Selected Scientific Observations 2001

	On This Page • Reducing Risk Factors for Chronic Disease • Chronic Disease Prevention and Control • Maternal and Child Health • Comprehensive Approaches

Reducing Risk Factors for Chronic Disease

An Economic Evaluation of Community Water Fluoridation

In 1999, community water fluoridation was cited by the Centers for Disease Control and Prevention as one of 10 great public health achievements of the 20th century. Due to the modern-day, widespread availability of fluoride in many forms such as toothpaste, mouthrinses, and tablets, some have questioned the current effectiveness of community water fluoridation. The results of this modern-day economic analysis of water fluoridation demonstrate that community water fluoridation is a cost-saving prevention method even under the most conservative of estimates.

The study found that under typical conditions, the annual reduction in treatment costs in fluoridated communities was $16–$19 per person, far above the average cost to fluoridate of 50 cents per person in communities with more than 20,000 residents. For such communities, for every $1 invested in community water fluoridation, $38 is saved in averted restorative treatment costs. In fact, fluoridation saves $16 per person even in communities with fewer than 5,000 residents, where per person fluoridation costs are highest. The analysis accounts for capital and operating costs for community water fluoridation, expected effectiveness of fluoridation, estimates of expected cavities in nonfluoridated communities and treatment of cavities, and time lost visiting the dentist for treatment. 

Griffin SO, Jones K, Tomar SL.
Journal of Public Health Dentistry 2001;61(2):78–86. 

Women and Smoking: A Report of the Surgeon General

Women and Smoking: A Report of the Surgeon General makes its overarching theme clear—smoking is a woman’s issue. This report summarizes what is now known about smoking among women, including patterns and trends in smoking habits, factors associated with starting to smoke and continuing to smoke, the consequences of smoking on women’s health, and interventions for cessation and prevention. What the report also makes apparent is how the tobacco industry has historically and contemporarily created marketing specifically targeted at women. Smoking is the leading known cause of preventable death and disease among women, attributing to more cancer deaths than breast cancer among women. 

Centers for Disease Control and Prevention.
Atlanta: U.S. Department of Health and Human Services, CDC, 2001. 

Quantifying the Diffused Benefit from Water Fluoridation in the United States

This analysis found that children living in nonfluoridated communities in states that are highly fluoridated (>55% of the population with community fluoridation) receive partial benefits of fluoridation from eating foods and drinking beverages processed in fluoridated communities. It explains how widespread community water fluoridation prevents cavities even in neighboring communities that are not fluoridated. For example, 12-year-old children living in nonfluoridated communities in highly fluoridated states typically experience 26% fewer decayed tooth surfaces than their counterparts living in states where relatively few residents (<25%) receive fluoridated water. Thus, a 12-year-old child typically would have one fewer cavity. Taking into account future maintenance of that filling, this could translate into $175 in lifetime dental treatment cost savings for that tooth. Additional benefits from fluoride accrue as the child ages and further decay is prevented. 

Griffin SO, Gooch BF, Lockwood SA, Tomar SL.
Community Dentistry and Oral Epidemiology
2001;29(2):120–9.

The Continuing Epidemics of Obesity and Diabetes in the United States

Americans witnessed dramatic increases in diabetes and obesity during the decade of the 1990s. At the same time, they showed little improvement in eating habits or in increasing their physical activity, the Centers for Disease Control and Prevention (CDC) has reported.

CDC scientists found a 61% increase in the number of Americans who were obese from 1991 to 2000 (12.0% to 19.8%). They also found a 49% increase in the number of Americans who had diabetes from 1990 to 2000 (4.9% to 7.3%). About 27.3% of Americans did not engage in any physical activity during the 1990s and only about a quarter of Americans consumed the recommended five or more servings of fruits and vegetables a day.

According to the study, the increases in both diabetes and obesity were observed in all demographic and geographic segments of the population. 

• Mississippi had the highest rates of both obesity (24.3%) and diagnosed diabetes (8.8%).
• Colorado had the lowest rate of obesity (13.8%).
• Alaska had the lowest rate of diabetes (4.4%).
• Blacks had the highest rates of both obesity (29.3%) and diabetes (11.1%) among all races and ethnic groups.
• People with less than a high school education had higher rates of both obesity (25.1%) and diabetes (13.1%) than those with high school education.

