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An Introduction to Evidence-Based Public Health. Neal D. Kohatsu, MD, MPH Associate Professor Dept. of Epidemiology. Case Presentation. Case Presentation. Assume that you are the health director of a local health department.

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An introduction to evidence based public health l.jpg

An Introduction to Evidence-Based Public Health

Neal D. Kohatsu, MD, MPH

Associate Professor

Dept. of Epidemiology



Case presentation3 l.jpg
Case Presentation

  • Assume that you are the health director of a local health department.

  • A community in your jurisdiction is concerned with its high rate of childhood obesity and requests your help.

  • How do you proceed?


Overview l.jpg
Overview

  • Rise of evidence-based medicine

  • Development of evidence-based PH

  • Current perspective on PH

  • New definition of EBPH

  • Evaluating and improving EBPH

  • Review of case presentation

  • Summary



Rise of evidence based medicine6 l.jpg
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



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Factors Driving EBM

  • Overwhelming size of the literature

  • Inadequacy of textbooks

  • Difficulty synthesizing evidence and translating into practice

  • Increased number of RCTs

  • Available computerized databases

  • Reproducible evidence strategies


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Definition of EBM

  • “The integration of best research evidence with clinical expertise and patient values.”

Sackett DL et al; Churchill Livingstone, 2000


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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 one’s clinical expertise and the individual patient

  • Evaluate

Sackett DL. EBM: how to practice and teach EBM.

Churchill Livingstone 2000


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Critique of EBM

  • De-emphasizes patient values

  • Doesn’t account for individual variation

  • Devalues clinical judgment

  • Leads to therapeutic nihilism


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Parachute use to prevent death and major trauma related to gravitational challenge; systematic review of randomised controlled trials. Smith GC, Pell JP. BMJ 327:1459-1461; 2003.


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Development of EBPH gravitational challenge; systematic review of randomised controlled trials.

  • 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


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Definition of EBPH (1) gravitational challenge; systematic review of randomised controlled trials.

  • “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)

Jenicek M. J Epidemiol 1997;7:187-97


Definition of ebph 2 l.jpg
Definition of EBPH (2) gravitational challenge; systematic review of randomised controlled trials.

  • “EBPH is 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 program planning models.”

    Brownson (1999)

Brownson RC. J Public Health Manag Pract 1999;5:86-97


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Steps of EBPH gravitational challenge; systematic review of randomised controlled trials.

  • 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

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


Steps of ebm17 l.jpg
Steps of EBM gravitational challenge; systematic review of randomised controlled trials.

  • Convert the need for info. into an answerable question

  • Track down the best evidence

  • Critically appraise that evidence

  • Integrate the appraisal with one’s clinical expertise and the individual patient

  • Evaluate

Sackett 2000


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EBM and EBPH Parallels gravitational challenge; systematic review of randomised controlled trials.

  • State the scientific question of interest

  • Identify the relevant evidence

  • Determine what information is needed to answer the scientific question

  • Determine the best course of action considering the patient or population

  • Evaluate process and outcome

Kohatsu et al. Am J Prev Med 2004;27:417-21


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Cochrane Collaboration gravitational challenge; systematic review of randomised controlled trials.

Mission:

“…an international organisation that aims to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions.”

www.cochrane.org


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Structure of the Collaboration gravitational challenge; systematic review of randomised controlled trials.

  • Collaborative Review Groups

  • Methods Groups

  • Fields

  • Consumer Network

  • Centres


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Guide to Community Preventive Services gravitational challenge; systematic review of randomised controlled trials.

  • Developed by the U.S. Task Force on Community Preventive Services

  • Supported by the U.S. Centers for Disease Control and Prevention (CDC)

  • Based on systematic reviews

  • Recommendations based on strength of evidence

Briss PA et al. AJPM 2000;18(1S):35-43.


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Vaccine-preventable diseases gravitational challenge; systematic review of randomised controlled trials.

Tobacco use prevention and control

Reducing motor vehicle occupant injury

Diabetes

Physical activity

Oral health

Social Environment

Prevention of injuries due to violence

Cancer

Topic Areas


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A Current Perspective on PH gravitational challenge; systematic review of randomised controlled trials.

