Evaluating health care performance: strengths and limitations of multilevel analysis

An increasing number of health services researchers are using multilevel analysis for evaluating health care performance. This method has the distinct advantage of accounting for within-provider correlation among patients. Alternatively, in a similar manner, estimators based on cluster sampling can also adjust for within-provider correlation. Cluster sampling methods do not require assumptions about error distribution as multilevel analysis does. To our knowledge, no comparison has been made between multilevel analysis and cluster sampling estimators in evaluating health care performance using either a simulated or real dataset. In this paper, we compare the cluster sampling estimators to multilevel estimators in evaluating screening mammography performance using Medicare claims data. We also discuss the strengths and limitations of multilevel analysis in profiling health care providers with small caseloads.     

Bayesian Partitioning for Modeling and Mapping Spatial Case–Control Data

Summary Methods for modeling and mapping spatial variation in disease risk continue to motivate much research. In particular, spatial analyses provide a useful tool for exploring geographical heterogeneity in health outcomes, and consequently can yield clues as to disease etiology, direct public health management, and generate research hypotheses. This article presents a Bayesian partitioning approach for the analysis of individual level geo‐referenced health data. The model makes few assumptions about the underlying form of the risk surface, is data adaptive, and allows for the inclusion of known determinants of disease. The methodology is used to model spatial variation in neonatal mortality in Porto Alegre, Brazil.     

Ancillary care in public health intervention research in low-resource settings: researchers' practices and decision-making

Little is known about researchers' practices regarding the provision of ancillary care (AC) in public health intervention studies they have conducted and the factors that influence their decisions about whether to provide ancillary care in low-resource settings. We conducted 52 in-person in-depth interviews with public health researchers. Data analysis was iterative and led to the identification of themes and patterns among themes. We found that researchers who conduct their research in the community setting are more likely to identify and plan for the AC needs of potential research subjects before a study begins, whereas those affiliated with a permanent facility are more likely to deliver AC to research subjects on an ad hoc basis. Our findings suggest that on the whole, at least for public health intervention research in low-resource settings, researchers conducting research in the community setting confront more complex ethical and operational challenges in their decision-making about AC than do researchers conducting facility-based studies.     

健康视角下绿色开放空间设计影响体力活动的要素研究

中国快速城市化带来一系列公共健康问题,体力活动为建立绿色开放空间与健康之间的联系提供了一条研究路径。在公共卫生、医学等学科的相关文献基础上,对绿色开放空间影响体力活动的要素进行了系统鉴别和梳理,旨在为绿色开放空间的健康干预性研究提供依据。文章从空间、场所和感知3个层面梳理了6个影响体力活动的要素,对每个要素的内容、指标、影响体力活动的类型等进行了归类,最终建立了绿色开放空间体力活动要素的初步指标框架,并基于此总结了相应的设计启示和未来研究趋势。     

Alleged misconceptions' distort perceptions of environmental cancer risks.

In a series of papers, Ames and colleagues allege that the scientific and public health communities have perpetuated a series of 'misconceptions' that resulted in inaccurate identification of chemicals that pose potential human cancer risks, and misguided cancer prevention strategies and regulatory policies. They conclude that exposures to industrial and synthetic chemicals represent negligible cancer risks and that animal studies have little or no scientific value for assessing human risks. Their conclusions are based on flawed and untested assumptions. For instance, they claim that synthetic residues on food can be ignored because 99.99% of pesticides humans eat are natural, chemicals in plants are pesticides, and their potential to cause cancer equals that of synthetic pesticides. Similarly, Ames does not offer any convincing scientific evidence to justify discrediting bioassays for identifying human carcinogens. Ironically, their arguments center on a ranking procedure that relies on the same experimental data and extrapolation methods they criticize as being unreliable for evaluating cancer risks. We address their inconsistencies and flaws, and present scientific facts and our perspectives surrounding Ames' nine alleged misconceptions. Our conclusions agree with the International Agency for Research on Cancer, the National Toxicology Program, and other respected scientific organizations: in the absence of human data, animal studies are the most definitive for assessing human cancer risks. Animal data should not be ignored, and precautions should be taken to lessen human exposures. Dismissing animal carcinogenicity findings would lead to human cancer cases as the only means of demonstrating carcinogenicity of environmental agents. This is unacceptable public health policy.     

