text:
Vaginal Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage Information for Vaginal Cancer
- General Information About Vaginal Cancer
- Stage Information for Vaginal Cancer
- Treatment Option Overview
- Stage 0 Vaginal Cancer
- Stage I Vaginal Cancer
- Stage II Vaginal Cancer
- Stage III Vaginal Cancer
- Stage IVA Vaginal Cancer
- Stage IVB Vaginal Cancer
- Recurrent Vaginal Cancer
- Changes to This Summary (02 / 21 / 2013)
- About This PDQ Summary
- Get More Information From NCI
If the cervix is intact, biopsies are mandatory to rule out a primary carcinoma of the cervix. Carcinoma of the vulva should also be ruled out.
Definitions: FIGO
The Féderation Internationale de Gynécologie et d'Obstétrique (FIGO) and the American Joint Committee on Cancer (AJCC) have designated staging to define vaginal cancer; the FIGO system is most commonly used.[1,2] The definitions of the AJCC's T, N, and M categories correspond to the stages accepted by FIGO.
FIGO staging system (and modified World Health Organization [WHO] prognostic scoring system)
The FIGO staging system is as follows:[1]
Table 1. Carcinoma of the Vaginaa
FIGO Nomenclature | |
FIGO = Féderation Internationale de Gynécologie et d'Obstétrique. | |
a Adapted from FIGO Committee on Gynecologic Oncology.[1] | |
Stage I | The carcinoma is limited to the vaginal wall. |
Stage II | The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall. |
Stage III | The carcinoma has extended to the pelvic wall. |
Stage IV | The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum; bullous edemas as such does not permit a case to be allotted to stage IV. |
IVa - Tumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvis. | |
IVb - Spread to distant organs. |
In addition, the FIGO staging system incorporates a modified WHO prognostic scoring system. The scores from the eight risk factors are summed and incorporated into the FIGO stage, separated by a colon (e.g., Stage II:4, Stage IV:9, etc.). Unfortunately, a variety of risk scoring systems have been published, making comparisons of results difficult.
- FIGO Committee on Gynecologic Oncology.: Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet 105 (1): 3-4, 2009.
- Vagina. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 387-9.
In this article
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http:// cancer .gov or call 1-800-4-CANCER.
WebMD Public Information from the National Cancer Institute


text:
Copies of the "The Casual Vacancy" by Rowling have hit bookstores in London.
LONDON: British bookshops opened their doors early Thursday and some grown-up Harry Potter fans lined up overnight as J.K. Rowling launched her long-anticipated first book for adults, "The Casual Vacancy." The lines were shorter and the wizard costumes missing, but the book was published to some of the same fanfare that greeted each Potter tome, with stores wheeling out crates of the books at precisely 8 a.m.
Published five years after the release of the last book in the boy wizard saga, "The Casual Vacancy" is already at No. 1 on Amazon's U.S. chart, and bookmaker William Hill put 2/1 odds on it outselling "Harry Potter and the Deathly Hallows," which shifted 2.6 million copies in Britain on its first day.
Many of the early buyers were Harry Potter fans who, like the author, have moved on to more adult fare.
"I just like how much excitement there is about a book," said 23-year-old Grace Proctor, a "massive" Potter fan who was first to buy the book at one London store.
"I think there are going to be people who will hate it just because they can hate it," she said. "But she's such an amazing writer, I don't think she can go wrong."
A story of ambition, poverty, politics and rivalry set in the fictional English village of Pagford, the novel recounts the civic warfare sparked when the unexpected death of a town official leaves a vacancy on the governing body.
Rowling has said she was aiming for Dickensian sweep in the multi-character saga, whose doses of sex, satire and swearing mark a distinct departure from wholesome Harry.
First reviews of the novel for adults Thursday praised its scope and social message, but warned that the gritty and at times even obscene tale was a far cry from Hogwarts.
Several reviewers said they were taken aback to read grimy scenes of sex and drugs, but added the author's most vivid writing was on the familiar ground of adolescence.
"I had just read a passage written by the world's favorite children's author in which a teenager is raped by her mother's heroin dealer, a man who may well be the father of the girl's own three-year-old stepbrother, although it's hard to know for sure when the mum concerned is a prostitute," wrote Allison Pearson in the Daily Telegraph.
She added that "The Casual Vacancy" was "sometimes funny, often startlingly well observed, and full of cruelty and despair."
The Mirror branded it "Harry Potter and the Goblet of Filth," warning that the author famed for her stories of young wizards was "sure to face stern criticism for featuring the C-word and F-word hundreds of times."
In The Independent, Boyd Tonkin called it a "song of freedom" after Rowling's seven children's books, which made her the world's first billionaire author.
While decrying the novel's "clunkily satirical set-pieces," he said it "picks up passion, verve and even magic" when dealing with teenage characters.
"All the social and hormonal turbulence that the later Potter volumes had to veil in the euphemisms of fantasy appear in plain sight here," he wrote.
"The novel builds into a vividly melodramatic climax with these kids at its heart."
But the Guardian's reviewer Theo Tait labeled the edgier scenes "superficial excitements," saying the novel created a sense of "slight anti-climax" despite its "richly peopled, densely imagined world."
Writing in The Times, Erica Wagner said the book was founded on "the idea of the novel as a force for social good" but could be "a tiny bit dull."
For the Telegraph's reviewer, however, a top concern was the risk of the book falling into the wrong hands.
"In the coming days, along with thousands of parents around the world," she wrote, "I will have to do something that offends our best instincts: I will try to stop my children reading a book."
It's likely nothing Rowling publishes will ever match the success of the Potter books, which have sold more than 450 million copies around the world.
But booksellers are confident "The Casual Vacancy" will be one of the year's best sellers, whatever the reviewers say.
"A lot of children have grown up with Harry Potter. They're now adults who love books," said Susan Sinclair, divisional manager for the Foyles bookstore chain.
"I think it's going to be a really big seller at Christmas. It'll be an easy gift – but also a good one."
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subset: commoncrawl


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listings 1-20 of 20 | ||
Date | Title | |
May 2012 |
05-31-2012 |
Community Action Award Profile: Leela Khanna '15
What are Bard students up to this summer? Our Community Action Award winners are making a difference with internships and research projects. Leela Khanna '15, a political studies and human rights major, is interning at the Center for Social Research (CSR), a women's rights NGO in New Delhi. "Just knowing that my work has a potential to impact many lives and help [people] make important decisions will be a really rewarding experience," she says.
http://blogs.bard.edu/civicengagement/ |
05-30-2012 |
Bard Alumni Comedians Take on Surreal Challenge
These Bard alumni created a film that "stands on its own as a meditation on the uncomfortable truths, and unexpected joys, of creative collaboration." The comedy troupe Olde English—comprised of Caleb Bark '12, Raphael Bob-Waksburg '06, Joel Clark '05, Adam Conover '04, Ben Popik '05, and Dave Segal '05—premiered their collaborative film The Exquisite Corpse at the Dances With Films Festival in Hollywood.
http://turnstylenews.com/2012/05/30/comedians-olde-english-take-surreal-challenge-in-the-exquisite-corpse-project/ |
05-30-2012 |
A Bard Alum on the Forefront of Green Technology
What would it take to make faster computers and more efficient solar panels? Jesse Kohl '07 is looking for answers at the crossroads of nanotechnology and clean energy.
http://posterhall.org/igert2012/posters/286 |
05-23-2012 |
Bard Awarded $800,000 Science Grant
The college has been awarded $800,000 from the Howard Hughes Medical Institute for science education, building on the success of the Citizen Science Program.
http://www.bard.edu/news/releases/pr/fstory.php?id=2305 |
05-22-2012 |
What's Green on Campus?
Bard won the food composting division of the national Recyclemania contest, beating Middlebury and Princeton. The college has also signed a contract to eliminate most delivered water bottles on campus and replace them with inline filtration.
