interventions
Do they work? How well? For whom? Under what circumstances are they
appropriate? What do they cost? Do they provide value? Are there barriers to their use? Are there any harms? Are there any unanticipated outcomes?
Community Guide Places Equal Weight on:
The quality of the systematic review methods and analysis
The group processes
Participants in the Community Guide
1. Task Force on Community Preventive Services
Nonfederal, independent, rotating Internationally renowned experts in public health
research, practice, policy Established by HHS as resource for public health Appointed by CDC director Oversee priority setting, topic and intervention
selection, and individual reviews Make recommendations for policy, practice,
research
Task Force on Community Preventive Services
Current Members
Jonathan C. Fielding, MD, MPH, MBA, Chair
Bruce Nedrow Calonge, MD, MPHJohn M. ClymerKay Dickersin, PhDKaren Glanz, PhD, MPHRon Goetzel, PhDRobert L. Johnson, MD
Barbara K. Rimer, DrPH, Vice-Chair
Ana Abraido-Lanza, PhDNico P. Pronk, PhDGilbert Ramirez, DrPHC. Tracy Orleans, PhDLawrence W. Green, DrPH
Current Consultants
Robert S. Lawrence, MD
J. Michael McGinnis, MD
Alonzo L. Plough, PhD, MPHSteven M. Teutsch, MD, MPH
Participants in the Community Guide
2. Official Liaisons >25 federal agency and organizational Provide input into prioritization, reviews,
recommendations Recommend, find participants for review teams Participate in dissemination, translation especially
to their constituents
Official Federal Agency Liaisons Agency for Healthcare
Research and Quality Centers for Medicare
and Medicaid Services Department of Health
and Human Services Department of
Veterans Affairs Health Resources and
Services Administration
National Institutes of Health
Indian Health Service Navy Environmental
Health Center Office of Disease
Prevention and Health Promotion
United States Air Force United States Army
Official Organizational Liaisons American Academy of
Family Physicians American Academy of
Nurse Practitioners American Academy of
Physician Assistants American Association
of Health Plans American Association
of Public Health Physicians
American College of Preventive Medicine
American Public Health Association
Association of Schools of Public Health
Association of Teachers of Preventive Medicine
Institute of Medicine
Official Organizational Liaisons (cont’d)
Association of State and Territorial Health Officials
National Association of County and City Health Officials
National Association of Local Boards of Health
Public Health Foundation
Society for Public Health Education
Bright Futures Education Center Advisory Committee
Participants in the Community Guide
3. Stakeholders, partners For specific topics, reviews Participate on review teams Provide input to Task Force on topic prioritization,
formation of recommendations Participate in dissemination, translation
Participants in Individual Reviews Coordination Team
Coordinating scientist (Community Guide) Fellows, abstractors (Community Guide) Subject matter experts
• From CDC, other federal agencies, academia, practice, policy settings
Task Force member(s) [Liaison(s)]
Consultation Team Subject matter experts
Community Guide Staff
Intended Users Participation: Are we…
Prioritizing the right topics and interventions?
Asking the right questions?
Appropriately considering context, other issues of external validity?
Thinking proactively about interpretability, relevance, usefulness, use?
Planning for dissemination from the outset?
Intended Users Participation in Planning for Dissemination
Aim: How do we create awareness, interest, support, buy-in, channels? Proactively
• Who should be involved on the teams?• Who should be kept apprised during the
review?• Whose buy-in is important?• Who can access appropriate channels?• Who has wide influence, credibility?
Reactively• How do we make sure we are ready to
respond to events, teachable moments, opportunities?
Transparency (A Minor Detail!)
Community Guide Review Process Convene review teams
Coordination team Consultation team
Develop a conceptual framework
Develop prioritized list of interventions
Develop, refine clear research questions
Search for evidence
Community Guide Review Process Abstract and critically evaluate the available
studies Summarize the evidence
Calculate effect sizes Summarize effect sizes
• Median or mean• Homogeneity tests• Meta-analysis• Meta-regression
Task Force discussion and recommendations Disseminate the results Support translation into action
Issues Considered in Guide Reviews
Intervention IntendedOutcomes
Morbidityand/or
MortalityAdditionalOutcomes
Benefits
Harms
Barriers
EconomicInformation
Applicability of the evidence
In General, a Conclusion About Effectiveness Requires….
A Body of Evidence
•Number of studies
•Quality of studies
•Suitability of study design
+
Consistency of Effect
Sufficient Magnitude of Effect+
“Most” studies demonstrated an effect in the direction of the intervention
The effect demonstrated across the body of evidence is “meaningful”
A Demonstration of Effectiveness
Strength of a Task Force Conclusion
STRONG evidence of effectiveness
SUFFICIENT evidence of effectiveness
INSUFFICIENT evidence Doesn’t mean the intervention is not effectiveBUT RATHER “We can’t determine at this time whether or
not this intervention works.”
