The Unhealthy State Of Health Policy Research

Impact of population distribution shifts in sugar-sweetened beverage consumption on type II diabetes incidence in Ireland

PURPOSE

We simulate population shifts in the distribution of sugar-sweetened beverage (SSB) consumption and address previous methodological limitations to provide valid and reliable estimates of the potential impact of public health interventions on type II diabetes incidence in Ireland.

METHODS

A comparative risk assessment was conducted, using distribution shift calculations to estimate potential impact fractions (PIFs) for percentage reductions in SSB consumption. Data from the Survey of Lifestyle, Attitudes and Nutrition was analyzed. Individual risk of developing type II diabetes was estimated using a risk prediction algorithm. PIFs were calculated using risk estimates, changes in SSB consumption, and an appropriately specified relative risk. The impact of a 20% levy on SSBs was explored. Monte-Carlo simulation with 150,000 iterations estimated uncertainty intervals (UIs). PIFs were applied to 2016 census data, estimating the absolute incident cases that may potentially be avoided through reduced SSB consumption.

RESULTS

Of the 7272 Survey of Lifestyle, Attitudes and Nutrition participants, 53.3% consumed SSBs. The 10-year rate of type II diabetes was estimated at 4.3% (95% confidence interval: 4.2%, 4.4%). Simulating a 100% reduction in SSB consumption, the population attributable fraction was 1.8% (95%UI: 0.1%, 3.3%). Population shifts in consumption after a 20% levy results in a PIF of 0.37% (95%UI: 0.02%, 0.7%). We estimate 135,850 incident type II diabetes cases over a 10-year period. Of these, 2446 (95% UI: 136, 4483) cases may be attributable to SSB consumption.

CONCLUSIONS

Overcoming previous methodological limitations, unbiased estimates demonstrate that a population shift in SSB consumption can potentially play a role in the primary prevention of type II diabetes.

Sensory Integration and Functional Reaching in Children With Rett Syndrome/Rett-Related Disorders

Background

The loss of functional hand skills is a primary characteristic of Rett syndrome. Stereotypies, dyspraxia, and other sensory processing issues severely limit the individual's ability to reach toward and sustain grasp on objects. This loss of functional reach and grasp severely limits their ability to participate in self-help, play, and school-related activities. We proposed that Ayres Sensory Integration (ASI) treatment would improve sensory processing and motor planning, which would lay the sensory-motor groundwork for improving grasp of objects, an important first step in developing functional hand use.

Objective

We examined effects of ASI treatment on rate of reaching and grasping for children with Rett syndrome/Rett-related disorders.

Methods

We used an interrupted time series design to measure changes in outcome variables occurring after intervention initiation and cessation. We analyzed daily video observations during baseline, intervention, and post-intervention periods, over a span of 7 months.

Results

During baseline, rate of grasping declined moderately. There was a 15% increase in grasping from the end of baseline to end of the post-intervention period. There was no significant change in rate of reaching.

Conclusions

This study provides preliminary data showing very small improvements in hand grasp of children with Rett syndrome following ASI treatment; larger studies in diverse settings are needed to establish the effectiveness of this approach. This study shows that an interrupted time series research design provides a valid template for evaluating interventions for children with rare disorders.

Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications

PURPOSE OF REVIEW

Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery.

RECENT FINDINGS

NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.

The development of scientific evidence for health policies for obesity: why and how?

Potential obesity-related policy approaches have recently been receiving more attention. Although some have been implemented and others only proposed, few have been formally evaluated. We discuss the relevance, and in some cases irrelevance, of some of the types of evidence that are often brought to bear in considering obesity-related policy decisions. We discuss major methods used to generate such evidence, emphasizing study design and the varying quality of the evidence obtained. Third, we consider what the standards of evidence should be in various contexts, who ought to set those standards, as well as the inherent subjectivity involved in making policy decisions. Finally, we suggest greater transparency from both academics and policymakers in the acknowledgment of subjectivities so they can distinguish and communicate the roles of empirical evidence and subjective values in the formulation of policy.

Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs

Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006-11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations.

The State of Diabetes Prevention Policy in the USA Following the Affordable Care Act

Type 2 diabetes is a major public health problem in the USA, affecting over 12 % of American adults and imposing considerable health and economic burden on individuals and society. There is a strong evidence base demonstrating that lifestyle behavioral changes and some medications can prevent or delay the onset of type 2 diabetes in high risk adults, and several policy and healthcare system changes motivated by the Patient Protection and Affordable Care Act (ACA) have the potential to accelerate diabetes prevention. In this narrative review, we (1) offer a conceptual framework for organizing how the ACA may influence diabetes prevention efforts at the level of individuals, healthcare providers, and health systems; (2) highlight ACA provisions at each of these levels that could accelerate type 2 diabetes prevention nationwide; and (3) explore possible policy gaps and opportunity areas for future research and action.

