Category Archives: Research
Do we need an endgame strategy to finally end the devastating hold tobacco has on its users? Scholars, scientists and policy experts grapple with endgame proposals in a special supplement to the journal Tobacco Control. Some of the articles are based on a workshop held last year at the University of Michigan, with financial support from the Robert Wood Johnson Foundation and the American Legacy Foundation. The workshop was hosted by Kenneth Warner, PhD, a former dean at the University of Michigan School of Public Health and now a professor at the School.
Although smoking has declined significantly in most developed nations in the last half-century, due to policy changes and increased education about the health hazards, says Warner, too many people continue to die from the most preventable cause of premature death and illness. It's estimated that worldwide six million people a year die from illnesses caused by cigarettes, including more than 400,000 in the U.S. alone."There is a newfound interest in discussing the idea of an endgame strategy. The fact that we can talk about it openly reflects a sea change,” says Warner.
>>Read the articles in the tobacco endgame supplement.
Some of the strategies in the supplement include:
- Requiring manufacturers to reduce nicotine content sufficiently to make cigarettes nonaddictive.
- A "sinking lid" strategy that would call for quotas on sales and imports of tobacco, which would reduce supply and drive up price to deter tobacco purchases.
- A "tobacco-free generation" proposal calling for laws that would prevent the sale of tobacco to those born after a given year, usually cited as 2000, to keep young people from starting to smoke; or ban the sale of cigarettes altogether.
"What we are doing today is not enough," says Warner. "Even if we do very well with tobacco control, as we have for several decades now, we'll have a huge number of smokers for years to come, and smoking will continue to cause millions of deaths.”
NewPublicHealth recently spoke with Dr. Warner about some of the strategies proposed for ending tobacco use.
NewPublicHealth: Why is there a need for novel, even radical, endgame strategy?
Ken Warner: While a lot of people have quit smoking, if you look at the rate at which people are quitting in the United States, in the last few years it may actually have declined. In Canada, there is some concern that their very low rates of smoking may actually have gone up. In Singapore, which had the lowest smoking prevalence among developed nations, the smoking rate went up from 12.6 percent to 14.3 percent between 2004 and 2010. So what we're observing is that in some of the countries that have had pretty good success with tobacco control, smoking is now being reduced somewhat more slowly, or possibly even increasing. And if we stay at the current rate of smoking, or even if the smoking rate continues to decline slowly, smoking will remain the leading cause of preventable premature death for many years to come.
NPH: What are some of the reasons that we’re seeing a plateau in the reduction of tobacco use?
During opening remarks at this year’s Keeneland Conference, hosted by the National Coordinating Center for Public Health Systems and Services Research (PHSSR) based at the University of Kentucky in Lexington, Professor Douglas Scutchfield, director of the Center, proudly announced that three of the first health departments to be accredited by the Public Health Accreditation Board (PHAB) earlier this year were in Kentucky. Accreditation had its own track during the conference scientific sessions, including a presentation from Jessica Kronstadt, MPP, PHAB’s director of research and evaluation.
NewPublicHealth caught up with Kronstadt to talk about her presentation on some very early findings from an internal evaluation of the accreditation process.
>>Read more on national public health department accreditation.
NewPublicHealth: What information is PHAB seeking to gain from an evaluation of the accreditation process?
Jessica Kronstadt: Just as we’re asking health departments to engage in quality improvement, PHAB is very much committed to engaging in quality improvement of the accreditation program. So these evaluation efforts will really help us understand what is working well in our accreditation program, and what the experience was like from the perspective of the health departments and the site visitors. This evaluation will allow us to continue to improve the accreditation process.
The last session of the Keeneland Conference focused on translation and dissemination of public health systems and services research, with the critical goal of more efficient and effective delivery of public health services and improving population health. NewPublicHealth spoke with Ross Brownson, PhD, of the Prevention Research Center at Washington University in St. Louis. Dr. Brownson has received funding from the Robert Wood Johnson Foundation to explore evidence-based decision making at local health departments.
NewPublicHealth: How far back does evidence-based public health go?
Ross Brownson: The formal underpinnings of evidence-based public health were developed in the late 1990s, so at least the formal literature has been around for probably about 15 years. Of course, research on effective interventions has been around for many more decades. The newer field of public health services and systems research is much newer, just within the last five years or so, and these different bodies of research are now converging.
The early research focused a lot on identifying evidence-based interventions. The newer research is more on the process of evidence-based public health—regardless of the intervention, how do you develop and implement an evidence-based health department?
We identified five domains that are really important:
- leadership of the agency;
- ability to develop, formalize and maintain good partnerships within the community;
- workforce training and development;
- focus on organizational climate and culture; and
- effective financial and budgeting processes.
The ultimate goal is to make the population healthier and we know that the way to improve the overall health of the public is largely through state and local governmental public health. To reach that ultimate goal you want to have the most effective health department possible and also make the most efficient use of resources. We’re always in a time of tight resources, but probably now more than ever. That calls on us to be as effective and efficient as we can be in the delivery of public health services.