Task Force Recommendation Options
Recommend Strong Evidence Sufficient Evidence
Recommend against Strong Evidence Sufficient Evidence
Insufficient evidence to recommend for or against
What to Do with Insufficient Evidence If the intervention is currently being used
May want to continue using it if there are no associated harms
May choose to stop due to issues such as cost
If the intervention is not being used May not want to begin using it
Consider: Are there are better-documented alternatives for
reaching the same goals?
What to Do with Sufficient Evidence
“Even if it is evidence-based, it is not certainty.”
McGinnis and Foege
Not a cookbook or a one-size-fits-all solution
Users must combine scientific information(e.g., effectiveness, cost) with other information (e.g., needs, values, capacities, resources)
Examples of Community Guide Recommendations
Breast, Cervical and Colorectal Cancer Screening
Tobacco Interventions
What Population-Based and Health System Interventions are Effective in Increasing
Breast, Cervical, and Colorectal Cancer Screening?
1. Looked for evidence of effectiveness of breast, cervical, colorectal cancer screening
Guide to Clinical Preventive Services
2. Grouped interventions into strategies:a) Client-directed- Increase community demand
• Knowledge/awareness, perception/fear/attitude, motivation, forgetfulness
b) Increase service delivery by health providers• Provider-client interaction
Initial Steps
Client reminder
Client incentive
Mass media
Small media
Group education
One-on-one education
Increasing Community Demand:
Provider reminder
Provider assessment and feedback
Provider incentive
Increasing Provider Delivery:
Change KnowledgeAttitudes Intentions
Other benefits or harms?
Efficacy Established
Increase demande.g., reminder, small media,
group education
Follow-upDiagnosisTreatment
Increase completedscreening
(Early detection)
Increasing Community Demand:Conceptual Approach
DecreaseMorbidityMortality
Provider role e.g., reminder, assessment &
feedback
Follow-upDiagnosis/Treatment
IncreaseTest offering/ordering
IncreaseDiscussion of test
with clients
Change providerKnowledgeAttitudesIntentions
Increase completed screening
(Early detection)
DecreaseMorbidityMortality
Change client Knowledge
Attitudes Intentions
Efficacy Established
Increasing Provider Delivery:Conceptual Approach
Other benefits or harms?
Step 2. Screen titles and abstracts
Step 3. Screen article text*
Step 4. Sort by intervention:
Step 1. Search data bases using key terms
> 8420 articles excluded
~ 336 articles excluded
*Inclusion criteria: published in English; primary study; one or more selected interventions; one or more selected outcomes; suitable comparison
~ 580 articles/studies pass screen
244 studies pass screen (“Candidate studies”)
> 9000 citations found
Client reminders Small media Client incentives
One-on-one education
Group education
Reducing out-of-pocket cost Reducing structural barriers
Mass media
Provider reminders Provider incentives Provider assessment & feedback
Multi-component interventions
Search Results
Printed (letter or postcard) or telephone messages advising people they are: Due (reminder) for screening Late (recall) for screening
May be enhanced by: A follow up printed or telephone reminder Additional text or discussion about
• Indications for screening• Benefits of screening• Overcoming barriers to screening
Assistance scheduling appointments Tailoring
Increasing Community Demand: Client Reminder
Client Reminders: Applicability
Studies: HMOs in US, clinics in Canada & Israel
Limited/no description of: SES, racial-ethnic, screening backgrounds of
study participants Geographic settings of studies
Studies of client reminders for breast, cervical screening suggest broad applicability
Client Reminders: Conclusions
FOBT: Recommended Sufficient evidence
Flexible sigmoidoscopy, colonoscopy, barium enema: Insufficient evidence No qualifying studies
Inform, cue, or remind providers or other health care professionals that individual clients are: Due (reminder) for screening, or Overdue (recall) for screening
Notes in client charts or Memorandum or letter
Provider Reminder: Breast, Cervical & Colorectal Cancer Screening
US, Italy, UK, Canada, Australia, and Israel
University hospitals, clinics, HMOs, and independent offices
Urban and rural White and African-American (clients)
Physician trainees (residents/interns) and non-trainees
Due and overdue for screening
Provider Reminders: Applicability
Barriers Access to electronic/computerized records Perceived physician time investment
Other benefits/harms May increase utilization of other preventive services No harms reported
Provider Reminders
Provider Reminders: Conclusions
For breast, cervical, colorectal (FOBT and flexible sigmoidoscopy) Recommended Strong evidence
Evidence of Effectiveness for Cancer Screening Interventions
Breast Cervical Colorectal
Community Demand:
Client reminder Strong Strong Sufficient
Client incentive Insufficient* Insufficient* Insufficient*
Mass media Insufficient* Insufficient** Insufficient*
Small media Strong Strong Strong
Group education Insufficient† Insufficient** Insufficient†
