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- Volume 23, 2002
Annual Review of Public Health - Volume 23, 2002
Volume 23, 2002
- Preface
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- Review Articles
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Public Health Quality Measurement: Concepts and Challenges1
Vol. 23 (2002), pp. 1–21More Less▪ AbstractPublic health agencies increasingly are recognizing the need to formally and quantitatively assess and improve the quality of their programs, information, and policies. Measuring quality can help organizations monitor their progress toward public health goals and become more accountable to both the populations they serve and policy makers. Yet quality assessment is a complex task that involves precise determination and specification of useful measures. We discuss a well-established conceptual framework for organizing quality assessment in the context of planning and delivery of programs and services by local health departments, and consider the strengths and limitations of this approach for guiding quality improvement. We review several past and present quality measurement–related initiatives designed for public health department use, and discuss current and future challenges in this evolving area of public health practice.
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Cascade Effects of Medical Technology
Vol. 23 (2002), pp. 23–44More Less▪ AbstractCascade effect refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. With regard to medical technology, the term refers to a chain of events initiated by an unnecessary test, an unexpected result, or patient or physician anxiety, which results in ill-advised tests or treatments that may cause avoidable adverse effects and/or morbidity. Examples include discovery of endocrine incidentalomas on head and body scans; irrelevant abnormalities on spinal imaging; tampering with random fluctuations in clinical measures; and unwanted aggressive care at the end of life. Common triggers include failing to understand the likelihood of false-positive results; errors in data interpretation; overestimating benefits or underestimating risks; and low tolerance of ambiguity. Excess capacity and perverse financial incentives may contribute to cascade effects as well. Preventing cascade effects may require better education of physicians and patients; research on the natural history of mild diagnostic abnormalities; achieving optimal capacity in health care systems; and awareness that more is not the same as better.
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The Effectiveness of State-Level Tobacco Control Interventions: A Review of Program Implementation and Behavioral Outcomes
Vol. 23 (2002), pp. 45–71More Less▪ AbstractIn 2001, nearly one billion dollars will be spent on statewide tobacco control programs, including those in California, Massachusetts, Arizona, and Oregon, funded by cigarette tax revenues, and the program in Florida, funded by the state's settlement with the tobacco industry. With such large expenditures, it is imperative to find out whether these programs are working. This paper reviews the effectiveness of the statewide tobacco control programs in California, Massachusetts, Arizona, Oregon, and Florida. It focuses on two aspects of process evaluation—the funding and implementation of the programs and the tobacco industry's response, and four elements of outcome evaluation—the programs' effects on cigarette consumption, adult and youth smoking prevalence, and protection of the public from secondhand smoke. The paper formulates general lessons learned from these existing programs and generates recommendations to improve and inform the development and implementation of these and future programs.
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Direct Marketing of Pharmaceuticals to Consumers
Vol. 23 (2002), pp. 73–91More Less▪ AbstractRevised FDA regulations governing pharmaceutical companies' broadcast advertisements directed to consumers produced substantial increases in direct-to-consumer advertising (DTCA) expenditures. Proponents of DTCA claim it supports patient autonomy in the patient-physician relationship and has motivated some consumers to seek a physician's care for conditions they previously had not discussed with a doctor. However, DTCA's blend of promotion and information has produced more prescription drug awareness than knowledge—it has been largely ineffective in educating patients with medical conditions about the medications for those conditions. The evidence for DTCA's increase in pharmaceutical sales is as impressive as is the lack of evidence concerning its impact on the health of the public. Broadcast advertisements are too brief to include extensive technical information; consequently, the impact of FDA regulations to assure a fair balance of risk and benefit in DTCA is still being assessed.
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Challenges in Motor Vehicle Safety
Vol. 23 (2002), pp. 93–113More Less▪ AbstractReductions in motor vehicle injury and death represent a major public health success. Since the advent of the federal program in highway safety in 1966, motor vehicle deaths have dropped dramatically, not only in rates per miles driven but also in absolute numbers. Key to this success has been the broad-based comprehensive approach promoted by the program's first administrator, a public health physician. The federal program provided leadership and coordination that leveraged national, state, and local programs to bring about safer vehicles, improved traffic records, more effective enforcement, enormously improved emergency medical services, more responsible judicial systems, and many other accomplishments. Although progress has been made on many fronts, major areas addressed here include federal motor vehicle safety standards, alcohol safety programs, occupant restraint laws and usage, and speed limits. The achievements in motor vehicle safety provide a model for other injury control efforts.
