Promoting Million Hearts® Goals Using The Community Preventive Services Task Force Recommendations

A Focus on Risk Factors for Cardiovascular Disease

A CONVERSATION WITH:

John M. Clymer, Member, U.S. Community Preventive Services Task Force

Philip Huang, MD, MPH, Medical Director, Austin-Travis County Health and Human Services

August 28th, 2014

Community Preventive Services Task Force Findings on Effectiveness of Interventions:

1) To Prevent Cardiovascular Disease2) To Reduce Tobacco Use

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CONTEXT FOR EVIDENCE-BASED PUBLIC HEALTH

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Benefits of Basing Guidelines on Systematic Research Synthesis

Reliability • Move us beyond anecdote and selective use of scientific

evidence

Transparency • Reduce bias • Make assumptions and procedures clear

Synthesis • Streamline enormous amounts of data • Reconcile or explain variable results

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Benefits of Basing Guidelines on Systematic Research Synthesis

Reliability • Move us beyond anecdote and selective use of scientific

evidence

Transparency • Reduce bias • Make assumptions and procedures clear

Synthesis • Streamline enormous amounts of data • Reconcile or explain variable results

Systematic Reviews and Developing Recommendations

Systematic Review

Meta-analysis

Narrative Review

Evaluations of individual

programs

Individual Studies

Findings

Evaluation of evaluations

Recommend

Recommend against

Insufficient

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What Do Public Health Interventions Look Like?

Programs, services, and policies• Often implemented opportunistically to address perceived needs,

considering available resources• Seldom permit random allocation to intervention and control

conditions

Usually more “complex” than clinical interventions• Multiple facets that vary across locations• Often adapted to meet local needs and resources• Rarely implemented in isolation—several potential confounding

factors to consider• Results may depend on context

Potential for substantial health impact at a modest cost

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OBJECTIVES AND GUIDING PRINCIPLES OF THE COMMUNITY GUIDE

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The Community Guide*

Product of an independent US Task Force: Community Preventive Services Task Force

A focus on population-based interventions in:• Communities• Health care systems

Evidence-based recommendations and conclusions regarding use

*www.thecommunityguide.org

Topics for Community Guide Reviews (as of 2013)

Reviews Organized by EnvironmentHealth Equity Social EnvironmentReviews by Risk Behavior Reviews by Specific ConditionAlcohol abuse/misuse Cancer

Tobacco use Mental health

Poor nutrition Vaccine-preventable disease

Physical inactivity Violence

Unhealthy sexual behaviors Motor vehicle injuries

Cardiovascular disease prevention Diabetes

Oral health

Reviews Organized by Setting Reviews Organized by Life StageWorksite health promotion Adolescent healthSpecial ProjectsHealth communications Pandemic influenza

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2013 Community Preventive Services Task Force

Jonathan C. Fielding, MD, MPH, MBA Los Angeles County Dep. Of Public Health Barbara K. Rimer, DrPH University of North

Carolina Bruce N. Calonge, MD, MPH Colorado Trust Marshall Chin, MD, MPH, FACP University of Chicago John M. Clymer Alliance to

Make US Healthiest Karen Glanz, PhD, MPH University of

Pennsylvania Ron Goetzel, PhD Emory University Larry Green, DrPH UC San Francisco David Grossman, MD, MPH Group Health Cooperative Robert L. Johnson, MD UMD-New Jersey

Medical School Shiriki Kumanyika, PhD, MPH University of Pennsylvania C. Tracy Orleans, PhD Robert Wood Johnson Nico P. Pronk, PhD HealthPartners Gilbert Ramirez, DrPH West Virginia University Patrick Remington, MD, MPH University of Wisconsin

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Overarching Goals of the Community Guide

Develop evidence-based guidance on interventions to improve population health that is of maximum utility for decision-makers:

• Provide evidence-based recommendations• Assess economic efficiency• Highlight important evidence gaps

Issues Considered in Community Guide Reviews

Populationor

Group

IntendedOutcomes

(Behavior, Health)

ReducedMorbidity

andMortality

Intervention(policy or program)

Is the evidence applicable to “my population”?

Considerations for Implementation

Economic Efficiency BenefitsCosts

Additional Benefits?

Potential Harms?

?

?

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Task Force Findings Options

Recommend• Based on strong evidence• Based on sufficient evidence

Recommend against• Based on strong evidence• Based on sufficient evidence

Insufficient evidence to recommend for or against

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Example Logic Model: Strategies to Prevent CVD

CVD RiskConditionsPrevented /Reduced /Controlled

Biological

Behavioral

Environmental

Social Context

Health Care

Hyperlipidemia

Hypertension

Determinants Intermediate Health Outcomes

Interventions to Prevent CVD risk

conditions (and CVD)

Interventions to

Increase/Improve management of clients

with CVD

ReducedCVD

MorbidityAnd

Mortality

Diabetes

Interventions to Increase/ Improve control

of CVD Risk Conditions

Tobacco Use

Obesity

Physical Activity

Nutrition

Alcohol

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COMMUNITY PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS FOR CARDIOVASCULAR DISEASE

