CDC Panel: Community Guides and US Preventive Services Task Force

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CDC Panel Community Guides and US Preventive
Services Task Force

• Theresa Ann Sipe, PhD, MPH, RN
• Statistician
• The Guide to Community Preventive Services
• National Center for Health Marketing
• Centers for Disease Control and Prevention

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(No Transcript)
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Overview

• What is the Guide to Community Preventive
  Services (Community Guide)?
• Is it credible? Relevant to the issues I face?
• What are key challenges to disseminating
  evidence-based information and translating it
  into action?
• How does the Community Guide aim for
• Credibility
• Dissemination of its recommendations?
• What are implications for nursing?

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The Community Guide is

• Systematic reviews of the available evidence
• Formulated by a team of renowned researchers,
  public health practitioners, representatives of
  health organizations
• Concise, carefully-considered recommendations for
  policy and practice
• Identification of research gaps

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The Clinical Guide and Community Guide Are
Complementary

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The Clinical and Community Guides Are
Complementary
Individual level Clinical settings Delivered by
healthcare providers Screening, Counseling,
etc.
Clinical Guide (USPSTF Recommendations)
Group level Health system changes
Insurance/benefits coverage Access
to/provision of services Community,
population-based Informational (Group
Education, Media) Behavioral, Social
Environmental Policy Change
Community Guide (TFCPS Recommendations)
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Community Guide (CG) Topics
The Environment The Environment
Social Environment Social Environment
Settings Settings
Worksites Schools Worksites Schools
Risk Behaviors Specific Conditions
Tobacco Use Alcohol Abuse/Misuse Other Substance Abuse Poor Nutrition Inadequate Physical Activity Unhealthy Sexual Behaviors Vaccine-Preventable Disease Pregnancy Outcomes Violence Motor Vehicle Injuries Depression Cancer Diabetes Oral Health Obesity
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Community Guide Accomplishments

• gt200 systematic review findings completed
• Family of Products
• Book
• First book published in January 2005
• www.thecommunityguide.org, Oxford Press
• Publications
• Web site
• www.thecommunityguide.org

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Community Guide How is it Used?

• To inform decision making around
• Practice
• Policy making
• Research
• Research Funding

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Community Guide Intended Users

• Public Health Practitioners
• Program planning, grant guidance, focus for
  research funding goals
• Healthcare Providers
• System-level interventions for effective clinical
  services delivery
• Group based interventions to prevent/reduce
• Employers
• Healthy worksite interventions, benefit plan
  design/selection
• Community-based Organizations
• Program planning, grant guidance, focus for
  research funding goals

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Community Guide Intended Users (contd)

• Legislators Policy Makers
• Broad policies, targeted laws, educational system
  requirements, community-wide interventions
• Researchers
• Conduct research on insufficient evidence
  findings, other research gaps
• Funders
• Develop requests for proposals, fund studies of
  identified research gaps
• The General Public a secondary audience

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Bottleneck in Translating Health Research into
Action

• There is insufficient recognition of the
  complexities inherent in putting health research
  findings into practice across diverse
  communities, settings, and situations

I want you to quit smoking and lose 35 pounds.
Then I want you to come back and tell me how the
hell you did it.
I want you to quit smoking and lose 35 pounds.
Then I want you to come back and tell me how the
hell you did it.
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Bottleneck Research Must Meet the Diversity of
Practice Needs

• If research is to guide practice, it must
  consider internal and external validity
• Internal
• Are we measuring what we purport to measure?
• External
• How applicable is this to real-world settings,
  situations?
• Generalizability
• Adaptaptability
• Locally appropriate and affordable
• Special populations, underserved areas, low
  SES/education

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Application Gaps

• Accessibility gap
• Do I have the same resources as the
  experimenters?
• Credibility gap
• How different is their situation of practice from
  mine?
• Expectations gap
• Is it really necessary for me to strive for such
  lofty goals in my practice?
• Lancaster B. Closing the gap between research and
  practice. Health Educ Q 199219408-411

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Addressing the Bottleneck 1

• If we want more evidence-based practice, then we
  need more practice-based evidence
• Lawrence W. Green
• Lesson for systematic reviews
• Consider external validity alongside internal
  validity

