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Health Promotion / Disease Prevention and Comparative Effectiveness Nico Pronk, Ph.D. VP and Health Science Officer, JourneyWell Senior Research Investigator, HealthPartners Research Foundation HealthPartners Minneapolis, Minnesota JourneyWell proprietary and confidential, © 2009 JourneyWell Considering Effectiveness Effectiveness • Provides guidance on what works – – For whom Under what conditions Comparative Effectiveness • Provides guidance on what works better – – For whom Under what conditions In terms of population health, we should ask: “Where is the greatest yield?” • • • • Medication A vs. medication B Medications vs. behavioral interventions Behavioral intervention A vs. behavioral intervention B Behavioral interventions vs. policy-based intervention The Comparative Effectiveness of Heart Disease Prevention and Treatment Strategies • Using U.S. mortality rates, we modeled a hypothetical popu8lation of 100,000 individuals aged 30-84 y • Population divided into 3 prevalence pools and 3 classes of acute events • Death rates were modeled for the prevalence pools and for acute interventions comparing current levels of care with “perfect care” Source: Kottke, et al. Am J Prev Med 2009;36(1):82-88 Individuals reside in 1 of 3 pools and travel between the pools via 1 of 3 “acute events” streams -------Acute Events------- Source: Kottke, et al. Am J Prev Med 2009;36(1):82-88 or --Prevalence Pool 3-- --Prevalence Pool 1-- --Prevalence Pool 2-- No apparent heart disease • Out-of-hospital cardiac arrest • Acute/emergent syndromes • Ambulatory/incidental presentation** Heart disease without symptomatic LV dilatation Heart disease with symptomatic LV dilatation The Model Considers Interventions of Known Efficacy Preventive Treatments 1. Tobacco free 2. Ideal blood pressure through medication 3. Ideal cholesterol level through nutrition and medication 4. Adequate physical activity 5. Optimal nutrition (fruits and vegetables) Out-of-Hospital Cardiac Arrest 6. Automated external defibrillators Acute/Emergent Presentation 7. Rescue angioplasty during acute coronary syndrome 8. Thrombolysis 9. Aspirin, heparin and glycoprotein IIB/IIIA inhibitors for acute coronary syndromes 10. Beta-blockers for acute coronary syndrome Ambulatory/Chronic Heart Disease 11. Aspirin, statins, beta-blockers, treatment of nicotine addiction, no exposure to ETS 12. Omega-3 fatty acid supplementation 13. Revascularization 14. Pacemakers 15. ACE inhibitors or angiotensin receptor blockers (ARBs) for left ventricular dysfunction 16. Spironolactone or eplerinone for left ventricular dysfunction 17. Implantable cardioverter defibrillators/biventricular pacemakers 18. Cardiac transplantation/left ventricular assist devices 19. Control of supraventricular arrhythmias 20. Management of valvular dysfunction 21. Cardiac rehabilitation Source: Kottke, et al. Am J Prev Med 2009;36(1):82-88 Deaths Prevented or Postponed by Implementing Perfect Care Current Treatment Levels Perfect Care 1000 900 Expected Mortality 800 700 600 500 400 300 200 100 0 No HD HD with Acute Apparent without LVD Events HD LVD |----------Prevalence Pools---------| • “Perfect Care” interventions available today and fully implemented across the prevalence pools, may prevent 60% of all deaths due to HD • Treatment during acute events are predicted to prevent 8% of all deaths • Largest yield is expected to come from the apparently healthy prevalence pool • Physical activity alone would account for 45% of preventable deaths The Comparative Effectiveness of Smoking Cessation Therapy • Impact of financial incentives appears to be at least as effective as pharmacological or behavioral treatment options Odds Ratios of 12 Months of Continuous Abstinence from Smoking for Groups Using Smoking-Cessation Therapy, as Compared with Control Groups. Source: Volpp K, Das A. N Engl J Med 2009;361-364. The Comparative Effectiveness of Weight Loss Treatment Strategies • Study question: – “What lifestyle strategies and/or treatment components contribute to successful weight management defined as 5% to 7% of starting (baseline) body weight, 5% loss maintained for 1 year or longer?” • Studies published after January 1997 – Randomized controlled trials 12 months in duration – Observational studies 5 years in duration – Meta-analysis of studies meeting study criteria • Results presented by intervention type – Advice-only; diet-only; diet plus PA; exercise-only; meal replacements; VLCD; anti-obesity medications Source: Franz, et al. J Am Diet Assoc 2007;107:1755-1767 Comparative Effectiveness of Weight Loss Treatment Strategies 80 Studies, 24, 698 Subjects, 16,823 Completers (68%) 2 0 -2 Weight Loss (kg) -4 -6 -8 -10 -12 Exercise A lo ne -14 Diet A lo ne -16 VLCD Diet + Exercise M eal Replacements Orlistat -18 Sibutramine A dvice A lo ne -20 1 2 6-mo 3 12-mo ©2007 copyright HealthPartners; Source: Franz, et al. J Am Diet Assoc 2007;107:1755-1767 4 24-mo 5 36-mo 6 48-mo Connecting Research and Practice • Two paths – Research-informed practice path – Practice-informed research path • First “translate”, then disseminate standardized solutions • Two-way communications as part of a collaborative interactive approach between research and practice • Product design and customer insights are paramount • Sustainability as an overarching goal and operating principle Source: Pronk NP ACSM’s Worksite Health Handbook, 2nd Ed. P. Chapter 11; pp. 92-100 Health Promotion / Disease Prevention Take Home Points • Comparative effectiveness studies indicate – Largest yield in health improvement comes from interventions at the population level, including those who are apparently healthy – Interventions designed to impact on health behaviors (PA, tobacco, etc.) generate robust effects • Comparative effectiveness studies will generate important learnings when such studies explicitly include behavioral and policy-based approaches to population health improvement • Translation and dissemination should be carefully considered with customer needs in mind and sustainability an overarching operating principle