05-19-2012 |
This is the BGC: Bard Graduate Center Releases New Video
"Throughout history, humankind has made things—for survival and daily life, for celebration and ritual. Things of beauty, and things of power. These objects speak to us of creativity and ingenuity, needs and concerns, values and tastes. At the Bard Graduate Center, this evidence of human effort to give shape and meaning to the world provides a lens through which we can view larger cultural and historical questions, to better understand and appreciate our shared heritage."
http://vimeo.com/42559186 |
05-18-2012 |
Professor Harvey Fite's Opus 40 Celebrates Anniversary
Opus 40, the six-acre environmental sculpture park of the late Bard professor and alum Harvey Fite '30, celebrates the 50th anniversary of the central monolith sculpture tomorrow.
http://www.hudsonvalleyalmanacweekly.com/2012/05/17/opus-40-celebrates-monoliths-50th-anniversary-this-saturday/ |
05-18-2012 |
Scheetz Smashes School Record, Finishes Fourth at ECAC Championships
Bard College junior Perry Scheetz capped an amazing spring with a fourth-place finish in the 3,000-meter steeplechase at the ECAC Championships on Thursday. It marked the fourth time this spring that Scheetz broke her own school record in the event. She also broke the school record in the 5,000 meters this spring.
http://www.bardathletics.com/news/2012/5/18/WTRACK_0518120624.aspx |
05-16-2012 |
Hazel Gurland '99 Coproduces Two Episodes of Finding Your Roots
Hazel Gurland '99 made her debut as a television producer with two episodes of Finding Your Roots with Henry Louis Gates, Jr., featuring John Legend and Michelle Rodriguez.
http://www.pbs.org/wnet/finding-your-roots/video/ |
05-15-2012 |
Peter Dinklage to Appear in The Imaginary Invalid
The Emmy Award–winning actor Peter Dinklage of HBO's Game of Thrones will play Toinette in Bard SummerScape's The Imaginary Invalid, as part of an all-male cast directed by Erica Schmidt.
http://myemail.constantcontact.com/Peter-Dinklage-to-Appear-as-Toinette-in-The-Imaginary-Invalid.html?soid=1107007864236&aid=slx97CIu7mU |
05-15-2012 |
An Interview with Thaddeus Strassberger, Director of The King in Spite of Himself at This Year's Bard SummerScape
"Bard is one of the few places where you can really see that level of commitment. The amount of rehearsal time and resources that are dedicated to the chorus is really special and unique and certainly keeps me coming back for more." —Thaddeus Strassberger
http://fishercenter.bard.edu/summerscape/2012/opera/videos/ |
05-14-2012 |
Riveted: The Obsession Issue of Bard's Literary Journal Conjunctions Now Available
Mesmerists and hoarders. Conspiracy theorists and martyrs. Fetishists and addicts. Saints and sinners. Riveted explores the idea of obsession, the world of fixation, the idée fixe.
http://www.conjunctions.com/addit.htm |
05-14-2012 |
Tessellations and Sidewalk Chalk: Bard Math Circle Works with Local Children
Bard Math Circle's last event of the year took place last weekend, and found Bard math students and local schoolchildren drawing tessellations with sidewalk chalk at the Kingston Library.
http://bardmathcircle.blogspot.com/2012/05/chalk-walk-and-tessellations-at.html |
05-14-2012 |
Bard Center for Civic Engagement Announces Community Action Award Winners
Nearly 40 students will receive Bard's Community Action Awards for internships, community projects, and research. The newly created awards fund student efforts to engage with communities locally, nationally, and internationally.
http://blogs.bard.edu/civicengagement/2012/05/14/community-action-award-winners/ |
05-10-2012 |
Bard Receives $50,000 Luce Exploration Grant for Environmental Studies in Asia
Bard College has been awarded an exploration grant of $50,000 from the Henry Luce Foundation through the Luce Initiative on Asian Studies and the Environment (LIASE) for the project Slow Water: Rivers and Community in Asia.
http://www.bard.edu/news/releases/pr/fstory.php?id=2292 |
05-10-2012 |
Student-Athletes Honored at Annual Banquet
Students received awards in categories ranging from sportsmanship and civic engagement to achievement as scholars and team leaders.
http://www.bardathletics.com/news/2012/5/9/GEN_0509125214.aspx |
05-09-2012 |
Bill T. Jones/Arnie Zane Dance Company in Residence at Bard in May
This season, as part of the Bill T. Jones/Arnie Zane Dance Company Residency, Company members will teach students in the Bard Dance Program and perform with them in new and developing works.
http://www.bard.edu/news/releases/pr/fstory.php?id=2291 |
05-07-2012 |
Leading a Student into the World: Senior Project Explores Crisis in Education
Steven Tatum's Senior Project explores the crisis in education, in the spirit of Hannah Arendt. "I did research in [Arendt's] personal library, read her letters, spoke with people who knew her, and sat by her grave. ... These experiences have done more than add personal touches to my research; they resonate with the content of this project in the sense that they have lead me to a deeper awareness of and appreciation for the world that I am entering."
http://www.hannaharendtcenter.org/?p=5575 |
05-04-2012 |
Bard Mourns Passing of Alumnus Adam Yauch '86, Beastie Boys Cofounder
Bard alumnus Adam Yauch '86 has passed away at the age of 47 after a battle with cancer. The Bard community mourns this loss. We are proud to have honored Adam last year at Commencement with the Kellogg Award in the arts.
http://www.rollingstone.com/music/news/beastie-boys-co-founder-adam-yauch-dead-at-48-20120504 |
05-01-2012 |
Bard SummerScape 2012 Revives Two Neglected Operas of Belle Époque France
Reviving important but neglected operas is one of the ways the Bard SummerScape festival paints a faithfully-nuanced portrait of each past age, and this year's exploration of "Saint-Saëns and His World" is no exception.
http://www.21cmediagroup.com/mediacenter/newsitem.php?i=936 |
listings 1-20 of 20 |


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My Personality According to Emergenetics
I don't think about my personality very much. As far as I can tell, it's an amalgam of North Texas friskiness blended with Boulder-based elitism. As part of my job, I had to take an Emergenetics assessment to determine my work preferences.
Here are the results:
I am blue/green, meaning I prefer analysis and structure. Given my aptitude and obsession with technology and general geekery, it makes a lot of sense. In a work setting, I am best suited for research and mapping out the best way to approach something step-by-step.
It also means I'm a robot.
My total lack of social preference kinda freaks me out and only reinforces my "I AM A ROBOT" hypothesis. Has anyone else taken an Emergenetics assessment? Are there any other robots out there?
References (2)
Response: his comment is hereFantastic Website, Maintain the wonderful work. Thanks!
Response: online successMy Personality According to Emergenetics - Ef Rodriguez - Copywriting, digital/social strategy, event director


text:
Man pleads guilty to threat of blowing up Shorewood apartments
MILWAUKEE - A man has pleaded guilty to threatening to blow up an apartment building in Shorewood.
Thomas Yela now awaits his sentence.
When prompted Monday in a Milwaukee courtroom to make his plea to Judge Dennis Moroney, he quietly said, "Guilty."
The threat came in August.
600 people had to evacuate, with some people running from their homes, afraid for their lives.
But Yela admits it was a hoax.
Investigators say Yela admitted he called in the threat because he claimed that the apartment manager disrespected the people who live there.
Police said Yela did not live there, but his mother used to.
Yela also threatened to blow up the Locust Street bridge.
He shall remain behind bars until his sentencing hearing on January 31st.


text:
Woman wearing pantyhose on head tries to rob hardware store
UPDATED 7:01 PM EDT Jul 01, 2013A hardware store owner though she was being pranked when a woman wearing pantyhose on her head tried to rob a hardware store in Volusia County.
