CDC Panel: Community Guides and US Preventive Services Task

Force

Theresa Ann Sipe, PhD, MPH, RN Statistician

The Guide to Community Preventive ServicesNational Center for Health Marketing

Centers for Disease Control and Prevention

Overview1. What is the Guide to Community Preventive

Services (Community Guide)? Is it credible? Relevant to the issues I face?

2. What are key challenges to disseminating evidence-based information and translating it into action?

3. How does the Community Guide aim for: Credibility Dissemination of its recommendations?

4. What are implications for nursing?

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

The Clinical Guide and Community Guide Are Complementary

The Clinical and Community Guides Are Complementary

Individual levelClinical settingsDelivered by healthcare providers Screening, Counseling, etc.

Group level Health system changes Insurance/benefits coverage Access to/provision of servicesCommunity, population-based Informational (Group Education, Media) Behavioral, Social Environmental & Policy Change

Community Guide(TFCPS

Recommendations)

Clinical Guide (USPSTF

Recommendations)

Community Guide (CG) TopicsThe EnvironmentSocial Environment

SettingsWorksites

Schools

Risk Behaviors Specific ConditionsTobacco 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

Community Guide Accomplishments >200 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

Community Guide: How is it Used?

To inform decision making around:

Practice

Policy making

Research

Research Funding

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

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]

Community Guide: Intended Users (cont’d)

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.”

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

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 1992;19:408-411

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

The Typical Approach to Dissemination of Evidence:

A Push Model

Systematic Review of the

Scientific Evidence

By researchers

Practice, PolicyDissemination

Knowledge to Action Continuum

Participationand Collaboration

Participationand Collaboration

DisseminationDissemination

Planning, AssessingUptake and Quality

Planning, AssessingUptake and Quality

Identify Research-Practice Gaps

Identify Research-Practice Gaps

How to MeasureEffects

How to MeasureEffects

TranslationTranslation

Public Health Research&

Systematic Reviews of Research

Surveillance & Evaluation

Monitoring, NeedsAssessment

ActionPractice, Policy

Lawrence W. Green, DrPH & Shawna L. Mercer, MSc, PhD

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

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.

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

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?

Community Guide Places Equal Weight on:

The quality of the systematic review methods and analysis

The group processes

Participants in the Community Guide

1. 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

Task Force on Community Preventive Services

Current Members

Jonathan C. Fielding, MD, MPH, MBA, Chair

Bruce Nedrow Calonge, MD, MPHJohn M. ClymerKay Dickersin, PhDKaren Glanz, PhD, MPHRon Goetzel, PhDRobert L. Johnson, MD

Barbara K. Rimer, DrPH, Vice-Chair

Ana Abraido-Lanza, PhDNico P. Pronk, PhDGilbert Ramirez, DrPHC. Tracy Orleans, PhDLawrence W. Green, DrPH

Current Consultants

Robert S. Lawrence, MD

J. Michael McGinnis, MD

Alonzo L. Plough, PhD, MPHSteven M. Teutsch, MD, MPH

Participants in the Community Guide

2. Official Liaisons >25 federal agency and organizational Provide input into prioritization, reviews,

recommendations Recommend, find participants for review teams Participate in dissemination, translation especially

to their constituents

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

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

Official Organizational Liaisons (cont’d)

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

Participants in the Community Guide

3. 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

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

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?

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?

Transparency (A Minor Detail!)

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

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

Issues Considered in Guide Reviews

Intervention IntendedOutcomes

Morbidityand/or

MortalityAdditionalOutcomes

Benefits

Harms

Barriers

EconomicInformation

Applicability of the evidence

In General, a Conclusion About Effectiveness Requires….

A Body of Evidence

•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”

A Demonstration of Effectiveness

Strength of a Task Force Conclusion

STRONG evidence of effectiveness

SUFFICIENT evidence of effectiveness

INSUFFICIENT evidence Doesn’t mean the intervention is not effectiveBUT RATHER “We can’t determine at this time whether or

not this intervention works.”

Task Force Recommendation Options

Recommend Strong Evidence Sufficient Evidence

Recommend against Strong Evidence Sufficient Evidence

Insufficient evidence to recommend for or against

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?

