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1.  The Role of Epidemiology in Evidence-based Policy Making: A Case Study of Tobacco Use in Youth 
Annals of epidemiology  2014;25(5):360-365.
Sound public health policy is based on relevant and timely information. A brief review of the history of youth tobacco control illustrates the central role of epidemiology to inform policy choices and evaluate their consequences.
A narrative review was conducted.
Epidemiologic studies have shown that most smokers begin as adolescents or young adults and individuals who reach their mid-twenties as non-smokers are unlikely to ever become smokers. This key recognition made it clear that long-term tobacco control must prevent initiation of smoking among youth. Over time, tobacco use prevention interventions have evolved, increasing in reach and effectiveness as they moved from initially focusing on the individual to an approach that targets both populations and communities. Effective interventions for preventing youth smoking include raising tobacco prices, clean indoor air laws, and intensive mass media campaigns.
Great strides have been made in youth tobacco control but 18% of high school students continue to smoke. It is up to epidemiologists, fellow scientists, practitioners, and advocates to assure that strategies that are known to work are fully implemented as well as to continue to find more successful solutions that can further lower the incidence of youth smoking initiation and can address new tobacco products and changing contexts.
PMCID: PMC4211989  PMID: 24875267
Tobacco; smoking; adolescents; public health policy
4.  Reducing Childhood Obesity through U.S. Federal Policy 
Childhood obesity prevalence remains high in the U.S., especially among racial/ethnic minorities and low-income populations. Federal policy is important in improving public health given its broad reach. Information is needed about federal policies that could reduce childhood obesity rates and by how much.
To estimate the impact of three federal policies on childhood obesity prevalence in 2032, after 20 years of implementation.
Criteria were used to select the three following policies to reduce childhood obesity from 26 recommended policies: afterschool physical activity programs, a $0.01/ounce sugar-sweetened beverage (SSB) excise tax, and a ban on child-directed fast food TV advertising. For each policy, the literature was reviewed from January 2000 through July 2012 to find evidence of effectiveness and create average effect sizes. In 2012, a Markov microsimulation model estimated each policy’s impact on diet or physical activity, and then BMI, in a simulated school-aged population in 2032.
The microsimulation predicted that afterschool physical activity programs would reduce obesity the most among children aged 6–12 years (1.8 percentage points) and the advertising ban would reduce obesity the least (0.9 percentage points). The SSB excise tax would reduce obesity the most among adolescents aged 13–18 years (2.4 percentage points). All three policies would reduce obesity more among blacks and Hispanics than whites, with the SSB excise tax reducing obesity disparities the most.
All three policies would reduce childhood obesity prevalence by 2032. However, a national $0.01/ounce SSB excise tax is the best option.
PMCID: PMC4762259  PMID: 25175764
5.  Coverage and Preventive Screening 
Health Services Research  2011;46(1 Pt 1):173-184.
Preventive care has been shown as a high-value health care service. Many employers now offer expanded coverage of preventive care to encourage utilization.
To determine whether expanding coverage is an effective means to encourage utilization.
Comparison of screening rates before and after introduction of deductible-free coverage.
People insured through large corporations between 2002 and 2006.
Patients or Other Participants
Preferred Provider Organization (PPO) enrollees from an employer introducing deductible-free coverage, and a control group enrolled in a PPO from a second employer with no policy change.
Main Outcome Measures
Adjusted probability of endoscopy, fecal occult blood test (FOBT), lipid screens, mammography, and Papanicolaou (pap) smears.
Introduction of first-dollar coverage (FDC) of preventive services in 2003.
After adjusting for demographics and secular trends, there were between 23 and 78 additional uses per 1,000 eligible patients of covered preventive screens (lipid screens, pap smears, mammograms, and FOBT), with no significant changes in the control group or in a service without FDC (endoscopy).
FDC improves utilization modestly among healthy individuals, particularly those in lower deductible plans. Compliance with guidelines can be encouraged by lowering out-of-pocket costs, but patients' predisposing characteristics merit attention.
