James H. Rimmer, Ph.D., Director

There has been a great debate over the last few years as to what constitutes evidence-based practice in public health, medicine, and rehabilitation. This debate has extended into the public health community, and many CEOs and CMOs of large health insurance companies are searching for that 'magic bullet' that will reduce medical expenditures and keep people out of hospitals. I refer to this as the New Age of  'rationed' health care, where health insurance corporations serve as the 'gatekeepers' for what gets paid for and what doesn't.

The theme of this year's annual American Public Health Association meeting in Philadelphia is "Evidence-Based Policy and Practice." The DisAbility SPIG Chair's Forum, which will be held on Sunday, December 11, from 2:30 p.m. to 5 p.m., will focus on topics relevant to evidence-based health promotion for people with disabilities. Presenters will discuss their views on how we might begin to build a stronger evidence base that will guide future practice.

Many public and private insurers are reluctant to pay for health promotion programs that don't have cost savings data associated with them. Because people with disabilities often have a preexisting condition, most reimbursement plans will not cover preventive care, i.e., health promotion programs. This short-sightedness on the part of many insurers is unfortunate because it will likely result in greater costs in later life when secondary conditions-health conditions resulting from the primary disability-have a greater negative effect on overall health and independence because of their interaction with the natural aging process. Chronic health conditions that affect the general population, including arthritis, Type 2 diabetes, and coronary heart disease, will also become greater concerns among aging individuals with disabilities, who are now living longer due to advances in health care. The interaction between these health conditions and the associated and secondary conditions accompanying various types of disabilities will impose greater financial demands on the individual and/or caregiver, and health insurer. Health complications that might have been avoided with subsidized health promotion services may result in substantial costs in later life.

How do we derive evidence-based health promotion practice guidelines for people with disabilities who may be at different stages of a progressive condition or who may have various chronic, associated, and secondary conditions, each affecting their overall health in varying degrees? What seems like a great enough challenge for public health professionals working with large populations (e.g., women, children), becomes a significantly greater challenge for health professionals working with a select subset of individuals with disabilities where in some cases there may only be a few hundred (or even less) people in a local community.

Most of the literature on what is considered 'evidence-based' suggests that several randomized controlled trials (often referred to as RCTs) must be completed before the research initiative can be identified as an 'evidence-based' practice guideline. However, finding that type of evidence in health promotion and disability that meets a standard adopted for large populations is nearly impossible without some type of support structure that allows researchers to collaborate with each other in addressing the most compelling and urgent questions in health and disability.

When a research grant is funded to demonstrate effectiveness of a health promotion program for the population at large or for a very large cohort (i.e., people with arthritis or diabetes, nurses, doctors), it is relatively easy to recruit a large enough sample to account for dropouts, 'no shows,' and poor adherers. When the eligibility criteria encompasses a very small subset of the population (i.e., individuals within a certain level of function who have multiple sclerosis, 18- to 40-year-old females with a spinal cord injury, children with cerebral palsy), recruiting a statistically adequate sample size to build an 'evidence base' is substantially more challenging. Even trying to find enough studies in the literature to run meta-analyses (a statistical procedure that groups studies with similar outcomes and samples together to determine the benefit or 'effect' of the treatment) is extremely difficult and often not possible because there are not enough studies that use the same treatments, samples, outcomes, and/or measures.

Public health and disability is in that 'emerging zone' of evidence-based practice that will take several years to determine how best to address this issue. We're not able to recruit the large numbers of subjects that public health professionals can, yet our populations are just as important in terms of addressing the scientific evidence that benefits the individual with a specific disability. It's unfortunate that funding agencies do not require investigators to include a subset of people with disabilities as they do with women, children, and minorities. The most convincing 'evidence-based' studies are those with very large samples that find statistical significance with smaller effect sizes than what is typically required with smaller samples. Professionals in public health and disability realize the importance of having 'evidence-based' practice guidelines, and this year's APHA Chair's Forum will begin a dialogue on this very important topic.