Barbara Gabella

Tools for implementing an evidence-based approach in public health practice

Increasing disease rates, limited funding, and the ever-growing scientific basis for intervention demand the use of proven strategies to improve population health. Public health practitioners must be ready to implement an evidence-based approach in their work to meet health goals and sustain necessary resources. We researched easily accessible and time-efficient tools for implementing an evidence-based public health (EBPH) approach to improve population health. Several tools have been developed to meet EBPH needs, including free online resources in the following topic areas: training and planning tools, US health surveillance, policy tracking and surveillance, systematic reviews and evidence-based guidelines, economic evaluation, and gray literature. Key elements of EBPH are engaging the community in assessment and decision making; using data and information systems systematically; making decisions on the basis of the best available peer-reviewed evidence (both quantitative and qualitative); applying program-planning frameworks (often based in health-behavior theory); conducting sound evaluation; and disseminating what is learned.

Mortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury: A Population-Based Study

UNLABELLED Ventura T, Harrison-Felix C, Carlson N, DiGuiseppi C, Gabella B, Brown A, DeVivo M, Whiteneck G. Mortality after discharge from acute care hospitalization with traumatic brain injury: a population-based study. OBJECTIVE To characterize mortality after acute hospitalization with traumatic brain injury (TBI) in a socioeconomically diverse population. DESIGN Population-based retrospective cohort study. SETTING Statewide TBI surveillance program. PARTICIPANTS Colorado residents with TBI discharged alive from acute hospitalization between 1998 and 2003 (N=18,998). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Vital status at the end of the study period (December 31, 2005) and statewide population mortality rates were used to calculate all-cause and cause-specific standardized mortality ratios (SMRs) and life expectancy compared with population mortality rates. The influence of demographics, injury severity, and comorbid conditions on time until death was investigated using age-stratified Cox proportional hazards modeling. RESULTS Patients with TBI carried about 2.5 times the risk of death compared with the general population (SMR=2.47; 95% confidence interval [CI], 2.31-2.65). Life expectancy reduction averaged 6 years. SMRs were largest for deaths caused by mental/behavioral (SMR=3.84; 95% CI, 2.67-5.51) and neurologic conditions (SMR=2.79; 95% CI, 2.07-3.77) and were smaller but significantly higher than 1.0 for an array of other causes. Injury severity and older age increased mortality among young people (age <20y). However, risk factors for mortality among adults age 20 and older involved multiple domains of demographics (eg, metropolitan residence), injury-related measures (eg, falls versus vehicular incidents), and comorbidity (eg, > or =3 comorbid health conditions versus none). CONCLUSIONS TBI confers an increased risk of mortality in the months and years after hospital discharge. Although life expectancy is reduced across the population, the excess in mortality lessens as time since injury increases. Specific risk factors (eg, high injury severity, poor general health) pose an especially high threat to survival and should prompt an increased vigilance of health status, especially among younger patients.

Relationship of helmet use and head injuries among motorcycle crash victims in El Paso county, Colorado, 1989–1990☆

A case-control study was conducted in El Paso County, Colorado to estimate differences in risk of head injury among persons in motorcycle crashes who were or were not wearing helmets. There were 71 cases, motorcyclists with head injuries from crashes, and 417 controls, motorcyclists in crashes without head injuries. Motorcyclists not wearing helmets were 2.4 times as likely to sustain head injuries (95% confidence limits: 1.23, 4.70) than motorcyclists wearing helmets. This odds ratio was adjusted for age and crash characteristics, using logistic regression. Alcohol intoxication and severity of motorcycle damage were also associated with significantly elevated odds ratios related to sustaining a head injury.

Community readiness and prevention of traumatic brain injury

Primary objective: The study aimed to understand the readiness of rural communities to engage in community-initiated traumatic brain injury (TBI) prevention. The utility of state-wide TBI surveillance to monitor outcomes of local TBI prevention efforts was also assessed. Research design: A quasi-experimental design was used to evaluate the effects of community-initiated TBI prevention programmes. Methods and procedures: The Community Readiness model was used to assess changes in communities before and after programmes. Four rural counties in Colorado, US, were selected based on population composition and TBI rates. Key informants in each county were interviewed to determine community readiness stages to engage in prevention. The interviews were repeated 2 years later. Results: In two study counties TBI prevention activities were initiated. One county conducted a number of prevention activities and moved from ‘vague awareness’ to ‘preplanning’ stage. Three counties moved from ‘denial’ to ‘vague awareness’. TBI surveillance did not capture rate changes in the counties. Conclusions: The Community Readiness model identified counties more likely to engage in prevention and change was observed in readiness where programmes were undertaken as well as in counties where no new programmes were initiated. Detailed local TBI data is necessary to monitor outcomes of community interventions.