PMCID: PMC3034268  PMID: 21029084
Health care financing/insurance/premiums; evaluation design research; health care costs
6.  A patient self-assessment diabetes screening score: 
Annals of internal medicine  2009;151(11):775-783.
National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed.
To develop a new diabetes screening score and compare it to other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association (ADA) and U.S. Preventive Services Task Force guidelines; two ADA risk questionnaires; and Rotterdam model)
Cross-sectional data.
National Health and Nutrition Examination Survey (NHANES) 1999–2004 for model development, and NHANES 2005–2006 plus a combined cohort of two community studies, Atherosclerosis Risk in Communities (ARIC) and Cardiovascular Health Study (CHS), for validation.
U.S. adults ≥20 years old.
A risk scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose ≥7.0 mmol/L(126 mg/dL) without known diabetes, was developed in the development dataset. Logistic regression was used to determine participant characteristics that were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures.
Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (in ARIC/CHS), the cutpoint of ≥5 selected 30(40)% of persons for diabetes screening and yielded sensitivity of 79(72)%, specificity of 67(62)%, positive predictive value of 10(10)% and likelihood ratio-positive of 2.39(1.89). In contrast, the comparison scores yielded sensitivity of 44–100%, specificity of 10–73%, positive predictive value of 5–8%, and likelihood ratio-positive of 1.11–1.98.
Data during pregnancy were not available.
This new diabetes screening score, simple and easily implemented, seems to demonstrate improvements upon the existing methods. Future studies are needed to evaluate it in diverse populations in real world settings.
Primary Funding Source
Clinical and Translational Science Center at Cornell Medical College.
PMCID: PMC3633111  PMID: 19949143
8.  The Scientific Foundation for Personal Genomics: Recommendations from a National Institutes of Health–Centers for Disease Control and Prevention Multidisciplinary Workshop 
The increasing availability of personal genomic tests has led to discussions about the validity and utility of such tests and the balance of benefits and harms. A multidisciplinary workshop was convened by the National Institutes of Health and the Centers for Disease Control and Prevention to review the scientific foundation for using personal genomics in risk assessment and disease prevention and to develop recommendations for targeted research. The clinical validity and utility of personal genomics is a moving target with rapidly developing discoveries but little translation research to close the gap between discoveries and health impact. Workshop participants made recommendations in five domains: (1) developing and applying scientific standards for assessing personal genomic tests; (2) developing and applying a multidisciplinary research agenda, including observational studies and clinical trials to fill knowledge gaps in clinical validity and utility; (3) enhancing credible knowledge synthesis and information dissemination to clinicians and consumers; (4) linking scientific findings to evidence-based recommendations for use of personal genomics; and (5) assessing how the concept of personal utility can affect health benefits, costs, and risks by developing appropriate metrics for evaluation. To fulfill the promise of personal genomics, a rigorous multidisciplinary research agenda is needed.
PMCID: PMC2936269  PMID: 19617843
behavioral sciences; epidemiologic methods; evidence-based medicine; genetics; genetic testing; genomics; medicine; public health
9.  Cholesterol Levels and Statin Use in Patients With Coronary Heart Disease Treated in Primary Care Settings 
Preventing Chronic Disease  2005;2(3):A05.
Therapy with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, has proven to be effective in the treatment of lipid disorders. However, statin therapy continues to be underused, even though statins are a relatively safe and well-tolerated class of agents. In this study, we assessed trends in lipid control in patients with heart disease who receive most of their health care in primary care clinics. The objective was to determine whether systems of care implemented within a large medical group are associated with improved treatment and control of dyslipidemia in a high-risk group of coronary heart disease patients.
All adults with heart disease in a Minnesota medical group (N = 2947) were identified using diagnosis and procedure codes related to coronary heart disease (sensitivity = 0.85; positive predictive value = 0.89) in 1996. Study subjects were observed from 1995 to 1998. Subjects had a baseline and follow-up test for low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. Changes between baseline and follow-up measurements and trends in the use of statins and other lipid-active agents among the study subjects were analyzed.