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)

Examples of Community Guide Recommendations

Breast, Cervical and Colorectal Cancer Screening

Tobacco Interventions

What Population-Based and Health System Interventions are Effective in Increasing

Breast, Cervical, and Colorectal Cancer Screening?

1. Looked for evidence of effectiveness of breast, cervical, colorectal cancer screening

Guide to Clinical Preventive Services

2. Grouped interventions into strategies:a) Client-directed- Increase community demand

• Knowledge/awareness, perception/fear/attitude, motivation, forgetfulness

b) Increase service delivery by health providers• Provider-client interaction

Initial Steps

Client reminder

Client incentive

Mass media

Small media

Group education

One-on-one education

Increasing Community Demand:

Provider reminder

Provider assessment and feedback

Provider incentive

Increasing Provider Delivery:

Change KnowledgeAttitudes Intentions

Other benefits or harms?

Efficacy Established

Increase demande.g., reminder, small media,

group education

Follow-upDiagnosisTreatment

Increase completedscreening

(Early detection)

Increasing Community Demand:Conceptual Approach

DecreaseMorbidityMortality

Provider role e.g., reminder, assessment &

feedback

Follow-upDiagnosis/Treatment

IncreaseTest offering/ordering

IncreaseDiscussion of test

with clients

Change providerKnowledgeAttitudesIntentions

Increase completed screening

(Early detection)

DecreaseMorbidityMortality

Change client Knowledge

Attitudes Intentions

Efficacy Established

Increasing Provider Delivery:Conceptual Approach

Other benefits or harms?

Step 2. Screen titles and abstracts

Step 3. Screen article text*

Step 4. Sort by intervention:

Step 1. Search data bases using key terms

> 8420 articles excluded

~ 336 articles excluded

*Inclusion criteria: published in English; primary study; one or more selected interventions; one or more selected outcomes; suitable comparison

~ 580 articles/studies pass screen

244 studies pass screen (“Candidate studies”)

> 9000 citations found

Client reminders Small media Client incentives

One-on-one education

Group education

Reducing out-of-pocket cost Reducing structural barriers

Mass media

Provider reminders Provider incentives Provider assessment & feedback

Multi-component interventions

Search Results

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

Increasing Community Demand: Client Reminder

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

Client Reminders: Conclusions

FOBT: Recommended Sufficient evidence

Flexible sigmoidoscopy, colonoscopy, barium enema: Insufficient evidence No qualifying studies

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

Provider Reminder: Breast, Cervical & Colorectal Cancer Screening

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

Provider Reminders: Applicability

Barriers Access to electronic/computerized records Perceived physician time investment

Other benefits/harms May increase utilization of other preventive services No harms reported

Provider Reminders

Provider Reminders: Conclusions

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

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

Provider assessment & feedback Sufficient

Provider incentive Insufficient**

Reason evidence insufficient: * No studies** Too few studies† Inconsistent findings

Community Guide reviews and recommendations to reduce

tobacco use and exposures to secondhand tobacco smoke

Selected interventions appropriate for

communities and health care systems

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

A Study Example with a Little Math

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 (N=3282)

Intervention: Proactive telephone counseling + self-help materials

Comparison: Self-help materials + call-back option

Follow-up: 1,3,6, and 12 months

Study Results and Review Calculations

Group n Quit at 12m f/uIntervention (I) 1973 9.1%Comparison (C) 1309 6.9%

p<0.001

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

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

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.

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

In Health Care SystemsGoal Task Force Recommendations for Use of

these InterventionsIncrease 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

In Health Care SystemsGoal 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

In CommunitiesGoal Task Force Recommendations for Use of

these InterventionsIncrease 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

In CommunitiesGoal 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

“Public health is purchasable. Within a few natural and important limitations any community can determine its’ own death rate.”

Hermann BiggsMedical Officer

New York City DOH 1905

For More Information Community Guide website:

www.thecommunityguide.org

American Journal of Preventive Medicine

Theresa Ann Sipe, Statistician, Community Guide tsipe@cdc.gov

Shawna Mercer, Community Guide Director SMercer@cdc.govThe findings and conclusions in this presentation are those of the presenter and do not necessarily represent the views of CDC.

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

Increasing Community Demand: Small Media

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

Small Media: Conclusions

FOBT: Recommended Strong evidence

Flexible sigmoidoscopy, colonoscopy, barium enema: Insufficient evidence No qualifying studies