Video TranscriptTHE OWNER OF A HARDWARE STORE IN VOLUSIA COUNTY THOUGHT HE SHE WAS BEING PRANKED. NADINE SAYS SHE SAW THE SUSPECT HIDING IN A AISLE IN A GET-UP THE VICTIM SAYS IS SO REDICK SHE LAUGHED. THE 54 WAS ALLEGEDLY WEARING PANTYHOSE WITH THE LEGS CUT OFF AN UNFORGETTABLE RED AND WHITE POLKA DOT TOP. I THOUGHT IT WAS ONE OF MY CUSTOMERS PLAYING A JOKE. UNTIL I LOOKED DOWN AT HER ARM AND NFBLG HER HAND WAS A KNIFE. THE VICTIM SAYS WILL KENSON GRABBED HER, THREATENED HER WITH A KNIFE AND DEMANDED MONEY.
The views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


text:
ClassicsOnline Home » SARASATE, P. de: Violin and Piano Music, Vol. 1 (Tianwa Yang, Hadulla)
Among the great virtuoso violinists of his generation, Pablo Sarasate not only inspired concertos and other works for solo violin from leading contemporary composers, but demonstrated his incredible skill in a series of compositions based on dances from his native Spain. This recording is devoted principally to works of this kind, in which he made full use of his own incomparable technical command of the instrument. In 2004 the violinist Tianwa Yang was awarded the prize of Best Young Violinist in China by Seiji Ozawa.
By Giv Cornfield The New Recordings, Cliffs Classics 01-Aug-2006
By Stephen Chin Stringendo 01-Oct-2008
All charm and no harm. Sarasate never wanted to write extended serious works and produced many gems working within the Romantic Spanish idiom. The dances on this disk are perhaps his most loved and feted. Perhaps the extended Balada steps more into the slightly serious realm and this is a welcome work as many other compilations omit it. The real star, however, is Tianwa Yang who plays with an almost superhuman command of every pyrotechnical flourish. There certainly is not the slightest hint of struggle from this violinist who recorded all the Paganini Caprices when just thirteen years of age. Each track simply abounds with taste, flair and a refined humanity that makes this most generous anthology compelling listening.
By Anthony Clarke Limelight Magazine 01-Nov-2006
Last Albums Viewed
SARASATE, P. de: Violin and Piano Music, Vol. 1 (T...


text:
Fruit Gardener Magazine CRFG Fruit Facts Plant/Tree Descriptions
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Join CRFG Or Renew Your Membership Add New Excitement to Your Gardening
Join CRFG online using PayPal for safe and secure payment. Or print the form below, fill it out and mail it, along with a check or money order in U.S. dollars for the correct dues amount to the address at the bottom. Memberships are for individuals/couples and begin from the date dues are received. Each membership, annually, receives six bimonthly issues of the Fruit Gardener magazine. *** Note New Rates ***
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Electronic deliver currently consists of an Adobe Acrobat email attachment. The attachment is quite large and a high-speed Internet connection is strongly suggested. The free Adobe Acrobat Reader is required.


text:
I'm James, I'm gay and awesome, nerdy, and that's it, go away with you now. D:<
Chances are if I don't have a conversation with you I'm not adding you. >__>
Also I delete profile comments a lot.
Favorite animes/mangas:
Deadman wonderland, Battle royale, Umineko, Higurashi, Soul Eater, Flcl.
Some pictures of me
"Haha! That was awful! Ok bye! Bye again! Bye!"
Viewing 12 of 37 friends
Please enter your journal title here
Just everyday life.
Questing: Adventure time items. 64/66
Last items: Gunter, and beemo
My adventure time quest thread, come chat and <3 my thread
My hoodie is awesome tip/donate? xD


text:
Negative Pressure Wound Therapy
Negative Pressure wound therapy is a convered benefit with conditions.
Authorization requirements
Is authorization required? |
How do I get pre-authorization? |
Yes |
L&I (State fund): By phone: To get the claim manager's phone number, call the Claim Information line (800-831-5227) By secure email: If you are the attending physician, IME, or concurrent care provider, log into to the Claims & Account Center (CAC) |
Self-insured: |
Related information on coverage and treatment
- Coverage decision: Negative pressure wound therapy. (Effective Date: December 1, 2013).
Billing and payment policies
- 2013 MARFS Billing & Payment Policies, Updates & Corrections (See fee schedule correction dated: October 24, 2013).
Related rules
- Treatment requiring authorization. WAC 296-20-03001.
- Medical coverage decisions. WAC 296-20-02700-02850.


text:
The preceding chapter outlines a standard for assembling evidence that requires access to potentially useful sources of information; the blending of theory, expert opinion, experience, and local wisdom; the availability of scientifically trained staff or colleagues skilled in using these resources; a time window that allows for the process
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
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OCR for page 159
Opportunities to
Generate Evidence
• The evidence base to inform decisions about obesity prevention is extremely limited, even taking into
account the expanded view of evidence proposed in this report (Chapter 5). Each step in the L.E.A.D.
framework can provide important insights about the types of evidence that are needed.
• In obesity prevention–related research, the evaluation of ongoing and emerging initiatives is of particu-
lar priority.
• Future research on obesity prevention, and in public health more generally, can employ a broad array of
study designs that support valid inferences about the effects of policies and programs without experi-
mentation, promoting transdisciplinary exchange.
• Published peer-reviewed reports on the results of obesity prevention efforts often lack useful information
related to generalizability to other individuals, settings, contexts, and time frames, adding to the problem
of incomplete evidence for decision making.
• If obesity prevention actions must be taken when evidence is limited, the L.E.A.D. framework calls for
developing credible evidence about those actions for use in decision making about future efforts, includ-
ing the use of natural experiments, and emerging and ongoing programs through "evaluability assess-
ments" and continuous quality assessments.
T he preceding chapter outlines a standard for assembling evidence that requires
access to potentially useful sources of information; the blending of theory, expert
opinion, experience, and local wisdom; the availability of scientifically trained staff or
colleagues skilled in using these resources; a time window that allows for the process
OCR for page 159
of locating, evaluating, and assembling evidence; and, most important, the existence
of relevant evidence. Use of the L.E.A.D. framework to broaden what is considered
useful, high-quality evidence and to gradually increase the availability of such evi-
dence will help in attaining this standard. Together with the importance of taking a
systems approach and making the best possible use of diverse types of evidence that
are relevant to the user's perspective and the question being asked, a major emphasis
of this report is the urgent need to generate more evidence to inform efforts to address
obesity prevention and other complex public health problems. Much of what is called
for in the framework will meet the expectations and needs of decision makers when
sufficient evidence exists, although clearly such is not yet the case (see Chapter 3). On
the other hand, failure to find relevant evidence may either (erroneously) reinforce
the perception that effective interventions cannot be identified, or increase skepticism
or resistance on the part of decision makers—who must proceed in the interim—with
respect to the utility of incorporating evidence into their decision-making process. As
described in Chapter 7, when decision makers face choices that must be made and
actions that must be taken in the relative absence of evidence, or at least on the basis
of inconclusive, inconsistent, or incomplete evidence, the L.E.A.D. framework calls for
critical evaluation and systematic building on experience in a continuous translation,
action, monitoring, surveillance, and feedback loop (i.e., matching, mapping, pooling,
and patching; see Appendix E for more detail).
The purpose of this chapter is to motivate researchers and others whose pri-
mary role is to generate (i.e., support, fund, publish) evidence to adopt the L.E.A.D.
framework as a guide to identifying and generating the types of evidence that are
needed to support decision making on obesity prevention and other complex public
health problems (see Figure 8-1). The focus is on evidence related to "What" and
"How" questions, that is, evidence demonstrating the types of interventions that are
effective in various contexts; what their impacts are; and which are relatively more or
less effective, whether they are associated with unexpected benefits or problems, and
what practical issues are involved in their implementation. As noted in Chapter 3 and
defined in Chapter 5, these concerns point to areas in which a lack of evidence is most
likely to be problematic. This chapter also anticipates a cycle that begins with plan-
ning from incomplete evidence, blended with theory, expert opinion, experience, and
local wisdom (see Chapter 7), and ends with evaluating the consequences of interven-
tions. Such a cycle, in turn, may produce the most credible evidence for other jurisdic-
tions seeking practical models to emulate.
