Practice-Based Evidence in Community Guide Systematic Reviews.

OBJECTIVES: To assess the relative contributions and quality of practice-based evidence (PBE) and research-based evidence (RBE) in The Guide to Community Preventive Services (The Community Guide). METHODS: We developed operational definitions for PBE and RBE in which the main distinguishing feature was whether allocation of participants to intervention and comparison conditions was under the control of researchers (RBE) or not (PBE). We conceptualized a continuum between RBE and PBE. We then categorized 3656 studies in 202 reviews completed since The Community Guide began in 1996. RESULTS: Fifty-four percent of studies were PBE and 46% RBE. Community-based and policy reviews had more PBE. Health care system and programmatic reviews had more RBE. The majority of both PBE and RBE studies were of high quality according to Community Guide scoring methods. CONCLUSIONS: The inclusion of substantial PBE in Community Guide reviews suggests that evidence of adequate rigor to inform practice is being produced. This should increase stakeholders' confidence that The Community Guide provides recommendations with real-world relevance. Limitations in some PBE studies suggest a need for strengthening practice-relevant designs and external validity reporting standards.

Standards Required for the Development of CDC Evidence-Based Guidelines.

CDC is the nation's premier health promotion, prevention, and preparedness agency. As such, CDC is an important source of public health and clinical guidelines. If CDC guidelines are to be trusted by partners and the public, they must be clear, valid, and reliable. Methods and processes used in CDC guideline development should follow universally accepted standards. This report describes the standards required by CDC for the development of evidence-based guidelines. These standards cover topics such as guideline scoping, soliciting external input, summarizing evidence, and crafting recommendations. Following these standards can help minimize bias and enhance the quality and consistency of CDC guidelines.

Patterns of alcohol consumption and alcohol-impaired driving in the United States.

BACKGROUND: Alcohol-related motor vehicle crashes kill approximately 17,000 Americans annually and were associated with more than $51 billion in total costs in 2000. Relatively little is known about the drinking patterns of alcohol-impaired (AI) drivers in the United States. METHODS: 2006 Behavioral Risk Factor Surveillance System (BRFSS) was analyzed for alcohol consumption and self-reported AI driving among U.S. adults aged > or =18 years for all states. Alcohol consumption was divided into 4 categories: binge/heavy, binge/nonheavy, nonbinge/heavy, and nonbinge/nonheavy. Binge drinking was defined as > or =5 drinks for men or > or =4 drinks for women on one or more occasions in the past month, and heavy drinking was defined as average daily consumption of >2 drinks/day (men) or >1 drink/day (women). The prevalence of AI driving was examined by drinking pattern and by demographic characteristics. Logistic regression analysis was used to assess the association between drinking patterns and AI driving. RESULTS: Five percent of drinkers were engaged in AI driving during the past 30 days. Overall, 84% of AI drivers were binge drinkers and 88% of AI driving episodes involved binge drinkers. By drinking category, binge/nonheavy drinkers accounted for the largest percentage of AI drivers (49.4%), while binge/heavy drinkers accounted for the most episodes of AI driving (51.3%). The adjusted odds of AI driving were 20.1 (95% CI: 16.7, 24.3) for binge/heavy, 8.2 (6.9, 9.7) for binge/nonheavy, and 3.9 (2.4, 6.3) for nonbinge/heavy drinkers, respectively. CONCLUSIONS: There is a strong association between binge drinking and AI driving. Most AI drivers and almost half of all AI driving episodes involve persons who are not heavy drinkers (based on average daily consumption). Implementing effective interventions to prevent binge drinking could substantially reduce AI driving.

Community Guide Cardiovascular Disease Economic Reviews: Tailoring Methods to Ensure Utility of Findings.

