Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: the China Da Qing Diabetes Prevention Outcome Study.

AIMS/HYPOTHESIS: We determined the effects of 6 years of lifestyle intervention in persons with impaired glucose tolerance (IGT) on the development of retinopathy, nephropathy and neuropathy over a 20 year period. METHODS: In 1986, 577 adults with IGT from 33 clinics in Da Qing, China were randomly assigned by clinic to a control group or one of three lifestyle intervention groups (diet, exercise, and diet plus exercise). Active intervention was carried out from 1986 to 1992. In 2006 we conducted a 20 year follow-up study of the original participants to compare the incidence of microvascular complications in the combined intervention group vs the control group. RESULTS: Follow-up information was obtained on 542 (94%) of the 577 original participants. The cumulative incidence of severe retinopathy was 9.2% in the combined intervention group and 16.2% in the control group (p = 0.03, log-rank test). After adjusting for clinic and age, the incidence of severe retinopathy was 47% lower in the intervention group than the control group (hazard rate ratio 0.53, 95% CI 0.29-0.99, p = 0.048). No significant differences were found in the incidence of severe nephropathy (hazard rate ratio 1.05, 95% CI 0.16-7.05, intervention vs control, p = 0.96) or in the prevalence of neuropathy (8.6% vs 9.1%, p = 0.89) among the 20 year survivors. CONCLUSIONS/INTERPRETATION: Lifestyle intervention for 6 years in IGT was associated with a 47% reduction in the incidence of severe, vision-threatening retinopathy over a 20 year interval, primarily due to the reduced incidence of diabetes in the intervention group. However, similar benefits were not seen for nephropathy or neuropathy.

Who's number one? The impact of variability on rankings based on public health indicators.

OBJECTIVE: Researchers, government, and the press often rank jurisdictions according to public health indicators; however, measures of uncertainty rarely accompany these comparisons. To demonstrate the variability associated with rankings that use public health measures, the authors examined the uncertainty associated with ranks based on three common methods used to derive public health indicators: age-adjustment, calculations based on census estimates, and calculations based on survey data. METHODS: The authors observed the effect of changing the standard population from the 1970 population to the 1997 population on rank-order lists of jurisdictions according to age-adjusted 1998 mortality rates. They used a Monte Carlo method to calculate confidence intervals (CIs) around ranks based on census estimates of 1998 infant mortality rates and based on 1999 Behavioral Risk Factor Surveillance System (BRFSS) survey data on the prevalence of hypertension. RESULTS: Changing the standard year from 1970 to 1997 resulted in a shift of at least three rank-order positions for seven states. Two states shifted five positions. CIs associated with ranking by infant mortality rates were broad, with a mean of 16 ranks. CIs around ranks for the prevalence of hypertension were also wide, with a mean of 18 ranks. CONCLUSION: While ranking based on public health indicators is an attractive and popular way of presenting public health data, caution and close examination of the underlying data are needed for proper interpretation. Alternative methods, such as longitudinal analysis or comparisons with standards, may prove more useful.

Full-time employees of U.S. local health departments, 1992-1993.

This article describes a study to assess the most recent data on full-time U.S. local health department (LHD) staff positions. The authors used data from the National Association of County and City Health Officials' 1992-1993 national survey of LHDs. The study concludes that nurses, environmental specialists, sanitarians, and administrators constitute the core of the public health workforce in smaller and mid-sized LHDs. Numerous vacancies in these core occupations signal a weakness in the front lines of public health and vulnerability in its ability to respond to urgent health threats. To address these problems, a renewed commitment to recruiting, retraining, and retaining the local public health worker is urgently needed.

The education of local health department top executives.

An analysis was done on the educational backgrounds of current top agency executives of U.S. local health departments (LHD), using the National Association of City and County Health Officials 1992-1993 national survey of LHDs as the data source. Nurses are often the executive in jurisdictions with less than 50,000, while executives of jurisdictions with more than 250,000 are predominantly physicians. Overall, 78 percent of LHD executives have no formal public health training, and executives of larger jurisdictions are more likely to have a public health degree. Because a majority of executives lack formal training opportunities for them need major expansion. Particular emphasis should be placed on expanding short-term opportunities such as state-based leadership and distance-based learning programs.

Determinants of US local health department expenditures, 1992 through 1993.

OBJECTIVES: This study examined local health department expenditures and their relationship to several departmental characteristics, including the size of the population in the department's jurisdiction. METHODS: Local health department characteristics were obtained from a 1992/93 nationwide mail survey and modeled by means of multiple linear regression. RESULTS: Great variability existed in the per capita expenditures of local health departments, and approximately 70% of the variability was accounted for by differences in jurisdiction population size. Additional characteristics of the health departments explained another 11%. The average unadjusted per capita expenditure by local health departments nationwide was $26. CONCLUSIONS: Local health department expenditures that support essential public health services average a dime a day per person.

Recent changes in local health department spending.

This study determined differences in U.S. local health department (LHD) expenditures between 1989 and 1993 and examined the factors that were associated with those changes. Adjusted to constant 1993 dollars, nearly half (48%) of the studied LHDs experienced budget decreases and 52% experienced budget increases. The median change in LHD budgets was 0.2% growth per year. Significant associations were found between the likelihood of a department experiencing a budget increase and several measures describing the LHD's administrative and economic environment.