Lessons learned from the first funding period of the CDC Assessment Initiative.

The Centers for Disease Control and Prevention Assessment Initiative enables state and local health departments to improve their capacity to use data for developing policy and ensuring that needed health services are provided. Using reports and comments submitted by staff from the participating states, lessons learned are summarized for the first funding period of the initiative. Although many activities were common among the participating states, the lessons learned varied for them. From a commitment to the concepts of assessment, policy development, and assurance, a vision for the national mission of public health is provided and the various roles in fulfilling the mission are defined.

A computerized tool for evaluating the effectiveness of preventive interventions.

In identifying appropriate strategies for effective use of preventive services for particular settings or populations, public health practitioners employ a systematic approach to evaluating the literature. Behavioral intervention studies that focus on prevention, however, pose special challenges for these traditional methods. Tools for synthesizing evidence on preventive interventions can improve public health practice. The authors developed a literature abstraction tool and a classification for preventive interventions. They incorporated the tool into a PC-based relational database and user-friendly evidence reporting system, then tested the system by reviewing behavioral interventions for hypertension management. They performed a structured literature search and reviewed 100 studies on behavioral interventions for hypertension management. They abstracted information using the abstraction tool and classified important elements of interventions for comparison across studies. The authors found that many studies in their pilot project did not report sufficient information to allow for complete evaluation, comparison across studies, or replication of the intervention. They propose that studies reporting on preventive interventions should (a) categorize interventions into discrete components; (b) report sufficient participant information; and (c) report characteristics such as intervention leaders, timing, and setting so that public health professionals can compare and select the most appropriate interventions.

Surveillance for use of preventive health-care services by older adults, 1995-1997.

PROBLEM/CONDITION: In 1995, a total of 55 million persons aged > or =55 years lived in the United States. The members of this large and growing segment of the population are major consumers of health care. Their access to medical and dental preventive services contributes to their likelihood of healthy later years and influences their long-term impact on the health-care delivery system. REPORTING PERIOD: 1995-1997. DESCRIPTION OF SYSTEMS: This report summarizes data from the National Health Interview Survey (NHIS), the state-based Behavioral Risk Factor Surveillance System (BRFSS), and the Medicare Current Beneficiary Study (MCBS) to describe national, regional, and state-specific patterns of access to and use of preventive services among persons aged > or =55 years. RESULTS: During 1995-1997, approximately 90% of persons aged > or =55 years living in the United States reported having a regular source of health-care services. However, only 75%-80% reported receiving a routine checkup during the preceding 2 years. The estimated percentage of persons who reported not being able to receive medical care because of cost was highest for those aged 55-64 years. Within this age group, the percentage was highest among Hispanics (4%) and persons without a high school diploma. Approximately 11% of Medicare beneficiaries reported delaying care be cause of cost or because they had no particular source of care. Percentage estimates varied according to age, race/ethnicity, and sociodemographic status. Approximately 95% of persons aged > or =55 years reported having their blood pressure checked during the preceding 2 years, but only 85%-88% had received a cholesterol evaluation during the preceding 5 years. The percentage of women receiving breast and cervical cancer screening decreased with increasing age, and the percentage of persons aged > or =55 years who had received some form of screening for colorectal cancer was low approximately 25% for fecal occult blood testing (FOBT) and 45% for endoscopy. State-specific rates of compliance with vaccination recommendations among persons aged > or =65 years were higher for influenza vaccine (range: 54%-74%) than for pneumococcal vaccine (range: 32%-59%), and compliance increased with advancing age. State-specific estimates of the percentage of annual dental visits varied 40%-75%, and 41%-88% of persons aged > or =65 years reported not having dental insurance. INTERPRETATION: Access to medical services among adults living in the United States is greater for persons aged > or =65 years, compared with those aged <65 years, presumably because of Medicare coverage. In contrast, use of dental services decreased, despite increased need for preventive and restorative dental care. Although Medicare covers many medical services for older adults, financial, personal, and physical barriers to both medical and dental care create racial, regional, and sociodemographic disparities in health status and use of health services in the United States. PUBLIC HEALTH ACTION: Continued surveillance of access to and use of health services among older adults (i.e., persons aged > or =65 years), as well as among persons aged 55-64 years, will help health-care providers target underserved groups, make Medicare coverage decisions, and develop public health programs to ensure equitable access to services and improve the health of older adults.

Comprehensive health data systems spanning the public-private divide: the Massachusetts experience.

As systems of health care delivery have evolved from claims-based fee-for-service to capitated or managed care, with its emphasis on cost-effectiveness, quality, and performance measurement, some states have begun to experiment with new ways to collect, organize, and share health information. In many cases, the drivers of these changes have been purchasers of health care, including large and small private employers and public agencies such as Medicaid. One of the results of these changes is the increased interest in the sharing of health information, between health plans and employers, and, in some instances, between private plans and public agencies such as public health. Massachusetts, which has one of the highest rates of managed care penetration in the United States, has brought together the various parties involved in the collection and utilization of health information, to craft agreements on standards and protocols that will allow the sharing of health data. While much of the activity involves business transactions between private sector health plans, the Department of Medical Assistance (Medicaid) has joined with its private sector purchasing partners in demanding cost-effective, high-quality care; it is these demands that have helped stimulate the need to reorganize previously proprietary health information systems. The activities of two public-private coalitions, the Massachusetts Healthcare Purchaser Group and the Massachusetts Health Data Consortium, have been critical in initiating and supporting the complex processes that have led to significant changes in state-based systems of health information.