  • Public health encompasses:

    “the efforts, science, art, and approaches used by all sectors of society to assure, maintain, protect, promote, and improve the health of the people.”

The future of the public's health in the 21st century. IOM 2002.


Public health l.jpg
Public Health gravitational challenge; systematic review of randomised controlled trials.

  • Communities

  • Healthcare system

  • Employers & business

  • Media

  • Academia

  • Government

IOM, 2002


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Definition of EBPH (3) gravitational challenge; systematic review of randomised controlled trials.

  • “The process of integrating science-based interventions with community preferences to improve the health of populations.”

Kohatsu, Robinson, Torner. AJPM 2004;27:417-21.


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The Future of Evidence-Based Public Health gravitational challenge; systematic review of randomised controlled trials.

  • How can we evaluate and improve EBPH in practice?


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Improving EBPH in Practice gravitational challenge; systematic review of randomised controlled trials.

  • Quality of the Science Base

  • Community Involvement

  • Effect on Public Health Outcomes


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Moving beyond RCTs gravitational challenge; systematic review of randomised controlled trials.

Transparent Reporting of Evaluations with Non-randomized Designs (TREND)

Grading of Recommendations Assessment, Development and Evaluation (GRADE)

Improving the Qualityof the Science Base


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Improving Community Involvement gravitational challenge; systematic review of randomised controlled trials.


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Improving Community Involvement gravitational challenge; systematic review of randomised controlled trials.

  • “Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.”

    --Public Health Leadership Society

www.phls.org


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Informed Consent at the Community Level gravitational challenge; systematic review of randomised controlled trials.

  • Community-based participatory research

  • Community advisory boards


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Improving EBPH Outcomes gravitational challenge; systematic review of randomised controlled trials.

  • Difficult to assess

  • Issues of sample size, contamination, blinding, long-term follow-up

  • Ethical constraints of withholding evidence

  • Patients do better in the “real world” when provided with evidence-based therapy


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Case Presentation gravitational challenge; systematic review of randomised controlled trials.

  • Assume that you are the health director of a local health department.

  • A community in your jurisdiction is concerned with its high rate of childhood obesity and requests your help.

  • How do you proceed?


Develop an initial statement of the issue l.jpg
Develop an Initial gravitational challenge; systematic review of randomised controlled trials. Statement of the Issue

  • The prevalence of obesity among the 327 elementary school children in the community is 35%. With the support of parents, school staff, and community-based organizations, how can this obesity rate be reduced through lifestyle interventions?


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Quantify the Issue gravitational challenge; systematic review of randomised controlled trials.

  • The prevalence of obesity was determined by a special survey.

  • The rate of obesity was found to increase by grade level.

  • The rates were about equal in girls and boys.

  • 100 minutes/wk provided at school for physical activity, but only 40 minutes is guided by a teacher.


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Search the Scientific Literature and Organize Information gravitational challenge; systematic review of randomised controlled trials.

  • Medline search

  • Cochrane Collaboration

  • Task Force on Community Preventive Services


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Task Force on Community Preventive Services gravitational challenge; systematic review of randomised controlled trials.

  • Insufficient evidence to recommend classroom-based health education to provide information on managing health risks.

  • Strongly recommended curricula and policies to increase the amount of moderate or vigorous activity, increase the amount of time in PE class, or the amount of time being active in PE.

MMWR 2001;50, No. RR-18


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Develop and Prioritize gravitational challenge; systematic review of randomised controlled trials. Program Options

  • A community-based work group develops a number of options to increase physical activity in school.

  • There are debates about losing time in the classroom and impact on test performance.


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Develop an Action Plan gravitational challenge; systematic review of randomised controlled trials.


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Develop an Action Plan gravitational challenge; systematic review of randomised controlled trials.

  • Agreement is reached on a pilot project for the next school year involving reducing the lunch hour and increasing time in physical education with an emphasis on activities that get all children to be active.

  • The program will be evaluated by all stakeholders (e.g., children will be surveyed)


Summary l.jpg
Summary gravitational challenge; systematic review of randomised controlled trials.

  • EBM has transformed medicine

  • EBM has fostered development of EBPH

  • EBPH continues to evolve

  • Increased community engagement


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