Data in the report were taken from the Behavioral Risk Factor Surveillance System, a state-based survey that collects information from adults aged 18 years or older. For this survey, participants were asked if they had ever been told by a doctor that they had diabetes or had been given advice by a health professional about weight. They were also asked to report on their diet, leisure-time physical activities, and weight-loss activities. Only 17.5% were following the recommended guidelines of at least 30 minutes of moderate physical activity most days of the week and a lower caloric intake. 

Mokdad AH, Bowman BA, Ford ES, Vinicor F,
Marks JS, Koplan JP.
JAMA 2001;286(10)1195–1200.

Recommendations for Using Fluoride to Prevent and Control Dental Caries

Fluoridation of community drinking water, which began in the late 1940s, and use of other fluoride products are credited for the dramatic reductions in tooth decay experienced by U.S. residents. In 1999, CDC included water fluoridation in its list of 10 great public health achievements of the 20th century. Studies show that fluoride prevents the formation, slows the progression, or even reverses newly forming cavities. Currently many different means of receiving fluoride are available. These recommendations provide guidance to dental and other health care providers, public health officials, policy makers, and the public in the use of all forms of fluoride to achieve maximum protection against dental caries (decay) while using resources efficiently and reducing the risk for enamel fluorosis. A work group of fluoride experts evaluated the scientific evidence for the various fluoride products used in the United States. 

Centers for Disease Control and Prevention.
MMWR 2001;50(RR-14).

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Chronic Disease Prevention and Control

Cost-Effectiveness of a School-Based Tobacco-Use Prevention Program

The effectiveness of selected school-based tobacco-use prevention programs has been established; however, no studies have examined their cost-effectiveness. The objective of this study is to use economic evaluation techniques to determine the cost-effectiveness of “Project Towards No Tobacco Use” (TNT), a school-based education program designed to prevent tobacco use among junior and senior high school students. The benefits measured were life years (LYs) saved, quality adjusted life years (QALYs) saved, and medical care costs saved, discounted at 3%. The costs measured were program costs. We quantified TNT’s cost-effectiveness as cost per LY saved and cost per QALY saved. 

Under base case assumptions, at an intervention cost of $16,403, TNT prevented an estimated 34.9 students from becoming established smokers. As a result, we could expect a saving of $13,316 per LY saved and a saving of $8,482 per QALY saved. Results from sensitivity analyses indicated TNT to be cost-saving over a reasonable range of model parameter estimates. The TNT program proved to be highly cost-effective compared with other widely accepted prevention interventions. School-based prevention programs of this type warrant careful consideration by policy makers and program planners. With increased funding for tobacco-use prevention as a result of state settlements with tobacco companies, policy makers should expand school-based primary-prevention programs as part of comprehensive tobacco-control programs to significantly reduce the adverse health outcomes of smoking in our society.

Wang LY, Crossett LS, Lowry R, Sussman S, Dent CW.
Archives of Pediatrics and Adolescent Medicine
2001;155(9):1043–50. 

Use of Prescription Weight Loss Pills Among U.S. Adults in 1996–1998

During the past decade, the prevalence of obesity has increased markedly in the United States, as has approval of weight loss drugs by the U.S. Food and Drug Administration. No direct estimates of the use of prescription weight loss pills by the U.S. population have ever been published. We used data from the 1998 Behavioral Risk Factor Surveillance System, a nationally representative telephone survey of adults aged 18 years or older (N=139,779), to estimate the prevalence of prescription weight loss pill use in the United States in 1997–1998. At the time of the survey, 0.5% of respondents were using prescription weight loss pills. The 2 year prevalence of pill use was 2.5% (95% CL, Å 0.4%). Use was highest among Hispanics (3.2%) and was four times higher among women (4.0%) than men (0.9%). The use rate was 6.7% among the obese (body mass index [BMI, kg/m²] Æ 30) and 1.5% among the nonobese. Among pill users, 44% (Å 4.9%) were not obese before using pills and 25% (Å 4.7%) had a prepill BMI < 27. Pill use by those with a prepill BMI < 27 was two times higher among women (27.9%) than men (13.2%) and two times higher among whites (26.1%) and Hispanics (26.4%) than blacks (15.0%).