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The Typical Approach to Dissemination of
Evidence A Push Model
Systematic Review of the Scientific Evidence By
researchers
Dissemination
Practice, Policy
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Knowledge to Action Continuum
How to Measure Effects
Dissemination
Participation and Collaboration
Identify Research- Practice Gaps
Translation
Planning, Assessing Uptake and Quality
Lawrence W. Green, DrPH Shawna L. Mercer, MSc,
PhD
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Addressing the Bottleneck 2

• Actively engaging those who will be users in the
  systematic review and dissemination processes, it
  is more likely the findings and recommendations
  will be relevant to their needs

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Participatory Research is

• Systematic inquiry
• With the collaboration of those affected by the
  issue being studied
• For the purposes of education and taking action
  or effecting social change
• Green, et al., 1995
• Study of Participatory Research in Health
  Promotion.

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Whose Participation Should be Sought in the
Systematic Review Process?

• Who is to be affected by the research results?
  Who are the intended users?
• Practitioners
• Policy makers
• Professional organizations
• Nongovernmental organizations
• Health departments
• Employers
• Representatives of minority or special
  populations

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The CG Seeks to Answer Key Questions about
Interventions

• Do they work?
• How well?
• For whom?
• Under what circumstances are they
  appropriate?
• What do they cost?
• Do they provide value?
• Are there barriers to their use?
• Are there any harms?
• Are there any unanticipated outcomes?

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Community Guide Places Equal Weight on

• The quality of the systematic review methods and
  analysis
• The group processes

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Participants in the Community Guide

• Task Force on Community Preventive Services
• Nonfederal, independent, rotating
• Internationally renowned experts in public health
  research, practice, policy
• Established by HHS as resource for public health
• Appointed by CDC director
• Oversee priority setting, topic and intervention
  selection, and individual reviews
• Make recommendations for policy, practice,
  research

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Task Force on Community Preventive Services
Current Members Current Members
Jonathan C. Fielding, MD, MPH, MBA, Chair Bruce Nedrow Calonge, MD, MPH John M. Clymer Kay Dickersin, PhD Karen Glanz, PhD, MPH Ron Goetzel, PhD Robert L. Johnson, MD Barbara K. Rimer, DrPH, Vice-Chair Ana Abraido-Lanza, PhD Nico P. Pronk, PhD Gilbert Ramirez, DrPH C. Tracy Orleans, PhD Lawrence W. Green, DrPH
Current Consultants Robert S. Lawrence, MD J. Michael McGinnis, MD Alonzo L. Plough, PhD, MPH Steven M. Teutsch, MD, MPH Current Consultants Robert S. Lawrence, MD J. Michael McGinnis, MD Alonzo L. Plough, PhD, MPH Steven M. Teutsch, MD, MPH

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Participants in the Community Guide

• Official Liaisons
• gt25 federal agency and organizational
• Provide input into prioritization, reviews,
  recommendations
• Recommend, find participants for review teams
• Participate in dissemination, translation
  especially to their constituents

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Official Federal Agency Liaisons

• Agency for Healthcare Research and Quality
• Centers for Medicare and Medicaid Services
• Department of Health and Human Services
• Department of Veterans Affairs
• Health Resources and Services Administration

• National Institutes of Health
• Indian Health Service
• Navy Environmental Health Center
• Office of Disease Prevention and Health Promotion
  
• United States Air Force
• United States Army

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Official Organizational Liaisons

• American Academy of Family Physicians
• American Academy of Nurse Practitioners
• American Academy of Physician Assistants
• American Association of Health Plans
• American Association of Public Health Physicians

• American College of Preventive Medicine
• American Public Health Association
• Association of Schools of Public Health
• Association of Teachers of Preventive Medicine
• Institute of Medicine

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Official Organizational Liaisons (contd)

• Association of State and Territorial Health
  Officials
• National Association of County and City Health
  Officials
• National Association of Local Boards of Health

• Public Health Foundation
• Society for Public Health Education
• Bright Futures Education Center Advisory
  Committee

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Participants in the Community Guide

• Stakeholders, partners
• For specific topics, reviews
• Participate on review teams
• Provide input to Task Force on topic
  prioritization, formation of recommendations
• Participate in dissemination, translation

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Participants in Individual Reviews

• Coordination Team
• Coordinating scientist (Community Guide)
• Fellows, abstractors (Community Guide)
• Subject matter experts
• From CDC, other federal agencies,
  academia, practice, policy settings
• Task Force member(s)
• Liaison(s)
• Consultation Team
• Subject matter experts
• Community Guide Staff

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Intended Users Participation Are we

• Prioritizing the right topics and interventions?
• Asking the right questions?
• Appropriately considering context, other issues
  of external validity?
• Thinking proactively about interpretability,
  relevance, usefulness, use?
• Planning for dissemination from the outset?

