evidence-based public health
DESCRIPTION
Evidence-based public health. Making decision about health services. Fellow 52 (EBM course): 26 Oct 10. outline. Why focus on decision making ? How the decision is made ? Analytic tools and approaches to enhance the uptake of EBPH Examples and shared experience Assignment. - PowerPoint PPT PresentationTRANSCRIPT
EVIDENCE-B
ASED PUBLIC
HEALTH
MAKING D
ECISIO
N ABOUT
HEALTH S
ERVICES
Fellow 52 (EBM course): 26 Oct 10
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OUTLINE
Why focus on decision making ?
How the decision is made ?
Analytic tools and approaches to enhance the uptake of EBPH
Examples and shared experience
Assignment
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WHY FOCUS ON DECISION MAKING ?
1. An enormous number of decisions is made
2. Under limited of health care resources
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HOW THE DECISION IS MADE ?
evidenceValuesneeds
resources
OBDM –opinion-based decision making
EBDM –opinion-based decision making
Increasing pressure
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EVIDENCE- BASED PUBLIC HEALTH INTERVENTIONAny intervention to improve the public health must act on at
least one of the health determinants of health
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genetic Health status
Physical env Social env
Biological env Health services
FOUR TYPES OF INTERVENTION
Health care
Educational
Social and community action
legislative
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HEALTH CARE
Effect population health > individual
Evidence of effectiveness of these intervention should meet the same requirement
Systematic review and RCT: gold standard
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EDUCATIONAL
Currently subject to less rigorous scrutiny then health care intervention
The Campbell Collaboration
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SOCIAL AND COMMUNITY ACTION
Difficult to evaluate in RCT
Unit of intervention = community
Cautious to interpreting the results
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THE USE OF LEGISLATIVE POWER TO IMPROVE THE PUBLIC HEALTH
Pragmatic about the influence of evidence during the decision making process
Public health profession VS politician
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ANALYTIC TOOLS AND APPROACHES TO ENHANCE THE UPTAKE OF EBPHWhat is the size of the public health problem?
Are there effective interventions for addressing problem?
What information about the local context and this particular intervention is helpful in deciding its potential use in the situation at hand?
Is a particular program or policy worth doing and will it provide a satisfactory return on investment, measured in monetary terms or in health impacts?
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PUBLIC HEALTH SURVEILLANCE
On going systematic collection, analysis and interpretation of specific health data
Integrated with the timely dissemination of these data to responsible person
Regularly evaluate the effectiveness of the use of the disseminated data
Exp: lead level in blood in the US population
used as the justification for eliminating lead painting and gasoline
Exercise: Identify the public health surveillance systems in your workplace and discussion about the systems, strength, weakness and possibility to improve
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SYSTEMATIC REVIEWS AND EVIDENCED-BASED GUIDELINES
One of the most useful sets of review for public health intervention:
the guide to community preventive services (http://www.thecommunityguide.org)
The quality of systematic review articles: see checklists
the local context condition
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Cost-effectiveness analysis (CEA)
Cost-utility analysis (CUA)
Cost-benefit analysis (CBA)
Economic evaluation
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MAJOR DIFFERENCE OF THESE ANALYSIS
Method Outcome Example Application
CEA Natural unit Life year save
Functional status
Compare between programme measured in same unit
CBA Monetary term $, Baht Compared between programme producing different type of health outcomes
CUA Both qualitative and quantitaive aspects of health outcome
Quality-adjusted life years (QALYs)
Compared between programme producing different type of health outcomes
ECONOMIC EVALUATION: OTHERS
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Sensitivity analysisOptimization of resource allocation
PARTICIPATORY APPROACH
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Promise communities in EBPHStakeholdersThree groups: program operations
: those affected by the program : primary users of the evaluation
CASE STUDY 1: กองทุ�นทุ�นตกรรม
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evidenceValuesneeds
resources
