Effectiveness in Disease and Injury Prevention Public Health Focus: Effectiveness of Disease and Injury Prevention

As part of its commemoration of CDC's 50th anniversary, MMWR is reprinting selected MMWR articles of historical interest to public health, accompanied by a current editorial note.

Reprinted below is the report published April 24, 1992, which first described the need for information on the economic and social impact of disease- and injury-prevention strategies, followed by a contemporary editorial note.

Public health practice is based on scientifically sound strategies for improving the quality of life and reducing morbidity and premature mortality. To maximize the health benefits of available resources, public health decision-makers require information on the effectiveness, as well as the economic and social impact, of disease and injury prevention strategies (1). This report introduces a monthly series of articles to be published in MMWR (weekly) that highlight prevention effectiveness.

The development of prevention technology begins with researchers in the basic public health and biomedical sciences identifying potentially effective technologies that can be used to reduce unnecessary morbidity and premature mortality. Applied research under carefully controlled conditions may then determine whether such techniques are efficacious (e.g., the effect of smoking cessation on lung cancer). As these techniques are applied at the community level, their impact and cost can be assessed first in demonstration settings and then in routine community settings, and improvements in techniques can then be incorporated into prevention strategies.

Important considerations in the assessment of disease and injury prevention strategies (i.e., the scientific method for evaluating the effectiveness of prevention strategies) include

• identification of efficacious and effective strategies to reduce morbidity and premature mortality and improve the quality of life;

• characterization of the social, legal, and ethical impact of these strategies;

• estimation of the economic impact of prevention strategies;

• determination of optimal methods for implementing those strategies; and

• evaluation of the health impact of prevention programs.

Each report in the monthly series will highlight the knowledge base regarding a specific prevention strategy and will address related considerations, including efficacy, effectiveness, safety, and economic factors. Topics have been selected based on their inclusion in the national health objectives for the year 2000 (2), CDC and other public health program efforts, and the availability of data. In particular, the reports will present specific examples of disease and injury prevention strategies and illustrate approaches to evaluating the effectiveness of such strategies.

Reported by: Office of Program Planning and Evaluation, Office of the Director; Office of the Director, Epidemiology Program Office, CDC.

editorial Note: Public health officials and policy-makers at all levels require a scientific framework for assessing the effectiveness of disease and injury prevention as a basis for establishing priorities, selecting prevention strategies, and allocating resources. The success of prevention activities can be defined by whether they delay or avert morbidity and mortality. However, the ability to evaluate objectively many prevention techniques with randomized controlled trials is often limited by fiscal, ethical, or other constraints. The MMWR Recommendations and Reports issue, "A Framework for Assessing the Effectiveness of Disease and Injury Prevention" (1), focuses on the challenges of assessment that arise as a consequence of these constraints. Reports in the MMWR (weekly) series will describe examples of how prevention effectiveness can be assessed.

Because public health programs sometimes may begin to implement preventive measures before appropriate assessments are completed, gaps may exist in knowledge of the efficacy, effectiveness, safety, or economic impact of specific prevention strategies. The series of reports in MMWR (weekly) will characterize many of these gaps and describe how they have been addressed. In addition, the reports in this series are intended to 1) provide decision-makers with information about the potential impact of these interventions on the health of their communities; 2) suggest approaches suitable for adaptation to public health practice; and 3) encourage further examination of these topics and stimulate additional systematic efforts by public health professionals to assess and enhance the effectiveness of public health programs. references

1. CDC. A framework for assessing the effectiveness of disease and injury prevention. MMWR 1992;41(no. RR-3).

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

   Editorial Note

Editorial Note -- 1997: Since the initiation of the series of articles (1-7) and publication of the MMWR Recommendations and Reports (8) on prevention effectiveness, the concepts have been institutionalized as a public health science at CDC and many other organizations in the public health community. Public health programs traditionally have been accountable for their effectiveness and have had to exist within resource constraints. Choices among competing priorities and intervention strategies have been and will continue to be made regardless of the information available. Prevention effectiveness integrates the best available information into the value of those choices.