Medicine, methodology, and values: trade-offs in clinical science and practice

The current guidelines of evidence-based medicine (EBM) presuppose that clinical research and clinical practice should advance from rigorous scientific tests as they generate reliable, value-free knowledge. Under this presupposition, hypotheses postulated by doctors and patients in the process of their decision making are preferably tested in randomized clinical trials (RCTs), and in systematic reviews and meta-analyses summarizing outcomes from multiple RCTs. Since testing under this scheme is predominantly focused on the criteria of generality and precision achieved through methodological rigor, at the cost of the criterion of realism, translating test results to clinical practice is often problematic. Choices concerning which methodological criteria should have priority are inevitable, however, as clinical trials, and scientific research in general, cannot meet all relevant criteria at the same time. Since these choices may be informed by considerations external to science, we must acknowledge that science cannot be value-free in a strict sense, and this invites a more prominent role for value-laden considerations in evaluating clinical research. The urgency for this becomes even more apparent when we consider the important yet implicit role of scientific theories in EBM, which may also be subjected to methodological evaluation and for which selectiveness in methodological focus is likewise inevitable.     

Complex adaptive system models and the genetic analysis of plasma HDL-cholesterol concentration

Despite remarkable advances in diagnosis and therapy, ischemic heart disease (IHD) remains a leading cause of morbidity and mortality in industrialized countries. Recent efforts to estimate the influence of genetic variation on IHD risk have focused on predicting individual plasma high-density lipoprotein cholesterol (HDL-C) concentration. Plasma HDL-C concentration (mg/dl), a quantitative risk factor for IHD, has a complex multifactorial etiology that involves the actions of many genes. Single gene variations may be necessary but are not individually sufficient to predict a statistically significant increase in risk of disease. The complexity of phenotype-genotype-environment relationships involved in determining plasma HDL-C concentration has challenged commonly held assumptions about genetic causation and has led to the question of which combination of variations, in which subset of genes, in which environmental strata of a particular population significantly improves our ability to predict high or low risk phenotypes. We document the limitations of inferences from genetic research based on commonly accepted biological models, consider how evidence for real-world dynamical interactions between HDL-C determinants challenges the simplifying assumptions implicit in traditional linear statistical genetic models, and conclude by considering research options for evaluating the utility of genetic information in predicting traits with complex etiologies.     

Improving outcomes for ill and injured children in emergency departments: protocol for a program in pediatric emergency medicine and knowledge translation science

Background

Implementation of evidence-based mental health assessment and intervention in community public health practice is a high priority for multiple stakeholders. Academic-community partnerships can assist in the implementation of efficacious treatments in community settings; yet, little is known about the processes by which these collaborations are developed. In this paper, we discuss our application of community-based participatory research (CBPR) approach to implementation, and we present six lessons we have learned from the establishment of an academic-community partnership.

Methods

With older adults with psychosis as a focus, we have developed a partnership between a university research center and a public mental health service system based on CBPR. The long-term goal of the partnership is to collaboratively establish an evidence-based implementation network that is sustainable within the public mental healthcare system.

Results

In building a sustainable partnership, we found that the following lessons were instrumental: changing attitudes; sharing staff; expecting obstacles and formalizing solutions; monitoring and evaluating; adapting and adjusting; and taking advantage of emerging opportunities. Some of these lessons were previously known principles that were modified as the result of the CBPR process, while some lessons derived directly from the interactive process of forming the partnership.