The Community Preventive Services Task Force recommended five interventions for cardiovascular disease prevention between 2012 and 2015. Systematic economic reviews of these interventions faced challenges that made it difficult to generate meaningful policy and programmatic conclusions. This paper describes the methods used to assess, synthesize, and evaluate the economic evidence to generate reliable and useful economic conclusions and address the comparability of economic findings across interventions. Specifically, steps were taken to assess completeness of data and identify the components and drivers of cost and benefit. Except for the intervention cost of self-measured blood pressure monitoring intervention, either alone or with patient support, all cost and benefit estimates were standardized as per patient per year. When possible, intermediate outcomes were converted to quality-adjusted life year. Differences within and between interventions were considered to generate economic conclusions and inform their comparability. The literature search period varied among interventions. This analysis was completed in 2016. Although team-based care, self-measured blood pressure monitoring with patient support, and self-measured blood pressure monitoring within team-based care were found to be cost effective, their cost-effectiveness estimates were not comparable because of differences in the intervention characteristics. Lack of enough data or incomplete information made it difficult to reach an overall economic finding for the other interventions. The Community Guide methods discussed here may help others conducting systematic economic reviews of public health interventions to respond to challenges with the synthesis of evidence and provide useful findings for public health decision makers.

Alcohol Electronic Screening and Brief Intervention: A Community Guide Systematic Review.

CONTEXT: Excessive drinking is responsible for one in ten deaths among working-age adults in the U.S. annually. Alcohol screening and brief intervention is an effective but underutilized intervention for reducing excessive drinking among adults. Electronic screening and brief intervention (e-SBI) uses electronic devices to deliver key elements of alcohol screening and brief intervention, with the potential to expand population reach. EVIDENCE ACQUISITION: Using Community Guide methods, a systematic review of the scientific literature on the effectiveness of e-SBI for reducing excessive alcohol consumption and related harms was conducted. The search covered studies published from 1967 to October 2011. A total of 31 studies with 36 study arms met quality criteria and were included in the review. Analyses were conducted in 2012. EVIDENCE SYNTHESIS: Twenty-four studies (28 study arms) provided results for excessive drinkers only and seven studies (eight study arms) reported results for all drinkers. Nearly all studies found that e-SBI reduced excessive alcohol consumption and related harms: nine study arms reported a median 23.9% reduction in binge-drinking intensity (maximum drinks/binge episode) and nine study arms reported a median 16.5% reduction in binge-drinking frequency. Reductions in drinking measures were sustained for up to 12 months. CONCLUSIONS: According to Community Guide rules of evidence, e-SBI is an effective method for reducing excessive alcohol consumption and related harms among intervention participants. Implementation of e-SBI could complement population-level strategies previously recommended by the Community Preventive Services Task Force for reducing excessive drinking (e.g., increasing alcohol taxes and regulating alcohol outlet density).

Aligning the Work of Two U.S. Task Forces on Behavioral Counseling Recommendations.

This paper highlights the collaboration and alignment between topics and recommendations related to behavioral counseling interventions from the U.S. Preventive Services Task Force (USPSTF) and Community Preventive Services Task Force (CPSTF). Although the scope and mandates of the USPSTF and CPSTF differ, there are many similarities in the methods and approaches used to select topics and make recommendations to their key stakeholders. Behavioral counseling recommendations represent an important domain for both Task Forces, given the importance of behavior change in promoting healthful lifestyles. This paper explores opportunities for greater alignment between the two Task Forces and compares and contrasts the groups and their current approaches to making recommendations that involve behavioral counseling interventions. Opportunities to enhance behavioral counseling preventive services through closer coordination when developing and disseminating recommendations as well as future collaboration between the USPSTF and CPSTF are discussed.

Effectiveness of mass media campaigns for reducing drinking and driving and alcohol-involved crashes: a systematic review.