Evidence: unit cost for specific servicePapers: Thai and other countriesAppraisal: methods and context : main papersAnalytic tool: Sensitivity analysis Present monetary valueApplication: based on these information
paper 1 paper2
Service UC-original Min%indirect Max%indirect Mean%indirect Min%LC Max%LC Mean%LC
Hexam 109 101 128 112 103 106 104OHImobile 41 37 49 42 38 40 39Hsealant 134 126 153 137 128 131 129Msealant 93 90 101 94 90 92 91HextractAdult 140 132 159 143 134 137 135HextractChild 125 117 144 128 119 122 120Mextract 84 81 92 85 81 83 82HfillAmgAdult 191 183 210 194 185 188 186HfillAmgChild 154 146 173 157 148 151 149MfillAmg 144 141 152 145 142 143 142HfillLC 318 310 337 320 311 315 313RCT 400 392 419 403 394 397 395Fixed 1758 1751 1778 1761 1752 1755 1754CD/SD 2693 2685 2712 2696 2687 2690 2688RPD 2265 2258 2285 2268 2259 2262 2261TP 603 595 622 606 597 600 598HScalingAdult 212 205 232 215 206 209 208HScalingChild 154 146 173 156 147 151 149MScaling 162 159 170 163 159 161 160
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CASE STUDY 2: RESOURCE ALLOCATION
Resource allocation for caries control program
in school dental health services
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nalysis of resource allocation in health care
The distribution of factors of production such as money,
plant and equipment, and skilled labor among alternative uses
( Shim JK, Siegel JG, Dictionary of Economics, 1995 )
A
Resource allocation
General objective
To identify optimal level and mix of three basic dental services (sealant and filling for permanent teeth and extraction of primary teeth) provided to primary school children under two different dental settings; hospital-based and mobile dental clinics under specified resources, service need and setting preference constraints
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Examples of developing modelExamples of developing model
A company produces 2 products: A and B
Resource requirements
are summarized in table
Resources available
Space 1,500 m2
Material 1,575 kg
Total hour 420 minutes
product
A B
Resource
Storage space (m2) 4 5
Material (kg) 5 3
Production time (mins) 60 30
Outcome
Selling price ($) 13 11
Developing LP modelDeveloping LP model
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Resource Resource datadataResource Resource datadata
Because of rigidities in hospital budget allocations, separate resource constraints were identified.
Provider time Assistant time Material cost Capital depreciated cost Supportive cost The mobile clinic included 2 dental nurses, 1 dental
assistant and 1 driver The average levels of service provision per school visit 30 sealants, 20 fillings or 50 extractions
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Need dataNeed data Need dataNeed data
Minimum cases of service need: hospital policies Sealant : all caries free first permanent molars of grade 1
children Filling and extraction : urgent cases Urgent fillings defined as caries in permanent teeth without history of continuous pain or abscess could be restored by amalgam filling. Urgent extractions defined as severe caries in primary
teeth which caused difficulty in chewing and cleansing.
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Preference dataPreference data Preference dataPreference data
Setting preference: parent’s WTP WTP hospital service VS WTP mobile service Example: WTP SH = 200, WTP SM = 220 Setting preference for sealant mobile > sealant hospital Setting preference for sealant = mobile Benefit of the service = adjusted WTP of each service Adjusted for SES, perception of child oral health,
experience of three basic dental services, experience of hospital or mobile dental clinic
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Data analysis
Solver linear programming module in Microsoft excel The output of the analysis is the level of services to be
provided for each service setting
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ResultsResultsResultsResults
Model 1:included all constraint, Model 2: included resource, Model 3: included resource and need, Model 4: actual service
Optimization condition of service-mix and WTP produced by service from different model
Model Service-mixed produced by service (cases)WTP produced by service (baht)
Hospital sealant
Mobile Sealant
Hospital filling
Mobile filling
Hospitalextraction
Mobile extraction
1 27061,020
18030,420
552124,752
828178,848
22828,044
53262,776
2 978221,028
00
22450,624
1,164251,424
00
5590
3 668150,968
00
21849,268
1,037223,992
00
74487,792
4 4810,848
28147,489
19143,166
17036,720
47958,917
67779,886
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ExerciseSealant program
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Sealant program
What do you think aboutsealant situation inlocal context?
