evidence-based policy & systems interventions for the prevention of heart disease and stroke...

Evidence-Based Policy & Systems Interventions for the Prevention of

Heart Disease and StrokeStrategic Alliance for Health- Action Institute

Houston, TXApril 28, 2010

Chastity L. Walker, DrPH, MPHOffice of the Director

Division for Heart Disease and Stroke PreventionCenters for Disease Control and Prevention

DHDSP Priorities

Disability & Risk of Recurrent CVD

Increased CVD Risk

Low CVD Risk

Acute CVD Events

ABCS Initiative

High Blood Pressure Control/Sodium Reduction

Cardiovascular DiseaseLeading Cause of Death in the U.S.• 80 million people in U.S. (1 in 3 adults) have CVD

– CVD kills ~865,000 Americans each year (35% of all deaths) – about 2,400 every day

– 150,000 CVD-related deaths/yr among people under 65

• High blood pressure causes– >1/3 of strokes– >1/2 of chronic kidney disease– >1/4 of total heart disease events in women– >1/3 of total heart disease events in men

Proportion of Global Deaths Attributable to Leading Risk Factors (2000)

Ezzati et al. WHO 2000 Report. Lancet 2002;360:1347-1360.

Attributable Mortality (In millions; total 55,861,000)

High mortality, developing region

Lower mortality, developing region

Developed region

0 87654321

High blood pressure

Tobacco

High cholesterol

Unsafe sex

High BMI

Physical inactivity

Alcohol

Indoor smoke from solid fuels

Iron deficiency

Underweight

Relatively even distribution among country income groups

Both Clinical and Public Health Progress Contributed to Decreased Heart Disease Deaths, U.S., 1980-2000

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Ford ES, et al. NEJM 2007:356;23.

Clinical interventions = ~50%

Risk factor reductions = ~50%

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LargestImpact

SmallestImpact

Factors that Affect HealthExamples

Eat healthy, be physically active

Rx for high blood pressure, high cholesterol, diabetes

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Socioeconomic Factors

Changing the Contextto make individuals’ default

decisions healthy

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

Frieden, TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J of Public Health., 2010

ABCS Framework

Socioeconomic Factors (Social

Determinants of Health)

Policies and Programs that

Support Behavior Change

Making the Healthy Choice the Easy Choice

Access to Affordable &

Quality Preventive

Services[Screenings,

lifestyle interventions,

medical referrals]

Access to Affordable &

Quality Medical Care

[“Medical Home" for Dx, Tx, and

Control of HBP]

Heart Disease and Stroke Are Preventable

• Community prevention• Tobacco control• Eliminate artificial trans fat• Reduce dietary sodium• Reduce obesity• Increase physical activity

• Clinical prevention• Aspirin use• Blood pressure control• Cholesterol control• Clinical tobacco cessation

Replacing Trans Fat Is Feasible

Partially hydrogenated vegetable oil

Vegetable shortening and margarine

Cakes, crackers, pastries, cookies, pies and hamburger buns

Fry oils for French fries, chicken nuggets, fish fillets, and doughnuts

Regular vegetable oils (canola, soy, corn) that have not been hydrogenated, or newly developed trans fat-free fry oils with similar “fry life”

Reformulated shortening and margarine with little or no trans fat

Many food brands are now free of trans fat

Regular oils or newly developed trans fat-free fry oils with longer “fry life”

King Co. WA

Multnomah Co. OR

San Francisco

Los Angeles

Madison, WI

Minneapolis & St. Paul

State & Local Trans Fat Regulations----------------------------------------- As of 4/16/09 ------------------------------------

Chicago

Miami-Dade Co.

Louisville, KY

Buffalo,Erie Co.

Boca Raton, FL

Proposals enacted

Proposals passed but not yet enacted

Proposals introduced

Proposals considered but not formally introduced (may include formal surveys/studies of trans fat)

Proposals include notification/disclosure (not necessarily a ban)

Voluntary reduction – educational campaign

New York City

Philadelphia

Boston

Nassau Co. NY

Brookline, MA

Montgomery Co. MD

Chatham Borough, NY

Baltimore

Washington, DC

Stamford, CT

Cambridge, MA

Nashville

Oakland Co. MISuffolk Co. NY

Cleveland

Westchester Co. NY

Albany Co. NY

Broome Co. NY

Niagara Falls, NY

El Paso, TX

Needham, MA

Lynn, MA

Newton, MA

Monroe Co. NY

Wilmington, MA

• Average consumption of sodium in the United States is far greater than recommended limits

– 2005 Dietary Guideline recommendation: <2,300 mg/day (1,500 mg for specific populations)

– Average intake: 3,466 mg/day• The majority of sodium consumed comes from processed

and restaurant foods.• Policy and environmental changes are needed to speed

decreases in sodium intake.