A systematic review of the effectiveness of mass media campaigns for reducing alcohol-impaired driving (AID) and alcohol-related crashes was conducted for the Guide to Community Preventive Services (Community Guide). In eight studies that met quality criteria for inclusion in the review, the median decrease in alcohol-related crashes resulting from the campaigns was 13% (interquartile range: 6% to 14%). Economic analyses of campaign effects indicated that the societal benefits were greater than the costs. The mass media campaigns reviewed were generally carefully planned, well executed, attained adequate audience exposure, and were implemented in conjunction with other ongoing prevention activities, such as high visibility enforcement. According to Community Guide rules of evidence, there is strong evidence that, under these conditions, mass media campaigns are effective in reducing AID and alcohol-related crashes.

Primary enforcement seat belt laws are effective even in the face of rising belt use rates.

A recent systematic literature review found that primary enforcement laws are more effective at increasing seat belt use than secondary laws in the United States. This report re-examines the studies included in the systematic review to explore whether the benefits of a primary law differ based on: (1) the baseline seat belt use rate; or (2) whether or not the primary law replaces a secondary law. States that directly enacted primary laws showed larger increases in observed seat belt use (median increase of 33 percentage points). These laws were enacted in the mid-1980s, when baseline belt use rates were below 35%. Smaller, but substantial increases in belt use were observed in states that replaced secondary with primary laws (median increase of 14 percentage points). Baseline belt use rates in these states ranged from 47 to 73%. Primary safety belt laws can further increase seat belt use even in states with relatively high baseline levels of belt use.

Alcohol-related emergency department visits among people ages 13 to 25 years.

OBJECTIVE: Data from a large, nationally representative sample of hospital emergency departments (EDs) were used to assess the prevalence and characteristics of alcohol-related ED visits among people ages 13 to 25 years in the United States. METHOD: Emergency department visits recorded in the National Electronic Injury Surveillance System-All Injury Program were coded for alcohol involvement based on alcohol product codes and abstractions of chart narratives. National estimates and confidence intervals were calculated using SUDAAN statistical software. RESULTS: Based on these chart data, in the United States in 2001 there were an estimated 244,331 alcohol-related ED visits among people ages 13 to 25 (3.2% of total visits). Of these, an estimated 119,503 (49%) involved people below the legal drinking age of 21. The number of alcohol-related visits increased throughout adolescence and young adulthood to the age of 21, after which they decreased to levels similar to those seen for 18 to 20 year olds. Alcohol-related visits were most frequent on weekends and among males and were more strongly associated with visits related to assault or self-harm than to visits for unintentional injuries or injuries of unknown intent. In this population, 38% of alcohol-related visits involved no external cause of injury (e.g., drinking to excess only). CONCLUSIONS: These data highlight the need for stronger efforts to delay initiation of alcohol use among adolescents as long as possible and to limit access to alcohol for underage drinkers.

Effectiveness of primary enforcement safety belt laws and enhanced enforcement of safety belt laws: a summary of the Guide to Community Preventive Services systematic reviews.

BACKGROUND: The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor-vehicle crashes. This paper summarizes the systematic reviews of two interventions to increase safety belt use: primary enforcement safety belt laws and enhanced enforcement of safety belt laws. The reviews were previously published in the American Journal of Preventive Medicine. METHODS: We conducted the systematic reviews using the methodology developed for the Guide to Community Preventive Services. RESULTS: These reviews provide strong evidence that primary laws are more effective than secondary laws in increasing safety belt use and decreasing fatalities and that enhanced enforcement is effective in increasing safety belt use. Increases in belt use are generally highest in states with low baseline rates of belt use. DISCUSSION: Primary safety belt laws and enhanced enforcement programs tend to result in greater increases in usage rates for target groups with lower baseline rates. Concerns regarding public opposition to these interventions may impede their implementation in some jurisdictions. However, surveys indicate that a substantial majority of the public supports implementation of both primary laws and enhanced enforcement programs. CONCLUSION: Based on the strong evidence for effectiveness of primary safety belt laws and enhanced enforcement programs, the Task Force on Community Preventive Services recommended that all states enact primary safety belt laws and that communities implement enhanced enforcement programs.

