Extreme Makeover Data Edition: Inside the Box

1
Extreme Makeover -- Data Edition Inside 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

2
Presentation Outline

• Definition of evidence
• Discussion of evidence-based medicine
• Discussion of evidence-based public health
• How to use evidence-based approaches
• Evidence-based maternal and child health

3
What is Evidence?

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

4
Are Evidence-Based Practices Applicable Only to
the Health Field?
5
Evidence-Based Baseball

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

6
Evidence-Based Baseball

• What predicts which amateur hitters make it to
  the big leagues and become successful players
• Ability to hit home-runs?
• Foot-speed?
• Fielding ability?
• Number of walks that a hitter drew?

7
Evidence-Based Baseball

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

8
Evidence-Based Baseball

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

9
Evidence-Based Baseball

• Answer On-base percentage.
• Lewis, Moneyball, 2003.

10
What is Evidence-Based Medicine?

• Health care practices that are based on review of
  the current best evidence on the effectiveness of
  a test, drug, surgery or other medical practice.
• Based on collecting and analyzing all of the
  research studies that have been conducted on a
  particular intervention.
• These reviews are called meta-analyses and
  systematic reviews.

11
Rise of Evidence-Based Medicine

• First described in 1992
• A new approach to teaching medicine
• A revolution in medical practice
• Other evidence-based approaches ethics,
  psychotherapy, occupational therapy, dentistry,
  nursing, and librarianship

12
Factors Driving EBM

• Overwhelming size of the literature
• Inadequacy of textbooks
• Difficulty synthesizing evidence and translating
  into practice
• Increased number of randomized control trials
• Available computerized databases
• Reproducible evidence strategies

13
Steps of EBM

• Convert the need for info. into an answerable
  question
• Track down the best evidence
• Critically appraise that evidence
• Integrate the appraisal with ones clinical
  expertise and the individual patient
• Evaluate

Sackett DL. EBM how to practice and teach EBM.
Churchill Livingstone 2000
14
Differences between Medicine and Public Health
15
Differences between Medicine and Public Health
(continued)
16
Development of Evidence Based Public Health

• Jenicek (1997) published a review discussing
  epidemiology, EBM, EBPH
• Epidemiology described as the foundation of both
  EBM and EBPH
• EBPH unique in using complex interventions with
  multiple community and societal issues

17
Definition of EBPH (1)

• EBPH is the conscientious, explicit, and
  judicious use of current best evidence in making
  decisions about the care of communities and
  populations in the domain of health protection,
  disease prevention, health maintenance and
  improvement.
• Jenicek (1997)

18
Definition of EBPH (2)

• Evidence-based public health is defined as the
  development, implementation, and evaluation of
  effective programs and policies in public health
  through application of principles of scientific
  reasoning, including systematic uses of data and
  information systems, and appropriate use of
  behavioral science theory and program planning
  models.
• Brownson, et al, 2003

19
Steps of EBPH

• Develop an initial statement of the issue
• Search the scientific literature and organize
  information
• Quantify the issue using sources of existing data
• Develop and prioritize program options implement
  interventions
• Evaluate the program or policy

20
Steps to Searching the Public Health Literature

• Determine the public health problem and define
  the question.
• Select information sources.
• Identify key concepts and terms.
• Conduct the search in subject-appropriate
  databases.
• Select documents for review.
• Abstract relevant information.
• Summarize and apply the literature review.
• Brownson, et al. 2003.

21
Evaluating the Quality and Methods of Public
Health Research Results

• What are the results?
• Were the results similar from study to study?
• What are the overall results of the review?
• How precise were the results?
• Can a causal association be inferred?
• Are the results valid?
• Did the review explicitly address the PH
  question?
• Was the search exhaustive?
• Were the primary studies of high methodological
  quality?
• How can the results be applied to PH practice?
• How can the results be interpreted and applied?
• Were all the important PH outcomes considered?
• Are the benefits worth the costs and potential
  risks?
• Brownson, et al. 2003.

22
How are Decisions Usually Made?

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

23
Evidence and Public Health Decision Making

• Good news
• Strong evidence on the effect of many policies/
  programs aimed to improve public health
• Major efforts underway to assess the body of
  evidence for wide range of public health
  interventions

24
What Works to Improve the Publics Health?

• Bad news
• Many public health professionals are unaware of
  this evidence
• Some who are aware dont use it
• Many existing disease control programs have
  interventions with insufficient evidence while
  others use interventions with strong evidence of
  effectiveness
• Lack of use of effective interventions can
  adversely affect fulfilling mission and getting
  public support

25
Barriers Facing Evidence-Based Public Health

• Evidence-based research tells you what you
  should do, not what you can do What a lot of us
  are facing is no matter how much evidence you
  have, you just dont have enough resources.
• A Title V Director (interviewed for an evaluation
  study)

26
Evidence-Based Maternal and Child Health

• True or False
• The more prenatal care a woman receives, the
  better her birth outcomes?

27
Evidence-Based Maternal and Child Health

• FALSE
• If a woman receives MORE than the recommended
  amount of care, she is more likely to have worse
  birth outcomes.

28
Evidence-Based Maternal and Child Health

• True or false
• For women who are experiencing problems with
  their pregnancy, bed rest is effective in
  preventing preterm labor.

29
Evidence-Based Maternal and Child Health

• FALSE
• Obstetric practices for which there is little
  evidence of effectiveness in preventing or
  treating preterm labor include bed rest.
• Goldenberg, Obstetrics and Gynecology, 2002

30
Resources

• Medline search (http//www.ncbi.nlm.nih.gov/sites/
  entrez)
• Cochrane Collaboration (www.cochrane.org)
• Task Force on Community Preventive Services
  (http//www.thecommunityguide.org/)
• National Guideline Clearinghouse
  (http//www.guideline.gov/)
• The Institute of Medicine (www.iom.edu)
• Evidence-Based Practice for Public Health
  (http//library.umassmed.edu/ebpph/)
• Best Practices at the Local Level
  (http//archive.naccho.org/modelPractices/)

31
Resources

• Promising Practices Network for Children
  (http//promisingpractices.net/programs_outcome.as
  p)

32
Acknowledgments

• Jonathan Fielding, MD, Los Angeles County Dept.
  of Health Services
• Neal Kohatsu, MD, University of Iowa
• Harvey Fineberg, MD, Harvard University

33
Contact Information

• Michael Kogan, Ph.D.
• HRSA/MCHB
• Director, Office of Data and Program Development
• 5600 Fishers Lane, Room 18-41
• Rockville, MD 20857
• 301-443-3145
• mkogan_at_hrsa.gov