The prevention-effectiveness initiative has helped to catalyze the integration of the principles of evidence-based medicine (9) into public health. A central feature of this approach is the focus on health outcomes. By examining the links between interventions, intermediate impacts, and health outcomes, synthetic analyses can be developed as tools to assist in selecting the best intervention strategies. These tools assist in clarifying the objectives, the strategies available to achieve those objectives, the logic of the causal pathways, and the evidence that supports the links in those pathways. In addition to facilitating understanding of problems and potential solutions, these tools provide a basis for developing practice guidelines (10) and, in the future, adapting those guidelines to communities with differing demographics, risk profiles, and health concerns (11).

Public health uses clinical interventions as well as behavioral, environmental, and social approaches. Many of the prevention-effectiveness methods that have been applied in the clinical arena (e.g., decision analyses and economic evaluations as applied to technology assessments, outcomes research, and health services research) needed to be adapted to public health. Recommendations for comparable methods for decision modeling and analysis and economic evaluation in public health are now available (12,13). These standards for analysis assure policymakers that studies conducted in accordance with these principles are reliable and comparable.

The need to spend limited health-care resources more efficiently is generally accepted. Managed-care and public health partners now routinely explore the broadest range of community-based intervention strategies to improve the health of the populations they serve. The tools of prevention effectiveness provide decision-makers with critical information necessary for improving decision-making to weigh along with ethics, feasibility, and the distribution of costs and benefits to different populations. For example, policy discussions on the fortification of food with folic acid to reduce neural tube defects used economic evaluations to compare the costs, benefits, and hazards associated with fortifying foods with different levels of folic acid, with diet supplementation, or with no intervention (14).

Since 1992, CDC has increased substantially its capability in prevention effectiveness through courses, postdoctoral fellowships, routine use of economic evaluations (cost-effectiveness and cost-benefit and cost-utility analyses), and the development of comparable methodologies (11). For example, a recent study of the cost-effectiveness of antibiotics for the treatment of chlamydia cervicitis (15) led to a negotiated public health price for a single-dose formulation of azithromycin suitable for administration in clinics. Prevention effectiveness has become a core science for public health, but additional efforts are required to clarify understanding of how prevention-effectiveness studies can be better used by decision-makers. Methods for measuring outcomes (such as quality-adjusted life-years and benefits estimation for cost-benefit analyses) and resource allocation need to be refined. Finally, improved, more complete, and comparable information on cost-effectiveness needs to be available to users. 1997 Editorial Note by Steven M Teutsch, MD, MPH, Office of the Director, Division of Prevention Research and Analytic Methods (proposed), Epidemiology Program Office, CDC.

References

1. CDC. Public health focus: fluoridation of community water systems. MMWR 1992;41:372-5,381.

2. CDC. Public health focus: mammography. MMWR 1992;41:454-9.

3. CDC. Public health focus: effectiveness of smoking-control strategies -- United States. MMWR 1992;41:645-7,653.

4. CDC. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR 1992;41:783-7.

5. CDC. Public health focus: effectiveness of rollover protective structures for preventing injuries associated with agricultural tractors. MMWR 1993;42:57-9.

6. CDC. Public health focus: prevention of blindness associated with diabetic retinopathy. MMWR 1993;42:191-5.

7. CDC. Public health focus: physical activity and the prevention of coronary heart disease. MMWR 1993;42:669-72.

8. Teutsch SM. A framework for assessing the effectiveness of disease and injury prevention. MMWR 1992;41(no. RR-3).

9. Field MJ, Lohr KN, eds. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press, 1990.

10. CDC. CDC guidelines: improving the quality. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1996.

11. Gold MR, McKay KI, Teutsch SM, Haddix AC. Assessing outcomes in population health: moving the field forward. Am J Prev Med 1997 (in press).

12. Haddix AC, Teutsch SM, Shaffer PA, Duĺet DO, eds. Prevention effectiveness: a guide to decision analysis and economic evaluation. New York, New York: Oxford University Press, 1996.

13. Gold MR, Siegel JE, Russell LB, Weinstein M. Cost effectiveness in health and medicine. New York, New York: Oxford University Press, 1996.

14. Kelly AE, Haddix AC, Scanlon KS, Helmick CG, Mulinare J. Cost-effectiveness of strategies to prevent neural tube defects. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-effectiveness in health and medicine. New York, New York: Oxford University Press, 1996: 313-48.

15. Haddix AC, Hillis SD, Kassler WJ. The cost-effectiveness of azithromycin for Chlamydia trachomatis infections in women. Sex Transm Dis 1995;22:274-80.

    
    

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