NPH: How will you disseminate these best practices and this evidence base to state and local public health officials?
Today’s plenary speaker at the 2013 Keeneland Conference is William Roper, MD, MPH, dean of the school of medicine, vice chancellor for medical affairs and CEO of the UNC Health Care System at the University of North Carolina at Chapel Hill. Earlier in his career, Dr. Roper was senior vice president of Prudential HealthCare, president of the Prudential Center for Health Care Research, director of the Centers for Disease Control and Prevention and administrator of the Health Care Financing System, the precursor to the Center for Medicare and Medicaid Services.
NewPublicHealth spoke with Dr. Roper on his way to the Keeneland Conference about the drive to better use data, instead of anecdotes and personal beliefs, to drive decision-making.
NewPublicHealth: What were some of the early efforts you were involved in that set the stage for the field of public health services and systems research we know today?
Dr. Roper: I didn’t do this by myself; I did it with a lot of other people, but one of the critical early efforts was the publication of Medicare mortality information on all American hospitals beginning in 1986 and continuing for a number of years thereafter. Another was creation of the Agency for Healthcare Policy and Research in 1989, which has since been renamed the Agency for Healthcare Research and Quality. Another was the launching of the Prevention Effectiveness Initiative at CDC in the early 90s. And then subsequently, work that I’ve done at the University of North Carolina, first at the School of Public Health and then at the School of Medicine using the tools of health services research broadly in health care and in public health.
NPH: What are some of the fruits of those efforts?
A constant theme of this year’s Keeneland Conference is the emergence of the discipline of public health systems and services research (PHSSR) from strict research and evaluation to results that are beginning to be used by public health departments and agencies. So who better a dinner speaker than Joe Selby, MD, MPH, head of the Patient-Centered Outcomes Research Institute (PCORI), authorized by Congress under the Affordable Care Act. PCORI’s role is to conduct research and provide information about the best available evidence to help patients and health care providers make more informed decisions. The Institute's goals include:
- Substantially increase the quantity, quality, and timeliness of useful, trustworthy information available to support health decisions.
- Speed the implementation of patient-centered knowledge into practice.
- Influence clinical and health care research funded by others to be more patient-centered.
NewPublicHealth spoke with Dr. Selby about PCORI’s work so far and the critical goal of disseminating scientific research to improve health.
NewPublicHealth: Tell us about your talk at the Keeneland Conference.
Dr. Selby: I’ll start by talking about the historical trends that led to PCORI’s formation. I think that these trends are bringing what we do, which is called comparative clinical effectiveness research, together with quality improvement and with public health systems and services research. There is a convergence of interests between what the conference attendees do as public health practitioners and public health researchers and systems-based researchers and what the quality improvement world is doing and what we’re trying to do at PCORI. There are many common bonds and a new appreciation for that.
It has suddenly dawned on everyone that you’ve got to put your patients or, in the case of public health, your communities, at the center of the research activity. And I know that in the public health world, they are involving communities and patients within communities and clients and consumers in their planning and intervention activities. That is one of the bonds that ties us together and that leads to enhanced productivity whether we’re doing clinical research like PCORI does, whether we’re doing quality improvement, or whether we’re doing public health.
Later today Lisa Simpson, MB, BCh, MPH, president and CEO of AcademyHealth, will moderate a “Washington Update” panel discussion at the sixth annual Keeneland Conference taking place this week in Lexington, Ky. The discussion will focus on issues to watch at the federal level and panelists include Paul Jarris, MD, MBA, Executive Director of the Association of State and Territorial Health Officials; Jeff Levi, PhD, Executive Director of Trust for America's Health; and Robert Pestronk, MPH, Executive Director of the National Association of County and City Health Officials.
NewPublicHealth spoke with Dr. Simpson ahead of the session.
NewPublicHealth: What will your “Washington Update” focus on?
Dr. Simpson: I have the good fortune of moderating a discussion with three important leaders from Washington—Jeff Levi, Paul Jarris and Bobby Pestronk—and we’ll be bringing an update about what is going on in Washington that affects the field of public health and public health services research (PHSR) specifically. We’re going to be talking about the general policy context and the conversation in Washington in terms of budget and priority and tradeoff, but also talking about how we think public health services research is informing the conversation and the kinds of questions that policymakers have.
NPH: How has public health services research evolved in the last few years in terms of informing the conversation?
The new issue of Frontiers in Public Health Services and Systems Research (PHSSR), an online journal that looks at early research on issues related to public health services and delivery, focuses on quality improvement in practice-based research networks.
