1. Extreme Makeover -- Data Edition: Inside the Box Presentation at the CityMatch Conference, August 2007 Michael Kogan, Ph.D. U.S. Department of Health and Human Services (DHHS) Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Director, Office of Data and Program Development

2. Presentation Outline  Definition of ‘evidence’  Discussion of evidence-based medicine  Discussion of evidence-based public health  How to use evidence-based approaches  Evidence-based maternal and child health

3. What is “Evidence”?  Information that is collected in an orderly way about a disease or its treatment. –CDC website

4. Are Evidence-Based Practices Applicable Only to the Health Field?

5. Evidence-Based Baseball  Michael Lewis's book, Moneyball, documents the effective use of evidence- based practices by Billy Beane, the general manager of the Oakland Athletics. Lewis shows how Beane's reliance on theoretically relevant statistics and on a scientific approach to baseball allowed him to achieve winning seasons despite being burdened with severe budget constraints.

6. Evidence-Based Baseball  What predicts which amateur hitters make it to the big leagues and become successful players: –Ability to hit home-runs? –Foot-speed? –Fielding ability? –Number of walks that a hitter drew?

7. Evidence-Based Baseball  Answer: The number of walks that a hitter drew, signifying his ability to understand how to control the strike zone. –Lewis, Moneyball, 2003.

8. 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?

9. Evidence-Based Baseball  Answer: On-base percentage. –Lewis, Moneyball, 2003.

10. What is “Evidence-Based Medicine”?  Health care practices that are based on review of the current best evidence on the effectiveness of a test, drug, surgery or other medical practice.  Based on collecting and analyzing all of the research studies that have been conducted on a particular intervention.  These reviews are called meta-analyses and systematic reviews.

11. Rise of Evidence-Based Medicine  First described in 1992  A new approach to teaching medicine  A “revolution” in medical practice  Other “evidence-based” approaches: ethics, psychotherapy, occupational therapy, dentistry, nursing, and librarianship

12. Factors Driving EBM  Overwhelming size of the literature  Inadequacy of textbooks  Difficulty synthesizing evidence and translating into practice  Increased number of randomized control trials  Available computerized databases  Reproducible evidence strategies

13. Steps of EBM  Convert the need for info. into an answerable question  Track down the best evidence  Critically appraise that evidence  Integrate the appraisal with one’s clinical expertise and the individual patient  Evaluate Sackett DL. EBM: how to practice and teach EBM. Churchill Livingstone 2000

14. Differences between Medicine and Public Health Public Health Medicine Primary Focus PopulationsIndividuals EmphasisPreventionDiagnosis Health Promotion Treatment Whole Community Whole Patient Paradigm Interventions aimed at Environment, Human Behavior and Lifestyle, and Medical Care Medical Care

15. Differences between Medicine and Public Health (continued) Public Health Medicine Organizational Lines of Specialization Analytical (Epidemiology) Organ (Cardiology) Setting and Population (Occupational Health) Patient Group (Pediatrics) Substantive Health Problem (Nutrition) Etiology, Pathophysiology (Oncology, Infectious Disease) Skills in Assessment, Policy Development, and Assurance Technical Skill (Radiology)

16. Development of Evidence Based Public Health  Jenicek (1997) published a review discussing epidemiology, EBM, EBPH  Epidemiology described as the foundation of both EBM and EBPH  EBPH unique in using complex interventions with multiple community and societal issues

17. Jenicek M. J Epidemiol 1997;7:187-97 Definition of EBPH (1)  “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)

18. Definition of EBPH (2)  Evidence-based public health is defined as the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models.  Brownson, et al, 2003

19. Brownson RC. J Public Health Manag Pract 1999;5:86-87 Steps of EBPH  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

20. Steps to Searching the Public Health Literature  Determine the public health problem and define the question.  Select information sources.  Identify key concepts and terms.  Conduct the search in subject- appropriate databases.  Select documents for review.  Abstract relevant information.  Summarize and apply the literature review.  Brownson, et al. 2003.

21. Evaluating the Quality and Methods of Public Health Research Results  What are the results? –Were the results similar from study to study? –What are the overall results of the review? –How precise were the results? –Can a causal association be inferred?  Are the results valid? –Did the review explicitly address the PH question? –Was the search exhaustive? –Were the primary studies of high methodological quality?  How can the results be applied to PH practice? –How can the results be interpreted and applied? –Were all the important PH outcomes considered? –Are the benefits worth the costs and potential risks?  Brownson, et al. 2003.

22. How are Decisions Usually 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

23. Evidence and Public Health Decision Making  Good news –Strong evidence on the effect of many policies/ programs aimed to improve public health –Major efforts underway to assess the body of evidence for wide range of public health interventions

24. What Works to Improve the Public’s Health?  Bad news –Many public health professionals are unaware of this evidence –Some who are aware don’t 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

25. Barriers Facing Evidence-Based Public Health  “Evidence-based research tells you what you should do, not what you can do … What a lot of us are facing is no matter how much evidence you have, you just don’t have enough resources.” –A Title V Director (interviewed for an evaluation study)

26. Evidence-Based Maternal and Child Health  True or False:  The more prenatal care a woman receives, the better her birth outcomes?

27. Evidence-Based Maternal and Child Health  FALSE:  If a woman receives MORE than the recommended amount of care, she is more likely to have worse birth outcomes.

28. 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.

29. 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

30. Resources  Medline search (http://www.ncbi.nlm.nih.gov/sites/entrez)  Cochrane Collaboration (www.cochrane.org)  Task Force on Community Preventive Services (http://www.thecommunityguide.org/)  National Guideline Clearinghouse (http://www.guideline.gov/)  The Institute of Medicine (www.iom.edu)  Evidence-Based Practice for Public Health (http://library.umassmed.edu/ebpph/)  Best Practices at the Local Level (http://archive.naccho.org/modelPractices/)

31. Resources  Promising Practices Network for Children (http://promisingpractices.net/programs_ outcome.asp)

32. Acknowledgments Jonathan Fielding, MD, Los Angeles County Dept. of Health Services Neal Kohatsu, MD, University of Iowa Harvey Fineberg, MD, Harvard University

33. Contact Information Michael Kogan, Ph.D. HRSA/MCHB Director, Office of Data and Program Development 5600 Fishers Lane, Room 18-41 Rockville, MD 20857 301-443-3145mkogan@hrsa.gov