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HALYs and QALYs and DALYs, Oh My: Similarities and Differences in Summary Measures of Population Health
Vol. 23 (2002), pp. 115–134More Less▪ AbstractHealth-adjusted life years (HALYs) are population health measures permitting morbidity and mortality to be simultaneously described within a single number. They are useful for overall estimates of burden of disease, comparisons of the relative impact of specific illnesses and conditions on communities, and in economic analyses. Quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs) are types of HALYs whose original purposes were at variance. Their growing importance and the varied uptake of the methodology by different U.S. and international entities makes it useful to understand their differences as well as their similarities. A brief history of both measures is presented and methods for calculating them are reviewed. Methodological and ethical issues that have been raised in association with HALYs more generally are presented. Finally, we raise concerns about the practice of using different types of HALYs within different decision-making contexts and urge action that builds and clarifies this useful measurement field.
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Morbidity and Mortality from Medical Errors: An Increasingly Serious Public Health Problem
Vol. 23 (2002), pp. 135–150More Less▪ AbstractFrom 1983 to 1998, U.S. fatalities from acknowledged prescription errors increased by 243%, from 2,876 to 9,856. This percentage increase was greater than for almost any other cause of death, and far outpaced the increase in the number of prescriptions. Many nonfatal prescription errors also occur, but estimates of the frequency of these errors vary widely, because various definitions, geographic settings, and institutions have been used. Efforts to reduce fatal and nonfatal prescription errors have encountered perceptual, legal, medical, and cultural barriers. It may be possible to reduce prescription errors by instituting a central agency responsible for collecting, analyzing, and reporting harmful or potentially harmful drug events, and for issuing recommendations and directives.
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The Importance of the Normality Assumption in Large Public Health Data Sets
Vol. 23 (2002), pp. 151–169More Less▪ AbstractIt is widely but incorrectly believed that the t-test and linear regression are valid only for Normally distributed outcomes. The t-test and linear regression compare the mean of an outcome variable for different subjects. While these are valid even in very small samples if the outcome variable is Normally distributed, their major usefulness comes from the fact that in large samples they are valid for any distribution. We demonstrate this validity by simulation in extremely non-Normal data. We discuss situations in which in other methods such as the Wilcoxon rank sum test and ordinal logistic regression (proportional odds model) have been recommended, and conclude that the t-test and linear regression often provide a convenient and practical alternative. The major limitation on the t-test and linear regression for inference about associations is not a distributional one, but whether detecting and estimating a difference in the mean of the outcome answers the scientific question at hand.
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Gambling and Related Mental Disorders: A Public Health Analysis
Vol. 23 (2002), pp. 171–212More Less▪ AbstractThis article reviews the prevalence of gambling and related mental disorders from a public health perspective. It traces the expansion of gambling in North America and the psychological, economic, and social consequences for the public's health, and then considers both the costs and benefits of gambling and the history of gambling prevalence research. A public health approach is applied to understanding the epidemiology of gambling-related problems. International prevalence rates are provided and the prevalence of mental disorders that often are comorbid with gambling problems is reviewed. Analysis includes an examination of groups vulnerable to gambling-related disorders and the methodological and conceptual matters that might influence epidemiological research and prevalence rates related to gambling. The major public health problems associated with gambling are considered and recommendations made for public health policy, practice, and research.
The enduring value of a public health perspective is that it applies different ‘lenses’ for understanding gambling behaviour, analysing its benefits and costs, as well as identifying strategies for action.
Harvey A. Skinner (160, p. 286)
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The Public Health Impact of Alzheimer's Disease, 2000–2050: Potential Implication of Treatment Advances
Vol. 23 (2002), pp. 213–231More Less▪ AbstractRecent developments in basic research suggest that therapeutic breakthroughs may occur in Alzheimer's disease treatment over the coming decades. To model the potential magnitude and nature of the effect of these advances, historical data from congestive heart failure and Parkinson's disease were used. Projections indicate that therapies which delay disease onset will markedly reduce overall disease prevalence, whereas therapies to treat existing disease will alter the proportion of cases that are mild as opposed to moderate/severe. The public health impact of such changes would likely involve both the amount and type of health services needed. Particularly likely to arise are new forms of outpatient services, such as disease-specific clinics and centers. None of our models predicts less than a threefold rise in the total number of persons with Alzheimer's disease between 2000 and 2050. Therefore, Alzheimer's care is likely to remain a major public health problem during the coming decades.