The chapter begins by briefly reviewing existing evidence needs and outlining
the need for new directions in evidence generation and transdisciplinary exchange.
It then addresses the limitations in the way evidence is reported in scientific journals
and the need to take advantage of natural experiments and emerging and ongoing
interventions as sources of practice-based evidence to fill the gaps in the best avail-
able evidence. The chapter concludes with a discussion of alternatives to randomized
Bridging the Evidence Gap in Obesity Prevention
OCR for page 159
Specif y
Identify and gather the
t ypes of evidence that are
potentially relevant to the
Apply standards of qualit y
as relevant to different
Evidence t ypes of evidence
Select and summarize the
Assemble relevant evidence according
to considerations for its use
Inform Use evidence in the
decision-makin g process
FIGURE 8-1 The Locate Evidence, Evaluate Evidence, Assemble Evidence, Inform Decisions (L.E.A.D.) framework for obesity
prevention decision making.
NOTE: The element of the framework addressed in this chapter is highlighted.
Figure 8-1.eps
experiments, with a focus on the level of certainty of the causal relationship between
an intervention and the observed outcomes.
The generation of evidence related to interventions and their effectiveness can be
approached through evaluation research, where evaluation is defined as "a systematic
assessment of the quality and effectiveness of an initiative, program, or policy . . ."
(IOM, 2007, p. 26). As explained in Chapter 1, the 2007 Institute of Medicine (IOM)
report Progress in Preventing Childhood Obesity, which is current through 2006,
strongly emphasizes the need for evaluation of ongoing and emerging initiatives. The
committee that produced the report found that, in response to the urgency of the
problem of childhood obesity with respect to prevalence and economic costs, numer-
ous efforts were being undertaken on the basis of what was already known from
theory or practice. Given the inherent relevance of implemented programs to natural
settings, such spontaneous or endogenous interventions may be of most interest to
Opportunities to Generate Evidence
OCR for page 159
decision makers. However, many of these programs are not evaluated. Issues for con-
sideration in increasing the use and appropriateness of such evaluation, taken from the
2007 IOM committee's assessment, are shown in Box 8-1.
A working group convened by the National Heart, Lung, and Blood Institute of
the National Institutes of Health (NIH) also has made several recommendations for
research needs related to the prevention of child obesity, many of which are directly
relevant to the types of population-based approaches addressed in this report (Pratt
et al., 2008). Several of these recommendations are listed in Box 8-2. Consistent with
the issues highlighted by the 2007 IOM committee, the NIH recommendations include
the evaluation of existing promising programs, as well as the conduct of studies of
multilevel and multicomponent interventions.
The examples in Box 8-2 relate specifically to child obesity. However, the need
for more evidence relevant to decision making is also recognized with respect to obe-
sity in adults and other complex public health problems. The Congressional Budget
Office (CBO), for example, has identified several areas in which having more evidence
would be helpful. CBO found some evidence on net cost reductions for certain disease
management programs, but it was unclear whether these strategies could be replicated
or applied in a broader population. In general, CBO found the availability of clinical
and economic research assessing and comparing treatments for preventive services to
be limited (CBO, 2008).
Box 8-1
Considerations for Increasing Evaluation of Obesity Prevention
• Evaluation is often not a priority for individuals and organizations that are developing a new policy, pro-
gram, or intervention.
• The time and resources needed to ensure appropriate baseline and outcome measures may not be avail-
able or allocated.
• Evaluation may seem too technically complex.
• Evaluation may not be identified as a responsibility of those undertaking the initiative.
• Evaluation outcomes are not always matched to the nature and stage of the program; e.g., intermediate
outcomes such as change in food intake, physical activity, or TV viewing may be more appropriate than
BMI (body mass index) for short-term programs.
• Evaluations of multiple, linked programs require collaborative efforts and systems approaches.
SOURCE: IOM, 2007, pp. 27-28.
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Box 8-2
Selected Recommendations for Research in Childhood Obesity
• Test interventions with physicians and other health care providers, combined with community involve-
ment (e.g., train physicians to screen, nurses to be coaches, and health care settings to refer to commu-
nity resources) (for young children).
• Conduct interventions in a variety of settings (e.g., home; child care; the U.S. Department of Agriculture's
Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; and health care set-
tings) (for young children).
• Examine multilevel and multicomponent, community-based interventions in multiple settings (e.g.,
schools, health care, home, community, built environment, public policy, social marketing, diet, physical
activity behaviors).
• Test a multilevel, comprehensive intervention that targets minority and low-income populations (e.g.,
culturally appropriate ways to reach Latino, African-American, Native American, and Asian/Pacific
Islander children).
• Develop and test interventions that can be incorporated effectively into existing school and community
infrastructures (e.g., curriculum, physical activity, school lunch programs) to maximize effectiveness and
minimize cost.
• Conduct intervention studies that address issues related to the interface between individual behaviors
and the environment.
Implementation, Dissemination, Translation, Evaluation
• Identify and test approaches for community partnerships in the dissemination and implementation of
evidence-based obesity-prevention programs.
• Evaluate the effectiveness of existing promising programs.
• Support methodological research on study designs and analytic approaches (identify optimal study
designs and analytic approaches for various types of research questions).
• Use appropriate study designs and methods, including natural experiments, quasi-experimental designs,
and randomized designs; develop time-sensitive funding mechanisms for natural experiments.
High-Risk Populations
• Study a diversity of high-risk and understudied subgroups, including low-income families, ethnically and
socioeconomically diverse populations, boys, and children in rural communities, as well as immigrants.
• Conduct environmental and policy intervention research to improve access to healthy foods and the
opportunity for physical activity in low-income communities.
Other Recommendations
• Analyze effectiveness–intervention studies for their cost-effectiveness.
SOURCE: Adapted and reprinted from Pratt et al., Copyright © 2008, with permission from Elsevier.
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The two methodological recommendations in Box 8-2 highlight one of the major
problems encountered by those who wish to generate policy- or program-relevant evi-
dence regarding population health problems such as obesity. These recommendations
refer to the need to identify optimal and appropriate study designs, including designs
that will allow for timely assessment of initiatives that constitute "natural experi-
ments" (detailed later in this chapter); quasi-experimental designs are mentioned in
addition to randomized designs. One major question raised by these recommendations
relates to the prevailing preference for randomized controlled trials (RCTs) in biomed-
ical science because of their advantages for drawing causal inferences: Are there good
alternatives to randomized designs that will accomplish the same thing but can be
implemented more flexibly in natural or field settings? (West et al., 2008). A related
question, also reflected in the considerations from the 2007 IOM report and the NIH
recommendations, is the complexity of many interventions conducted in the commu-
nity: To what degree do the multiple components of interventions need to be separated
to isolate their causal effects? In some, perhaps many, cases, the separation may be
artificial—the effectiveness of each component may be dependent on the others, and
the full treatment package may be of primary interest (West and Aiken, 1997). In
other cases, components may need to be deleted because of ineffectiveness or iatro-
genic effects or for cost-effectiveness reasons. Chapter 4 provides a fuller discussion of
these conceptual issues.
A more general issue is how experts who are trained in a particular research
approach can expand their capabilities for addressing issues that can be well stud-
ied only with different, less familiar approaches. For example, how do biomedical
researchers, who have traditionally conducted the research on obesity, become con-
versant with methods for evaluating evidence that may be available from other fields
and with the experts, or expertise, in implementing those methods? How do research-
ers in fields other than biomedicine—for example, education, community design, or
economics—become involved and expert in studying problems, such as obesity, some
aspects of which do not lend themselves to their typical methods? And how can obe-
sity researchers benefit from the scholarship of colleagues who have focused on differ-
ent, similarly complex public health problems, such as tobacco control?
