the evidence base for community preventative services and examples from states of astdd best...

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The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation, and Research Team Division of Oral Health Centers for Disease Control and Prevention (CDC) Atlanta, Georgia Texas Oral Health Summit: Advocacy, Equity & Access Austin, Texas September 9-10, 2004

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Page 1: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices

Dolores Malvitz, DrPHChief

Surveillance, Investigation, and Research TeamDivision of Oral Health Centers for Disease Control and Prevention

(CDC)Atlanta, Georgia

Texas Oral Health Summit: Advocacy, Equity & AccessAustin, Texas

September 9-10, 2004

Page 2: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Systematic Reviews and Evidence-Based

Recommendations

Promoting Oral Health

Page 3: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

The Community Guide Is:

• A set of recommendations for action based on the scientific evidence

• Evidence comes from systematic reviews

• Reviews coordinated by CDC staff• Recommendations determined by

independent Task Force

Page 4: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

What Will Be Reviewed in the Community Guide?

• Sociocultural Issues

Specific ConditionsRisk Behaviors

The Environment

• Vaccine Preventable Disease• Pregnancy Outcomes• Violence• Motor Vehicle Injuries• Depression• Cancer• Diabetes• Oral Health

•Tobacco Use •Alcohol Abuse/Misuse• Other Substance Abuse• Poor Nutrition• Inadequate Physical Activity• Unhealthy Sexual Behaviors

Page 5: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Healthy People 2010

Guide to ClinicalPreventive Services

Priorities for Prevention

Put Prevention

into Practice

The Community Guide is Part of a Family of Federal Initiatives

Page 6: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Promoting Oral Health

Recommendations from the

Guide to Community Preventive Services

Page 7: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Oral Health ChapterCommunity Guide

Interventions for Preventing:

• Dental Caries

• Oral and Pharyngeal Cancers

• Sports-related Craniofacial Injuries

Page 8: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Methods for Conducting Systematic Reviews: Five Steps

• Develop conceptual approach• Search for and retrieve evidence• Rate quality of evidence• Summarize evidence• Translate strength of evidence into

recommendation

Page 9: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Key Findings

Page 10: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Oral Health ChapterCommunity Guide

Strong evidence for:• Community water fluoridation

• School sealant programs

Page 11: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Translate strength of evidence into recommendations

Preventing dental caries• Community water fluoridation

(strongly recommended)• School-based sealant programs

(strongly recommended)

Page 12: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Oral Health ChapterCommunity Guide

Insufficient evidence for:

• Community-wide sealant promotion programs

• Oral cancer awareness and screening programs

• Promoting use of dental and craniofacial protectors in contact sports

Page 13: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Insufficient evidence should not be confused with evidence of

ineffectiveness

Page 14: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Benefits of the Community Guide

• Stronger foundation for advocacy, research, and programs –proof of effectiveness may be better

(semi-quantitative vs. narrative summary)

–recommendations issued by independent, objective Task Force

Page 15: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,
Page 16: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

www.thecommunityguide.org

Page 17: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

ASTDD Best Practices Project

Putting scienceinto practice

www.astdd.org

Page 18: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Purpose of the Project

(1)Provide guidance for programs

(2)Meet the Surgeon General’s Call to

Action

(3)Help achieve Healthy People 2010

objectives

Page 19: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Approaches

Dental public health strategies

supported by evidence

of effectiveness.

Page 20: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice ApproachesStrength of Evidence

Promising ProvenApproaches....................….….…….....….…

Approaches

Strength of Evidence

Research + Research +++

Expert Opinion + Expert Opinion +++

Field Lessons + Field Lessons +++

Theoretical Rationale +++

Theoretical Rationale+++

Page 21: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Strong Evidence

Research Evidence

+++ Systematic review

Expert Opinion

+++ Multiple authoritative sources

Field Lessons

+++ Cluster evaluation of several states

Page 22: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice ApproachesStrength of Evidence

Best Practice Research Expert FieldTheoretical

Approaches Opinion Lessons Rationale

Surveillance Systems + +++ ++ +++

State Coalitions + +++ ++ +++

State Plans + +++ ++ +++

State Mandate for Program + +++ ++

+++

Community Water Fluoridation +++ +++ ++

+++

School Sealant Programs +++ +++ ++ +++

School Fluoride Programs ++ +++ + +++

Workforce Development + +++ ++ +++

Page 23: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Community Water Program Evidence Supporting Effectiveness

Summary of Evidence Supporting

Community Water Fluoridation

Research +++

Expert Opinion +++

Field Lessons ++

Theoretical Rationale +++

Page 24: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

School-based Sealant ProgramsEvidence Supporting Effectiveness

Summary of Evidence Supporting

School-based Dental Sealant Programs

Research +++

Expert Opinion +++

Field Lessons ++

Theoretical Rationale +++

Page 25: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria

Effectiveness

Efficiency

Collaboration & Integration

Sustainability

Rationale & Objectives

“Best Practice”

Page 26: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

ASTDD Best Practices Project

Community Water Fluoridation

Page 27: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Description of a Community Water Fluoridation Program

Legislation & policies

Advocacy & promotion

Supporting communities starting fluoridation

Training, monitoring, surveillance, reporting and inspection

Page 28: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Description of a Community Water Fluoridation Program

Collaborate with water quality and other partners

Develop human resources to support community water fluoridation efforts

Secure financial resources to support community water fluoridation efforts

Page 29: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(1) Effectiveness

Review Standard:

Compare % population served by water systems with optimally fluoridated water to HP 2010 target (75%).