One-on-one education Strong Strong Insufficient**
Community Access:
Reduce structural barrier Strong Insufficient** Strong
Reduce out-of-pocket expense Sufficient Insufficient** Insufficient*
Provider Role:
Provider reminder Strong
Provider assessment & feedback Sufficient
Provider incentive Insufficient**
Reason evidence insufficient: * No studies** Too few studies† Inconsistent findings
Community Guide reviews and recommendations to reduce
tobacco use and exposures to secondhand tobacco smoke
Selected interventions appropriate for
communities and health care systems
Background Efforts to reduce tobacco use are
measured in two important ways A change (increase) in tobacco use cessation
in a study population of tobacco users
A change (reduction) in tobacco use prevalence in an overall population• In populations of youth, prevalence change
is a proxy for tobacco use initiation
A Study Example with a Little Math
Evidence of Real-World Effectiveness of a Telephone Quitline for Smokers
(Zhu et al. NEJM 2002)
California Smokers’ Helpline Randomized, controlled trial of telephone-based
cessation assistance Smokers who were ready to quit (N=3282)
Intervention: Proactive telephone counseling + self-help materials
Comparison: Self-help materials + call-back option
Follow-up: 1,3,6, and 12 months
Study Results and Review Calculations
Group n Quit at 12m f/uIntervention (I) 1973 9.1%Comparison (C) 1309 6.9%
p<0.001
Absolute change: I-C = +2.2 percentage points
Relative change: (100) (I-C)/C = +32%
Number Needed to Treat: 100/(I-C)= 45 smokers to get one additional quit
One Study in an Overall Review
Evidence from 32 different studies contributed to the final Task Force assessment and conclusion
Across this body of evidence: Median change in tobacco cessation
• Absolute +2.6 percentage points at 12m f/u• Relative +41%• Number needed to treat: 38 smokers to get one additional quit
Task Force Conclusion
The Task Force recommends telephone cessation support when implemented with other interventions (e.g. other educational approaches or clinical therapies) based on strong evidence of effectiveness in increasing tobacco use cessation among participants in both clinical and community settings. The minimum effective combination identified in this review was proactive telephone support combined with patient education materials.
Recommendations from the Task Force on Community Preventive
Services
Selected Interventions, appropriate for communities and health care systems, to reduce tobacco use and exposures to secondhand tobacco smoke
In Health Care SystemsGoal Task Force Recommendations for Use of
these InterventionsIncrease Cessation
- Provider reminder systems alone or with additional efforts- Telephone Quit services + additional efforts- Reducing patient costs for effective cessation therapies
Reduce Initiation
( Not reviewed)
Reduce Exposures
- Smoke-free policies
In Health Care SystemsGoal Task Force findings of Insufficient Evidence
to draw a conclusion
Increase Cessation
- Provider education programs (alone)- Provider feedback systems
Reduce Initiation
(Not reviewed)
Reduce Exposures
In CommunitiesGoal Task Force Recommendations for Use of
these InterventionsIncrease Cessation
- Increase the price (tax)- Mass media campaigns + additional efforts - Telephone Quit services + additional efforts- Smoke-free policies (New)
Reduce Initiation
- Increase the price (tax)- Mass media campaigns + additional efforts- Community mobilization + additional efforts to reduce youth access
Reduce Exposures
- Smoke-free policies
In CommunitiesGoal Task Force findings of Insufficient Evidence
to draw a conclusion
Increase Cessation
- Community-based cessation contests- Cessation broadcast series
Reduce Initiation
- School-based programs when implemented alone- Retailer education to reduce access when implemented alone- Active enforcement of sales laws when implemented alone
Reduce Exposures
- Efforts to reduce secondhand smoke exposure in the home
“Public health is purchasable. Within a few natural and important limitations any community can determine its’ own death rate.”
Hermann BiggsMedical Officer
New York City DOH 1905
For More Information Community Guide website:
www.thecommunityguide.org
American Journal of Preventive Medicine
Theresa Ann Sipe, Statistician, Community Guide [email protected]
Shawna Mercer, Community Guide Director [email protected] findings and conclusions in this presentation are those of the presenter and do not necessarily represent the views of CDC.
Videos or printed materials Letters, brochures, pamphlets, flyers,
newsletters
Distributed from healthcare or community settings
Educational or motivational information Based on behavior change theories
May be tailored or untailored
Increasing Community Demand: Small Media
Small Media: Applicability
Studies in UK and US
Study participants White, African-American Some low SES Urban and rural Clinical and community settings
Suggest broad applicability
Only one tailored intervention
Small Media: Conclusions
FOBT: Recommended Strong evidence
Flexible sigmoidoscopy, colonoscopy, barium enema: Insufficient evidence No qualifying studies