Regression to the Mean: A Commonly Overlooked and Misunderstood Factor Leading to Unjustified Conclusions in Pediatric Obesity Research

OBJECTIVE

In this paper we discuss what regression to the mean (RTM) is, the magnitude of RTM in realistic situations, interpretation of RTM, and recommendations for how to address RTM in study design.

METHODS

Public health research faces many challenges in conducting gold standard randomized, controlled trials (RCT). Although there are many threats to validity in uncontrolled trials, RTM is often overlooked or not adequately considered. RTM is a statistical phenomenon that occurs with any pair of variables that have a correlation not equal to |1.0|. With RTM, subjects' average values on an outcome variable (e.g., BMI) change in a systematic direction over time despite there being no treatment effect. Without a proper control group, changes thought to be associated with an intervention may be due entirely to RTM. Investigators may draw erroneous conclusions based on results showing greater declines in a variable among participants with higher baseline of that variable compared to those with lower baseline of that variable, and label this evidence for differential treatment efficacy.

CONCLUSIONS

Ignoring RTM can lead to unsubstantiated conclusions about the effects of treatments. These conclusions can lead to the waste of time, money, and other resources, which distract from finding appropriate interventions. When a true RCT design is not feasible, reasonable design alternatives involving nonrandomized control groups should be implemented.

Did Medicare Part D Affect National Trends in Health Outcomes or Hospitalizations? A Time-Series Analysis

BACKGROUND

Medicare Part D increased economic access to medications, but its effect on population-level health outcomes and use of other medical services remains unclear.

OBJECTIVE

To examine changes in health outcomes and medical services in the Medicare population after implementation of Part D.

DESIGN

Population-level longitudinal time-series analysis with generalized linear models.

SETTING

Community.

PATIENTS

Nationally representative sample of Medicare beneficiaries (n = 56,293 [unweighted and unique]) from 2000 to 2010.

MEASUREMENTS

Changes in self-reported health status, limitations in activities of daily living (ADLs) (ADLs and instrumental ADLs), emergency department visits and hospital admissions (prevalence, counts, and spending), and mortality. Medicare claims data were used for confirmatory analyses.

RESULTS

Five years after Part D implementation, no clinically or statistically significant reductions in the prevalence of fair or poor health status or limitations in ADLs or instrumental ADLs, relative to historical trends, were detected. Compared with trends before Part D, no changes in emergency department visits, hospital admissions or days, inpatient costs, or mortality after Part D were seen. Confirmatory analyses were consistent.

LIMITATIONS

Only total population-level outcomes were studied. Self-reported measures may lack sensitivity.

CONCLUSION

Five years after implementation, and contrary to previous reports, no evidence was found of Part D's effect on a range of population-level health indicators among Medicare enrollees. Further, there was no clear evidence of gains in medical care efficiencies.

Evaluating diabetes health policies using natural experiments: the natural experiments for translation in diabetes study

The high prevalence and costs of type 2 diabetes makes it a rapidly evolving focus of policy action. Health systems, employers, community organizations, and public agencies have increasingly looked to translate the benefits of promising research interventions into innovative policies intended to prevent or control diabetes. Though guided by research, these health policies provide no guarantee of effectiveness and may have opportunity costs or unintended consequences. Natural experiments use pragmatic and available data sources to compare specific policies to other policy alternatives or predictions of what would likely have happened in the absence of any intervention. The Natural Experiments for Translation in Diabetes (NEXT-D) Study is a network of academic, community, industry, and policy partners, collaborating to advance the methods and practice of natural experimental research, with a shared aim of identifying and prioritizing the best policies to prevent and control diabetes. This manuscript describes the NEXT-D Study group's multi-sector natural experiments in areas of diabetes prevention or control as case examples to illustrate the selection, design, analysis, and challenges inherent to natural experimental study approaches to inform development or evaluation of health policies.

Ignoring regression to the mean leads to unsupported conclusion about obesity

Childhood obesity remains a substantial health concern for our population and thoughtful attempts to develop and evaluate the utility of programs to reduce childhood obesity levels are needed. Unfortunately, we believe the conclusion by Burke et al. that the HealthMPowers program produces positive change in body composition is incorrect because the results obtained are likely due to regression to the mean (RTM), a well-known threat to the validity of studies that is often overlooked. Using empirical data, we demonstrate that RTM is likely to be the cause for the changes reported. A more reasonable conclusion than the one of effectiveness the authors offered would be that the results did not support the effectiveness of the intervention. Public health officials, parents, school leaders, community leaders, and regulators need and deserve valid evidence free from spin on which they can base decisions.