Conclusion

The process of forming of academic-public partnerships is challenging and time consuming, yet crucial for the development and implementation of state-of-the-art approaches to assessment and interventions to improve the functioning and quality of life for persons with serious mental illnesses. These partnerships provide necessary organizational support to facilitate the implementation of clinical research findings in community practice benefiting consumers, researchers, and providers.     

Looking for rules in a world of exceptions: reflections on evidence-based practice

After more than a decade, evidence-based medicine (EBM) is well established as an important influence in health care. EBM has engendered a wide range of responses from near-evangelical fervor to angered rejection, with supporters convinced of its scientific superiority and detractors of its needless reductionism. EBM is not a philosophical doctrine, and its originators and proponents have, for the most part, ignored critics and foresworn theorizing. However, EBM claims to be a normative guide to being a better physician. The theoretical, practical, and philosophical dimensions of EBM are intimately intertwined. This essay is a sustained reflection on the issues raised by EBM as experienced by a clinician/teacher who has tried to apply the tenets of EBM in clinical care and teaching over the past decade, and who has sought to expand the borders of EBM from a philosophical point of view.     

Guidelines for Community-based Ethics Review of Children’s Science Fair Projects

Low-level community based ethics committees staffed by teachers, parents and community representatives can readily review children’s science fair projects subject to the revision of two core assumptions currently governing children’s Science Fairs. The first part of the paper recasts the New Zealand Royal Society guidelines from its primary emphasis on risk to a new assumption, without benefit there can be no risk. Equally, this revision gives more prominence to the participant information sheet, allowing it to act as a quasi application form which provides ethical transparency between student researchers, participants and a community based ethics committee. A second core assumption, more accurately labeled a cult of originality, produces a random, open-ended array of student topics taking ethics review beyond the confidence level of most community based ethics review committees. This paper reins in Science Fair coordinators recommending they make community level ethics review more manageable by providing a list of preapproved topics for those students wanting to conduct research involving human participants. These revised assumptions create a workable division of labour. Teachers’ preapproved topics involving human participants are more likely to be low risk, permitting community level ethics review to focus primarily on two aspects of the minimization of harm: first, for all participants, especially those with diminished autonomy, and second, for the child researchers themselves, as some participants may be unknown to the student. These revised assumptions make science and ethics more accessible to public education thus demonstrating how Science Fairs can lead students and the community into better understanding the role and function that ethics has in all scientific research human participants. Martin Tolich chaired New Zealand’s National Health Ethics committee, the multi-region ethics committee.     

Epidemiological reflections of the contribution of anthropology to public health policy and practice

Academic disciplines like anthropology and epidemiology provide a niche for researchers to speak the same language, and to interrogate the assumptions that they use to investigate problems. How anthropological and epidemiological methods communicate and relate to each other affects the way public health policy is created but the philosophical underpinnings of each discipline makes this difficult. Anthropology is reflective, subjective and investigates complexity and the individual; epidemiology, in contrast, is objective and studies populations. Within epidemiological methods there is the utilitarian concept of potentially sacrificing the interests of the individual for the benefits of maximizing population welfare, whereas in anthropology the individual is always included. Other strengths of anthropology in the creation of public health policy include: its attention to complexity, questioning the familiar; helping with language and translation; reconfiguring boundaries to create novel frameworks; and being reflective. Public health requires research that is multi-, inter- and trans-disciplinary. To do this, there is a need for each discipline to respect the 'dignity of difference' between disciplines in order to help create appropriate and effective public health policy.     