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Example Priorities List for Task Force Consideration: CVD Prevention

1. Interventions to improve hypertension control

2. CVD risk reduction interventions that bundle preventive services

3. Health system implementation/organizational variables and processes

4. Policies to reduce dietary sodium

5. Comprehensive Tobacco Control programs*

6. Community-based campaigns to increase awareness

7. Improved access to quality care for CVD

8. Setting-based CVD risk reduction interventions

9. Technology-enabled CVD risk reduction interventions

<Task Force consensus additions (if any)>

*Intervention review covered by CG Tobacco team

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Community Guide CVD Prevention Reviews

Intervention Description Task Force FindingTeam-based care (TBC)

A health systems intervention that uses a team—including primary care providers, other health professionals(usually nurses and pharmacists), and patients—working together to improve blood pressure control among patients at risk for CVD

Strong Evidence• Increased proportion of

patients with controlled BP • Reduced Systolic and

Diastolic BP

Reducing out-of-pocket costs (ROPC)

ROPC for medications to control high blood pressure and high cholesterol, when combined with additional policies or actions to improve patient–provider interaction and patient knowledge

Strong Evidence• Improved medication

adherence• Improved BP and cholesterol

outcomes

Clinical Decision-Support Systems (CDSS)

Computer-based information systems, specifically aimed at CVD prevention, designed to assist healthcare providers in implementing clinical guidelines at the point of care

Sufficient Evidence• Improved screening for CVD

risk factors by providers• Improving practices for CVD-

related preventive care, clinical tests, and treatments

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Community Guide Tobacco Use Reduction Reviews

Intervention Description Task Force FindingComprehensive Tobacco Control Programs

These programs are typically organized and funded at the state level in the U.S., providing a platform for effective implementation of core components such as mass-reach health communication interventions, state-wide cessation services, and partnerships with community-based coalitions and programs to pursue grassroots-level efforts to reduce tobacco use.

Strong Evidence• Reduced tobacco use

prevalence • Reduced tobacco product

consumption• Increased quitting• Reduced secondhand

smoke exposure• Reduced tobacco-related

morbidity and mortality

Increase the Unit Price of Tobacco Products

Public policies at the federal, state, or local level that increase the purchase price per unit of sale for tobacco products. The review considered excise tax through legislations or fees levied on tobacco products at the point of sale.

Strong Evidence• Reduced tobacco use

prevalence• Reduced tobacco product

consumption• Increased quitting• Reduced initiation of

tobacco use• Reduced tobacco-related

morbidity and mortality

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Community Guide Tobacco Use Reduction Reviews (contd.)

Intervention Description Task Force FindingSmoke-free Policies

Public-sector regulations and private-sector rules that prohibit smoking in indoor spaces and designated indoor and outdoor public areas.

Strong Evidence• Reduced secondhand

smoke exposure• Reduced tobacco use

prevalence • Reduced initiation of

tobacco use• Increased quitting• Reduced tobacco-related

morbidity and mortality

Mass-reach Health Communication Interventions

Interventions target large audiences through various media channels (TV, radio, print, out-of-home placements, digital) to change knowledge, beliefs, attitudes, and behaviors about tobacco use. Intervention messages are typically developed through formative research and broadcasted on TV, targeting both tobacco users and the general public.

Strong Evidence• Reduced tobacco use

prevalence• Increased use of

available services, e.g., quitlines

• Increased quitting• Reduced initiation of

tobacco use

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Community Guide Tobacco Use Reduction Reviews (contd.)

Intervention Description Task Force FindingQuitline Interventions

Evidence-based behavioral counseling offered via telephone to support tobacco users who want to quit. Quitlines typically offer proactive counseling (cessation specialists schedule follow-ups) that is widely accessible, convenient to use, and generally at no cost to callers.

Strong Evidence• Increased quitting

Reducing Out-of-Pocket Costs for Evidence-based Cessation Treatments

Policy or program changes that make evidence-based treatments more affordable. Benefit changes may be communicated to tobacco users and health care providers to increase use of these benefits in quitting efforts.

Strong Evidence• Increased quitting

Mobile Phone-based Cessation Intervention

Interventions use interactive features to deliver evidence-based information, strategies, and behavioral support directly to tobacco users interested in quitting. Messages are targeted to specific populations, tailored to specific users, or automated.

Sufficient Evidence• Increased quitting

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Community Guide CVD Prevention http://www.thecommunityguide.org/cvd/index.html

Community Guide Tobacco Use Reductionhttp://www.thecommunityguide.org/tobacco/index.html

Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) Division of Epidemiology, Analysis, and Library Services (DEALS)

Evidence-Based Recommendations Slides from the Community Preventive Services Task Force

Provided Courtesy of Anil Thota, MBBS, MPH

athota@cdc.govCommunity Guide Branch

Acknowledgement

Disclaimer

The findings and opinions expressed in this presentation are those of the presenters and the

Community Preventive Services Task Force. They may not represent the official positions of the Centers for

Disease Control and Prevention (CDC).

The Centers for Disease Control and Prevention provides

administrative, research, and technical support for the Community Preventive Services Task

Force.

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