American journal of preventive medicine
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More adults in the United States have quit smoking than remain current smokers. But 45 million adults (20.9%) continue to smoke, with highest rates among low socioeconomic status (SES), blue-collar, and Native American populations. More than two thirds (70%) of adult smokers want to quit, and approximately 40% make a serious quit attempt each year, but only 20%-30% of quitters use an effective behavioral counseling or pharmacologic treatment. ⋯ This paper uses the "push-pull capacity" model as a framework for illustrating strategies to achieve this goal. This model recommends: (1) improving and communicating effective treatments for wide population use; (2) building the capacity of healthcare and other systems to deliver effective treatments; and (3) boosting consumer, health plan, and insurer demand for them through policy interventions shown to motivate and support quitting (e.g., clean indoor-air laws, tobacco tax increases, expanded insurance coverage/reimbursement) and efforts to improve treatment access and appeal, especially for smokers who use them least. Innovations recommended by the National Consumer Demand Roundtable for achieving "breakthrough" improvements in cessation treatment demand and use are described.
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Review
Limitations of the randomized controlled trial in evaluating population-based health interventions.
Population- and systems-based interventions need evaluation, but the randomized controlled trial (RCT) research design has significant limitations when applied to their complexity. After some years of being largely dismissed in the ranking of evidence in medicine, alternatives to the RCT have been debated recently in public health and related population and social service fields to identify the trade-offs in their use when randomization is impractical or unethical. This review summarizes recent debates and considers the pragmatic and economic issues associated with evaluating whole-population interventions while maintaining scientific validity and credibility.
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Universal, school-based programs, intended to prevent violent behavior, have been used at all grade levels from pre-kindergarten through high school. These programs may be targeted to schools in a high-risk area-defined by low socioeconomic status or high crime rate-and to selected grades as well. ⋯ Program effects were consistent at all grade levels. An independent, recently updated meta-analysis of school-based programs confirms and supplements the Community Guide findings.
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Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health. This paper (1) introduces evidence-based recommendations from the U. S. Preventive Services Task Force sponsored by the Agency for Healthcare Research and Quality and the Community Task Force sponsored by the Centers for Disease Control and Prevention, (2) examines, using a social-ecologic model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity, and (3) advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them.
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Several studies have shown wide variations in the delivery of hospital-based care to patients with acute ischemic stroke. The findings of these studies suggest that recommendations drawn from published evidence-based or consensus-based guidelines are implemented inconsistently. Although rates of adherence to stroke quality indicators can be increased through the use of targeted quality improvement (QI) efforts, stroke QI programs are still in their infancy. ⋯ Key barriers to long-term success of these programs include inadequate funding at the local and national level, lack of infrastructure to support electronic data capture for QI as part of the process of patient care, lack of a single clearinghouse for uniform data definitions and performance indicator descriptions, competing survey instruments to monitor hospitalized stroke care, and constraints on inpatient and post-discharge data collection imposed by the new Federal Health Insurance Portability and Accountability Act Privacy Rule. In addition, the competing needs of registry activities (e.g., complete case ascertainment) versus QI efforts (e.g., incremental tests of change) must be balanced. Potential solutions include: (1) financial incentives to healthcare providers and institutions for participation in QI initiatives; (2) financial incentives to healthcare providers and institutions for measurable improvements in care; (3) mandatory data reporting on key measures of stroke care; and (4) promotion of active and sustainable collaborations among key stakeholders including healthcare providers (e.g., physicians, nurses), healthcare organizations (e.g., hospitals, physicians' groups), quality improvement organizations, health payers and insurers, public health departments, and state and federal health agencies to create a single national stroke registry for stroke QI.