Approximately 4.6 million U.S. adults used prescription weight loss pills in 1997–1998. Over 40% of users were not obese, which suggests that weight loss pills may be inappropriately used, especially by women, whites, and Hispanics. 

Kettel-Khan L, Serdula MK, Bowman BA, Williamson DF.
Annals of Internal Medicine 2001;134(4)282–6.

Progress Toward Nationwide Cancer Surveillance: An Evaluation of the National Program of Cancer Registries, 1994–1999

This paper describes an evaluation of the first 5-year project period of CDC’s National Program of Cancer Registries (NPCR). Participants in this analysis included central cancer registries in 45 states and the District of Columbia. NPCR staff developed program objectives and evaluation criteria, selected a “before and after” evaluation design, and collected data annually by reviewing program documents and consulting with participants. A structured evaluation instrument was used. A multiyear analysis compared the proportion of state registries achieving selected criteria at three time points: baseline (e.g., the year NPCR funds were first received by the state health department or its designee), fall 1997, and fall 1999.

Findings indicate notable progress during 1994–1999 in the proportion of states having the following: a statewide registry, a law authorizing the registry, supporting statewide regulations, at least 90% of required data elements, a standardized record layout, and selected standardized approaches to improving data quality. A basic structure is now in place for nationwide surveillance of cancer. There has been substantial improvement in the proportion of states conducting activities known to be related to improved cancer registration. During its second 5-year project period, NPCR will continue to monitor these activities while placing increased emphasis on data completeness, timeliness, quality, and use. 

Hutton MD, Simpson LD, Miller DS, Weir HK,
McDavid K, Hall I.
Journal of Registry Management 2001;28(3)113–20. 

Self-Reported Papanicolaou Smears and Hysterectomies Among Women in the United States

The authors examined the potential overuse of Papanicolaou smears among women who have had a hysterectomy by using two surveys of U.S. adults, the Behavioral Risk Factor Surveillance System (1992–1997) and the National Health Interview Survey (1993–1994), and one survey of U.S. hospitals (National Hospital Discharge Survey, 1980–1997). They reported the number of women who have had a hysterectomy who had a recent (within 3 years) Papanicolaou smear and trends in the proportions and rates of hysterectomies by diagnoses and type of procedure that potentially could require a Papanicolaou smear. From the Behavioral Risk Factor Surveillance System, an estimated 21.2% of women have had a hysterectomy. Among women who have had a hysterectomy, 78.3% had a recent Papanicolaou smear. Among those reporting no hysterectomy, 82.1% had a recent Papanicolaou smear. Estimates from the National Health Interview Survey were similar. From the National Hospital Discharge Survey, an estimated 6.7% to 15.4% of women with a history of hysterectomy would require a subsequent Papanicolaou smear because they had a diagnosis related to cervical neoplasia or because they had undergone a supracervical hysterectomy. For an estimated 10.6–11.6 million of the 12.5 million women who had a hysterectomy and a recent Papanicolaou smear, that test could be considered unnecessary. Continued Papanicolaou screening of women without an intact uterus may result in excessive utilization of resources in time and money with minimal impact on decreasing cervical cancer. 

Saraiya M, Lee NC, Blackman D, Smith MJ, 
Morrow B, McKenna MT.
Obstetrics and Gynecology 2001;98(2):269–78. 

Projection of Diabetes Burden Through 2050: Impact of Changing Demography and Disease Prevalence in the United States

The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 (prevalence of 4.0%), to 29 million in 2050 (prevalence of 7.2%). Including age, sex, and race, rates are based on diagnosed diabetes prevalence trends data from the National Health Interview Survey (predicted from 1980 to 1998) and Bureau of Census population demographic projections. 

• The highest percent increase in diagnosed diabetes will be among those aged 75 years or older (+271% in women and +437% in men).
• The fastest growing ethnic group with diagnosed diabetes is expected to be black males (+363% from 2000 to 2050), with black females (+217%), white males (+148%), and white females (+107%) following.
• The number of people who actually have diabetes will likely be even higher, because roughly one-third who have the disease at any given time have not yet been diagnosed.
• Of the projected 18 million increase in the number of cases of diagnosed diabetes in 2050, 37% are due to changes in demographic composition, 27% are due to population growth, and 36% are due to increasing prevalence rates.