Implementing preventive services: to what extent can we change provider performance in ambulatory care? A review of the screening, immunization, and counseling literature.

Strategies to improve the delivery of preventive care often consist of office-based interventions, which are designed to modify provider behaviors or practice patterns. We report on a meta-analysis of 117 behavioral outcomes extracted from 43 studies. Meta-analytic techniques were used to express the results in a common metric, which allowed quantitative comparisons across outcomes. Studies were examined by domains of preventive care (screening, immunization, and counseling) and divided into two groups based on unit of analysis (provider or patient categories). The mean effect size reflects the difference in proportion of physicians providing the targeted behavior between the experimental and comparison groups. In the provider category, the weighted mean effect size for screening was .14, for immunization was .18, and for counseling was .28. In the patient category, the weighted means for screening and immunization were .12 and .15, respectively, but were smaller for the counseling (.08). Because tests for homogeneity of effect sizes were rejected in the patient category, caution in interpreting mean effect sizes is warranted because of variability across individual values. In summary, office-based interventions were found to have positive effects on providers' adherence to preventive recommendations. We discuss the methodological issues and needs for future work to enhance the delivery of preventive services.

Diabetes in urban African Americans. Body image, satisfaction with size, and weight change attempts.

We developed two gender specific sets of body-size silhouettes for evaluating body image in African Americans; 370 clinic-based adult participants with diabetes were queried on body image, perceptions, current efforts to change weight, and psychosocial variables. Comparisons were made by weight group and sex after classification as overweight or not overweight according to body mass index (BMI). Regardless of sex or weight category, perceived current body size was significantly related to BMI. Both men and women who were classified as overweight selected a desired body size that was significantly smaller than their perceived current size. Men, however, were more likely than women to select a larger desired size relative to their current size. Both men and women expected the dietician to favor a body size smaller than their own desired size and felt their designated important adult would choose the same desired size that they selected. Given the importance of cognitive perspectives in understanding weight management, it may be useful to incorporate body image measures into both observational and interventional studies.

A twin study of the association of post-traumatic stress disorder and combat exposure with long-term socioeconomic status in Vietnam veterans.

This study examines the association between post-traumatic stress disorder (PTSD) and combat exposure with the socioeconomic status of 2210 male monozygotic veteran twin pairs in 1987. In the unadjusted analysis on individuals, modest correlations indicated that those with PTSD were more likely to have been divorced, and less likely to be currently employed or to achieve high status in income, education or occupation. In the crude analysis of veterans not suffering from PTSD, there were small positive correlations between combat level experienced and the likelihood of ever being married, ever being divorced, and the number of years employed at the current job. However, when we examined identical twins discordant for PTSD, and adjusted for pre-military and military service factors, only unemployment remained significant. Likewise, in combat-discordant twins, no significant effects on the socioeconomic indicators were seen. We conclude that PTSD and combat experience in Southeast Asia have not had a major impact on the socioeconomic status of veterans.

Comparison of the performance on prosthodontic criteria of several alternative alloys used for fixed crown and partial denture restorations: Department of Veterans Affairs Cooperative Studies project 147.

In a 10-year, multicenter, double-blind clinical trial, comparisons of the clinical behavior of crown and fixed partial denture restorations were made between a gold alloy and four less costly alternative alloys. The endpoints of interest were (1) the development of unacceptable ratings on any of 11 individual prosthodontic criteria and an overall rating, (2) the removal of the restoration, and (3) an event combining unacceptable overall rating and restoration removal. Each of 630 patients had two restorations completed, one from gold-palladium alloy and the other from one of four alternative alloys. The patients were enrolled during a period of 3 1/2 years, with some patients followed up as long as 10 years after restoration. Analysis of the endpoints showed that one of the alternative alloys was significantly poorer than the other materials for certain criteria.

Reliability and validity of a combat exposure index for Vietnam era veterans.

The reliability and validity of a self-report measure of combat exposure are examined in a cohort of male-male twin pairs who served in the military during the Vietnam era. Test-retest reliability for a five-level ordinal index of combat exposure is assessed by use of 192 duplicate sets of responses. The chance-corrected proportion in agreement (as measured by the kappa coefficient) is .84. As a measure of criterion-related validity, the combat index is correlated with the award of combat-related military medals ascertained from the military records. The probability of receiving a Purple Heart, Bronze Star, Commendation Medal and Combat Infantry Badge is associated strongly with the combat exposure index. These results show that this simple index is a reliable and valid measure of combat exposure.

The effect of lyophilization on steroid receptor behavior, as defined by sucrose density gradient analysis.

The effects of lyophilization of both cytosol and tissue powder were examined by sucrose density gradient analysis (SDGA) of uterine estrogen receptor (ER) and progesterone receptor (PgR) from pig and calf. Cytosol prepared from lyophilized material (both cytosol and tissue powder) was compared to that prepared concomitantly from frozen, pulverized powders of the same tissue. It was found that both ER and PgR responses to SDG ionic strength and the ability of ER to demonstrate temperature-dependent 4S leads to 5S transformation were unimpaired by lyophilization. In addition, lyophilized cytosol and lyophilized tissue powder gave equivalent results. A few experiments examining lyophilization effects on steroid receptors from human breast biopsies did note some diminution of the 8S form of both ER and PgR following lyophilization, although this effect was variable in extent. It is nevertheless concluded that much lyophilized material exhibits many of the same responses as frozen, and may be used in lieu of the latter, at least within the confines of the parameters described here.