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Utilization Management: Issues, Effects, and Future Prospects
Vol. 23 (2002), pp. 233–254More Less▪ AbstractUtilization management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption. Utilization management, which has become one of the most widely used cost-containment approaches, has engendered debate and controversy. Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden. Insurance carriers, managed care plans, and third-party payers have defended the use of utilization management as an imperfect—but necessary—practice that is needed to reduce consumption of unnecessary or inappropriate health care services. This review examines the operation and effects of three widely used utilization management procedures: prospective utilization review, case management, and physician gatekeeping programs. In addition, it explores the future role of utilization management in the health care system and outlines a set of principles that we believe should be used to guide the development of utilization management strategies in the future.
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Dietary Interventions to Prevent Disease
Vol. 23 (2002), pp. 255–286More Less▪ AbstractChanging dietary behaviors to prevent chronic disease has been an important research focus for the last 25 years. Here we present a review of published articles on the results of research to identify methods to change key dietary habits: fat intake, fiber intake, and consumption of fruits and vegetables. We divided the research reviewed into sections, based on the channel through which the intervention activities were delivered. We conclude that the field is making progress in identifying successful dietary change strategies, but that more can be learned. Particularly, we need to transfer some of the knowledge from the individual-based trials to community-level interventions. Also, more research with rigorous methodology must be done to test current and future intervention options.
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The Macroeconomic Determinants of Health
Vol. 23 (2002), pp. 287–302More Less▪ AbstractWhy are some societies healthier than others? The consensus in development economics is that the health achievement of nations has to do with their levels of economic development. Higher per capita incomes, through steady and stable economic growth, increase a nation's capacity to purchase the necessary economic goods and services that promote health. In this paper, we review the conceptual and empirical linkages between poverty and poor health in both developing and developed countries. The empirical evidence is overwhelming that poverty, measured at the level of societies as well as individuals, is causally related to poor health of societies and individuals, respectively. Recent macroeconomic research has also drawn attention to the role of health as a form of human capital that is vital for achieving economic stability. In particular, attention has been drawn toward the ways in which unhealthy societies impede the process of economic development. However, the reciprocal connection between economic prosperity and improved health is neither automatic nor universal. Other features of society, such as the equality in the distribution of the national wealth, seem to matter as well for improving average population health and especially for reducing inequalities in health. We conclude by arguing for a need to reexamine the way in which health is conceptualized within the macroeconomic development framework.
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Socioeconomic Status and Health: The Potential Role of Environmental Risk Exposure
Vol. 23 (2002), pp. 303–331More Less▪ AbstractAmong several viable explanations for the ubiquitous SES-health gradient is differential exposure to environmental risk. We document evidence of inverse relations between income and other indices of SES with environmental risk factors including hazardous wastes and other toxins, ambient and indoor air pollutants, water quality, ambient noise, residential crowding, housing quality, educational facilities, work environments, and neighborhood conditions. We then briefly overview evidence that such exposures are inimical to health and well-being. We conclude with a discussion of the research and policy implications of environmental justice, arguing that a particularly salient feature of poverty for health consequences is exposure to multiple environmental risk factors.
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Effects of Smoking Restrictions in the Workplace*
Vol. 23 (2002), pp. 333–348More Less▪ AbstractThe health hazards caused by exposure to environmental tobacco smoke (ETS) are well established. Workplace exposure to ETS is strongly influenced by the types of workplace and smoking policy—total bans on smoking have become common in many countries. Blue-collar and service workers are more likely than other types of workers to be exposed to ETS in the workplace. Smokers who are employed in workplaces with smoking bans are likely to consume fewer cigarettes per day, are more likely to be considering quitting, and quit at an increased rate compared with smokers employed in workplaces with no or weaker policies. Despite substantial progress in protecting workers from ETS, additional efforts are needed in areas that include attention to exposure among blue-collar and service workers; policies in workplaces with a limited number of employees; and studies of enforcement, effects on smoking cessation in multiple settings, and cost-effectiveness.
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Socioeconomic Inequalities in Injury: Critical Issues in Design and Analysis
Vol. 23 (2002), pp. 349–375More Less▪ AbstractInjuries continue to place a tremendous burden on the public's health and rates vary widely among different groups in the population. Increasing attention has recently been given to the effects of socioeconomic status (SES) as a determinant of health among both individuals and communities. However, relatively few studies have focused on the influence of SES and injuries. Furthermore, those that have, and the other injury studies that have included measures of SES in their analysis, have varying degrees of conceptual and methodological rigor in their use of this measure. Recent advances in data linkage and analytic techniques have, however, provided new and improved methods to assess the relationship between SES and injuries. This review summarizes the relevant literature on SES and injuries, with particular attention to study design, and the measurement and interpretation of SES. We found that increasing SES has a strong inverse association with the risk of both homicide and fatal unintentional injuries, although the results for suicide were mixed. However, the relationship between SES and nonfatal injuries was less consistent than for fatal injuries. We offer potential explanatory mechanisms for the relationship between SES and injuries and make recommendations for future research in this area.