Transdisciplinary exchange refers to researchers' use of a "shared conceptual
framework drawing together disciplinary-specific theories, concepts, and approaches
to address a common problem" (Rosenfield, 1992, p. 1351). Both the medical and
social sciences are challenged to expand their notion of methods and study designs
that can inform the study of obesity prevention and other population health problems
by considering contextual concerns (social, economic, environmental, institutional,
and political factors) that influence health outcomes. For example, NIH's National
Institute on Aging has supported a network or team approach to studying the "biolog-
ical, psychological and social pathways to positive and not-so-positive health" (Kessel
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and Rosenfield, 2008, p. S229); the result has been enhanced quality of published
research that crosses disciplinary lines. Funding agencies such as NIH have therefore
been encouraged to continue to support this type of research and urge researchers to
value collaboration and partnerships in a variety of fields.
Stimulated by a 2006 National Cancer Institute conference that highlighted the
need for transdisciplinary research in health, Kessel and Rosenfield (2008) describe a
number of factors that have both facilitated and constrained transdisciplinary science
(Table 8-1). The authors identified these factors from research programs that have
successfully crossed disciplinary boundaries. Reflecting the type of transdisciplinary
TABLE 8-1 Factors Facilitating and Constraining Transdisciplinary Team Science
Factor Facilitating Constraining
Focus on major PIs able to bring researchers together across Some areas seen as unrealistic
problems disciplines and program-unifying themes Lack of integrative research framework
Few "how-to" models
Team members Possess complementary and intersecting skills See skills as competitive
Able to develop common language Tension between solo and collaborative work
Positive open attitude Power–prestige differences social and medical
Appreciative of others' knowledge sciences
Shared understanding of scientific problem Worry about diffusion of focus and loss of identity
Mutual trust and respect Research seen as time-consuming/multiple projects
Open to mentoring Disincentive for practitioners
Sharing credit affects promotion, tenure,
publications, funding
Training Complementary training Historical barriers across fields
Mentored graduate students to participate in Location of departments
transdisciplinary research team Funding limited
SERCA grants for training in new field
Institutions Support, promote, and fund centers, networks, Rigid university policies
and teams across disciplines, departments, and Centers lack funds
medical and social science facilities on same
Technology Facilitate communication even when teams and
researchers physically dispersed
Funding Foundations and government support network/ Grant applications more challenging,
team approach (e.g., MacArthur, NIH) time-consuming
Publication Journals discourage multiple authors
Peer review hard to judge
Need to frame more narrowly
NOTE: NIH = National Institutes of Health; PI = principal investigator; SERCA = Special Emphasis Research Career Award.
SOURCE: Reprinted from Kessel and Rosenfield, Copyright © 2008, with permission of Elsevier; and Kessel and Rosenfield, page 401—
Table 19.3, "Fostering interdisciplinary innovation: The way forward" from "Expanding the boundaries of health and social science: Case
studies of interdisciplinary innovation" (2003), by permission of Oxford University Press, Inc.
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exchange that is needed among researchers, the final section of this chapter examines
alternatives to randomized experiments from the perspective of evaluation experts in
the behavioral sciences, economometrics, education, public health, and statistics and
explains why these alternatives are particularly important for obesity prevention (a
more detailed discussion of selected study designs is offered in Appendix E).
Decision makers (e.g., policy makers, professional caregivers, public health officials,
and advocates) have concerns beyond scientists' certainty of causal relationships in
judging the utility and persuasiveness of evidence (see Chapter 7). All of these con-
cerns fall to some degree under the broad rubric of generalizability (Garfield et al.,
2003; Glasgow et al., 2003, 2006; Green, 2001; Green and Glasgow, 2006; Green and
Lewis, 1981; Green et al., 1980; Shadish et al., 2002, Chapters 11-13). As described
in Chapter 5, the generalizability of a study refers to the degree to which its results
can be expected to apply equally to other individuals, settings, contexts, and time
frames. The generalizability of evidence-based practices is seldom considered in indi-
vidual studies or systematic reviews of the evidence, but is often decisive in decision
makers' adoption of research evidence for practical purposes such as obesity preven-
tion. Some authors have begun to make a regular practice of noting the "applicabil-
ity" of findings, with caveats when the range of populations or settings in which the
evidence from trials was derived is notably limited (Shepherd and Moore, 2008).
Others have proposed combining reviews of clinical and community evidence in a
more "ecologically comprehensive" (multimethod, multilevel) approach to the use of
evidence in such areas as tobacco and obesity control (Ockene et al., 2007). And some
journals have begun to make the generalizability of a study more of an issue in consid-
ering manuscripts (e.g., Eriksen, 2006; Steckler and McLeroy, 2008), on occasion with
qualifications and noted constraints (Patrick et al., 2008).
The usual manner of reporting results of obesity prevention efforts in journals
often adds to the problem of incomplete evidence because useful aspects of an inter-
vention and research related to its generalizability are not discussed. At a meeting
of the editors of 13 medical and health journals, several agreed to make individual
and joint efforts to devote more attention to issues of a study's generalizability and
to press for more reporting of (1) recruitment and selection procedures, participation
rates, and representativeness at the levels of individuals, intervention staff, and deliv-
ery settings; (2) the level of consistency with which the intervention being tested was
implemented in the study; (3) the impact on a variety of outcomes, especially those
important to patients, clinicians, program cost, and adverse consequences; and (4) in
follow-up reports, attrition of subjects in the study at all levels, long-term effects on
outcomes, and program institutionalization, modification, or discontinuation (Green
et al., 2009; supported by Cook and Campbell, 1979, pp. 74-80; Glasgow et al.,
2007; Shadish et al., 2002). These moves by journal editors relevant to obesity control
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hold promise for the greater relevance and usefulness of the published scientific litera-
ture for other decision makers, responding to some of their major concerns.
Specifically in childhood obesity prevention, Klesges and colleagues (2008)
examined studies published between 1980 and 2004 that were controlled, long-term
research trials with a behavioral target of either physical activity or healthful eating
or both, together with at least one anthropometric outcome. Using review criteria
for a study's generalizability to other individuals, settings, contexts, and time frames
(external validity) developed by Green and Glasgow (2006), they found that all of the
19 publications that met their selection criteria lacked full reporting on the 24 dimen-
sions of external validity expected in an optimal paper to enable users to judge poten-
tial generalizability (see Box 8-3). Median reporting over all elements was 34.5 per-
cent; the mode was 0 percent with a range of 0 percent to 100 percent. Only four
dimensions (descriptions of the target audience and target setting, inclusion−exclusion
criteria, and attrition rate) were reported in at least 90 percent of the studies. Most
infrequent were reports of setting-level selection criteria and representativeness,
characteristics of intervention staff, implementation of intervention content, costs,
and program sustainability. These limitations of individual studies are also seen and
sometimes multiplied in systematic reviews, such as meta-analyses, of whole bodies of
literature. The cumulative problems of inadequate reporting of sampling, settings, and
interventions have been noted, for example, in meta-analyses of the patient education
literature on preventive health interventions in clinical settings (Simons-Morton et al.,
1992; Tabak et al., 1991).
These findings provide strong support for the conclusion of Klesges and col-
leagues (2008) that the aspects of generalizability that potential users need most to see
reported more thoroughly in the published evidence are the "3 Rs": the representative-
ness of participants, settings, and intervention staff; the robustness of the intervention
across varied populations and staffing or delivery approaches; and the replicability of
study results in other places. The specific questions most decision makers will have
within these broad categories relate to cost (affordability); scalability; and acceptabil-
ity in particular populations, times, and settings.
Even with more complete reporting on these issues of a study's generalizability
to other populations, gaps will inevitably remain. RCTs can never fill all of the cells
in a matrix of potentially relevant evidence representing all combinations of a study's
dimensions of generalizability: population × setting × intervention × time × staffing ×
other resources. The empty cells in such a matrix require potential users of evidence
to make inferential leaps or more studied extrapolations from the existing coverage of
the evidence to their own population, setting, intervention, time, staffing, and other
resources. In short, users should bring to bear on their decisions their own theories or
assumptions about the fit of the evidence to their situation, which will vary along each
of the above dimensions.
