Putting meat on the mantra: evidence-based public health for Colorado

There is a mantra in clinical medicine that includes the phrase "evidence-based".  Federal health care reform plans call for increased attention to the application of evidence to guide clinical practice and policy.  There is little controversy about the general rationale, as everyone wants to use the most effective interventions and to avoid those that are ineffective or dangerous, but controversy comes in the details.  Even in clinical practice, where we have the benefit of many randomized controlled trials, judgments about the three-way balance of risks, benefits, and costs are often unstable.  The most recent example of how controversy can emerge even in the presence of ample data from trials was the flap following the mammography recommendations by the US Preventive Services Task Force (USPSTF) last year.  That controversy emerged during debates on health care reform, and was clouded by the ominous image of federal government "death panels" of green-shaded bureaucrats deciding grandma's fate.  

In the meantime, both policy and practice require that public health also acquire, interpret, and act on an "evidence base".   In public health interventions and policies, randomized controlled trials are the exception rather than the rule.  The inference we must make about efficacy in public health programs and policies must therefore be forged from a more complex set of types of evidence.  CDC has taken some first steps to establish a framework for evidence-based public health decisions by the creation of the Task Force for Community Preventive Services, which uses a process analogous to that of the USPSTF.   The “Guide to Community Preventive Services” is a good beginning - a publication of selected reviews of the evidence for efficacy of various approaches to disease prevention and control.  However, the Guide only addresses a small proportion of the questions we have every day regarding what works and what does not work in public health. 

Here in Colorado we all apply our own personal standards for what we judge to be "evidence-based".  CDPHE leaders, local health department leaders, academicians, foundations, and review committees for Amendment 35 funds all employ their own brand of judging evidence.  We should develop a better way.  In the clinical care realm, the Colorado Clinical Guidelines Collaborative (CCGC, recently re-named "HealthTeamWorks") was formed to bring together interested parties to forge collective judgments about clinical care guidelines for Colorado.  That process typically begins with guidelines from the USPSTF and other professional groups, then it incorporates other information in the creation of consensus on what we here in Colorado judge to be the best "evidence-based" clinical care.  That process has been very helpful in the clinical realm.  What we now need for public health is an analogous process to develop consensus about the evidence for community-level interventions and policies. 

More explicitly defining a process for collectively judging the evidence to set priorities for Colorado's public health programs could help to improve the effectiveness and efficiency of our future investments in public health, whether from Federal, state, or private funding sources.  What I envision is an open and transparent public process that would bring together Colorado’s public health leaders, academicians, foundations, and others involved in allocating resources and setting policy for public health.   This could take the form of an organization like HealthTeamWorks, and/or this could be a more virtual (wiki) type of process. 

Between August 1-5 fourteen public health professionals joined together in Vail to form a public health evidence workgroup at the 12th annual Evidence Based Health Care Workshop (Judy Baxter, Emily Burns, Tim Byers, Lynne Fox, Barbara Gabella, Jan Gascoigne, Jillian Jacobellis, Carol Kaufman, Kristin MsDermott, Kindra Mulch, Sandra Mortensen, Sara Rodriguez, Karen Trierweiler, Lisa VanRaemdonck).  This group spent four days learning about methods used to assemble and judge evidence, specifically exploring the similarities and differences between the clinical and the public health realms.  The group will meet again soon to discuss some specific ideas about how we might better move forward in Colorado in the application of evidence in public health.  We welcome any ideas.  Stay tuned for more information on this process in future blogs.