This issue’s commentary, from the journal’s editor, Glen Mays, PhD, MPH, is about a series of studies sponsored by the Robert Wood Johnson Foundation that look at how public health decision-makers are responding to accreditation, quality improvement, and public reporting initiatives during ongoing fiscal problems. Mays is co-principal Investigator of the National Coordinating Center on PHSSR, Director of the Public Health Practice-Based Research Networks and the F. Douglas Scutchfield Endowed Professor at the University of Kentucky College of Public Health. Mays says that, overall, the current evidence shows that “these initiatives represent promising strategies for strengthening evidence-based decision-making and expanding the delivery of evidence-tested programs and policies in local public health settings.”
Mays adds that continued comparative research and evaluation activities are needed to provide more definitive evidence about which combination of strategies work best, for which population groups, in which community and organizational settings, and why.
Public Health Law Research, a national program of the Robert Wood Johnson Foundation housed at the Temple University Beasley School of Law, recently released a new, comprehensive online portal called LawAtlas that allows users to explore variation in laws across U.S. states and over time. Having more information about state laws, and their effect on health over time, is a critical step toward understanding what works to improve health. LawAtlas offers:
- Interactive Law Maps to show how certain laws differ by state and how they have changed over time.
- Policy Surveillance Reports to summarize the state of various public health laws across the country
- Data that public health law researchers can work with to expand upon existing research
NewPublicHealth caught up with Damika Webb, JD, Law Fellow at the Center for Health Law Policy and Practice at Temple University, at last week’s APHA Annual Meeting to chat about LawAtlas and how it can be used to better understand why policy surveillance is critical, and what we can learn from a program like LawAtlas.
NewPublicHealth: Why is it important to conduct research to know whether particular laws and policies are working to improve public health?
Damika Webb: By measuring the dimensions of a law, you can figure out which components of the law are having a positive or negative effect on health outcomes.
NPH: Why is it important to track how public health laws and policies differ from state to state?
While the syringe has often been the visual image most closely associated with public health, in just a short time the cell phone could be the go-to icon.The Yale School of Public Health has announced a novel, two-year clinical trialthat will use participants’ cell phones, and the text messages those cell phones transmit, to develop mobile phone-based health interventions that target specific peer groups. The trial is being funded by the National Institutes of Health.
The participants in this first trial are young men ages 18 to 25 who have agreed to allow their cell phones to be tracked by Yale researchers. Each participant’s physical location will be tracked through global positioning systems, and a computer program will register all incoming and outgoing calls and text messages, which will not be shared outside the trial. The clinical trial will have three social networks which will each start with a single person and then recruit his friends, and then their friends, until each of the three groups has 40 active members. The researchers are specifically looking for text messages that relate to sexually transmitted diseases and substance abuse.
“Cell phones have made it easier to maintain and develop network ties,” says Trace Kershaw, PhD, associate professor in the Department of Chronic Disease Epidemiology, and leader of the trial. “The nature of how this communication flows and how it relates to network characteristics and risk within networks will allow us to develop communication technology-delivered peer interventions by suggesting the most effective modes, frequency and patterns of information delivery.”
>>Bonus Link: Read about a smartphone-based trial being run by Asthmapolis, a Madison, Wisc., company that is using sensor-enhanced smart phones to help better understand when and where people with asthma develop symptoms.
>>Weigh In: What novels efforts is your community, company or research group using to collect or disseminate public health information?
At the Health Data Initiative III: The Health Datapalooza this summer, which looked at the role health data plays in transforming health and health care, the Robert Wood Johnson Foundation (RWJF) announced the three winners of an app challenge calling for developers to create applications that would allow consumers to easily access and make use of comparative information about the quality of care provided in various regions of the country. The data behind the apps came from Aligning Forces for Quality, the Foundation’s initiative to improve the quality of health care in 16 targeted communities.
John Lumpkin, MD, MPH, senior vice president and director of the Health Care Group at RWJF, presented the awards to the top three winners of the challenge. Recently, NewPublicHealth spoke with Dr. Lumpkin about the explosion of health care data, and how to find the strongest data and use it well.
NewPublicHealth: Quantities of health data are increasing at a speedy clip. What kind of challenge does that pose in order to make sense of the numbers?
Dr. Lumpkin: In a single day there are over 300 million photos that are being posted on Facebook, and 3.2 billion likes and comments. We have 115,000 people participating in web sites such as Patients Like Me and about 9 million tweets each day. So we have all this data, but how do we access it in ways that make it meaningful? Kerr White, MD, the chairman for the U.S. National Committee on Vital and Health Statistics once said: “With the advent of new technology, data can be collected in any format, aggregated by the computer and arrayed in any desired output…untouched by human thought.” And so our challenge is to present it in a way that we actually have it touched by human thought.
Some good examples of this would include the County Health Rankings and the Aligning Forces for Quality Initiative where we have coalitions of consumers, purchasers and providers who, through public reporting of quality and price information and consumer engagement, we encourage to adopt quality improvement methods and use the data in ways that move that process forward.
NPH: Does everyone mean the same thing when they talk about “evidence-based” data?