Comparison of Nursing Home Residents With and Without Traumatic Brain Injury: Use of the Minimum Data Set

ObjectiveTo describe the magnitude of the population with traumatic brain injury (TBI) in Colorado living in nursing homes and compare these residents to the nursing home residents with neither TBI nor dementia. MethodsThe standardized Minimum Data Set of resident assessments was used to describe the behavior, cognitive performance, activities of daily living, and discharge potential of residents. ResultsThere were 16,478 nursing home residents in 2005, of whom 1.4% had TBI but not dementia, 0.7% had both TBI and dementia, and 50.2% had neither diagnosis. The prevalence of TBI in this population was 2.1%. TBI residents without dementia were younger (median age 53 years). A larger proportion consisted of men (64%), from a racial/ethnic minority (24%), and needed greater assistance with eating, toileting, and hygiene. The percent with severe cognitive impairment was greater for individuals with TBI (22%) compared to those with neither TBI nor dementia (5%). Fewer TBI residents expressed a preference to return to the community. ConclusionThese differences suggest the need for increased training and staffing to care for nursing home residents with TBI.

Sex differences in mortality after traumatic brain injury, Colorado 1994–1998

Primary objective: The purpose of this study was to assess the relationship between sex and traumatic brain injury (TBI) mortality. Methods and procedures: A total of 20 465 persons with TBI were identified from a Colorado population-based surveillance system for 1994–1998. Case fatality ratios were calculated to identify sex differences for selected risk factors. Unconditional logistic regression was used to determine the relationship between TBI mortality and sex controlling for risk factors. Main outcomes and results: Adjusting for age, race, metropolitan residence and penetrating injury, the estimated odds of TBI mortality for males compared to females was 1.21 (95% CI 1.10, 1.34) for pre-hospital fatalities and 1.19 (95% CI 1.05, 1.37) for hospital fatalities. Conclusion: Results indicate differences in TBI mortality comparing males and females. Future studies are warranted to identify if behaviour and physiological responses are associated with TBI outcomes among males and females.

Can traumatic brain injury surveillance systems be used to link individuals with TBI to services

Primary objective: This study was conducted to determine the feasibility of using Colorado Traumatic Brain Injury (TBI) Surveillance System data to link individuals to information and services in their communities. Methods and procedures: Using a qualitative exploratory approach, the investigators conducted focus groups of individuals with TBI and family members (n = 29) and individual interviews with state agency, medical and community services representatives (n = 15). Main outcomes: The results showed that the participants saw many current problems with linking persons to services and with accessing care. The participants supported using TBI surveillance data to link persons to information and services, offered suggestions, discussed confidentiality and consent issues, described possible cultural competence issues and addressed cost feasibility. Conclusions: Overall persons with TBI and their family members overwhelmingly supported using the Colorado TBI Surveillance System to link persons to services. One major concern, however, was how to link persons who were not included in the surveillance data because their TBI happened before the surveillance system was implemented or because their injury did not result in hospitalization. This concern is addressed in a Linkage Model.

Tools for identifying and prioritizing evidence-based obesity prevention strategies, Colorado.

Colorado’s adult obesity rate has more than doubled since 1995, prompting its Department of Public Health and Environment to list obesity as its top prevention priority. To initiate comprehensive and effective action, the department used a well-known evidence-based public health framework developed by Brownson and others. This article describes the tools and process developed to conduct 2 of the 7 stages in this framework that challenge public health organizations: reviewing the literature and prioritizing effective strategies from that literature. Forty-five department staff participated in an intensive literature review training to identify physical activity and nutrition strategies that effectively address obesity and worked with external stakeholders to prioritize strategies for the state. Divided into 8 multidisciplinary teams organized by the setting where public health could exert leverage, they scanned the scientific literature to identify potential strategies to implement. These teams were trained to use standardized tools to critique findings, systematically abstract key information, and classify the evidence level for each of 58 identified strategies. Next, departmental subject matter experts and representatives from local public health and nonprofit health agencies selected and applied prioritization criteria to rank the 58 strategies. A team charter, group facilitation tools, and 2 web-based surveys were used in the prioritization stage. This process offered the staff a shared experience to gain hands-on practice completing literature reviews and selecting evidence-based strategies, thereby enhancing Colorado’s obesity prevention efforts and improving public health capacity. Practitioners can use these tools and methodology to replicate this process for other health priorities.