Packet randomized experiments for eliminating classes of confounders

BACKGROUND

Although randomization is considered essential for causal inference, it is often not possible to randomize in nutrition and obesity research. To address this, we develop a framework for an experimental design-packet randomized experiments (PREs), which improves causal inferences when randomization on a single treatment variable is not possible. This situation arises when subjects are randomly assigned to a condition (such as a new roommate) which varies in one characteristic of interest (such as weight), but also varies across many others. There has been no general discussion of this experimental design, including its strengths, limitations, and statistical properties. As such, researchers are left to develop and apply PREs on an ad hoc basis, limiting its potential to improve causal inferences among nutrition and obesity researchers.

METHODS

We introduce PREs as an intermediary design between randomized controlled trials and observational studies. We review previous research that used the PRE design and describe its application in obesity-related research, including random roommate assignments, heterochronic parabiosis, and the quasi-random assignment of subjects to geographic areas. We then provide a statistical framework to control for potential packet-level confounders not accounted for by randomization.

RESULTS

Packet randomized experiments have successfully been used to improve causal estimates of the effect of roommates, altitude, and breastfeeding on weight outcomes. When certain assumptions are met, PREs can asymptotically control for packet-level characteristics. This has the potential to statistically estimate the effect of a single treatment even when randomization to a single treatment did not occur.

CONCLUSIONS

Applying PREs to obesity-related research will improve decisions about clinical, public health, and policy actions insofar as it offers researchers new insight into cause and effect relationships among variables.

Policymaking Under Uncertainty: Routine Screening for Intimate Partner Violence

Intimate partner violence (IPV) is a significant public health issue affecting around three million U.S. women during their lifetimes; this article provides guidance to policymakers on addressing IPV. In 2011, an Institute of Medicine panel recommended routine IPV screening for women and adolescents as part of comprehensive preventive care services, which is in conflict with the 2004 U.S. Preventive Services Task Force recommendations. The current evidence base for policymaking suffers weaknesses related to study design, which should be addressed in future research. Meanwhile, policymakers should consider available evidence in their settings, assess local needs, and make recommendations where appropriate.

Health services and policy research in hepatology

PURPOSE OF REVIEW

This article examines recent health services and policy research studies in hepatology and liver transplantation.

RECENT FINDINGS

Critical issues include access to medical care, timeliness of referral and consultation, resource utilization in clinical practice, comparative effectiveness research, and the evaluation of care delivery models. Despite policymaking efforts, there continues to be unwarranted variation in access to subspecialty care and liver transplantation services based on race and geographic location. Variations in primary care and specialist awareness of practice guidelines for liver disease contribute to disparities in appropriateness and timeliness of treatments. Defining the cost-effectiveness of increased resource utilization for novel antiviral therapies and liver transplantation continues to stimulate controversy. Few comparative effectiveness studies in hepatology exist to date, yet a growing number of analyses using national datasets will help inform policy in this arena. Identifying care delivery models that demonstrate high value for populations with chronic liver disease is critical in the context of recent healthcare reform efforts.

SUMMARY

Health services and policy research is a growing field of investigation in hepatology and liver transplantation. Further emphasis on research training and workforce development in this area will be critical for understanding and improving patient-centered outcomes for this population.

Evaluation of a diabetes management program using selected HEDIS measures

OBJECTIVE

To evaluate the efficacy of a community-based, pharmacist-directed diabetes management program among managed care organization enrollees using National Committee for Quality Assurance (NCQA)-Healthcare Effectiveness Data and Information Set (HEDIS) performance measures.

DESIGN

Randomized controlled trial.

SETTING

Regional community pharmacy chain in Tulsa, OK, from November 2005 to July 2007.

PATIENTS

52 participants with diabetes and hypertension who were enrolled in a managed care organization.

INTERVENTION

Diabetes management versus standard care.

MAIN OUTCOME MEASURES

Comprehensive diabetes care measures of glycosylated hemoglobin (A1C <7.0%), blood pressure (<130/80 mm Hg), and low-density lipoprotein (LDL) cholesterol (<100 mg/dL). A composite research outcome of success was created by determining whether a participant achieved two of the three HEDIS goals at the end of 9 months.

