1. CLINICAL EPIDEMIOLOGY IN SUPPORT FOR TBI QUALITY OF CARE POLICIES Prof. MUDr. Martin Rusnák, CSc Department of Public Health, Faculty of Health Care and Social Work, Trnava University Trnava, Slovak Republic

2.  Introduce Epidemiology and Evidence Based Public Health as closely related practical disciplines supporting development and implementation of PH policies  Share several examples from the field of Traumatic Brain Injuries to illustrate the concept Aims of the presentation

3. 2013 is the bicentenary of the birth of John Snow (1813–58), whose elegant studies of cholera in the mid-19th century earned him iconic status among the founders of epidemiology, the basic science of public health. PEM Fine, BM Goldacre, A Haines: Epidemiology—a science for the people. The Lancet, Volume 381, Issue 9874 (13–19 April 2013) John Snow, 1st epidemiologist

4.  The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems.  "Study" includes surveillance, observation, hypothesis testing, analytic research, and experiments.  "Distribution" refers to analysis by time, place, and classes of persons affected.  "Determinants" are all the physical, biological, social, cultural, and behavioural factors that influence health.  "Health-related states and events" include diseases, causes of death, behaviours such as use of tobacco, reactions to preventive regimens, and provision and use of health services.  "Specified populations" are those with identifiable characteristics such as precisely defined numbers.  "Application to control...“ makes explicit the aim of epidemiology—to promote, protect, and restore health. Definition of epidemiology Definition of epidemiology Last, J.M., A Dictionary of Epidemiology. 1995, Oxford: Oxford University Press. 196.

5.  Application of the best available evidence in setting public health policies and practices.  The evidence may be derived from epidemiologic, demographic, sociologic, economic, and many other relevant sources, preferably published, peer-reviewed, and critically appraised articles and reports.  Implementation of public health policies, programs and practices requires good evidence on feasibility, EFFICACY, EFFECTIVENESS, EFFICIENCY, COST, acceptability to the target population, and consideration of ethical and political implications. Evidence Based Public Health

6.  Making decisions using the best available peer-reviewed evidence (both quantitative and qualitative research),  Using data and information systems systematically,  Other …. Key characteristics of EBPH related to epidemiology Key characteristics of EBPH related to epidemiology Brownson, R.C., J.E. Fielding, and C.M. Maylahn, Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health, 2009. 30: p. 175-201

7.  Scientific literature in systematic reviews  Scientific literature in one or more journal articles  Public health surveillance data  Program evaluations  Qualitative data  Community members  Other stakeholders  Media/marketing data  Word of mouth  Personal experience Different forms of evidence Chambers D, Kerner J. Closing the gap between discovery and delivery. Dissemination and Implementation Research Workshop: Harnessing Science to Maximize Health, Rockville, MD, 2007. Objective Subjective

8.  Type 1 evidence defines the causes of diseases and the magnitude, severity, and preventability of risk factors and diseases. It suggests that “Something should be done” about a particular disease or risk factor.  Type 2 evidence describes the relative impact of specific interventions that do or do not improve health, adding, “Specifically, this should be done.”  Type 3 evidence shows how and under what contextual conditions interventions were implemented and how they were received, thus informing “how something should be done“. Types of scientific evidence for public health practice Types of scientific evidence for public health practice Ross C. Brownson, E.A.B., Terry L. Leet, Kathleen N. Gillespie, William R. True, Evidence-Based Public Health. 2nd ed. 2010: Oxford University Press, USA.

9. CharacteristicType 1Type 2Type 3 Typical data/ relationship Size and strength of preventable risk — disease relationship (measures of burden, etiologic Research) Relative effectiveness of public health intervention Information on the adaptation and translation of an effective intervention Common setting Clinic or controlled community setting Socially intact groups or community-wide Socially intact groups or community-wide ExampleSmoking causes lung cancer. Price increases with a targeted media campaign reduce smoking rates. Understanding the political challenges of price increases or targeting media messages to particular audience segments. QuantityMoreLess ActionSomething should be done. This particular intervention should be implemented. How an intervention should be implemented

10. Public Health Surveillance  Involves the on-going systematic collection, analysis, and interpretation of specific health data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease or injury.  Systems should have a capacity to collect and analyse data, disseminate data to public health programs, and regularly evaluate the effectiveness of the use of the disseminated data.

11. Epidemiology of TBI Epidemiology of TBI Rosso, A., Brazinova, A., Janciak, I., Wilbacher, I., Rusnak, M., Mauritz, W., Severe traumatic brain injury in Austria II: epidemiology of hospital admissions. Wien Klin Wochenschr, 2007. 119(1-2): p. 29-34

12. Guidelines and Survival Guidelines and Survival Rusnak, M., et al., Severe traumatic brain injury in Austria VI: Effects of guideline- based management. Wiener Klinische Wochenschrift, 2007. 119(1-2): p. 64-71

13. Assessment of Quality Brazinova, A., Rusnak, M., Mauritz, W., Lecky, F., Kaniansky, M., Evaluation of traumatic brain injury guidelines using AGREE instrument. Bratislava Medical Journal-Bratislavske Lekarske Listy, 2008. 109(8): p. 374-380.

14.  Epidemiologists should recognize the policy system and model that are in place, and adapt their work to that model; there is no use making grand plans if the system will not accommodate them, and no use communicating with the wrong people.  Four main headings:  a population focus,  health and prevention,  health services, and  health information. What is the nature of contributions from epidemiology to policy? Robert A. Spasoff, Epidemiologic Methods for Health Policy. 1999: Oxford University Press Inc. 240.

15. Linkages Between Program Planning and Evaluation

17.  Applying advances from molecular biology  Increasing attention to ethical issues  Measuring and communicating weak associations  Measuring outcomes and quality of health care  Setting priorities and measuring progress  Investigating public health outbreaks  Preventing chronic diseases and other "modern epidemics"  Measuring the effects of public health interventions  Informing public health policies  Applying new computer and information technologies  Increasing epidemiologic capacity in applied settings Summary of Modern Challenges and Opportunities in Epidemiology Brownson, R.C. and D.B. Petitti, Applied epidemiology: Theory to practice. 1998: Oxford University Press on Demand.

18.  Epidemiology provides tools, results and interpretations to develop evidence  Epidemiologists have to be involved in transforming evidence to policies  Epidemiology methods are to be used in verifying what intervention work and in what extent  Epidemiologists are an integral part of policy processes in health care and social development Summary

19. Join us in efforts to get the epidemiology the voice in policies making. Thank you.