Skepticism, statistical methods, and the cigarette: a historical analysis of a methodological debate

The discipline of modern "risk factor" epidemiology was in its formative stages in the early 1950s, when epidemiologic studies revealed a strong association between cigarette smoking and lung cancer mortality. Many medical scientists and physicians were reluctant to accept these studies as a demonstration of causation because the methods were "statistical" and involved data collected in uncontrolled conditions outside the laboratory. But a substantial number of senior biostatisticians and epidemiologists also voiced concerns, albeit more methodologically sophisticated, about the quality of the evidence at the time. Statistical methods were just beginning to work their way into medicine and public health, and many epidemiologists and statisticians were concerned about the potential misuse of these methods by untrained investigators. When studies of smoking and lung cancer gained increasing publicity and were being used to recommend public health policies, some prominent epidemiologists and statisticians highlighted this debate in their efforts to pursue methodological reform. Participants in the debate over smoking and lung cancer saw the need for explicit and rigorous standards for evaluating etiologic hypotheses, but they held conflicting views about what those standards should be. These diverging views reflect an underlying tension within the discipline of epidemiology between the search for "objective" methods of scientific inference and the practical needs of public health research that persists today.     

Placebo, meaning, and health

Placebos are boon and bane to medical theory and clinical practice. On the one hand, randomized controlled trials employ concealed allocations of placebo to control for effects not due to specific pharmacological mechanisms. As a result, nearly all of evidence-based medicine derives from principles and practices based on placebo. On the other hand, medical researchers and physicians have tended to ignore, minimize, or deride placebos and placebo effects, perhaps due to values emphasizing scientific understanding of mechanistic pathways. We argue that intention, expectation, culture, and meaning are central to placebo-effect phenomena and are substantive determinants of health. We introduce three dualities that are integral to placebo/meaning phenomena: body-mind, subconscious-conscious, and passive-active. These placebo-related dualities should be acknowledged, explored with research, and incorporated in theory. While we view consideration of placebo and meaning effects as essential to any adequate understanding of human health, we feel that lessons from this area of inquiry may already provide practical tools for astute clinicians. Toward this end, we list eight specific clinical actions: speak positively about treatments, provide encouragement, develop trust, provide reassurance, support relationships, respect uniqueness, explore values, and create ceremony. These clinical actions can empower patients to seek greater health and may provide a healthful sense of being cared for.     

Survey of Argentine Health Researchers on the Use of Evidence in Policymaking

Objective

In this study, Argentine health researchers were surveyed regarding their perceptions of facilitators and barriers to evidence-based policymaking in Argentina, as well as their publication activities, and research environment satisfaction.

Methods

A self-administered online survey was sent to health researchers in Argentina. The survey questions were based on a preceding qualitative study of Argentine health researchers, as well as the scientific literature.

Results

Of the 647 researchers that were reached, 226 accessed the survey, for a response rate of 34.9%. Over 80% of researchers surveyed had never been involved in or contributed to decision-making, while over 90% of researchers indicated they would like to be involved in the decision-making process. Decision-maker self-interest was perceived to be the driving factor in the development of health and healthcare policies. Research conducted by a research leader was seen to be the most influential factor in influencing health policy, followed by policy relevance of the research. With respect to their occupational environment, researchers rated highest and most favourably the opportunities available to present, discuss and publish research results and their ability to further their education and training. Argentine researchers surveyed demonstrated a strong interest and willingness to contribute their work and expertise to inform Argentine health policy development.

Conclusion

Despite Argentina’s long scientific tradition, there are relatively few institutionalized linkages between health research results and health policymaking. Based on the results of this study, the disconnect between political decision-making and the health research system, coupled with fewer opportunities for formalized or informal researcher/decision-maker interaction, contribute to the challenges in evidence informing health policymaking in Argentina. Improving personal contact and the building of relationships between researchers and policymakers in Argentina will require taking into account researcher perceptions of policymakers, as highlighted in this study.     

Free-living amoebae and other neglected protistan pathogens: Health emergency signals?

Protistan parasites have an undisputed global health impact. However, outside of a few key exceptions, e.g. the agent of malaria, most of these infectious agents are neglected as important health threats. The Symposium entitled “Free-living amoebae and neglected pathogenic protozoa: health emergency signals?” held at the European Congress of Protistology in Rome, July 2019, brought together researchers addressing scientific and clinical questions about some of these fascinating organisms. Topics presented included the molecular basis of pathogenicity in Acanthamoeba; genomics of Naegleria fowleri; and epidemiology of poorly diagnosed enteric protistan species, including Giardia, Cryptosporidium, Blastocystis, Dientamoeba. The Symposium aim was to excite the audience about the opportunities and challenges of research in these underexplored organisms and to underline the public health implications of currently under-appreciated protistan infections. The major take home message is that any knowledge that we gain about these organisms will allow us to better address them, in terms of monitoring and treatment, as sources of future health emergencies.     

