A framework for synthesizing intervention evidence from multiple sources into a single certainty of evidence rating: Methodological developments from a US National Academies of Sciences, Engineering, and Medicine Committee.

Despite research investment and a growing body of diverse evidence there has been no comprehensive review and grading of evidence for public health emergency preparedness and response practices comparable to those in medicine and other public health fields. The National Academies of Sciences, Engineering, and Medicine convened an ad hoc committee to develop and use methods for grading and synthesizing diverse types of evidence to create a single certainty of intervention-related evidence to support recommendations for Public Health Emergency Preparedness and Response Research. A 13-step consensus building method was used. Experts were first canvassed in public meetings, and a comprehensive review of existing methods was undertaken. Although aspects of existing review methodologies and evidence grading systems were relevant, none adequately covered all requirements for this specific context. Starting with a desire to synthesize diverse sources of evidence not usually included in systematic reviews and using GRADE for assessing certainty and confidence in quantitative and qualitative evidence as the foundation, we developed a mixed-methods synthesis review and grading methodology that drew on (and in some cases adapted) those elements of existing frameworks and methods that were most applicable. Four topics were selected as test cases. The process was operationalized with a suite of method-specific reviews of diverse evidence types for each topic. Further consensus building was undertaken through stakeholder engagement and feedback The NASEM committee's GRADE adaption for mixed-methods reviews will further evolve over time and has yet to be endorsed by the GRADE working group.

Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States.

Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health.To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse.Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation.

Reduction in US Health Care Spending Required to Meet the Institute of Medicine's 2030 Target.

Objectives. To quantify changes in US health care spending required to reach parity with high-resource nations by 2030 or 2040 and identify historical precedents for these changes.Methods. We analyzed multiple sources of historical and projected spending from 1970 through 2040. Parity was defined as the Organisation for Economic Co-operation and Development (OECD) median or 90th percentile for per capita health care spending.Results. Sustained annual declines of 7.0% and 3.3% would be required to reach the median of other high-resource nations by 2030 and 2040, respectively (3.2% and 1.3% to reach the 90th percentile). Such declines do not have historical precedent among US states or OECD nations.Conclusions. Traditional approaches to reducing health care spending will not enable the United States to achieve parity with high-resource nations; strategies to eliminate waste and reduce the demand for health care are essential.Public Health Implications. Excess spending reduces the ability of the United States to meet critical public health needs and affects the country's economic competitiveness. Rising health care spending has been identified as a threat to the nation's health. Public health can add voices, leadership, and expertise for reversing this course.

REPRINT OF: Current Methods of the U.S. Preventive Services Task Force: A Review of the Process.

Editor's Note: This article is a reprint of a previously published article. For citation purposes, please use the original publication details: Harris RP, Helfand M, Woolf SH, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3S):21-35. The U.S. Preventive Services Task Force (USPSTF/Task Force) represents one of several efforts to take a more evidence-based approach to the development of clinical practice guidelines. As methods have matured for assembling and reviewing evidence and for translating evidence into guidelines, so too have the methods of the USPSTF. This paper summarizes the current methods of the third USPSTF, supported by the Agency for Healthcare Research and Quality (AHRQ) and two of the AHRQ Evidence-based Practice Centers (EPCs). The Task Force limits the topics it reviews to those conditions that cause a large burden of suffering to society and that also have available a potentially effective preventive service. It focuses its reviews on the questions and evidence most critical to making a recommendation. It uses analytic frameworks to specify the linkages and key questions connecting the preventive service with health outcomes. These linkages, together with explicit inclusion criteria, guide the literature searches for admissible evidence. Once assembled, admissible evidence is reviewed at three strata: (1) the individual study, (2) the body of evidence concerning a single linkage in the analytic framework, and (3) the body of evidence concerning the entire preventive service. For each stratum, the Task Force uses explicit criteria as general guidelines to assign one of three grades of evidence: good, fair, or poor. Good or fair quality evidence for the entire preventive service must include studies of sufficient design and quality to provide an unbroken chain of evidence-supported linkages, generalizable to the general primary care population, that connect the preventive service with health outcomes. Poor evidence contains a formidable break in the evidence chain such that the connection between the preventive service and health outcomes is uncertain. For services supported by overall good or fair evidence, the Task Force uses outcomes tables to help categorize the magnitude of benefits, harms, and net benefit from implementation of the preventive service into one of four categories: substantial, moderate, small, or zero/negative. The Task Force uses its assessment of the evidence and magnitude of net benefit to make a recommendation, coded as a letter: from A (strongly recommended) to D (recommend against). It gives an I recommendation in situations in which the evidence is insufficient to determine net benefit. The third Task Force and the EPCs will continue to examine a variety of methodologic issues and document work group progress in future communications.

