Perspectives on the Future of Epidemiology: A Framework for Training.

Over the past century, the field of epidemiology has evolved and adapted to changing public health needs. Challenges include newly emerging public health concerns across broad and diverse content areas, new methods, and vast data sources. We recognize the need to engage and educate the next generation of epidemiologists and prepare them to tackle these issues of the 21st century. In this commentary, we suggest a skeleton framework upon which departments of epidemiology should build their curriculum. We propose domains that include applied epidemiology, biological and social determinants of health, communication, creativity and ability to collaborate and lead, statistical methods, and study design. We believe all students should gain skills across these domains to tackle the challenges posed to us. The aim is to train smart thinkers, not technicians, to embrace challenges and move the expanding field of epidemiology forward.

Demographic, emotional and social determinants of cannabis use in early pregnancy: the Generation R study.

AIMS: To ascertain demographic, emotional and social determinants of cannabis use in early pregnancy. DESIGN: This study was embedded in the Generation R study, a multiethnic population-based cohort of parents and their children, followed from pregnancy to childhood. SETTING: Rotterdam, The Netherlands. PARTICIPANTS: Mothers enrolled in pregnancy who answered questions about their own and their partners substance use before and during pregnancy (n=7610). MEASUREMENTS: Using self-report questionnaires, information was collected on maternal demographics, psychopathology, delinquency, childhood trauma, social stress, family functioning, and parental alcohol, tobacco and substance use. Multinomial logistic regression analysis was used, with non-using women as reference. FINDINGS: 246 (3.2%) women used cannabis before pregnancy and 220 (2.9%) women used cannabis both before and during pregnancy. The strongest determinant for maternal cannabis use during pregnancy was cannabis use by the biological father of the child (OR=38.56; 95%CI=26.14-58.88). Maternal cannabis use during pregnancy was also independently associated with being single (OR=4.25; 95%CI=2.33-7.75) or having a partner without being married (OR=2.75; 95%CI=1.56-4.85), childhood trauma (OR=1.39; 95%CI=1.22-1.57) and delinquency (OR=3.37; 95%CI=1.90-5.98), but not with maternal age, ethnicity, psychopathology, family functioning and perceived stress. Being religious was protective (Islam: OR=0.25; 95%CI=0.09-0.65) for maternal cannabis use during pregnancy. Additionally, lower educational level determined continued cannabis use in ever-users (OR=3.22; 95%CI=1.54-6.74). CONCLUSIONS: Our results showed that multiple demographic, emotional and social characteristics were associated with maternal cannabis use. These characteristics should be considered when investigating offspring exposed to cannabis in utero, as they may play an important role in mother-child interaction and child development.

Drug costs associated with non-adherence to cholesterol management guidelines for primary prevention of cardiovascular disease in an elderly population: the Rotterdam study.

BACKGROUND: In The Netherlands, costs of HMG-CoA reductase inhibitor (statin) use have recently increased sharply compared with costs of other drugs. However, several studies have established both undertreatment and non-guidelines-indicated treatment with statins, suggesting a suboptimal use of resources. OBJECTIVE: To estimate the drug costs associated with non-guidelines-indicated treatment and undertreatment with statins in an elderly population. PATIENTS AND SETTING: Data were obtained from the Rotterdam Study, a population-based prospective cohort study which began in 1990 with 7983 participants aged > or =55 years. Subjects with a history of cardiovascular disease (CVD) were excluded. Pharmacy records were used to assess patterns of medication use in daily medical practice. MAIN OUTCOME MEASURE: Non-guidelines-indicated treatment and undertreatment with statins were established in relation to Dutch cholesterol management guidelines for all participants. We calculated the costs of statin therapy associated with non-guidelines-indicated treatment, and the costs of statins if all those undertreated were to receive statins. The results were projected on to the Dutch population to determine the economic implications of non-adherence to cholesterol management guidelines in the elderly. RESULTS: Of the participants who started treatment with statins for the primary prevention of CVD during follow-up, 69% received non-guidelines-indicated treatment. More men (7.5%) were undertreated than women (1.6%) and more women (6.2%) received non-guidelines-indicated treatment than men (1.5%). Among the participants without CVD who were still alive at 1 January 2002, 14% were eligible for statin therapy but were untreated. After projection of the prevalence of non-guidelines-indicated treatment and undertreatment to the Dutch population, the absolute costs for non-guidelines-indicated treatment with statins in 2005 were estimated to be approximately 23 million euro(uncertainty limits [UL]: 19-28 million euro), while the cost to eliminate undertreatment was also 23 million euro (UL: 19-28 million euro). CONCLUSION: Reallocation of resources used for statin therapy from those receiving non-guidelines-indicated treatment to those being undertreated could lead to a more efficient use of resources.