If recent trends in diabetes prevalence rates continue over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with diagnosed diabetes. The economic cost of diabetes is already staggering, and future increases in the numbers with the disease and future advances in technology will likely increase these costs further. In the reality of finite resources, the optimal management of diabetes will be an increasingly tougher challenge. 

Boyle JP, Honeycutt AA, Venkat Narayan KM, Hoerger TJ, Geiss LS, Chen H, Thompson TJ.
Diabetes Care 2001;24(11):1936–40.

Sudden Cardiac Death in the United States, 1989 to 1998

Sudden cardiac death (SCD) is a major clinical and public health problem. To examine the secular trend of SCD in the United States, the authors analyzed U.S. Vital Statistics mortality data from 1989 to 1998. SCD is defined as deaths occurring out of the hospital, in the emergency room, or before arrival, with an underlying cause of death reported as a cardiac disease (ICD-9 code 390–398, 402 or 404–429). Death rates were calculated for U.S. residents aged 35 years or older, and standardized to the 2000 U.S. population. Of 719,456 cardiac deaths among adults aged 35 years or older in 1998, 456,076 (63%) were defined as SCD. Among decedents aged 35–44 years, 74% of cardiac deaths were SCD. Of all SCDs in 1998, coronary heart disease (ICD-9 codes 410– 414) was the underlying cause on 62% of the death certificates. Death rates for SCD increased with age and were higher in men than women, although there was no difference at ages 85 years or older. African Americans had higher death rates for SCD than whites, American Indians/Alaska Natives, or Asian/Pacific Islanders. Hispanics had lower death rates for SCD than non-Hispanics. From 1989 to 1998, SCD, as the proportion of all cardiac deaths, increased 12.4% (56.3% to 63.9%), and age-adjusted SCD rates declined 11.7% in men and 5.8% in women. During the same time, age-specific death rates for SCD increased 21% among women aged 35–44 years. The authors concluded that SCD remains an important public health problem in the United States. The increase in death rates for SCD among younger women warrants further investigation. 

Zheng ZJ, Croft JB, Giles WH, Mensah GA.
Circulation 2001;104(18)2158–63.

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Maternal and Child Health

The Healthy Newborn: A Reference Manual for Program Managers

Of the estimated 8 million babies who die just before birth or in the first 28 days of life, 98% die in developing countries. Yet almost all the books about newborn health are aimed at the 2% of deaths that occur in industrialized countries providing high-technology care. The largest health disparities in the world are found when comparing maternal and neonatal mortality figures from industrialized countries with the poorest sections of the poorest countries. Young lives would be saved if the skills and knowledge that have been accumulated by health workers around the world could be readily applied. In precisely the places with the fewest resources, we find the largest problems, many of which occur because of lack of management resources rather than lack of scientific knowledge. The Healthy Newborn: A Reference Manual for Program Managers is a graduate course in management aimed at providing information on the health of newborns to communities. The primary audience is program managers including regional or district level health professionals, nongovernmental organization (NGO) project managers, and other programmers in developing countries. This information may be useful for Ministry of Health officials, NGO headquarters staff, and technical staff of international donor agencies. It may also serve as a supplemental training guide for medical, nursing, and public health professionals. This manual has grown out of a partnership between the WHO Collaborating Center in Perinatal Care in the Centers for Disease Control and Prevention and CARE. While implementing programs to address fetal and neonatal mortality, we realized the need for such a reference manual and CD-ROM resource. 

Lawn JE, McCarthy BJ, Ross SR. 
CARE-CDC Health Initiative 2001. In press. 

Oral Health During Pregnancy: An Analysis of Information Collected by the Pregnancy Risk Assessment Monitoring System

An analysis of 1998 data from four states (Arizona, Illinois, Louisiana, and New Mexico) was summarized in this article. One major finding of this research was that about a quarter of new mothers reported that they had experienced a dental problem during pregnancy, but only about half of these women had seen a dentist. To further translate the findings, a Division of Reproductive Health intern developed fact sheets based on each state’s 1998 data for use with the public and maternal and child health community. In addition, two oral health questions have been accepted as Pregnancy Risk Assessment Monitoring System (PRAMS) standard questions for 2000 and 2001. With support from the Association of State and Territorial Dental Directors, 12 PRAMS states and New York City decided to include one or more of these questions. In addition, some states that conduct their own surveys of new mothers (e.g., Oregon, North Dakota) are including the standard questions.