State population with optimally fluoridated water

Illinois 99%

Indiana 95%

Texas 66%

Arkansas 60%

Mississippi 39%

California 29%

Page 30: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(1) Effectiveness

Review Standard:

Document number of communities or public water systems with optimally fluoridated water.

In 2002: 44 of the 50 largest cities in the U.S. fluoridated

Illinois: 860 of the 1800 community water systems adjust their fluoride levels

Indiana: 482 water systems adjust their fluoride levels

Page 31: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(2) Efficiency

Estimating costs

Initial cost of capital equipment

Replacement cost of capital equipment

Annual operational costs (chemicals, human resources, maintenance & repairs)

Review Standard:

Compare average state cost for fluoridation (cost per per person year) to national estimates.

Page 32: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(3) Sustainability

State Community Water Fluoridation Programs

Indiana since 1950’s

Oklahoma since 1950’s

Missouri since 1960’s

Virginia since 1980’s

Review Standard:

Demonstrate sustainability through the number of years that identifiable water fluoridation program at state level has operated.

Page 33: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(4) Collaboration & Integration

Fluoridation PartnersProfessional association

Grant makers

Health departments

Water authorities

Universities

(dental, medical and public health schools)

Dental hygiene programs

Local community leaders

Review Standard:

Demonstrate partnerships & coalitions with stakeholders and organizations to provide political, financial and scientific expertise to local constituents.

Page 34: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(5) Rationale & Objectives

Healthy People 2010 Objective 21-9

Increase proportion of U.S. population served by community water systems with optimally fluoridated water

2010 target: 75%

Review Standard:

Program is linked to state &/or national goals and objectives.

Page 35: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

ASTDD Best Practices Project

School-basedDental Sealant Programs

Page 36: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Description of School-based Sealant Programs

Program conducted within the school setting

Provide education to increase awareness of the benefit of sealants

Obtain parental consent for screening/sealants

Program provider teams include dentists, dental hygienists and dental assistants

Utilize portable dental equipment or a fixed dental facility within the school setting

Page 37: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Description of School-based Sealant Programs

Usual practice: Dentists examine the children and prescribe the sealants; dental hygienists apply the sealants

For quality assurance, children re-examined within 1 year after sealant placement to check on retention and need for repair

The program should address unmet dental care needs of children

Page 38: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

State Practice Examples

Illinois Dental Sealant Grant Program

Ohio Dept. of Health School-based Dental Sealant Program

Arizona Dental Sealant Program

New Mexico School-based Dental Sealant Program

Page 39: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(1) Effectiveness

Review Standard:

Program delivers to a large number of high risk children.

Sealant Programs

Ohio 28,000 children

Illinois 21,000 children

Target Schools50-65% students infree & reduced lunch programs

Page 40: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(1) Effectiveness

Review Standard:

Program maintains a quality assurance system.

Sealant retention

Arizona

1-week assessment

1-year assessment

New Mexico

1-year assessment

Page 41: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(1) Effectiveness

Sealant Prevalence

Ohio children aged 8:

11% in 1988

30% in 1999

New Mexico 3rd graders:

47-52% in health district

with program

19% in health district

without program

Review Standard:

Documentation of program benefits or outcomes.

Page 42: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(2) Efficiency

New Mexico

Dentists screen children

Dental hygienists apply sealants

Dental assistants also apply sealants

Review Standard:

Program uses the least expensive personnel permitted by state law.

Page 43: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(3) Sustainability

Sealant Programs

New Mexico 26 yrs.

Ohio 20 yrs.

Illinois 19 yrs.

Arizona 17 yrs.

Funding

Ohio…MCH/Tobacco $

Arizona………Medicaid

Review Standard:

Program with a track record or a plan for covering program expenses.

Page 44: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(4) Collaboration & Integration

Sealant PartnersLocal health departments

Community agencies

School health services

Medicaid

Primary Care Office

Foundations

Private dentists & dental hygienists

Review Standard:

Partnerships are established to administer & sustain the program.

Page 45: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Best Practice Criteria(5) Rationale & Objectives

Healthy People 2010 Objective 21-8:

Increase of childrenwho have receivedsealants on theirmolar teeth

Aged 8 years 50%

Aged 14 years 50%

Review Standard:

Program is linked to state &/or national goals and objectives.

Page 46: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

ASTDD Best Practices Project

Putting scienceinto practice

Page 47: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

www.astdd.org

Best Practice Approach Reports

ASTDD Web Site

Page 48: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

www.astdd.org

Page 49: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,
Page 50: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,
Page 51: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,
Page 52: The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best Practices Dolores Malvitz, DrPH Chief Surveillance, Investigation,

Building a System:Ongoing and Dynamic Development

IdentifyBest

Practices

Cultivate Best

Practices

PromoteBest

Practices

Collaborate& Integrate

Science& Art

Supportive

Environment