Communicating about ocean health: theoretical and practical considerations

As anthropogenic stressors threaten the health of marine ecosystems, there is a need to better understand how the public processes and responds to information about ocean health. Recent studies of public perceptions about ocean issues report high concern but limited knowledge, prompting calls for information campaigns to mobilize public support for ocean restoration policy. Drawing on the literature from communication, psychology and related social science disciplines, we consider a set of social-cognitive challenges that researchers and advocates are likely to encounter when communicating with the public about ocean health and emerging marine diseases—namely, the psychological distance at which ocean issues are construed, the unfamiliarity of aquatic systems to many members of the public and the potential for marine health issues to be interpreted through politicized schemas that encourage motivated reasoning over the dispassionate consideration of scientific evidence. We offer theory-based strategies to help public outreach efforts address these challenges and present data from a recent experiment exploring the role of message framing (emphasizing the public health or environmental consequences of marine disease) in shaping public support for environmental policy.     

Fair Resource Allocation to Health Research: Priority Topics for Bioethics Scholarship

This article draws attention to the limited amount of scholarship on what constitutes fairness and equity in resource allocation to health research by individual funders. It identifies three key decisions of ethical significance about resource allocation that research funders make regularly and calls for prioritizing scholarship on those topics – namely, how health resources should be fairly apportioned amongst public health and health care delivery versus health research, how health research resources should be fairly allocated between health problems experienced domestically versus other health problems typically experienced by disadvantaged populations outside the funder's country, and how domestic and non‐domestic health research funding should be further apportioned to different areas, e.g. types of research and recipients. These three topics should be priorities for bioethics research because their outcomes have a substantial bearing on the achievement of health justice. The proposed agenda aims to move discussion on the ethics of health research funding beyond its current focus on the mismatch between worldwide basic and clinical research investment and the global burden of disease. Individual funders’ decision‐making on whether and to what extent to allocate resources to non‐domestic health research, health systems research, research on the social determinants of health, capacity development, and recipients in certain countries should also be the focus of ethical scrutiny.     

Artificial Intelligence text generators for overcoming language barriers in ecological research communication

Language barriers can impede the dissemination of research findings, restrict collaboration and exclude non-English-speaking researchers from the global scientific community. To overcome this challenge, we explore the potential of Generative Artificial Intelligence (GenAI) text generators to assist non-anglophone researchers in producing high-quality academic texts for publication in scientific journals, with a focus on the field of ecological research. These tools can produce grammatically correct, coherent and contextually appropriate text, improving scientific communication quality. Improving scientific communication is vital in Ecology, where research findings can have important implications for the environment and public policy. GenAI text generators can generate summaries of research findings, abstracts and social media posts promoting research findings. Nonetheless, researchers must exercise caution and use these tools together with human review and editing to ensure accuracy and clarity. As natural language processing and machine learning continue to evolve, the use of GenAI text generators in scientific communication is poised to become increasingly important.     

Gezamenlijke besluitvorming zorgt voor een betere toepassing van evidence-based medicine in de geriatrische patiënt

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.     

How can health service users contribute to the NHS research and development programme?

The National Childbirth Trust, along with other groups of health service users, is working with health professionals and researchers in planning clinical trials, setting priorities for research, systematically reviewing research reports, and getting research findings into practice. User groups may bridge the gap between the public and researchers by explaining research issues to a wide audience, presenting the needs and views of health service users to the research community, and suggesting how members of the public may be approached for their views directly. Service users recognise their need for training and support, and they call for development and evaluation of this work.