Gaffield ME, Colley Gilbert BJ, Malvitz DM, Romaguera R.
Journal of the American Dental Association 2001;132(7):1009–16.

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Comprehensive Approaches

Investment in Tobacco Control: State Highlights—2001

The third State Highlights publication from the Office on Smoking and Health (OSH) provides an analysis of current investments in tobacco control by state, places these investments in the context of health and economic consequences of tobacco use specific to the state, and compares current investments with the specific funding ranges contained in CDC’s Best Practices for Comprehensive Tobacco Control Programs. Data on excise taxes and state-by-state tobacco control investments came from analysis of state appropriations and from contacts with state budget offices and health departments. CDC collected data on youth tobacco use from the National Youth Tobacco Survey, the state-specific Youth Tobacco Survey, and the Youth Risk Behavior Survey, and on adult tobacco use from the Behavioral Risk Factor Surveillance System. Lung cancer death rates were collected from CDC’s National Vital Statistics System, and health impact and costs were estimated using the Smoking Attributable Mortality, Morbidity, and Economic Costs software package. This report, a tool for states to use in developing their own tobacco control programs, specifically enables states to compare their own efforts with those of other states. The investment report showed that seven states (Arizona, Indiana, Maine, Massachusetts, Mississippi, Ohio, and Vermont) met or exceeded OSH’s Best Practices minimal funding recommendations for effective tobacco control programs. 

Centers for Disease Control and Prevention.
Atlanta: U.S. Department of Health and Human Services, CDC, 2001.

The Guide to Community Preventive Services: Tobacco Use Prevention and Control—Reviews, Recommendations, and Expert Commentaries

The Office on Smoking and Health has consistently recognized, and science-based evidence has consistently shown, that a comprehensive approach to tobacco control is the most successful. A significant report released in February 2001, The Guide to Community Preventive Services: Tobacco Use Prevention and Control—Reviews, Recommendations, and Expert Commentaries, reinforced this fact. The Task Force on Community Preventive Services, a nonfederal public health panel, released their findings as a special supplement to the American Journal of Preventive Medicine.

The report contained in-depth science-based analyses of selected tobacco interventions, and concluded that 1) smoking bans and restrictions are the most effective measures to reduce exposure to second-hand smoke; 2) increasing the price of tobacco products and conducting mass media campaigns are effective in reducing tobacco use initiation by young people; and 3) increasing prices, conducting mass media campaigns, reducing the cost of tobacco use treatment, institutionalizing tobacco use screens in health care systems, and sponsoring telephone “quit lines” are effective in increasing the number of tobacco users who quit. 

Hopkins DP, Fielding JE, the Task Force on
Community Preventive Services.
American Journal of Preventive Medicine 2001; 20(2 Suppl).

Who Counts in Medical School? Increasing Training in Epidemiology and Other Quantitative Decision-Making Sciences

In addition to advances in individualized medical treatment, interventions for the major problems of the 21^st century rely heavily upon distinct strategies the physician can use to influence the individual patient’s behavior (e.g., smoking cessation, weight loss, reduction in alcohol consumption) and those which represent effective interventions at the population level. Second, for philosophical, conceptual, and practical reasons, clinicians must pay increasing attention to prevention and related tools for prevention, in part, as a function of the managed care environment. With recent changes in health care delivery that have placed new emphasis on the evaluation of physicians’ practices, physicians must become familiar with quantitative principles of evaluating health care delivery and outcomes at the population level.

In addition to the effects of managed care on clinical practice, the proliferation of public information sources may have served to complicate medical decision making. This explosion of consumer-directed health information—largely not subjected to rigorous peer review—mandates that physicians be able to quantitatively assess evidence from all sources and be able to communicate the validity and limitations of reports, as well as their patients’ levels of risk. This article argues the importance of equipping medical students with an understanding of population-based health and the skills to use the tools of quantitative decision making. Authors show how this understanding is necessary for the health problems of today’s communities and illustrate that these curriculum elements can be incorporated into existing requirements for medical school accreditation. Finally, the authors provide available resources for medical school faculty to accomplish this curriculum revision.

