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Evidence-based Public Health . . . and some reasons why we need it. Russell S. Kirby, PhD, MS, FACE Professor and Vice Chair Department of Maternal and Child Health School of Public Health University of Alabama at Birmingham. Objectives. Describe the evidence-based practice (EBP) paradigm

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evidence based public health and some reasons why we need it

Evidence-based Public Health . . .and some reasons why we need it

Russell S. Kirby, PhD, MS, FACE

Professor and Vice Chair

Department of Maternal and Child Health

School of Public Health

University of Alabama at Birmingham

objectives
Objectives
  • Describe the evidence-based practice (EBP) paradigm
  • Identify key characteristics of evidence-based public health (EBPH)
  • Differentiate between EBP and EBPH
  • Review several recent controversies and their impact
  • Speculate on the future uses of evidence
slide3

Brief Summary for Those Who Are Knitting, Doing Crossword Puzzles, or Discerning the Geometric Pattern in the Carpeting

  • Evidence-based public health is the leading edge of modern public health practice.
  • It requires the same level of diligence with understanding principles of study design, sources of bias, internal and external generalizability, and research synthesis as is necessary in evidence-based practice.
  • Many of the necessary materials are ephemeral, but this is also true of clinical research due to the publication bias.
  • Several examples serve to show how this can work well, and . . . perhaps, not so well.
the practice of evidence based practice
The Practice of Evidence-based Practice
  • “integrating individual clinical expertise with the best available external clinical evidence from systematic research”
  • individual clinical expertise: the proficiency and judgment acquired through experience and practice in clinical settings
  • external clinical evidence: clinically relevant research, from basic medical science and patient-centered clinical research
how do we practice ebp
How Do We Practice EBP?
  • EBP is a life-long process of self-directed learning, in which caring for patients creates for the clinician a need for clinically important information about diagnosis, therapy, prognosis, and other clinical and health services issues. In this process, we:
    • Convert information needs into answerable questions (testable hypotheses)
    • Track down the best evidence with which to answer them
    • Critically appraise the evidence for validity and usefulness
    • Apply the results of this appraisal in clinical practice
    • Evaluate performance
why ebp
Why EBP?
  • New types of evidence are being generated which, when known and understood, have the potential to create frequent and major changes in the way we care for our patients
  • Although we need this evidence daily, we usually fail to get it
  • Because of this, both our up-to-date knowledge and clinical performance deteriorate over time
  • Trying to remedy this personally through traditional CME/CEU programs generally doesn’t improve clinical performance
  • A different approach to clinical learning has been shown to keep its practitioners up-to-date. EBP is that different approach.
quality of evidence
Quality of Evidence

I: Evidence obtained from at least one properly randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (i.e. results of introduction of penicillin treatment in 1940s) could also be regarded as this type of evidence.

III: Opinions of well-respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.

slide9

Develop

an initial

statement

of the issue

Sequential Framework for Enhancing

Evidence-based Public Health

(Brownson, et al.)

Tools: rates and risks,

surveillance data

Quantify

the issue

Evaluate

the program

or policy

Tools: systematic reviews,

risk assessment, economic

data

Implement

Search the

scientific literature

and organize

information

Re-tool

Develop an

action

plan and

implement

interventions

Develop and

prioritize program

options

Refine the

issue

key differences between ebp and ebph
Key Differences Between EBP and EBPH

Characteristic EBP EBPH

Quality of evidence Experimental Studies Observational and quasi-

experimental studies

Volume of evidence Larger Smaller

Time from intervention Shorter Longer

to outcome

Professional training More formal, with Less formal,

certification/licensing no standard certification

Decision making Individual Team

comparison of the types of scientific evidence
Comparison of the Types of Scientific Evidence

Characteristic Type I Type II

Typical data/ Strength of preventable Relative effectiveness of

relationship risk-disease relationship public health intervention

Common setting Clinic or controlled Socially intact groups or

community setting community-wide

Quantity of evidence More Less

Action “Something should be done” “This should be done”

types of evidence
Types of evidence
  • Type I: ‘something should be done’
    • Analytic data on specific health condition and its link to preventable risk factor(s)
  • Type II: ‘specifically, this should be done’
    • Focus on relative effectiveness of specific interventions to address a particular health condition
the realistic evidence based rating scale
The Realistic Evidence-Based Rating Scale
  • Class 0: Things I believe
  • Class 0a:Things I believe despite the available data
  • Class 1: Randomized controlled clinical trials that agree with what I believe
  • Class 2: Other prospectively collected data
  • Class 3: Expert opinion
  • Class 4: Randomized controlled clinical trials that don’t agree with what I believe
  • Class 5: What you believe that I don’t
some examples
Some examples
  • VBAC and Cesarean section
  • Folic Acid and prevention of neural tube defects
  • Back to Sleep
  • HRTs: the mystery continues
slide15

Trends in Cesarean Deliveries and VBACs, United States 1990-2002

30.0

25.0

20.0

Percent of Live Births

15.0

Total C- Section

Rate

10.0

Primary C-Section

Rate

5.0

VBAC Rate

0.0

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Year

trends
Trends
  • The velocity of the increase in the primary Cesarean section rate and the decline in VBAC rates in the recent past in the US is unprecedented.
  • In less than five years, more than ten years of increasing VBAC rates has disappeared.
  • Is this a good thing, or even a matter of concern?
slide17