Economics of mass media health campaigns with health-related product distribution: a community guide systematic review.

CONTEXT: The objective of this systematic review was to determine the costs, benefits, and overall economic value of communication campaigns that included mass media and distribution of specified health-related products at reduced price or free of charge. EVIDENCE ACQUISITION: Economic evaluation studies from a literature search from January 1980 to December 2009 were screened and abstracted following systematic economic review methods developed by The Community Guide. Data were analyzed in 2011. EVIDENCE SYNTHESIS: The economic evidence was grouped and assessed by type of product distributed and health risk addressed. A total of 15 evaluation studies were included in the economic review, involving campaigns promoting the use of child car seats or booster seats, pedometers, condoms, recreational safety helmets, and nicotine replacement therapy. CONCLUSIONS: Economic merits of the intervention could not be determined for health communication campaigns associated with use of recreational helmets, child car seats, and pedometers, primarily because available economic information and analyses were incomplete. There is some evidence that campaigns with free condom distribution to promote safer sex practices were cost-effective among high-risk populations and the cost per quit achieved in campaigns promoting tobacco cessation with nicotine replacement therapy products may translate to a cost per quality-adjusted life-year less than $50,000. Many interventions were publicly funded trials or programs, and the failure to properly evaluate their economic cost and benefit is a serious gap in the science and practice of public health.

Publicized sobriety checkpoint programs: a community guide systematic review.

CONTEXT: Publicized sobriety checkpoint programs deter alcohol-impaired driving by stopping drivers systematically to assess their alcohol impairment. Sobriety checkpoints were recommended in 2001 by the Community Preventive Services Task Force for reducing alcohol-impaired driving, based on strong evidence of effectiveness. Since the 2001 review, attention to alcohol-impaired driving as a U.S. public health problem has decreased. This systematic review was conducted to determine if available evidence supports the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-impaired driving, given the current context. The economic costs and benefits of the intervention were also assessed. EVIDENCE ACQUISITION: This review focused on studies that evaluated the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities. Using Community Guide methods, a systematic search was conducted for studies published between July 2000 and March 2012 that assessed the effectiveness of publicized sobriety checkpoint programs. EVIDENCE SYNTHESIS: Fourteen evaluations of selective breath testing and one of random breath testing checkpoints met the inclusion criteria for the systematic review, conducted in 2012. Ten evaluations assessed the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities, finding a median reduction of 8.9% in this crash type (interquartile interval=-16.5%, -3.5%). Five economic evaluations showed benefit-cost ratios ranging from 2:1 to 57:1. CONCLUSIONS: The number of studies, magnitude of effect, and consistency of findings indicate strong evidence of the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-involved crash fatalities. Economic evidence shows that these programs also have the potential for substantial cost savings.

Mass media health communication campaigns combined with health-related product distribution: a community guide systematic review.

CONTEXT: Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury. EVIDENCE ACQUISITION: Using methods previously developed for the Community Guide, a systematic review (search period, January 1980-December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products. EVIDENCE SYNTHESIS: Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns. CONCLUSIONS: Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

Scientific evidence and policy change: lowering the legal blood alcohol limit for drivers to 0.08% in the USA.

The United States (US) Centers for Disease Control and Prevention (CDC), and key partners conducted a systematic review of the effectiveness of 0.08% blood alcohol concentration (BAC) laws on alcohol-related traffic mortality. Review findings of strong evidence of effectiveness were presented by partners during US Congressional hearings contributing to the passage of a bill requiring states to lower the legal BAC limit to 0.08% (80 mg of alcohol/100 ml of blood) or lose a portion of their federal highway funds. The bill was signed into law, making 0.08 the new national standard. Extensive and targeted dissemination of the evidence and recommendations to key stakeholders and partners built support for policy change at the state level.