Goodman RA, Stroup DF, Koplan JP.
Academic Medicine 2001;76(8):806–8.

School Health Policies and Programs Study 2000: A Summary Report

The School Health Policies and Programs Study (SHPPS) 2000 is the most comprehensive assessment of school health programs ever undertaken. SHPPS assessed school health programs at the state, district, school, and classroom levels nationwide. Data were collected from all 50 states, a nationally representative sample of school districts, and a nationally representative sample of public and private elementary, middle/junior high, and senior high schools between January and June 2000. SHPPS assessed characteristics of eight components of school health programs at all school levels: health education, physical education and activity, health services, mental health and social services, food service, school policy and environment, faculty and staff health promotion, and family and community involvement. This report presents findings from the study. Results demonstrate that more than 80% of states and districts require schools to teach some health education. Although the percentage of schools that require health education increases by grade during elementary school (from 33% in kindergarten to 44% in grade 5), the percentage decreases from 27% in grade 6 to just 2% in grade 12. Nearly all states, districts, and schools also require students to take some physical education, but only 8% of elementary schools and 6% of middle/junior and senior high schools require daily physical education or its equivalent for the entire school year for students in all grades in the school. School nurses provide most of the health services offered to students in schools; 78% of schools have a part-time or full-time school nurse who provides health services. However, only 53% of schools have the recommended nurse-to-student ratio of 1:750 or better. Nearly all schools offer food service to students. However, many foods offered outside of the federally regulated school breakfast and lunch programs are high in fat, sodium, or added sugars. For example, 43% of elementary schools, 74% of middle/junior high schools, and 98% of senior high schools have either vending machines or a school store where the foods most commonly available are high-fat salty snacks, high-fat cookies or baked goods, and soft drinks, sports drinks, or fruit juices that are not 100% juice. In addition, 63% of all milk ordered by schools is high in fat (whole or 2% milk).

Many school health policies and programs have remained basically unchanged between 1994, the first time SHPPS was conducted, and 2000. However, important health and education problems such as tobacco use and violence have received greater attention across components of the school health program and at all levels of the education system. The success of SHPPS 2000 will be determined not only by how well it measures changes but also by how much it stimulates improvements in school health policies and programs nationwide.

Centers for Disease Control and Prevention.
Atlanta: U.S. Department of Health and Human Services,
CDC, 2001. 

Childhood Abuse, Household Dysfunction and the Risk of Attempted Suicide Throughout the Life Span: Findings from the Adverse Childhood Experiences Study

The Adverse Childhood Experiences (ACE) Study is a collaboration between the Kaiser Health Plan’s Health Appraisal Center in San Diego, California, and the Centers for Disease Control and Prevention. The overall objective is to assess the impact of numerous, interrelated, adverse childhood experiences on a wide variety of health behaviors and outcomes. Adverse childhood experiences included in the study are childhood abuse, neglect, and types of household dysfunction such as growing up with domestic violence, household substance abuse, mental illness in the home, parental separation or divorce, or a criminal household member.

In this retrospective cohort study, the authors examined the risk for suicide attempts throughout the life span for over 17,000 adult members of the Kaiser Health Plan who attended the Health Appraisal Center. Adverse childhood experiences were common and tended to co-occur; 64% reported experiencing at least one of them. Individual ACEs increased the risk of ever attempting suicide 2- to 5-fold. The ACE score (total number of ACEs) had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P<.001).

Compared with persons with no ACEs, the adjusted odds ratio of ever attempting suicide among persons with ≥7 ACEs was 31.1 (95% CI 20.6, 47.1). Adjustment for illicit drug use, depressed affect, and self-reported alcoholism reduced the strength of the relationship between the ACE score and suicide attempts, suggesting partial mediation of the ACE-suicide attempt relationship by these factors. Because ACEs are common and have a strong relationship to suicide attempts, the attributable risk fractions were remarkably high; for ≥1 ACEs they were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively.

