Making Data Count: Assuring That We Do Things Right and Do The Right Things

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Making Data Count Assuring That We Do Things
Right and Do The Right Things
Plenary Session at AMCHP Michael Kogan,
Ph.D. U.S. Department of Health and Human
Services Health Resources and Services
Administration (HRSA) U.S. Maternal and Child
Health Bureau (MCHB) Director, Office of
Data and Program Development Juan Acuña, MD,
MSc U.S. Department of Health and Human
Services Centers for Disease Control and
Prevention (CDC) Division of Reproductive
Health Team Leader, Maternal and Child
Health Epidemiology
March 5, 2008

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• Where Are We
• With MCH Data?

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• And

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• How Does It Relate to the History of the Roman
  Empire?

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The Roman Republic 509 BC-44 BC

• Marked by steady growth in territories.
• Achieved by Roman Legions with high levels of
  professionalism, training, and discipline

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MCH Epidemiology 2000-2007

• Marked by steady growth in states and
  territories.
• The number of registrants at the MCH epidemiology
  conference grew from 400 to 533.
• The number of CDC/HRSA MCH epidemiology state
  assignees grew from one (in 1987) to nine.

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MCH Epidemiology 2000-2007

• Marked by steady growth in states and
  territories.
• MCH epidemiology had the second greatest increase
  in state-based epidemiologists (after
  bioterrorism)
• The percent of states able to provide substantial
  to full capacity in MCH epidemiology increased
  from 35 (in 2001) to 52 (in 2006).
• The number increased from 106 to 171.

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MCH Epidemiology 2000-2007

• Achieved by MCH Data Legions with high levels of
  professionalism, training, and discipline
• Almost 300 people have been trained in
  epidemiology methods through the HRSA/CDC course
  in MCH epidemiology.
• Another 300 have received the AMCHP two day
  trainings before the MCH Epidemiology Conference.

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Pax Romana 44 BC-180 AD

• Marked by relative peace, minimal expansion, and
  growth in knowledge.

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• Are We in a Period of Pax Maternalus and Child
  Healthus?

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Pax Maternalus and Child Healthus, 2000-2007

• Marked by minimal expansion.
• Block grant has changed from 709 million to 693
  million. It is now at its 1993 level.

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Pax Maternalus and Child Healthus, 2000-2007

• Marked by growth in knowledge
• The number of submissions to the MCH Journal has
  increased from 74 to 200.
• The number of articles in 8 prominent US public
  health journals mentioning child health has
  increased from 115 to 129.

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Pax Maternalus and Child Healthus, 2000-2007

• Marked by growth in knowledge
• The number of articles in the same 8 US public
  health journals mentioning preterm has
  increased from 46 to 80.
• The number of articles mentioning birth weight
  has increased from 94 to 125.

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• And yet

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Rate of Cesarean Delivery100 BC - 2006
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Percent Preterm Births in the US, 1990-2006
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Percent Low Birth Weight Births in the US,
1990-2006
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Pax Romana 44 BC-180 AD Problems

• Even during this period of Pax Romana, there were
  challenging periods
• Nero, beset by uprisings in the territories,
  focused more on his musical talents

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Little Known Fact

• After every AMCHP meeting, Peter van Dyck spends
  A LOT of time playing music

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Pax Romana 44 BC-180 AD Problems

• Caligula became famous for his debauchery

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• Will we degenerate into debauchery?

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The Decline and Fall of the Roman Empire 180
AD-1453 AD

• Succumbed to barbarian invasions by the Goths,
  Huns, and Vandals
• Did not convert the information about the growing
  number of barbarians into effective programs to
  prevent invasions.

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• Are we going to follow the path of the Roman
  Empire, and if not, how can we prevent it?

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• How do we convert information into more effective
  programs?

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• Gathering the Best Evidence
• Applying the Evidence to Programs and Policies

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Evidence-Based Medicine

• Health care practices based on review of current
  best evidence on the effectiveness of a test,
  drug, surgery or other medical practice.
• Collect and analyze all of the research studies
  conducted on a particular intervention.
• Evidence is then graded.
• Best evidence is clinical trials and
  meta-analysis. Weakest is case reports.

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Differences between Medicine and Public Health
Public Health Medicine
Primary Focus Populations Individuals
Emphasis Prevention Diagnosis
Health Promotion Treatment
Whole Community Whole Patient
Paradigm Interventions aimed at Environment, Human Behavior and Lifestyle, and Medical Care Medical Care
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Definition of Evidence-Based Public Health

• 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)

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• So what is best evidence?

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Best Evidence

• Makes sense (its relevant)
• Unbiased
• Available
• Statistically significant
• Significant to public health
• Leads to correct decisions

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Evidence
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Steps of Evidence-Based Public Health

• 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

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Different Sources of Evidence in Public Health

• Soft information review processes, personal
  information, gut feelings
• Adequate information routinely collected
  information, case review programs
• Strong information active surveillance, and
  some clinical studies
• Very strong randomized control trials

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• So why isnt evidence-based decision-making used
  more often?

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How are Decisions Often 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

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Evidence and Public Health Decision Making

• Good news
• Strong evidence on the effect of many policies/
  programs aimed to improve public health, like
  immunizations or smoking cessation
• Major efforts underway to assess the body of
  evidence for wide range of public health
  interventions, like the Cochrane Collaborative or
  the AMCHP Best Practices program.

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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

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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.

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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

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• Are evidence-based approaches only applicable to
  the health field?

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Evidence-Based Baseball

• Evidence-based approach by Oakland Athletics
• Relied on theoretically relevant statistics and
  scientific approach to baseball.
• Achieved winning seasons despite being burdened
  with severe budget constraints.

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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?

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Evidence-Based Baseball

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

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• Are evidence-based approaches sufficient?

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• Not always
• Sometimes MCH outcomes are affected by issues in
  other areas

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Day of the Week Delivery Route
Index of Occurrence of Delivery Route Florida
2004-2006 Singletons, 34-41 Weeks, No Previous
Cesarean, Low Documented Risk, and No Medical
Induction (N263,326)
140
120
100
Index of Occurrence
80
Vaginal
Cesarean with Labor
60
Cesarean without Labor
40
20
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Day of Week
Goodman, et al, 2008.
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Day of the Week Late Preterm
Index of Occurrence of Late Preterm Florida
2004-2006 Singletons, 34-41 Weeks, No Previous
Cesarean, Low Documented Risk, and No Medical
Induction (N263,326)
140
120
100
Index of Occurrence
80
Vaginal
60
Cesarean with Labor
Cesarean without Labor
40
20
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Day of Week
Goodman, et al, 2008.
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From Evidence-Based Public Health to
Translational Research

• Translational ResearchPublic Health
• Translating research into practice ie ensuring
  that new treatments and research knowledge
  actually reach the patients or populations for
  whom they are intended and are implemented
  correctly.

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Sudden Infant Death SyndromeProviding
Appropriate Translation

• Growing evidence that reduction of SIDS related
  to infant sleep position
• Back to Sleep campaigns in the US
• Significant declines in the SIDS rate from
  1989-1998
• Mostly in the white population
• Was the evidence appropriately targeted for
  different audiences?

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Model of Evidence to Translation
Stage 1 Review of Evidence-Based
Recommendations
Stage 2 Consultations on Recommendations for
Practice
Stage 3 Synthesis and Development of
Recommendations
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MCH Legions Moving Forward Armed with the Right
Evidence and Translation
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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