National Institutes of Health Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services.

Expert groups, including the U.S. Preventive Services Task Force (USPSTF), recommend a range of clinical preventive services for persons at average risk for disease. Use of these services often is substantially lower among racial and ethnic minority groups, rural residents, and persons of lower socioeconomic status. On 19 and 20 June 2019, the National Institutes of Health (NIH) convened the Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services to assess the available evidence on disparities in the use of 10 USPSTF-recommended clinical preventive services for cancer, heart disease, and diabetes. The workshop was cosponsored by the NIH Office of Disease Prevention; National Institute on Minority Health and Health Disparities; National Cancer Institute; National Heart, Lung, and Blood Institute; and National Institute of Diabetes and Digestive and Kidney Diseases. A multidisciplinary working group developed the agenda, and an Evidence-based Practice Center prepared the evidence report. During the workshop, invited experts considered the evidence, with discussion among attendees. After weighing evidence from the review, presentations, and public comments, an independent panel prepared a draft report that was posted for public comment. This final report summarizes the panel's findings, identifying current gaps in knowledge. The panel made 26 recommendations for new research and methods development to improve implementation of proven services to reduce disparities in preventable conditions.

Male Mortality Trends in the United States, 1900-2010: Progress, Challenges, and Opportunities.

OBJECTIVES: Male mortality fell substantially during the past century, and major causes of death changed. Building on our recent analysis of female mortality trends in the United States, we examined all-cause and cause-specific mortality trends at each decade from 1900 to 2010 among US males. METHODS: We conducted a descriptive study of age-adjusted death rates (AADRs) for 11 categories of disease and injury stratified by race (white, nonwhite, and, when available, black), the excess of male mortality over female mortality ([male AADR - female AADR]/female AADR), and potential causes of persistent excess of male mortality. We used national mortality data for each decade. RESULTS: From 1900 to 2010, the all-cause AADR declined 66.4% among white males and 74.5% among nonwhite males. Five major causes of death in 1900 were pneumonia and influenza, heart disease, stroke, tuberculosis, and unintentional nonmotor vehicle injuries; in 2010, infectious conditions were replaced by cancers and chronic lower respiratory diseases. The all-cause excess of male mortality rose from 9.1% in 1900 to 65.5% in 1980 among white males and a peak of 63.7% in 1990 among nonwhite males, subsequently falling among all groups. CONCLUSION: During the last century, AADRs among males declined more slowly than among females. Although the gap diminished in recent decades, exploration of social and behavioral factors may inform interventions that could further reduce death rates among males.

Making Strides Toward Health Equity: The Experiences of Public Health Departments.

OBJECTIVES: We explored the definition of health equity being used by public health departments and the extent of engagement of public health departments in activities to improve health equity, as well as facilitators and barriers to this work. DESIGN: We conducted 25 semistructured qualitative interviews with lead public health officials (n = 20) and their designees (n = 5). All interviews were transcribed and thematically analyzed. SETTING: We conducted interviews with respondents from local public health departments in the United States (April 2017-June 2017). PARTICIPANTS: Respondents were from local or state public health departments that were members of the Big Cities Health Coalition, accredited or both. RESULTS: Many departments were using a definition of health equity that emphasized an equal opportunity to improve health for all, with a special emphasis on socially disadvantaged populations. Improving health equity was a high priority for most departments and targeting the social determinants of health was viewed as the optimal approach for improving health equity. Having the capacity to frame issues of health equity in ways that resonated with sectors outside of public health was seen as a particularly valuable skill for facilitating cross-sector collaborations and promoting work to improve health equity. Barriers to engaging in work to improve health equity included lack of flexible and sustainable funding sources as well as limited training and guidance on how to conduct this type of work. CONCLUSIONS: Work to improve health equity among public health departments can be fostered and strengthened by building capacity among them to do more targeted framing of health equity issues and by providing more flexible and sustained funding sources. In addition, supporting peer networks that will allow for the exchange of resources, ideas, and best practices will likely build capacity among public health departments to effectively do this work.

Quantifying the Value of Prevention: A Survey of Public Health Departments' Quantitative and Economic Modeling Capacity.