A particular challenge for obesity prevention, as in some other areas of chronic
disease control, is the multiplicity and complexity of these dimensions. For each
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Box 8-3
Percentage of 19 Studies Reporting External Validitya
Dimensions, 1980-2004
External Validity Dimensionb Percent Reporting
Reach and Representativeness
Individual Participants
Description of targets 100
Individual inclusion/exclusion criteria 90
Participation rate 63
Representativeness 10
Description of targets 95
Setting inclusion/exclusion criteria 11
Participation rate 22
Representativeness 0
Delivery Staff
Participation rate 5
Implementation and Adaptation
Consistency of implementation 26
Staff expertise or training 89
Variations in implementation by staff 5
Program adaptation 42
Outcomes of Decision Making
Outcomes compared with goal 37
Adverse consequences 32
Moderation of effect by participant characteristic(s) 53
Moderation of effect by staff/setting 10
Number of sessions or time needed to deliver intervention 68
Costs 0
Maintenance and Institutionalization
Long-term effects (at least 12 months) 74
Program sustainability 0
Attrition rate 100
Differential attrition by condition tested 21
Drop-out representativeness 42
a External validity is defined according to Leviton (2001).
b See Green and Glasgow (2006) for a detailed description of coding dimensions.
SOURCE: Reprinted from Klesges et al., Copyright © 2008, with permission from Elsevier.
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intervention, for example, there will be a multiplicity of points of intervention, from
individuals to families, social groups, organizations, whole communities, regions, or
states, each calling for different sources or types of evidence. Complexity will further
confound the translation of evidence with respect to the projected time frame, even
across the lifespan, to account for variations in interventions that make them age-
appropriate and account for such relevant background variables as media coverage of
the issue, social discourse, and changing social norms.
This section examines the need to take advantage of natural experiments and emerg-
ing and ongoing interventions as sources of practice-based evidence to compensate for
the fundamental limitations of even the best available evidence.
Natural Experiments as Sources of Practice-Based Evidence
Rather than waiting for the funding, vetting, implementation, and publication of
RCTs (and other forms of research) to answer practical and locally specific questions,
one alternative is to treat the myriad programs and policies being implemented across
the country as natural experiments (Ramanathan et al., 2008). Applying more system-
atic evaluation to interventions as they emerge, even with limited experimental control
over their implementation, will yield more immediate and practice-based evidence
for what is possible, acceptable, and effective in real-world settings and populations.
What makes such evaluation of these natural experiments even more valuable is that
it produces data from settings that decision makers in other jurisdictions can view as
more like their own than the settings of the typical published trials. Seeing how other
state and local jurisdictions are performing in a given sphere of public concern also
may activate competitive instincts that spur state and local decision makers to take
The Centers for Disease Control and Prevention's (CDC's) Office on Smoking
and Health used this strategy of making comparisons across jurisdictions when
California and Massachusetts raised cigarette taxes and launched tax-based, com-
prehensive statewide tobacco control programs (see Chapter 4). Noting the acceler-
ated rates of reduced tobacco consumption in those states compared with the other
48 states, CDC collaborated with the two states to evaluate these natural experiments
and analyze their components (e.g., mass media, school programs) and the associated
costs. CDC then offered the per capita costs of each component as a recommended
basis for budgeting for other states wishing to emulate these successful programs
(CDC, 1999). Many of the states used these budgetary allocations, at least temporarily
before the tobacco settlement funds from the tobacco industry were diverted to gen-
eral revenue or other purposes.
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TABLE 8-2 Key Assumptions/Threats to Internal Validitya and Example Remedies for Randomized
Controlled Trials and Alternatives
Approaches to Mitigating the Threat
to Internal Validity
Assumption or Threat to Internal
Validity Design Approach Statistical Approach
Randomized controlled experiment
Independent units Temporal or geographical isolation Multilevel analysis (other statistical
of units adjustment for clustering)
Full treatment adherence Incentives for adherence Instrumental variable analysis (assume
exclusion restriction)
No attrition Sample retention procedures Missing data analysis (assume missing
at random)
Other treatment conditions do Temporal or geographical isolation of Statistical adjustment for measured
not affect participant's outcome treatment groups exposure to other treatments
Randomized encouragement design
Exclusion restriction No design approach yet available Sensitivity analysis
Regression discontinuity design
Functional form of the relationship Replication with different threshold; Nonparametric regression; sensitivity
between assignment variable and nonequivalent dependent variable analysis
outcome is properly specified
Interrupted time series analysis
Functional form of the relationship Nonequivalent control series in which Diagnostic plots (autocorrelogram;
for the time series is properly intervention is not introduced; spectral density); sensitivity analysis
specified; another historical event, a switching replication in which
change in population (selection), or intervention is introduced at
a change in measures coincides with another time point; nonequivalent
the introduction of the intervention dependent measure
Observational study
Measured baseline variables equated; Multiple control groups; Propensity score analysis; sensitivity
unmeasured baseline variables nonequivalent dependent measures; analysis; subgroup analysis; correction
equated; differential maturation; additional pre- and postintervention for measurement error
baseline variables reliably measured measurements
a Internal validity is defined as a study's level of certainty of the causal relationship between an intervention and the observed outcomes.
NOTE: SUTVA = stable unit treatment value assumption. The list of assumptions and threats to internal validity identifies issues that com-
monly occur in each of the designs. The alternative designs may be subject to each of the issues listed for the randomized conrolled trial in
addition to the issues listed for the specific design. The examples of statistical and design approaches for mitigating the threat to internal
validity illustrate some commonly used approaches and are not exhaustive. For the observational study design, the potential outcomes and
Campbellian frameworks study differ so that the statistical and design approaches do not map 1-to-1 onto the assumptions or threats to
internal validity that are listed.
SOURCE: West et al., 2008. Reprinted with permission. West et al., Alternatives to the randomized controlled trial, American Journal of
Public Health, 98(8):1364, Copyright © 2008 by the American Public Health Association.
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ness of individual components in multiple-component designs. West and Aiken (1997)
and MacKinnon (2008) also consider the statistical method of mediational analysis
that permits researchers to probe these issues, although in a less definitive manner.
Rubin's Perspective
Rubin's potential outcomes model takes a formal mathematical/statistical approach
to causal inference. Building on earlier work by Splawa-Neyman (1990), it empha-
sizes precise definition of the desired causal effect and specification of explicit, ideally
verifiable assumptions that are sufficient to draw causal inferences for each research
design. Rubin defines a causal effect as the difference between the outcomes for a
single unit (e.g., person, community) given two different well-defined treatments at the
identical time and in the same context. This definition represents a conceptually useful
ideal that cannot be realized in practice.
Holland (1986) notes that three approaches, each with its own assumptions,
can be taken to approximate this ideal. First, a within-subjects design can be used in
which the two treatments (e.g., intervention, control) are given to the same unit. This
design assumes (1) temporal stability in which the same outcome will be observed
regardless of when the treatment is delivered and (2) causal transience in which the
administration of the first treatment has no effect on the outcome of the second treat-
ment. These assumptions will frequently be violated in research on obesity. Second,
homogeneous units can be selected or created so that each unit can be expected to
have the same response to the treatment. This strategy is commonly used in engi-
neering applications, but raises concern about the comparability of units in human
research—even monozygotic twins raised in similar environments can differ in impor-
tant ways in some research contexts. The matching procedures used in the potential
outcomes approach discussed below rely on this approach; they assume that the units
can indeed be made homogeneous on all potentially important background variables.