Trends in Induction of Labor, United States, 1980-2002

25.0

Induction NHDS

Medical Induction NHDS

20.0

Surgical Induction NHDS

Induction-Birth Certificates

15.0

Percent of Live Births/Deliveries

10.0

5.0

0.0

1980

1985

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Year

trends1
Trends
  • Rates of induction have increased dramatically across the nation.
  • There are differences based on data source, but no one can dispute the direction of the trend.
  • Let’s look at some specifics for Alabama:
slide19

Trends in Induction, C-Section, and VBAC, Alabama 1998-2002

35

30

25

C-Section Rate

20

VBAC Rate

Primary C-S Rate

Percent

15

Repeat C-S Rate

Induction %

10

5

0

1998

1999

2000

2001

2002

Year

is this a public health concern
Is this a public health concern?
  • Con: public health does not focus on clinical management of patients. That is in the responsibility of the health care system, peer review, quality compliance, and provider organizations.
  • Pro: Cesarean section is among the most common surgical procedures. It is more expensive per total hospital stay than vaginal delivery, and leads to more complications and re-hospitalizations.
is this a public health concern continued
Is this a public health concern?(continued)
  • The Public Health Service has established goals for the year 2010 promoting continued reduction in overall Cesarean section rates and increases in VBAC rates for the United States.
    • Objective 16-9a: Reduce C-S among low-risk nulliparous women
    • Objective 16-9b: Reduce C-S among women with prior Cesarean birth
where do alabama and wisconsin fit in
Where do Alabama and Wisconsin fit in?
  • Historically, Wisconsin has had one of the lowest C-section rates in the US. Alabama, on the other hand, generally has one of the highest.
  • In 1960, the national rate was 4%, and from the 1970s on the C-section rate has tended to be 25-33% lower than the national rate.
  • Wisconsin has also been a leader in the use of vaginal birth after Cesarean section, while Alabama has been comparatively slow to adopt.
slide23
Total Cesarean Section Rate and VBAC Rateby Race of Mother, 2001United States Compared to Wisconsin and Alabama

Wisconsin

US

Alabama

Rate

Rate

State Rank

Rate

State Rank

Total C-Section Rate

19.1

45th highest

27.6

4th highest

24.4

White Non-Hispanic

24.5

19.7

28.5

Black Non-Hispanic

25.9

16.9

26.8

Hispanic

23.6

18.4

21.5

VBAC Rate

16.4

23.0

43rd lowest

11.8

6th lowest

White Non-Hispanic

16.8

22.3

11.0

Black Non-Hispanic

16.7

28.8

13.5

Hispanic

14.7

22.9

12.3

risk factors associated with cesarean delivery
Risk Factors Associated with Cesarean Delivery
  • Many patient, health care system, and physician characteristics are associated with higher or lower rates of Cesarean section.
  • A partial list includes maternal age (increased risk), parity (decreased risk), obesity and short stature (increased risk), estimated fetal weight > 4000g (increased risk), breech presentation (increased risk), delivery in teaching hospital (decreased risk), private insurance (increased risk), fear of malpractice suits (greatly increased risk).
method of delivery by body mass index bmi sinai samaritan cnm patients 1994 1998
Method of Delivery by Body Mass Index (BMI)Sinai Samaritan CNM Patients, 1994-1998

BMI Cesarean Vaginal Total

No. % No. % No. %

< 20 9 3.2 271 97.1 279 15

20 - 24.9 31 3.9 759 96.1 790 42

25 - 25.9 28 6.5 407 93.8 434 23

30 + 28 7.4 348 92.6 376 20

Total 96 5.1 1785 94.9 1881

Chi-Square (3 df) = 10.19, p<0.018

slide26

Adjusted Odds of Cesarean Delivery,

SSMC CNM Patients, 1994-1998

Characteristic

Odds Ratio

95 % C.I.

p-value

Obesity (BMI 30 +)

3.26

(1.60, 6.67)

0.0012

Weight Gain > Recommended

2.09

(1.06, 4.11)

0.0326

Short Stature (< 155 cm)

2.52

(1.12, 5.64)

0.0252

No Previous Live Births

4.30

(1.78, 10.37)

0.0012

Age 35 +

4.93

(1.08, 22.61)

0.0399

60.42

(29.86, 122.24)

0.0001

Failure to Progress

458.34

(133.74, 999)

0.0001

Breech Presentation

82.56

(19.00, 358.67)

0.0001

Placental Abruption

0.0001

5.71

(2.58, 12.64)

Fetal Distress

0.0412

8.68

(1.09, 69.20)

Severe Pre-eclampsia

Adjusted for race of mother (black), marital status, primigravidity and very low birth weight.

clinical documentation of previous cesarean section
Clinical Documentation of Previous Cesarean Section
  • Most clinicians practice in settings that do not have comprehensive, unified clinical informatics applications.
  • In a patient who’s previous delivery was with another provider, how likely is it that the patient’s history will document the type of incision, the position of the uterine scar, whether single- or double-suturing was used, etc?