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Intended Users Participation in Planning for
Dissemination

• Aim How do we create awareness, interest,
  support, buy-in, channels?
• Proactively
• Who should be involved on the teams?
• Who should be kept apprised during the review?
• Whose buy-in is important?
• Who can access appropriate channels?
• Who has wide influence, credibility?
• Reactively
• How do we make sure we are ready to respond to
  events, teachable moments, opportunities?

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Transparency (A Minor Detail!)
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Community Guide Review Process

• Convene review teams
• Coordination team
• Consultation team
• Develop a conceptual framework
• Develop prioritized list of
  interventions
• Develop, refine clear research
  questions
• Search for evidence

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Community Guide Review Process

• Abstract and critically evaluate the available
  studies
• Summarize the evidence
• Calculate effect sizes
• Summarize effect sizes
• Median or mean
• Homogeneity tests
• Meta-analysis
• Meta-regression
• Task Force discussion and recommendations
• Disseminate the results
• Support translation into action

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Issues Considered in Guide Reviews
Intervention
Barriers
Intended Outcomes
Morbidity and/or Mortality
Economic Information
Additional Outcomes
Benefits
Harms
Applicability of the evidence
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In General, a Conclusion About Effectiveness
Requires.
A Body of Evidence
A Demonstration of Effectiveness

• Number of studies
• Quality of studies
• Suitability of study design

Consistency of Effect
Sufficient Magnitude of Effect

Most studies demonstrated an effect in the
direction of the intervention
The effect demonstrated across the body of
evidence is meaningful
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Strength of a Task Force Conclusion

• STRONG evidence of effectiveness
• SUFFICIENT evidence of effectiveness
• INSUFFICIENT evidence
• Doesnt mean the intervention is not effective
• BUT RATHER
• We cant determine at this time whether or not
  this intervention works.

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Task Force Recommendation Options

• Recommend
• Strong Evidence
• Sufficient Evidence
• Recommend against
• Strong Evidence
• Sufficient Evidence
• Insufficient evidence to
  recommend for or against

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What to Do with Insufficient Evidence

• If the intervention is currently being used
• May want to continue using it if there are no
  associated harms
• May choose to stop due to issues such as cost
• If the intervention is not being used
• May not want to begin using it
• Consider
• Are there are better-documented alternatives for
  reaching the same goals?

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What to Do with Sufficient Evidence

• Even if it is evidence-based,
  it is not certainty.
• McGinnis and Foege
• Not a cookbook or a one-size-fits-all solution
• Users must combine scientific information(e.g.,
  effectiveness, cost) with other information
  (e.g., needs, values, capacities, resources)

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Examples of Community Guide Recommendations

• Breast, Cervical and Colorectal Cancer Screening
• Tobacco Interventions

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What Population-Based and Health System
Interventions are Effective in Increasing Breast,
Cervical, and Colorectal Cancer Screening?

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Initial Steps

• Looked for evidence of effectiveness of breast,
  cervical, colorectal cancer screening
• Guide to Clinical Preventive Services
• Grouped interventions into strategies
• Client-directed- Increase community demand
• Knowledge/awareness, perception/fear/attitude,
  motivation, forgetfulness
• Increase service delivery by health providers
• Provider-client interaction

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Increasing Community Demand

• Client reminder
• Client incentive
• Mass media
• Small media
• Group education
• One-on-one education

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Increasing Provider Delivery

