Evidence-Based Public Health. Overview. Getting It Wrong. Evidence Helps Us Get It Right. The right focus. The right intervention

Transcription

1 Evidence-Based Public Health Overview Jeffrey R. Harris, MD MPH MBA Evidence-Based Public Health Getting It Wrong Evidence Helps Us Get It Right The right focus The right intervention Implemented the right way 1

2 Or Avoid Getting It Wrong Overview Evidence-based decision-making Uses of evidence Using evidence Evidence-based public health framework What is Evidence? Objective Scientific literature Public health surveillance Program evaluations Qualitative data Media/marketing data Word of mouth Personal experience Like beauty, it s in the eye of the beholder Subjective 2

3 Uses of Evidence Focus Intervention Implementation Using Evidence: Focus Choose one cancer site for screening Do you want to screen at all? Good Bad THE GOOD THE BAD AND THE UGLY 3

4 Focus: What Would You Like to Know? Sources of Evidence: Cancer Focus Governmental public health agencies: National Cancer Institute s Cancer PLANET Voluntary agencies: American Cancer Society Clinical specialty societies: American Society of Clinical Oncology Which Cancer Site Would You Choose? Incidence Mortality A. Colon Cancer ~3,000 per year ~1,000 per year B. Prostate Cancer ~5,000 per year ~600 per year 4

5 Epi Evidence: Colon vs. Prostate Cancer Screening accurate? A. Colon Cancer Sensitive Combo specific Treatment effective? 5-year survival higher if diagnosed early B. Prostate Cancer Insensitive Non-specific? effective What really happened? Using Evidence: Intervention You must pick a screening test 5

6 Picking a Screening Test: Search Strategies Search for studies Expert consensus Literature reviews Systematic Reviews Move beyond cite what I agree with Specify: Search strategy Rules for summarizing evidence Meta-analysis a subset statistical summation US Preventive Services Task Force Clinical preventive care Panel of non-governmental experts Specific literature-search protocol Evaluate: Study design Weight/balance of evidence Harms Strength of evidence & of intervention Coverage decisions under Affordable Care Act 6

7 Things You Don t Want to Watch Being Made Sausage Laws Evidence-Based Guidelines USPSTF-Recommended Tests: Colon Cancer Fecal Occult Blood Test Colonoscopy Flexible Sigmoidoscopy USPSTF Evidence Update, 2008 Fecal Occult Blood Test Done at home Stool on a stick Rub it on the card Mail it in Detects blood in stool 7

8 Colonoscopy Done in endoscopy suite Clear bowel with laxative Conscious sedation Takes min What Else Would You Like to Know? Test-related Evidence: Colon Cancer Fecal Occult Blood Test Colonoscopy Periodicity 1 year 10 years Cost $7-$15 $557 Safety No risk Risk of bleeding, perforation Convenience Handling stool distasteful Prep debilitating Need ride home Definitiveness 30% require colonoscopy over 10 years Best we have 8

9 Cost-Effectiveness: Clinical Cancer Prevention Cost-saving Tobacco screening & cessation treatment Cost-neutral Colon cancer screening FOBT & Colonoscopy similar Moderate cost Mammography Pap Source: National Commission on Prevention Priorities, Which test would you pick A. Fecal Occult Blood Test B. Colonoscopy What really happened? 9

10 Using Evidence: Implementation You seek effective interventions to increase use CDC s Guide to Community Preventive Services Systematic review like USPSTF What works to make prevention happen In clinical care In communities Via policies and laws Evidence: Increasing Colon Cancer Screening Providers: Assessment & feedback Reminders Patients: Barriers reduced (worksite FOBT) One-on-one education Reminders Small media posters, pamphlets, etc 10

11 Evidence Into Practice RTIP Example: In Chinese Americans Seattle Clinic Chinese language: Health Educator Brochure decision making Brochure FOBT how to Video people discussing screening Success Fecal Occult Blood Test Screening Rates Percentage Receiving FOBT Screening 80% 70% 60% 50% 40% 30% 20% 10% 0% 69.5% Intervention 27.6% Control 11

12 Discontinue Disseminate widely Retool Barriers to EBPH Lack of leadership Lack of a view of the long-term horizon External (including political) pressures Inadequate training in key public health disciplines Lack of time Lack of incentives When Evidence Is Not Enough Cultural and geographical limitations Bias in deciding what gets studied Emerging health issues Community-based & participatory approaches 12

13 Summary Evidence helps avoid mistakes Uses of evidence: focus, intervene, implement EBPH Framework useful It ain t easy 13