RESULTS

46.7% of intervention group participants achieved the A1C goal, while 9.1% of control group participants achieved the goal ( P < 0.002). More than one-half (53.3%) of intervention participants achieved the blood pressure goal compared with 22.7% of control participants ( P < 0.02). Among control group participants, 50% achieved the LDL cholesterol goal compared with 46.67% of intervention group participants. The odds of the intervention group attaining the composite goal were 5.87 times greater than the control group.

CONCLUSION

A community pharmacy-based diabetes management program was effective in achieving A1C and blood pressure goals measured by NCQA-HEDIS performance standards. Program participants were statistically significantly more likely to achieve two of three HEDIS standards during a 9-month period.

New Jersey's efforts to improve postpartum depression care did not change treatment patterns for women on medicaid

Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey's policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.

The value prescription: relative value theorem as a call to action

The Joint Commission of Pharmacy Practitioners Future Vision of Pharmacy Practice 2015 (2005) and Project Destiny (2008) clearly defined a vision for transforming community practice pharmacy from a culture of dispensing drugs to the provision of services. Several viable service offerings were identified. Pharmacy has not yet fully capitalized on these opportunities. Pharmacy must demonstrate value in providing these services to remain viable in the marketplace. Many pharmacists do not understand how value is created and lack sufficient marketing skills to position their practice for long-term success. The relative value theorem (RVT) describes in simple terms the key elements that drive purchase decisions and thus marketing decisions: (P+S)×PV=RV (P, price; S, service; PV, perceived value; RV, relative value). A consumer compares the P, extra S, and PV of the purchase against all potential uses of their scarce resources before deciding what to buy. Evidence suggests that understanding and applying the principles of RVT is a critical skill for pharmacy professionals in all practice settings to master if they plan to remain viable players in the health care marketplace of the future.

A T-2 translational research perspective on interventions to improve post-fracture osteoporosis care

The objectives of this paper are to: quickly outline the extent of the care gap in osteoporosis; define T-2 (knowledge) translation and its relationship to quality improvement; discuss the barriers to best practice in osteoporosis care after a fracture; convey the importance of rigor in design and evaluation of translational interventions by drawing upon examples from the broader literature; describe in some detail a series of post-fracture intervention trials conducted in Alberta, Canada; and make some conclusions specifically about osteoporosis interventions and more generally about T-2 translational research.

Risks, benefits, and issues in creating a behind-the-counter category of medications

OBJECTIVE

To examine the issues surrounding the development and implementation of a behind-the-counter (BTC) category of medications.

DATA SOURCES

Testimony from organizations submitting comments to the Food and Drug Administration (FDA) panel hearings in November 2007, the 2009 final report of the U. S. General Accounting Office regarding a BTC drug category, literature review of research that has been conducted, experiences from other countries, and publically available information from agencies in charge of regulating medications similar to BTC.

SUMMARY

Based on evidence attained from the current work, the following six recommendations regarding a BTC category of medications are provided. (1) Demonstration needs to occur that the risks and/or costs of BTC are outweighed by benefits, positive measurable outcomes, and financial savings to society. (2) Sufficient resources, including personnel, equipment, and facilities, need to be available for the appropriate provision of BTC services and to ensure ongoing monitoring and controls. (3) An appropriate compensation structure needs to be developed. (4) Encounters and outcomes should be documented in an electronic record, the information should be shared with other health care providers involved in patients' care, and interprofessional collaboration and communication should occur. (5) Criteria for designating candidates for transition, ongoing review for safety, and reverse transition must be developed. (6) Applicable lessons learned from other countries should be incorporated into BTC strategies. In addition to implementation recommendations, we also summarize additional evidence that needs to be gathered to optimize the BTC model.

CONCLUSION

Based on the accumulated evidence, comments to FDA's request, and information from other countries, implementation of a BTC model probably is feasible in the United States. However, the optimal model remains uncertain and various aspects of a program need to be prioritized and rigorously tested.

The diverse ethics of translational research

Commentators on the ethics of translational research find it morally problematic. Types of translational research are said to involve questionable benefits, special risks, additional barriers to informed consent, and severe conflicts of interest. Translational research conducted on the global poor is thought to exploit them and increase international disparities. Some commentators support especially stringent ethical review. However, such concerns are grounded only in pre-approval translational research (now called T1). Whether or not T1 has these features, translational research beyond approval (T2: phase IV, health services, and implementation research) is unlikely to and, when conducted on the global poor, may support development. Therefore, insofar as T1 is morally problematic, and no independent objections to T2 exist, the ethics of translational research is diverse: while some translational research is problematic, some is not. Funding and oversight should reflect this diversity, and T2 should be encouraged, particularly when conducted among the global poor.