The Appalachia Cancer Network: cancer control research among a rural, medically underserved population.

Residents of Appalachia, especially those in rural Appalachia, are generally considered to be medically underserved. In fact, cancer mortality in Appalachia, especially in rural Appalachia, is higher than it is in the remainder of the United States. Developing from the Appalachia Leadership Initiative on Cancer, the Appalachia Cancer Network (ACN) is a network of academic and community organizations that seek to conduct surveillance, intervention, and dissemination research to reduce this excess cancer burden in Appalachia. The purpose of this report is to (1) describe the approach to cancer control research in ACN, a Special Population Network, among the medically underserved of Appalachia, and (2) to put forward observations from this experience to enhance the research of other academic and community networks among underserved populations. ACN has instituted a conceptual model, organizational structure, and other methods to foster this research and to develop junior and community-based investigators. Important issues and questions related to the effectiveness of such research networks have also been articulated.

Rural-urban variation in breast-conserving surgery in Kentucky.

Recently researchers from the University of Kentucky published a study showing that, in the early 1990s, Appalachian women were less likely to receive breast-conserving surgery (BCS) in the treatment of early stage cancer, than other Kentucky women diagnosed with early stage breast cancer, and that poverty was the only predictor of lowered probability of receiving BCS. In that study, analyses were performed on a dataset of Kentucky Medicare beneficiary claims of treatment information that had been linked with data from the Kentucky Cancer Registry for staging information. County-level data were also used, from the 1990 census and other sources, on poverty and education rates for women, and hospital bed and physician ratios per population. While the findings of the study are significant, the study is generalizable only to women aged 65 years and older because a Medicare dataset was used. In addition, the study represented Kentucky practice seven to ten years ago, from 1992 through 1995, which raises interest in obtaining BCS rates for more current practice. In this article, we update the previous study with the most recent data on BCS, and include women of all ages, not just those over age 64 years. Access was obtained to the Kentucky Cancer Registry, which contains records of the initial treatment for breast cancer, as well as staging information about the extent of disease at diagnosis. Data from the 2000 census were not available for this analysis, however.

Content and criterion validity evaluation of National Public Health Performance Standards measurement instruments.

OBJECTIVE: The Centers for Disease Control and Prevention's National Public Health Performance Standards Program (NPHPSP) has developed instruments to measure the performance of local and state public health departments on the 10 "Essential Services of Public Health," which have been tested in several states. This article is a report of the evaluation of the content and criterion validity of the local public health performance assessment instrument, and the content validity of the state public health performance assessment instrument. METHODS: Health department performance is measured using a set of indicators developed for the 10 Essential Services of Public Health and a model standard for each indicator. Content validity of each model standard in the local instrument was addressed by community partners along the following dimensions: the importance of each standard as a measure of the associated Essential Service, its completeness as a measure, and its reasonableness for achievement. All standards for each Essential Service were then judged in terms of their completeness in measuring performance in that service. Content validity of the state instrument was evaluated in a group interview of health department staff members from three states. Criterion validity of the local instrument was assessed for a sample of eight public health departments in Florida and six in New York by examining documentary evidence for selected responses. Criterion validity was also evaluated for a sample of Florida local public health departments and one Hawaii public health department by comparing state health department staffs' judgments of performance against the instrument score. RESULTS: Criterion validity was upheld for a summary performance score on the local instrument, but was not upheld for performance judgments on individual Essential Services. The NPHPSP standards based on the Essential Services have validity for measuring local public health system performance, according to community partners. The model standards are valid measures of state performance, according to state public health departments in three states. CONCLUSIONS: Within the scope of the validity evaluations completed, the NPHPSP state and local performance assessment instruments were found to be valid measures of public health performance.

Recommendations from testing of the National Public Health Performance Standards instruments.

The National Public Health performance Standards Program (NPHPSP) has developed assessment instruments based on the ten essential public health services (EPHS) for state and local health departments. The article reviews validity testing of the state and local instruments. The study employed multiple approaches to validity testing with state and local health departments in Florida, Hawaii, Minnesota, Mississippi, and New York. The New York State validity checks included the judgments of community partners. The study found that the EPHS have content and face validity as a basis for measuring public health system performance. The article includes recommendations for continued development of the NPHPS.

Assessment of validity of the national public health performance standards: the local public health performance assessment instrument.

The National Public Health Performance Standards Program (NPHPSP) has developed performance standards measurement instruments, based on the 10 "Essential Services of Public Health" that are being tested in several states. This article is a report on the face and content validity of the instrument designed for local public health systems. Judgments about the face validity of the standards were obtained in a survey of local public health systems that had used the instrument in a test state. The validity of each standard was addressed along the following dimensions: the importance of the standard as a measure of the Essential Service; its completeness as a measure; and its reasonableness for achievement. All standards for each Essential Service were then judged in terms of their completeness in measuring performance of that service. Respondents judged the standards to be highly valid measures of local public health system performance. Some respondents had reservations about whether standards related to "enforcing laws and regulations" were achievable. Holding local public health systems accountable for the activities of other agencies was a factor mentioned in conjunction with those standards. The NPHPSP standards have face and content validity for measuring local public health system performance. Further testing of their validity and reliability is continuing.

Challenges in evaluating rural health programs.

Complex community-based prevention programs are being held to scientific evidence of their effectiveness and rural public health departments that implement such programs often are not equipped to evaluate them. Rural public health departments are fettered by small budgets, small staffs, and less access to evaluation experts and similar resources. Community-based health promotion programs can include complex designs that may work differently in rural areas and evaluation of rural programs can be hampered by lack of control groups and the instability of results from small populations. The University of Kentucky has entered into a contract with the state Department for Public Health to implement an internal, participatory model of evaluation. In this model, the university evaluation expert trains local public health department staff in technical skills for program evaluation and acts as mentor and technical consultant to local public health departments on an ongoing basis. Through training and site visits, this model is one approach to addressing the challenges of evaluating rural health promotion programs.

Geographic variation in breast-conserving surgery in Kentucky's Medicare population.

Breast cancer represents a significant disease burden in Kentucky, affecting some 2,900 newly diagnosed women each year. About 600 Kentucky women will die of breast cancer in 2001. Kentucky's age-adjusted death rate for breast cancer in 1995 was 24.2 per 100,000 women, ranking 30th in the United States. In Kentucky and nationally, it is known that breast cancer treatment and prognosis may be complicated by elderly women's age and comorbid illnesses. Not all differences in treatment and prognosis can be explained, however, by patient characteristics or illness severity. A large body of health services research has developed over the last thirty years that documents the relationship between the supply of health care resources (e.g., physicians, hospital beds) and variances in treatment. This line of research has particular significance in Kentucky, where the supply of resources varies greatly across the state. Because breast cancer treatment variations unrelated to breast cancer disease may affect prognosis and outcome, it is important that these treatment variations be understood. The purpose of this study was to determine the existence and extent to which Kentucky women over 65 with the same stage of breast cancer receive breast-conserving surgery in different geographic regions, and to link geographic differences to differences in population characteristics, and the availability of health care resources for cancer treatment.

Public health competencies required by managed care organizations.

The authors developed a list of population-based public health competencies. They surveyed the chief executive officer, chief medical officer, and chief quality control person at a randomly selected group of managed care organizations drawn from the membership of the American Association of Health Plans. The authors asked them to rank those competencies that were essential for them in their work with their organization. The authors identified both the most commonly required competencies across all groups and the most essential for each specific job in the managed care organization. This article discusses these competencies and their implications for those who are responsible for ensuring that graduates have achieved required competencies.