evidence values
resources
Rationale
First AuthorFirst AuthorBaselineBaseline
Age, ToothAge, Tooth %% Loss Loss
YearYear
11 22 33 44 55 1515
Forss,1994 5-14, All 4 82
Bravo,1996 6-8, M1,2 17 87 75 62
Messer,1997 6-12, All N.A. 67 56
Holst, 1998 6-10, M1,2 N.A. 91 85 81 76 69
Wendt, 2001 6-8, M1 38 65
RReview of eview of ssealant ealant retention in retention in WWestern estern
CCountriesountries
RReview of eview of ssealant ealant retention in retention in WWestern estern
CCountriesountries
M1 = First permanent molar M2 = second permanent molar All = All permanent teeth, premolar and molar
First AuthorFirst AuthorBaselineBaseline
Age, ToothAge, Tooth %% Loss Loss
YearYear
11 22 33 44 55 66 1515
Forss,1994 5-14, All 4 5
Holst, 1998 6-10, M1,2 N.A. 8
Wendt, 2001 6-8, M1 38 13
RReview of eview of caries on sealed caries on sealed surfacesurface in in WWestern estern
CCountriesountries
RReview of eview of caries on sealed caries on sealed surfacesurface in in WWestern estern
CCountriesountries
M1 = First permanent molar M2 = second permanent molar All = All permanent teeth, premolar and molar
Rationale
Rationale
First AuthorFirst AuthorBaselineBaseline
Age, ToothAge, Tooth %% Loss Loss
YearYear
11 22 33 44 55
Bonyaves,1994 6-9, M1 N.A. 64 56 49
Prashaya,1993 6-8, M1 N.A. 35 28
Tianviwat,2001 6-8, M1 N.A. 19
Thipsoonthornchai, 2003 6-7, M1 16 20 9M1 = First permanent molar
RReview of eview of ssealant ealant retention inretention in
ThailandThailand
RReview of eview of ssealant ealant retention inretention in
ThailandThailand
First AuthorFirst AuthorBaselineBaseline
Age, ToothAge, Tooth %% Loss Loss
YearYear
11 22 33
Prashaya,1993 6-8, M1 N.A. 30
Tianviwat,2001 6-8, M1 N.A. 22
Thipsoonthornchai, 2003 6-7, M1 16 24 25
RReview of eview of caries on sealed caries on sealed surfacesurface in in ThailandThailand
RReview of eview of caries on sealed caries on sealed surfacesurface in in ThailandThailand
M1 = First permanent molar
Rationale
TTransition analysis of ransition analysis of RRetention and etention and CCariesaries
TTransition analysis of ransition analysis of RRetention and etention and CCariesaries
SSealant inealant in M Mobile obile DDental ental CCliniclinicSSealant inealant in M Mobile obile DDental ental CCliniclinic
DDiscussioiscussionn
DDiscussioiscussionn
1. This study has lower retention rate of sealant and higher caries rate on sealed surface compared to western countries, although slightly better result than other Thai studies
2. Probability of losing of full retention was high in the first 6 months, approximately 1/3
The rate of this loss become less at around 12-25% in subsequence cycle
However, the transition probability toward caries is small (2-4%)
3. After partial loss, the probability of getting caries remarkably increased to 11-20%, whereas, the probability of total loss turning to caries is around 2-5%
Summary of findingsSummary of findings
FromMarkov process
FromDescriptive analysis
Discussion
4. Determinants of sealant retention includes 4. Determinants of sealant retention includes moisture control, assistant and cooperation moisture control, assistant and cooperation of childrenof children
5. Partial loss lead to caries within 6 months with a rate 2.8 times higher than total sealant loss and 6.5 times that of among full retention group
DDiscussioiscussionn
DDiscussioiscussionnSummary of findingsSummary of findings (cont.)
From Transition OR
From Life table
SEALANT PROGRAM IN LOCAL CONTEXT
What do you think about sealant program situation in your area?
Is it effective?
Is it worth to do? Good VS Harm
Any data or information do you need to answer this problem?
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