The evolution of the steps program, 2003-2010: transforming the federal public health practice of chronic disease prevention.

The Steps program, formerly known as Steps to a HealthierUS, was the first Centers for Disease Control and Prevention (CDC) program to support a community-based, integrated approach to chronic disease prevention. Steps interventions addressed both diseases and risk factors, focusing on the 3 leading causes of preventable deaths in the United States--tobacco use, poor nutrition, and physical inactivity--and the associated chronic conditions of asthma, diabetes, and obesity. When Steps shifted from interventions focused on individual health-risk behaviors to the implementation of policy, systems, and environmental changes, the program became an integral part of changing the way CDC addressed chronic disease prevention. In this article, we describe the shift in intervention strategies that occurred among Steps communities, the model that was developed as Steps evolved, common interventions implemented before and after the shift in approach, challenges experienced by Steps communities, and CDC programs that were modeled after Steps.

Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses.

Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.

Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017.

OBJECTIVE: Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD. METHODS: A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children. RESULTS: Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017. CONCLUSIONS: During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.

Preventing skin cancer: findings of the Task Force on Community Preventive Services On reducing Exposure to Ultraviolet Light.

Rates of skin cancer, the most common cancer in the United States, are increasing. The most preventable risk factor for skin cancer is unprotected ultraviolet (UV) exposure. Seeking to identify effective approaches to reducing the incidence of skin cancer by improving individual and community efforts to reduce unprotected UV exposure, the Task Force on Community Preventive Services conducted systematic reviews of community interventions to reduce exposure to ultraviolet light and increase protective behaviors. The Task Force found sufficient evidence to recommend two interventions that are based on improvements in sun protective or "covering-up" behavior (wearing protective clothing including long-sleeved clothing or hats): educational and policy approaches in two settings--primary schools and recreational or tourism sites. They found insufficient evidence to determine the effectiveness of a range of other population-based interventions and recommended additional research in these areas: educational and policy approaches in child care centers, secondary schools and colleges, recreational or tourism sites for children, and workplaces; interventions conducted in health-care settings and targeted to both providers and children's parents or caregivers; media campaigns alone; and community wide multicomponent interventions. This report also presents additional information regarding the recommended community interventions, briefly describes how the reviews were conducted, provides resources for further information, and provides information that can help in applying the interventions locally. The U.S. Preventive Services Task Force conducted a systematic review of counseling by primary care clinicians to prevent skin cancer (CDC. Counseling to prevent skin cancer: recommendation and rationale of the U.S. Preventive Services Task Force. MMWR 2003;52[No. RR-15]:13-17), which is also included in this issue, the first jointly released findings from the Task Force on Community Preventive Services and the U.S. Preventive Services Task Force.

Increasing diabetes self-management education in community settings. A systematic review.

This report presents the results of a systematic review of the effectiveness and economic efficiency of self-management education interventions for people with diabetes and forms the basis for recommendations by the Task Force on Community Preventive Services. Data on glycemic control provide sufficient evidence that self-management education is effective in community gathering places for adults with type 2 diabetes and in the home for adolescents with type 1 diabetes. Evidence is insufficient to assess the effectiveness of self-management education interventions at the worksite or in summer camps for either type 1 or type 2 diabetes or in the home for type 2 diabetes. Evidence is also insufficient to assess the effectiveness of educating coworkers and school personnel about diabetes.

The effectiveness of disease and case management for people with diabetes. A systematic review.

This report presents the results of a systematic review of the effectiveness and economic efficiency of disease management and case management for people with diabetes and forms the basis for recommendations by the Task Force on Community Preventive Services on the use of these two interventions. Evidence supports the effectiveness of disease management on glycemic control; on screening for diabetic retinopathy, foot lesions and peripheral neuropathy, and proteinuria; and on the monitoring of lipid concentrations. This evidence is applicable to adults with diabetes in managed care organizations and community clinics in the United States and Europe. Case management is effective in improving both glycemic control and provider monitoring of glycemic control. This evidence is applicable primarily in the U.S. managed care setting for adults with type 2 diabetes. Case management is effective both when delivered in conjunction with disease management and when delivered with one or more additional educational, reminder, or support interventions.

Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review.

The relationship between skin cancer and ultraviolet radiation is well established. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection. Sunscreen use alone is not considered an adequate protection against ultraviolet radiation. This report presents the results of systematic reviews of effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to use of selected interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches to increasing sun-protective behaviors were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness when implemented in other settings, such as child care centers, secondary schools and colleges, and occupational settings. They also found insufficient evidence to determine the effectiveness of interventions oriented to healthcare settings and providers, media campaigns alone, interventions oriented to parents or caregivers of children, and community-wide multicomponent interventions. The report also provides suggestions for areas for future research.

A systematic literature review of the effectiveness of diabetes education of school personnel.

PURPOSE: This paper describes current knowledge levels of school personnel about diabetes, discusses the findings of a systematic review of the literature on the effectiveness of diabetes educational interventions for school personnel, and presents recommendations for future research. METHODS: English language literature published between January 1966 and May 2001 regarding the effectiveness of diabetes education of school personnel was systematically reviewed using multiple electronic databases. RESULTS: Four studies that examined the effectiveness of diabetes education of school personnel were identified. One study demonstrated improvement in teacher knowledge of treatment, another reported significant improvement in comprehensive knowledge scores, and a third study demonstrated significant knowledge deficits across 4 measures of teacher knowledge about diabetes. A fourth study demonstrated a decrease in the cumulative frequency of diabetic ketoacidosis. CONCLUSIONS: The literature regarding the effectiveness of diabetes education of school personnel is scant, the methodology is inadequate, the results are mixed, and the focus is on a narrow range of outcomes. Further research is needed to define effective interventions for improving the health and quality of life of school-age children and adolescents with diabetes.

Case completeness and data accuracy in the Centers for Disease Control and Prevention's National Program of Cancer Registries.

BACKGROUND: Issues of case completeness (CC) and data quality within the National Program of Cancer Registries (NPCR)-Cancer Surveillance System (NPCR-CSS) are assessed in part by the NPCR Technical Assistance and Audit Program (NPCR-TAA). In addition, the NPCR Annual Program Evaluation Instrument (NPCR-APEI) provides information about NPCR-supported central cancer registries (CCRs). The current report includes a unique, national-level analysis of NPCR-TAA results linked with NPCR-APEI data and other covariates. METHODS: NPCR-TAA results for 34 CCRs were aggregated across diagnosis years 1998 to 2001 for analysis of average CC rates and site-specific data accuracy (DA) rates by covariates obtained from the NPCR-APEI, United States Cancer Statistics (USCS) publications, and the North American Association of Central Cancer Registries (NAACCR) Web site. Site-specific DA rates were calculated for the 13 data elements examined in the audit program. Small-sample Student t tests were used to determine statistically significant differences in covariates (alpha = .05). RESULTS: Overall, the average CC and DA rates were 96.4% and 95%, respectively. Both site- and data element-specific DA issues were highlighted. Higher CC and DA rates were observed for CCRs that were staffed with more certified tumor registrars, had supplementary sources reporting, and met USCS publication standards and/or achieved NAACCR certification. CONCLUSIONS: Study findings underscored the importance of CCRs having adequate, well-trained staff, procuring supplemental reporting sources, and attaining compliance with national data standards. The study results also demonstrated the overall high completeness and quality of NPCR-CSS data and provided guidance to users of the data.