OBJECTIVE: To improve the understanding of local health departments' (LHDs') capacity for and perceived barriers to using quantitative/economic modeling information to inform policy and program decisions. DESIGN: We developed, tested, and deployed a novel survey to examine this topic. SETTING: The study's sample frame included the 200 largest LHDs in terms of size of population served plus all other accredited LHDs (n = 67). The survey was e-mailed to 267 LHDs; respondents completed the survey online using SurveyMonkey. PARTICIPANTS: Survey instructions requested that the survey be completed from the perspective of the entire health department by LHD's top executive or designate. A total of 63 unique LHDs responded (response rate: 39%). MAIN OUTCOME MEASURE(S): Capacity for quantitative and economic modeling was measured in 5 categories (routinely use information from models we create ourselves; routinely use information from models created by others; sometimes use information from models we create ourselves; sometimes use information from models created by others; never use information from modeling). Experience with modeling was measured in 4 categories (very, somewhat, not so, not at all). RESULTS: Few (9.5%) respondents reported routinely using information from models, and most who did used information from models created by others. By contrast, respondents reported high levels of interest in using models and in gaining training in their use and the communication of model results. The most commonly reported barriers to modeling were funding and technical skills. Nearly all types of training topics listed were of interest. CONCLUSIONS: Across a sample of large and/or accredited LHDs, we found modest levels of use of modeling coupled with strong interest in capacity for modeling and therefore highlight an opportunity for LHD growth and support. Both funding constraints and a lack of knowledge of how to develop and/or use modeling are barriers to desired progress around modeling. Educational or funding opportunities to promote capacity for and use of quantitative and economic modeling may catalyze use of modeling by public health practitioners.

Evidentiary needs of US public health departments with a mission to advance equity and health: a qualitative analysis.

OBJECTIVES: We sought the perspectives of lead public health officials working to improve health equity in the USA regarding the drivers of scientific evidence use, the supply of scientific evidence and the gap between their evidentiary needs and the available scientific evidence. DESIGN: We conducted 25 semistructured qualitative interviews (April 2017 to June 2017) with lead public health officials and their designees. All interviews were transcribed and thematically analysed. SETTING: Public health departments from all geographical regions in the USA. PARTICIPANTS: Participants included lead public health officials (20) and their designees (5) from public health departments that were either accredited or part of the Big Cities Health Coalition. RESULTS: Many respondents were using scientific evidence in the context of grant writing. Professional organisations and government agencies, rather than specific researchers or research journals, were the primary sources of scientific evidence. Respondents wanted to see more locally tailored cost-effectiveness research and often desired to participate in the planning phase of research projects. In addition to the scientific content recommendations, respondents felt the usefulness of scientific evidence could be improved by simplifying it and framing it for diverse audiences including elected officials and community stakeholders. CONCLUSIONS: Respondents are eager to use scientific evidence but also need to have it designed and packaged in ways that meet their needs.

Trends in Mortality Among Females in the United States, 1900-2010: Progress and Challenges.

INTRODUCTION: We analyzed trends in US female mortality rates by decade from 1900 through 2010, assessed age and racial differences, and proposed explanations and considered implications. METHODS: We conducted a descriptive study of trends in mortality rates from major causes of death for females in the United States from 1900 through 2010. We analyzed all-cause unadjusted death rates (UDRs) for males and females and for white and nonwhite males and females from 1900 through 2010. Data for blacks, distinct from other nonwhites, were available beginning in 1970 and are reported for this and following decades. We also computed age-adjusted all-cause death rates (AADRs) by the direct method using age-specific death rates and the 2000 US standard population. Data for the analysis of decadal trends in mortality rates were obtained from yearly tabulations of causes of death from published compilations and from public use computer data files. RESULTS: In 1900, UDRs and AADRs were higher for nonwhites than whites and decreased more rapidly for nonwhite females than for white females. Reductions were highest among younger females and lowest among older females. Rates for infectious diseases decreased the most. AADRs for heart disease increased 96.5% in the first 5 decades, then declined by 70.6%. AADRs for cancer rose, then decreased. Stroke decreased steadily. Unintentional motor vehicle injury AADRs increased, leveled off, then decreased. Differences between white and nonwhite female all-cause AADRs almost disappeared during the study period (5.4 per 100,000); differences in white and black AADRs remained high (121.7 per 100,000). CONCLUSION: Improvements in social and environmental determinants of health probably account for decreased mortality rates among females in the early 20th century, partially offset by increased smoking. In the second half of the century, other public health and clinical measures contributed to reductions. The persistent prevalence of risk behaviors and underuse of preventive and medical services indicate opportunities for increased female longevity, particularly in racial minority populations.