Effectiveness of ignition interlocks for preventing alcohol-impaired driving and alcohol-related crashes: a Community Guide systematic review.

A systematic review of the literature to assess the effectiveness of ignition interlocks for reducing alcohol-impaired driving and alcohol-related crashes was conducted for the Guide to Community Preventive Services (Community Guide). Because one of the primary research issues of interest--the degree to which the installation of interlocks in offenders' vehicles reduces alcohol-impaired driving in comparison to alternative sanctions (primarily license suspension)--was addressed by a 2004 systematic review conducted for the Cochrane Collaboration, the current review incorporates that previous work and extends it to include more recent literature and crash outcomes. The body of evidence evaluated includes the 11 studies from the prior review, plus four more recent studies published through December 2007. The installation of ignition interlocks was associated consistently with large reductions in re-arrest rates for alcohol-impaired driving within both the earlier and later bodies of evidence. Following removal of interlocks, re-arrest rates reverted to levels similar to those for comparison groups. The limited available evidence from three studies that evaluated crash rates suggests that alcohol-related crashes decrease while interlocks are installed in vehicles. According to Community Guide rules of evidence, these findings provide strong evidence that interlocks, while they are in use in offenders' vehicles, are effective in reducing re-arrest rates. However, the potential for interlock programs to reduce alcohol-related crashes is currently limited by the small proportion of offenders who participate in the programs and the lack of a persistent beneficial effect once the interlock is removed. Suggestions for facilitating more widespread and sustained use of ignition interlocks are provided.

Translating evidence into policy: lessons learned from the case of lowering the legal blood alcohol limit for drivers.

This case study examines the translation of evidence on the effectiveness of laws to reduce the blood alcohol concentration (BAC) of drivers into policy. It was reconstructed through discussions among individuals involved in the processes as well as a review of documentation and feedback on oral presentations. The Centers for Disease Control and Prevention collaborated extensively with federal and non-federal partners and stakeholders in conducting a rigorous systematic review, using the processes of the Guide to Community Preventive Services to evaluate the body of empirical evidence on 0.08% BAC laws. The timely dissemination of the findings and related policy recommendations-made by the independent Task Force on Community Preventive Services-to Congress very likely contributed to the inclusion of strong incentives to States to adopt 0.08 BAC laws by October 2003. Subsequent dissemination to partners and stakeholders informed decision-making about support for state legislative and policy action. This case study suggests the value of: clearly outlining the relationships between health problems, interventions and outcomes; systematically assessing and synthesizing the evidence; using a credible group and rigorous process to assess the evidence; having an impartial body make specific policy recommendations on the basis of the evidence; being ready to capitalize in briefly opening policy windows; engaging key partners and stakeholders throughout the production and dissemination of the evidence and recommendations; undertaking personalized, targeted and compelling dissemination of the evidence and recommendations; involving multiple stakeholders in encouraging uptake and adherence of policy recommendations; and addressing sustainability. These lessons learned may help others working to translate evidence into policy.

The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms.

A systematic review of the literature to assess the effectiveness of alcohol tax policy interventions for reducing excessive alcohol consumption and related harms was conducted for the Guide to Community Preventive Services (Community Guide). Seventy-two papers or technical reports, which were published prior to July 2005, met specified quality criteria, and included evaluation outcomes relevant to public health (e.g., binge drinking, alcohol-related crash fatalities), were included in the final review. Nearly all studies, including those with different study designs, found that there was an inverse relationship between the tax or price of alcohol and indices of excessive drinking or alcohol-related health outcomes. Among studies restricted to underage populations, most found that increased taxes were also significantly associated with reduced consumption and alcohol-related harms. According to Community Guide rules of evidence, these results constitute strong evidence that raising alcohol excise taxes is an effective strategy for reducing excessive alcohol consumption and related harms. The impact of a potential tax increase is expected to be proportional to its magnitude and to be modified by such factors as disposable income and the demand elasticity for alcohol among various population groups.