Third, units can be randomly assigned to treatment and control conditions. This strat-
egy creates groups that are, on average, equal on all possible background variables at
pretest so that the difference between the means of the two groups now represents the
average causal effect. This strategy makes several assumptions (see Table 8-2; Holland,
1986; West and Thoemmes, 2010), including full treatment adherence, independence
of units, no attrition from posttest measurement, and the nondependence of the
response of a unit to a treatment on the treatment received by other units (or SUTVA,
the stable unit treatment value assumption). The SUTVA highlights the challenges in
community research of considering possible dependence between units and possible
variation in each treatment across sites (Rubin, 2010). Well-defined treatment (and
no-treatment) conditions that are implemented identically across units are a key fea-
ture of strong causal inference in Rubin's perspective. Hernan and Traubman (2008)
discuss the importance of this assumption in the context of obesity research. Beyond
requiring this set of foundational assumptions, randomization has another subtle
effect: it shifts the focus from a causal effect defined at the level of the individual to an
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Box 8-4
Design Elements Used in Constructing Quasi-Experiments
Assignment (control of assignment strategies to increase group comparability)
• Cutoff-based assignment: controlled assignment to conditions based solely on one or more fully measured covariates; this
yields an unbiased effect estimate.
• Other nonrandom assignment: various forms of "haphazard" assignment that sometimes approximate randomization (e.g.,
alternating assignment in a two-condition quasi-experiment whereby every other unit is assigned to one condition).
Measurement (use of measures to learn whether threats to causal inference actually operate)
• Posttest observations
− Nonequivalent dependent variables: measures that are not sensitive to the causal forces of the treatment, but are
sensitive to all or most of the confounding causal forces that might lead to false conclusions about treatment effects (if
such measures show no effect, but the outcome measures do show an effect, the causal inference is bolstered because
it is less likely due to the confounds).
− Multiple substantive posttests: used to assess whether the treatment affects a complex pattern of theoretical predicted
• Pretest observations
− Single pretest: a pretreatment measure on the outcome variable, useful to help diagnose selection bias.
− Retrospective pretest: reconstructed pretests when actual pretests are not feasible—by itself, a very weak design fea-
ture, but sometimes better than nothing.
− Proxy pretest: when a true pretest is not feasible, a pretest on a variable correlated with the outcome—also often
weak by itself.
− Multiple pretest time points on the outcome: helps reveal pretreatment trends or regression artifacts that might com-
plicate causal inference.
• Pretests on independent samples: when a pretest is not feasible on the treated sample, one is obtained from a randomly
equivalent sample.
• Complex predictions such as predicted interaction: successfully predicted interactions lend support to causal inference
because alternative explanations become less plausible.
average causal effect that characterizes the difference between the treatment and con-
trol groups. The ability to make statements about individual causal effects, important
in many clinical and health contexts, is diminished without additional assumptions
being made (e.g., the causal effect is constant for all individuals).
A key idea in Rubin's perspective is that of possible outcomes. The outcome of
a single unit (participant) receiving a treatment is compared with the outcome that
would have occurred if the same unit had received the alternative treatment. This idea
has proven to be a remarkably generative way of thinking about how to obtain precise
estimates of causal effects. It focuses the researcher on the precise nature of the com-
parison that needs to be made and clearly delineates the participants for whom the
comparison is appropriate. It provides a basis for elegant solutions to such problems
as treatment nonadherence and appropriate matching in nonrandomized studies (West
and Thoemmes, 2010).
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• Measurement of threats to internal validity:a helps diagnose the presence of specific threats to the inference that A caused
B, such as whether units actively sought out additional treatments outside the experiment.
Comparison groups (selecting comparisons that are "less nonequivalent" or that bracket the treatment group at the
• Single nonequivalent groups: compared with studies without control groups, using a nonequivalent control group helps
identify many plausible threats to validity.
• Multiple nonequivalent groups: serve several functions; for instance, groups are selected that are as similar as possible to
the treated group, but at least one outperforms it initially and at least one underperforms it, thus bracketing the treated
• Cohorts: comparison groups chosen from the same institute in a different cycle (e.g., sibling controls in families or last
year's students in schools).
• Internal (versus external) controls: plausibly chosen from within the same population (e.g., within the same school rather
than from a different school).
Treatment (manipulations of the treatment to demonstrate that treatment variability affects outcome variability)
• Removed treatments: shows that an effect diminishes if treatment is removed.
• Repeated treatments: reintroduces treatments after they have been removed from some group—common in laboratory
• Switched replications: treatment and control group roles are reversed so that one group is the control while the other
receives treatment, but the controls receive treatment later, whereas the original treatment group receives no further treat-
ment or has treatment removed.
• Reversed treatments: provides a conceptually similar treatment that reverses an effect—for example, reducing access for
some students to a computer being studied by increasing access for others.
• Dosage variation (treatment partitioning): demonstrates that an outcome responds systematically to different levels of
a Internal validity denotes the level of certainty of the causal relationship between an intervention and the observed outcomes.
SOURCE: Reprinted, with permission. Shadish and Cook, 1999. Copyright © 1999 by the Institute of Mathematical Statistics.
Other Perspectives on Causality
Other perspectives on causal inference exist. In economics, Granger (1988; Granger
and Newbold, 1977; see also Bollen, 1989, in sociology and Kenny, 1979, in psychol-
ogy) argues that three conditions are necessary to infer that one variable X causes
changes in another variable Y:
• Association—The two variables X and Y must be associated (nonlinear associa-
tion is permitted).
• Temporal precedence—X must precede Y in time.
• Nonspuriousness—X contains unique information about Y that is not available
elsewhere. Otherwise stated, with all other causes partialed out, X still pre-
dicts Y.
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This perspective can be particularly useful for thinking about causal inference when X
cannot be manipulated (e.g., age), but is typically less useful for studying the effects of
interventions. The primary challenge is how one can establish nonspuriousness, and
Granger's perspective provides few guidelines in this regard relative to the Campbell
and Rubin perspectives.
A second class of perspectives, founded in philosophical and computer science,
takes a graph theoretic approach. In this approach, a complex model of the process is
specified and is compared with data. If the model and its underlying assumptions are
true, the approach can discern whether causal inferences can be supported. Within this
approach, a computer program known as Tetrad (Spirtes et al., 2000) can identify any
other models involving the set of variables in the system that provide an equally good
account of the data, if they exist. In separate work, Pearl (2009) has also utilized the
graph theoretic approach, developing a mathematical calculus for problems of causal
inference. This approach offers great promise as a source of understanding of causal
effects in complex systems in the future. Compared with the Campbell and Rubin
approaches, however, to date it has provided little practical guidance for researchers
attempting to strengthen the inferences about the effectiveness of interventions that
can be drawn from evaluation studies.
How Well Do Alternative Designs Work?
Early attempts to compare the magnitude of the causal effects estimated from RCTs
and nonrandomized designs used one of two approaches. First, the results from an
RCT and a separate observational study investigating the same question were com-
pared. For example, LaLonde (1986) found that an RCT and nonrandomized evalua-
tions of the effectiveness of job training programs led to completely different results.
Second, the results of interventions in a research area evaluated using randomized and
nonrandomized designs were compared in a meta-analytic review. For example, Sacks
and colleagues (1983) compared results of RCTs of medical interventions with results
of nonrandomized designs using historical controls, finding that the nonrandom-
ized designs overestimated the effectiveness of the interventions. A number of studies
showing the noncomparability of results of RCTs and nonrandomized designs exist,
although many of the larger meta-analyses in medicine (Ioannidis et al., 2001) and the
behavioral sciences (Lipsey and Wilson, 1993) find no evidence of consistent bias.
More recently, Cook and colleagues (2008) compared the small set of random-
ized and nonrandomized studies that shared the same treatment group and the same
measurement of the outcome variable. All cases in which an RCT was compared with
a regression discontinuity or interrupted time series study design (see Appendix E for
discussion of these study designs) showed no differences in effect size. Observational
studies produced more variable results, but the results did not differ from those of
an RCT given that (1) a control group of similar participants was employed or (2)
the mechanism for selection into treatment and control groups was known. Hernán
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and colleagues (2008) considered the disparate results of an RCT (Women's Health
Initiative) and an observational study (Nurses' Health Study) of the effectiveness of
postmenopausal hormone replacement therapy. When the observational study was
analyzed using propensity score methods with participants who met the same eligibil-
ity criteria and the same intention-to-treat causal effect was estimated, discrepancies
were minimal. Finally, Shadish and colleagues (2008) randomly assigned student par-
ticipants to an RCT or observational study (self-selection) of the effects of math or
vocabulary training. They found little difference in the estimates of causal effects after
adjusting for an extensive set of baseline covariates in the observational study.