• Provider reminder
• Provider assessment and feedback
• Provider incentive

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Increasing Community DemandConceptual Approach
Other benefits or harms?
Efficacy Established
Decrease Morbidity Mortality
Change Knowledge Attitudes Intentions
Increase demand e.g., reminder, small media,
group education
Increase completed screening (Early detection)
Follow-up Diagnosis Treatment
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Increasing Provider DeliveryConceptual Approach
Increase Discussion of test with clients
Change client Knowledge Attitudes Intentions
Other benefits or harms?
Provider role e.g., reminder, assessment
feedback
Increase completed screening (Early detection)
Increase Test offering/ordering
Change provider Knowledge Attitudes Intentions
Follow-up Diagnosis/ Treatment
Efficacy Established
Decrease Morbidity Mortality
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Search Results
Step 1. Search data bases using key terms
gt 9000 citations found
Step 2. Screen titles and abstracts
gt 8420 articles excluded
580 articles/studies pass screen
Step 3. Screen article text
336 articles excluded
244 studies pass screen (Candidate studies)
Step 4. Sort by intervention
Client reminders
Small media
Client incentives
Mass media
Group education
One-on-one education
Reducing out-of-pocket cost
Reducing structural barriers
Provider reminders
Provider incentives
Provider assessment feedback
Multi-component interventions
Inclusion criteria published in English
primary study one or more selected
interventions one or more selected outcomes
suitable comparison
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Increasing Community Demand Client Reminder

• Printed (letter or postcard) or telephone
  messages advising people they are
• Due (reminder) for screening
• Late (recall) for screening
• May be enhanced by
• A follow up printed or telephone reminder
• Additional text or discussion about
• Indications for screening
• Benefits of screening
• Overcoming barriers to screening
• Assistance scheduling appointments
• Tailoring

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Client Reminders Applicability

• Studies HMOs in US, clinics in Canada Israel
• Limited/no description of
• SES, racial-ethnic, screening backgrounds of
  study participants
• Geographic settings of studies
• Studies of client reminders for breast, cervical
  screening suggest broad applicability

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Client Reminders Conclusions

• FOBT
• Recommended
• Sufficient evidence
• Flexible sigmoidoscopy, colonoscopy, barium
  enema
• Insufficient evidence
• No qualifying studies

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Provider Reminder Breast, Cervical Colorectal
Cancer Screening

• Inform, cue, or remind providers or other health
  care professionals that individual clients are
• Due (reminder) for screening, or
• Overdue (recall) for screening
• Notes in client charts or
• Memorandum or letter

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Provider Reminders Applicability

• US, Italy, UK, Canada, Australia, and Israel
• University hospitals, clinics, HMOs, and
  independent offices
• Urban and rural
• White and African-American (clients)
• Physician trainees (residents/interns) and
  non-trainees
• Due and overdue for screening

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Provider Reminders

• Barriers
• Access to electronic/computerized records
• Perceived physician time investment
• Other benefits/harms
• May increase utilization of other preventive
  services
• No harms reported

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Provider Reminders Conclusions

• For breast, cervical, colorectal (FOBT and
  flexible sigmoidoscopy)
• Recommended
• Strong evidence

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Evidence of Effectiveness for Cancer Screening Interventions Evidence of Effectiveness for Cancer Screening Interventions Evidence of Effectiveness for Cancer Screening Interventions Evidence of Effectiveness for Cancer Screening Interventions
Breast Cervical Colorectal
Community Demand
Client reminder Strong Strong Sufficient
Client incentive Insufficient Insufficient Insufficient
Mass media Insufficient Insufficient Insufficient
Small media Strong Strong Strong
Group education Insufficient Insufficient Insufficient
One-on-one education Strong Strong Insufficient
Community Access
Reduce structural barrier Strong Insufficient Strong
Reduce out-of-pocket expense Sufficient Insufficient Insufficient
Provider Role
Provider reminder Strong Strong Strong
Provider assessment feedback Sufficient Sufficient Sufficient
Provider incentive Insufficient Insufficient Insufficient
Reason evidence insufficient No studies
Too few studies Inconsistent findings
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Community Guide reviews and recommendations to
reduce tobacco use and exposures to secondhand
tobacco smoke
Selected interventions appropriate for
communities and health care systems

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Background

• Efforts to reduce tobacco use are measured in two
  important ways
• A change (increase) in tobacco use cessation in a
  study population of tobacco users
• A change (reduction) in tobacco use prevalence in
  an overall population
• In populations of youth, prevalence change is a
  proxy for tobacco use initiation

