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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 Disease 2) To Reduce Tobacco Use CONTEXT FOR EVIDENCE-BASED PUBLIC HEALTH 3 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 4 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 5 Systematic Reviews and Developing Recommendations Evaluations of individual programs Individual Studies Narrative Review Systematic Review Meta-analysis Evaluation of evaluations Findings Recommend Recommend against Insufficient 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 7 OBJECTIVES AND GUIDING PRINCIPLES OF THE COMMUNITY GUIDE 8 The Community Guide* Product of an independent US Task Force: Community Preventive Services Task Force A focus on populationbased interventions in: • Communities • Health care systems Evidence-based recommendations and conclusions regarding use *www.thecommunityguide.org 9 Topics for Community Guide Reviews (as of 2013) Reviews Organized by Environment Health Equity Social Environment Reviews by Risk Behavior Reviews by Specific Condition Alcohol 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 Stage Worksite health promotion Adolescent health Special Projects Health communications Pandemic influenza 10 2013 Community Preventive Services Task Force Jonathan C. Fielding, MD, MPH, MBA Barbara K. Rimer, DrPH Bruce N. Calonge, MD, MPH Marshall Chin, MD, MPH, FACP John M. Clymer Karen Glanz, PhD, MPH Ron Goetzel, PhD Larry Green, DrPH David Grossman, MD, MPH Robert L. Johnson, MD Shiriki Kumanyika, PhD, MPH C. Tracy Orleans, PhD Nico P. Pronk, PhD Gilbert Ramirez, DrPH Patrick Remington, MD, MPH Los Angeles County Dep. Of Public Health University of North Carolina Colorado Trust University of Chicago Alliance to Make US Healthiest University of Pennsylvania Emory University UC San Francisco Group Health Cooperative UMD-New Jersey Medical School University of Pennsylvania Robert Wood Johnson HealthPartners West Virginia University University of Wisconsin 11 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 12 Issues Considered in Community Guide Reviews Intervention (policy or program) Considerations for Implementation Population or Group Costs Additional Benefits? ? Potential Harms? ? Reduced Morbidity and Mortality Intended Outcomes (Behavior, Health) Economic Efficiency Benefits Is the evidence applicable to “my population”? 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 14 Example Logic Model: Strategies to Prevent CVD Interventions to Prevent CVD risk conditions (and CVD) Interventions to Increase/ Improve control of CVD Risk Conditions Biological Tobacco Use Behavioral Alcohol Environmental Nutrition Social Context Obesity Hyperlipidemia Health Care Physical Activity Diabetes Determinants Hypertension Interventions to Increase/Improve management of clients with CVD CVD Risk Conditions Prevented / Reduced / Controlled Intermediate Health Outcomes Reduced CVD Morbidity And Mortality 15 COMMUNITY PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS FOR CARDIOVASCULAR DISEASE 16 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 17 Community Guide CVD Prevention Reviews Intervention Description Task Force Finding Team-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 outof-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 Computer-based information Clinical systems, specifically aimed at CVD Decisionprevention, designed to assist Support healthcare providers in implementing Systems (CDSS) clinical guidelines at the point of care Sufficient Evidence • Improved screening for CVD risk factors by providers • Improving practices for CVDrelated preventive care, clinical tests, and treatments 18 Community Guide Tobacco Use Reduction Reviews Intervention Description Task Force Finding Comprehensive 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 19 Community Guide Tobacco Use Reduction Reviews (contd.) Intervention Description Task Force Finding Smoke-free Policies Public-sector regulations and privatesector 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 20 Community Guide Tobacco Use Reduction Reviews (contd.) Intervention Quitline Interventions Description 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. Reducing OutPolicy or program changes that make of-Pocket Costs evidence-based treatments more for Evidenceaffordable. Benefit changes may be based Cessation communicated to tobacco users and health Treatments care providers to increase use of these benefits in quitting efforts. Mobile Phone- Interventions use interactive features to based Cessation deliver evidence-based information, Intervention strategies, and behavioral support directly to tobacco users interested in quitting. Messages are targeted to specific populations, tailored to specific users, or automated. Task Force Finding Strong Evidence • Increased quitting Strong Evidence • Increased quitting Sufficient Evidence • Increased quitting 21 Community Guide CVD Prevention http://www.thecommunityguide.org/cvd/index.html Community Guide Tobacco Use Reduction http://www.thecommunityguide.org/tobacco/index.html 22 Acknowledgement Evidence-Based Recommendations Slides from the Community Preventive Services Task Force Provided Courtesy of Anil Thota, MBBS, MPH [email protected] Community Guide Branch Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) Division of Epidemiology, Analysis, and Library Services (DEALS) 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. 24