Evidence-based Public Health Interventions Robert S. Lawrence, MD Bloomberg School of Public Health Johns Hopkins University April 20, 2005

Background and History Use of clinical trials to determine efficacy of clinical preventive services - e.g., H.I.P. study of mammography by Shapiro et al LeLonde Commission report on health determinants, Led to formation of Canadian Task Force on the Periodic Health Examination Canadian Task Force reported in 1979 on evidence for including primary and secondary prevention interventions in the PHE

Background and History Methodology adopted by Canadian Task Force: –Grade I evidence requires data from one or more randomized prospective clinical trials –Grade II evidence requires data from case-control, cohort, or time-series studies. In rare instances, such as the introduction of penicillin, uncontrolled interventions with dramatic results may be considered Grade II –Grade III evidence includes expert opinion

Background and History Methodology adopted by Canadian Task Force: –“A” recommendation indicates Grade I evidence or good evidence exists that the intervention should be included (e.g., mammography for women 50-65) –“B” recommendation indicates that Grade II or fair evidence exists that the intervention should be included –“C” recommendation indicates that the evidence is neither sufficient to include or exclude the intervention –“D” recommendation indicates that Grade II evidence exists that the intervention should be excluded –“E” recommendation excludes the intervention based on Grade I evidence (e.g., routine screening chest x- rays

U.S. Preventive Services Task Force U. S. Preventive Services Task Force created in 1984 to develop evidence-based recommendations for the U.S. population U.S. Task Force adopted the Canadian methodology and worked collaboratively with the Canadian Task Force U.S. Task Force issued first report in 1989 evaluating 169 interventions for 60 conditions

USPSTF Criteria of Effectiveness Screening tests: Efficacy of Screening Tests Effectiveness of Early Detection Counseling Interventions: Efficacy of Risk Reduction Effectiveness of Counseling Immunizations: Efficacy of Vaccine Chemoprophylaxis: Efficacy of Chemoprophylactic Agent Effectiveness of Counseling

U.S. Preventive Services Task Force USPSTF recommendations gradually adopted by HMOs, insurers and federal agencies as the reference standard for determining what clinical preventive services to include in the periodic health exam and what services to reimburse Sponsorship of the USPSTF transferred from the Office of Disease Prevention and Health Promotion to the Agency for Healthcare Research and Quality USPSTF recently celebrated its 20th anniversary and continues to review new evidence

U.S. Community Preventive Services Task Force Centers for Disease Control and Prevention established the U.S. Community Preventive Services Task Force in 1995 to evaluate the evidence for health interventions provided at the community or population level to complement the ongoing activities of the USPSTF Like the USPSTF the Community Preventive Services Task Force included a group of non- federal health professional with a broad range of expertise in population health

U.S. Community Preventive Services Task Force The Guide to Community Preventive Services: What Works to Promote Health published by Oxford University Press in 2005 Contains chapters related to the following major causes of premature disability and death: –Tobacco –Physical Activity –The Social Environment –Cancer –Diabetes –Vaccine-Preventable Diseases –Oral Health –Motor Vehicle Occupant Injury –Violence

U.S. Community Preventive Services Task Force The Guide to Community Preventive Services: What Works to Promote Health published by Oxford University Press in 2005 Contains chapters related to the following major causes of premature disability and death: –Tobacco –Physical Activity –The Social Environment –Cancer –Diabetes –Vaccine-Preventable Diseases –Oral Health –Motor Vehicle Occupant Injury –Violence