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Thinking Outside the Box: Recent Advances in the Analysis and Presentation of Uncertainty in Cost-Effectiveness Studies
Vol. 23 (2002), pp. 377–401More Less▪ AbstractAs many more clinical trials collect economic information within their study design, so health economics analysts are increasingly working with patient-level data on both costs and effects. In this paper, we review recent advances in the use of statistical methods for economic analysis of information collected alongside clinical trials. In particular, we focus on the handling and presentation of uncertainty, including the importance of estimation rather than hypothesis testing, the use of the net-benefit statistic, and the presentation of cost-effectiveness acceptability curves. We also discuss the appropriate sample size calculations for cost-effectiveness analysis at the design stage of a study. Finally, we outline some of the challenges for future research in this area—particularly in relation to the appropriate use of Bayesian methods and methods for analyzing costs that are typically skewed and often incomplete.
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Tuberculosis
Vol. 23 (2002), pp. 403–426More Less▪ AbstractTuberculosis is an infectious disease caused by bacteria in the Mycobacterium tuberculosis complex. Of these, the most common species to infect humans is M. tuberculosis. The TB bacillus is an extremely successful human pathogen, infecting two billion persons worldwide; an estimated 2 to 3 million people die from tuberculosis each year. In the United States, TB rates decreased steadily at the rate of 5% per year from 1953 until 1985 when the trend reversed, with the number of TB cases peaking in 1992. Outbreaks of multidrug-resistant TB (MDR TB) were reported, and these cases were documented to be transmitted in nosocomial and congregate settings, including hospitals and prisons. AIDS patients infected with M. tb developed disease rapidly, and case-fatality rates of >80% were noted in those infected with multidrug-resistant M. tb. Intensive intervention, at enormous cost, caused the number of TB cases to decline. This article discusses factors that led to the increase in TB cases, their subsequent decline, and measures needed in the future if TB is to be eliminated in the United States.
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The Future of Benefit-Cost Analyses of the Clean Air Act
Vol. 23 (2002), pp. 427–448More Less▪ AbstractThis review examines the first two studies conducted pursuant to a Congressional mandate that the U.S. Environmental Protection Agency analyze the effects of the Clean Air Act on the “public health, economy, and the environment of the United States.” While these studies indicate that overall, the nation received good value for the resources it invested in improving air quality over the past three decades, we don't know if even higher value could have been obtained by changing or eliminating certain potentially inefficient elements. The review focuses on the critical policy and technical choices made in the analyses, including the selection of the appropriate baseline and the level of disaggregation for the studies. It is proposed that a potential third analysis focus on potential new policies not yet mandated by law or regulation. It is also proposed that the next study fill in key information gaps, expand the benefit categories, and incorporate new research on topics such as mortality and morbidity benefits, cost uncertainties, and others.
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Previous Volumes
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Volume 45 (2024)
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Volume 44 (2023)
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Volume 43 (2022)
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Volume 42 (2021)
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Volume 41 (2020)
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Volume 40 (2019)
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Volume 39 (2018)
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Volume 38 (2017)
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Volume 37 (2016)
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Volume 36 (2015)
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Volume 35 (2014)
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Volume 34 (2013)
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Volume 33 (2012)
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Volume 32 (2011)
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Volume 31 (2010)
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Volume 30 (2009)
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Volume 29 (2008)
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Volume 28 (2007)
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Volume 27 (2006)
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Volume 26 (2005)
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Volume 25 (2004)
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Volume 24 (2003)
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Volume 23 (2002)
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Volume 22 (2001)
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Volume 21 (2000)
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Volume 20 (1999)
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Volume 19 (1998)
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Volume 18 (1997)
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Volume 17 (1996)
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Volume 16 (1995)
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Volume 15 (1994)
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Volume 14 (1993)
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Volume 13 (1992)
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Volume 12 (1991)
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Volume 11 (1990)
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Volume 10 (1989)
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Volume 9 (1988)
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Volume 8 (1987)
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Volume 7 (1986)
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Volume 6 (1985)
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Volume 5 (1984)
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Volume 4 (1983)
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Volume 3 (1982)
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Volume 2 (1981)
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Volume 1 (1980)
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Volume 0 (1932)