These data highlight the underlying risk factors for suicide attempt; ACEs have a powerful graded relationship to the risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with ACEs, appear to partially mediate this relationship. Because estimates of the attributable risk fractions due to ACEs were large, prevention of ACEs and the treatment of persons affected by them may lead to progress in suicide prevention.

Dube SR, Anda RF, Felitti VJ, Chapman DP,
Williamson DF, Giles WH.
JAMA 2001. In press.

Characteristics of Meta-Analyses Related to Acceptance for Publication in a Medical Journal

Editors of medical journals select manuscripts for publication based, in part, on the perceived quality of the manuscript submitted. This manuscript describes associations between acceptance for publication and quality-related methodologic characteristics of meta-analyses. We conducted a prospective observational study using manuscripts submitted to JAMA during 1996 and 1997. We analyzed 112 consecutive meta-analyses submitted to JAMA whose authors agreed to participate. Our main outcome measures were ratings of 16 methodologic characteristics reflecting quality of the meta-analysis and acceptance for publication.

A high rating for one methodologic characteristic, whether the report of the meta-analysis provided sufficient detail to enable replication, was related significantly to publication (RR=2.79, 95% CI = 1.13-6.89). This relationship persisted when other variables were controlled for in the model. Generally, rejected manuscripts had fewer factors rated high, but differences were not significant. We found that inclusion of sufficient detail to allow a reader to replicate meta-analytic methods was the only characteristic related to acceptance for publication.

Stroup DF, Thacker SB, Olson CM, Glass RM, Hutwagner L.
Journal of Clinical Epidemiology 2001;54(7):655–60.

Strengthening the Evidence Base for Health Promotion

Expert opinions on the purpose of collecting evidence ranges from those who view evidence as a western notion of little use in the developing world to those who choose to focus on opportunities to demonstrate the effectiveness of health promotion. There is also much disagreement on what constitutes evidence. Some view evidence as strict outcomes of randomized clinical trials and others place greater value on other unpublished sources not traditionally viewed as valuable information. A challenge for health promotion in the new century is to foster and develop high-quality, widely recognized, and acceptable standards for evidence-based evaluation. This paper describes the evidence-based debate from the many players who currently attempt to define best practices in health promotion, presenting a number of viewpoints pertinent to the future of evidence-based evaluation.

McQueen D.
Health Promotions International 2001;16(3):261–8.

A Diabetes Report Card for the United States: Quality of Care in the 1990s

Diabetes care is not as good as it should be and varies widely across the United States. American health care systems are under considerable pressure to improve this situation and to deliver high-quality care while keeping costs under control. One powerful initiative that can help is the Diabetes Quality Improvement Project (DQIP). The standard measures proposed by DQIP were incorporated into the National Committee for Quality Assurance, Health Plan Employer and Data Information Set (HEDIS). DQIP measures are designed to assess the performance of health care systems for a population, and they offer a way to compare across settings.

This is the first report on the national quality of diabetes care in the United States using DQIP as a standard set of measures. Data clearly show that a wide gap exists in this country between our knowledge of effective diabetes interventions and their use in the real world. To narrow this gap and improve the quality of diabetes care, we must identify mechanisms at the levels of the patient and health care providers and systems. DQIP data can also enable various organizations to compare and assess their own performances.

We used two nationally representative population-based surveys: the National Health and Nutrition Examination Survey III (1988–1994) and the Behavioral Risk Factor Surveillance System (1995), and found that

• 19% had poor glycemic control (HbA _1c > 9.5%).
• 34% had blood pressure =140/90mm/Hg. 
• 85% had their cholesterol checked, but only 42% had LDL < 130 mg/dL.
• 63% had a dilated eye examination and 55% had a foot examination during the previous year.

Controlled for age, sex, race/ethnicity, and education, people with health insurance were more likely to have a dilated eye examination (67% vs. 43%) and less likely to have HbA _1c = 9.5% (18% vs. 35%) than those without insurance. Patients taking insulin were more likely than those who were not to have dilated eye exams (72% vs. 58%) and a foot examination (67% vs. 47%), but they were also more likely to have poor glycemic control (27% vs. 15%). 

Saaddine J, Engelgau MM, Gregg E, Beckles GL,
Venkat Narayan KM.
Annals of Internal Medicine 2001. In press.

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