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