The results of the small number of focused comparisons of randomized and
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RAGBRAI news team
Riding to remember: Carter LeBeau honored Friday
Thu, Jul 24, 2014 | by Timothy Meinch
MASON CITY, Ia. – The deaths of notable figures from the four decades of the Register's Annual Great Bicycle Ride Across Iowa often have triggered a similar grieving process for families and teammates: a time to weep, a time to laugh, a time to mourn — and then a time to bike hundreds of miles.
Today, the RAGBRAI pedaling parade will include a blur of mismatched pinstripe socks (at minimum, the 1,000pairs that sold out Thursday) in honor of Carter LeBeau, a Davenport biking guru who died in August at age 87.
RAGBRAI has always drawn riders who trek in memory of a fallen friend or relative, and LeBeau is one of several well-known cycling figures being honored this year.
LeBeau was one of only eight people to participate in RAGBRAI for 40 years straight since its start in 1973. And every mile he sported the vintage soccer socks.
"He wanted to have something that set him apart," Carter's widow, Kaye LeBeau, 74, said this week. She has pedaled every day of this year's RAGBRAI with Carter's daughter, Carol. And both are wearing the iconic socks.
"I feel like he's still with me and encouraging me along the way," Kaye said.
Carter LeBeau's resume of adventurous undertakings is nothing short of extraordinary, with bricks such as hiking to the base of Mount Everest, jogging the Grand Canyon and biking across the United States.
LeBeau's biking days did not begin until well into his 40s, after a scary scuba diving accident in the Cayman Islands, said Carol LeBeau, one of the three children LeBeau raised with his first wife, Dorothy, who died in 1980.
Carter ran out of oxygen while searching for a missing dive buddy at a depth of 100feet. He had to surface rapidly, without proper decompression, and suffered a bad case of the bends.
It was a slow recovery, after weeks in a decompression tank, without feeling in his feet and lack of control in extremities. His scuba buddy was never found.
Therapy doctors pointed LeBeau to cycling, which he embraced like everything else in his life.
"Dad did everything like a million percent," Carol said.
Family members say RAGBRAI merged perfectly with his extroverted personality. But it wasn't enough, and he went on to organize about a half-dozen other annual rides, like the Other Great Iowa Ride, the Bicycle Early Agricultural Roads ride, and another that visited numerous college campuses across Iowa.
Carter was hardly a gear head, according to family members, who recall him frequently saying "a red one" when asked what kind of bike he rode.
"He just loved meeting people and riding," said his son, Carter Jr., who planned to join RAGBRAI today with his sons.
Carter Jr. rode with his father on the second RAGBRAI, at the age of 14. But this year marks the first for Carol, who has gained a new understanding of her dad's legacy this week.
"It's just been like, 'Wow. Dad's a statewide celebrity,'" she said.
Road bike, clothes recall cycling legend
As a kid, "RAGBRAI" and "Team Breedlove" were everyday words for Joseph Leaming, 31, long before he knew what they meant.
Leaming's grandfather, John Gooding of West Des Moines, was a mechanic and dear friend to Bob Breedlove, a hall-of-fame ultracyclist from Des Moines who was hit by a car and died while competing in his sixth Race Across America in 2005. Leaming, now 30 and an avid hobby cyclist in Des Moines, has since become well acquainted with the Breedlove name and career.
This week he is tackling his first RAGBRAI on one of Breedlove's road bikes, a 1989 titanium Panasonic. The bike was a Father's Day gift from his grandfather two years ago, something Leaming describes as a sort of rite of passage or stamp of approval.
"I think I finally passed a point where I was serious enough," said Leaming. "It is probably one of the best gifts I ever had."
Leaming recalls frequent encounters from his childhood with Breedlove.
"Dr. Breedlove would come over and take naps on my grandpa's couch after grandma made his lunch," Leaming said.
The habit went hand in hand with Breedlove's careers as an on-call surgeon and as an ultracyclist, which included five separate races, roughly 10 days each, that spanned the country from West Coast to East.
As for his RAGBRAI connection, he was known to traverse the entire route in one day.
Now Leaming, who is also wearing Breedlove's old bike clothes, says he is realizing a much deeper appreciation for the legend and family friend.
"It's pretty eerie how well it fits," he said. "There have been moments for sure out there on the road by myself, head down, pedaling, that I feel my grandpa with me, who is still alive, and the spirit of Bob digging in."
Since starting RAGBRAI this week, multiple mechanics have recognized Leaming's bike and inquired about it.
"Usually they'll know Bob and my grandpa," Leaming said, noting that he's collected some new stories about the old Breedlove team.
Team Gourmet missing a member
Team Gourmet, a RAGBRAI team since 1996, could have amended its running slogan "It's all about the food" for just this year.
Because this year, the ride is very much about Wayne Santi, the team's founder, who died of heart failure at the age of 65 in October.
"We're definitely grieving through this ride," said Santi's daughter, Carrie Santi DeLucchi, a 15-year RAGBRAI veteran.
Her father died three days after her wedding in October.
A quadruple heart bypass more than a decade ago sidelined Santi from riding. But he embraced his role as food manager and planner for Team Gourmet, still traveling the route in a support vehicle with two chefs to plan and prepare an unforgettable nightly dinner.
"He showed us how to treat people and do this right," said team member Bruce Gaultney of Muskegon, Mich.
Each team member on Team Gourmet, which has been featured on the Food Network, carries wooden cooking spoons with catchphrases or memories on them. This year, many of them have inside jokes Santi started, or "Waynisms," like "More butter" or "Heather, another grape please."
The team, with about 35 riders, says they're carrying on the Santi tradition, which includes a ceremonial circle, prayer and grand presentation before every meal with host families.
But things have felt a bit different this year, said Elise Naught of Colorado Springs, Colo.: "It will never be the same without him."
4 Responses on "Riding to remember: Carter LeBeau honored Friday"
Chuck Offenburger
July 25, 2014 at 7:31 am
I'll be grinning all day remembering stories about my great pal Carter LeBeau! But the first one that comes to mind is always his advice in 1995 when we were getting ready to take 308 people on the Iowa 150 Bike Ride/A Sesquicentennial Expedition — a 100-day, 5,048-mile ride across the US. A lot of people were jittery about the arrangements and plans, including their own. Carter, who'd already done one trans-USA ride and lots of other tours, calmed everybody when he stood up at a meeting and announced: "Remember, it's just not an adventure if you know every detail in advance!" Godspeed & tailwinds to one of the most enthusiastic bicyclists ever, Carter LeBeau, and hello to all the LeBeaus out there riding today on RAGBRAI.
Deb Hanson
July 25, 2014 at 7:55 am
I had the pleasure of hosting Kaye and Carol on their stop in Mason City. (In fact, that's my house in the background.) Their stories of Carter were incredible. He must have been quite the man. Have a fantastic Friday remembering and honoring him!
Jimmer Pech
July 25, 2014 at 7:56 am
This Saturday morning, a mile north of Lamont, my mother Rosalea Pech will raise a United States flag to greet the RAGBRAI riders as they begin their trek through the hills of northeast Iowa. Three years ago this flag draped the casket of her husband, Don Pech, who loved this ride not only as a participant but also sagging for his son Jimmer, grandson James and granddaughter Katie. After Don's stroke 10 years ago one of things he often "wished he could do one more time" was to ride his bike with the people of RAGBRAI, and maybe through this flag he cannot have that wish.
John Keane
July 27, 2014 at 2:32 pm
I remember Carter well. The two of us rode across the U.S. together in 1981. We rode from Melbourne to Sydney Australia in 1988 and in lots of tailwind rides and RAGBRAIs. At the end of most days of riding we would buy a six pack and he would drink two cans and let me drink four. What a guy.
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