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A Study Example with a Little Math
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Evidence of Real-World Effectiveness of a
Telephone Quitline for Smokers(Zhu et al. NEJM
2002)

• California Smokers Helpline
• Randomized, controlled trial of telephone-based
  cessation assistance
• Smokers who were ready to quit (N3282)
• Intervention Proactive telephone counseling
  self-help materials
• Comparison Self-help materials call-back
  option
• Follow-up 1,3,6, and 12 months
  

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Study Results and Review Calculations

• Group n Quit at 12m
  f/u
• Intervention (I) 1973 9.1
• Comparison (C) 1309 6.9
• 
  plt0.001
• Absolute change I-C 2.2 percentage points
• Relative change (100) (I-C)/C 32
• Number Needed to Treat 100/(I-C)
• 45 smokers to get one additional quit

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One Study in an Overall Review

• Evidence from 32 different studies contributed to
  the final Task Force assessment and conclusion
• Across this body of evidence
• Median change in tobacco cessation
• Absolute 2.6 percentage points at 12m f/u
• Relative 41
• Number needed to treat
• 38 smokers to get one additional quit

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Task Force Conclusion

• The Task Force recommends telephone cessation
  support when implemented with other interventions
  (e.g. other educational approaches or clinical
  therapies) based on strong evidence of
  effectiveness in increasing tobacco use cessation
  among participants in both clinical and community
  settings. The minimum effective combination
  identified in this review was proactive telephone
  support combined with patient education materials.

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Recommendations from the Task Force on Community
Preventive Services
Selected Interventions, appropriate for
communities and health care systems, to reduce
tobacco use and exposures to secondhand tobacco
smoke
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In Health Care Systems
Goal Task Force Recommendations for Use of these Interventions
Increase Cessation - Provider reminder systems alone or with additional efforts - Telephone Quit services additional efforts - Reducing patient costs for effective cessation therapies
Reduce Initiation ( Not reviewed)
Reduce Exposures - Smoke-free policies
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In Health Care Systems
Goal Task Force findings of Insufficient Evidence to draw a conclusion
Increase Cessation - Provider education programs (alone) - Provider feedback systems
Reduce Initiation (Not reviewed)
Reduce Exposures
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In Communities
Goal Task Force Recommendations for Use of these Interventions
Increase Cessation - Increase the price (tax) - Mass media campaigns additional efforts - Telephone Quit services additional efforts - Smoke-free policies (New)
Reduce Initiation - Increase the price (tax) - Mass media campaigns additional efforts - Community mobilization additional efforts to reduce youth access
Reduce Exposures - Smoke-free policies
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In Communities
Goal Task Force findings of Insufficient Evidence to draw a conclusion
Increase Cessation - Community-based cessation contests - Cessation broadcast series
Reduce Initiation - School-based programs when implemented alone - Retailer education to reduce access when implemented alone - Active enforcement of sales laws when implemented alone
Reduce Exposures - Efforts to reduce secondhand smoke exposure in the home
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Public health is purchasable. Within a few
natural and important limitations any community
can determine its own death rate. Hermann
Biggs Medical Officer New York City
DOH 1905
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For More Information

• Community Guide website
• www.thecommunityguide.org
• American Journal of Preventive Medicine
• Theresa Ann Sipe, Statistician, Community Guide
• tsipe_at_cdc.gov
• Shawna Mercer, Community Guide Director
• SMercer_at_cdc.gov

The findings and conclusions in this presentation
are those of the presenter and do not necessarily
represent the views of CDC.
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Increasing Community Demand Small Media

• Videos or printed materials
• Letters, brochures, pamphlets, flyers,
  newsletters
• Distributed from healthcare or community settings
• Educational or motivational information
• Based on behavior change theories
• May be tailored or untailored

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Small Media Applicability

• Studies in UK and US
• Study participants
• White, African-American
• Some low SES
• Urban and rural
• Clinical and community settings
• Suggest broad applicability
• Only one tailored intervention

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Small Media Conclusions

• FOBT
• Recommended
• Strong evidence
• Flexible sigmoidoscopy, colonoscopy, barium
  enema
• Insufficient evidence
• No qualifying studies