Among 1388 subjects with two or more eligible lipid measurements, mean low-density lipoprotein cholesterol improved from 137.6 mg/dL to 111.0 mg/dL (P < .001), and mean high-density lipoprotein cholesterol improved from 42.3 mg/dL to 46.3 mg/dL (P < .001). The percentage of patients with low-density lipoprotein cholesterol ≤100 mg/dL rose from 12.5% to 39.8% (P < .001), and the percentage with high-density lipoprotein cholesterol ≥40 mg/dL rose from 52.5% to 67.6% (P < .001). In multivariate models, statin use was identified as the main factor that contributed to the improvement in low-density lipoprotein cholesterol (P < .001). Men had greater decreases in low-density lipoprotein cholesterol than women after adjusting for other variables (P < .001). Statin use rose from 24.3% at baseline to 69.6% at follow-up. The statin discontinuation rate was 8.3% for baseline statin users and 12.2% for subjects who used statins at any time during the study period.
Investment in better heart disease care for patients in primary care clinics led to major improvement in lipid control over 30 months, primarily due to increased statin use. Improvements in low-density lipoprotein cholesterol and high-density lipoprotein cholesterol were sufficient to substantially reduce risk of subsequent major cardiovascular events.
PMCID: PMC1364514  PMID: 15963307
10.  A Randomized Controlled Open Trial of Population-based Disease and Case Management in a Medicare Plus Choice Health Maintenance Organization 
Preventing Chronic Disease  2004;1(4):A05.
The object of this study was to examine the effect of population-based disease management and case management on resource use, self-reported health status, and member satisfaction with and retention in a Medicare Plus Choice health maintenance organization (HMO).
Study design consisted of a prospective, randomized controlled open trial of 18 months' duration. Participants were 8504 Medicare beneficiaries aged 65 and older who had been continuously enrolled for at least 12 months in a network model Medicare Plus Choice HMO serving a contiguous nine-county metropolitan area. Members were care managed with an expert clinical information system and frequent telephone contact. Main outcomes included self-reported health status measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), resource use measured by admission rates and bed-days per thousand per year, member satisfaction, and costs measured by paid claims.
More favorable outcomes occurred in the intervention group for satisfaction with the health plan (P < .01) and the social function domain as measured by SF-36 (P = .04). There was no difference in member retention or mortality between groups. Use of skilled nursing home services was significantly lower in the intervention group than in the control (616 vs 747 days per thousand members per year, P = .02). This reduction, however, did not lead to lower mean total expenditures in the intervention group compared with the control ($6828 per member for 18 months vs $7001, P = .61).
Population-based disease management and case management led to improved self-reported satisfaction and social function but not to a global net decrease in resource use or improved member retention.
PMCID: PMC1277945  PMID: 15670436
11.  Yes 
Western Journal of Medicine  2001;174(2):84.
PMCID: PMC1071252  PMID: 11156898
12.  Health in All Policies for Big Cities 
This article reviews case examples on the use of health in all policies (HiAP) and related approaches in large US cities. It also identifies common elements of HiAP initiatives and discusses challenges and recommendations to facilitate successful implementation of HiAP.
PMCID: PMC4243805  PMID: 25423058
13.  The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) initiative: methods of the EGAPP Working Group 
Genetics in Medicine  2009;11(1):3-14.
The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Initiative, established by the National Office of Public Health Genomics at the Centers for Disease Control and Prevention, supports the development and implementation of a rigorous, evidence-based process for evaluating genetic tests and other genomic applications for clinical and public health practice in the United States. An independent, non-federal EGAPP Working Group (EWG), a multidisciplinary expert panel selects topics, oversees the systematic review of evidence, and makes recommendations based on that evidence. This article describes the EGAPP processes and details the specific methods and approaches used by the EWG.
PMCID: PMC2743609  PMID: 18813139
Evidence-based medicine; review; systematic

Results 1-13 (13)