Why Sodium Reduction?

15

Salt and High Blood Pressure

• High blood pressure (HBP) is a major public health issue and the leading risk factor for heart disease and stroke.

• Nearly one in three U.S. adults has HBP

• Excess sodium intake is a known risk factor for HBP and, subsequently, cardiovascular events.

• HBP’s enormous burden takes an economic toll.*

• Sodium reduction can have a significant impact on reducing disparities, cardiovascular events, and economic burden.

* Woteki CE. 1992. Eat for Life: The Food and Nutrition Board’s Guide to Reducing Your Risk of Chronic Disease. http://www.nap.edu/openbook.php?record_id=1365&page=118; American Heart Association. Heart Disease and Stroke Statistics – 2010 Update. http://circ.ahajournals.org/cgi/content/full/121/7/e46.

GOAL: National health organizations call for a 50% reduction in the amount of salt in processed and restaurant foods in 10 years

To ensure progress toward the 40% reduction in population salt intake, commit to an interim goal of a 20% reduction in 5 years

Reduce salt content of processed and restaurant foods by 50%

~40%reduction in population salt intake

Decrease in blood pressure

Lives saved

IOM Sodium Recommendations

“Food retailers, governments, businesses , institutions , and other large-scale organizations

that purchase or distribute food should establish sodium specifications for the foods they purchase and the food operations they

oversee.”

IOM Sodium Recommendations

“Government agencies, public health and consumer organizations, health professionals, the

food industry, and public-private partnerships should continue or expand efforts to support consumers in making behavior changes to

reduce sodium intake in a manner consistent with the Dietary Guidelines for Americans.”

What Can Communities do to Reduce Sodium ?• Promote voluntary collaborations• Procurement• Support consumers behavior change• Implement innovative initiatives to facilitate and

sustain decreased sodium in foods• Implement activities to support and promote policy

initiatives to reduce sodium intake• Support and participate in state or local level

monitoring and evaluation efforts

Heart Disease and Stroke Are Preventable• Community prevention

• Tobacco control• Eliminate artificial trans fat• Reduce dietary sodium• Reduce obesity• Increase physical activity


Policy Package to Prevent and Reverse Obesity• Price

• Decrease cost of fruits and vegetables• Increase cost of unhealthy foods

• Exposure• Increase exposure to healthy foods, water• Reduce sugar-sweetened beverage consumption• Junk food to be removed from all schools, health care

facilities, government institutions (at minimum)• Image

• Restrict ads to kids• Show human impact of nutritionally harmful

beverages and foods

Environments and Policies that Promote Physical Activity

• Urban design and land use to encourage physical activity as part of transportation– Minimize long, non-walkable distances– Use grid street layouts, build high-density mixed

development near public transit

• Street design that makes walking and biking safe and pleasant– Sidewalks, bike lanes, improved lighting, trees

• Building and site design that does not favor automobiles over pedestrians

ABCS of Heart Disease & Stroke Prevention

Sodium Consumption

ASPIRIN

CHOLESTEROL

SMOKING

BLOODPRESSURE

On ABCS, USA Gets an “F”

• People at increased risk of CVD who are taking Aspirin – 33%

• People with hypertension who have adequately controlled Blood pressure – 44%

• People with high Cholesterol who have adequately controlled hyperlipidemia – 29%

• Smokers who try to quit who get help – 20%

Despite spending nearly 1 out of every 6 dollars on health care

Aspirin Use IncreasingBut Under-Prescribed for U.S. Patients at Risk of CVD

Low risk

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High risk

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• Affects nearly 1 in 3 US adults

• Leading risk factor for heart disease and stroke

• 65% of people with hypertension do not have it under control

• Prevalence has increased from Healthy People 2010 baseline

• $73.4 billion (2009) in estimated direct and indirect costs

• A population shift in SBP of 12-13 points could reduce:

• heart attacks by 21%

• strokes by 37%

• total CVD deaths 25%

Why Hypertension (Blood Pressure)?

IOM Hypertension (HBP) Recommendations• Population-based

Approaches• Improve Surveillance and

Reporting of HTN and Risk Factors

• Leadership in Reducing Sodium Intake and Increasing Potassium Intake

• Improve Quality of Care to Individuals with HTN

• Remove Economic Barriers to Effective Antihypertensive Meds

• Provide Community Support for Individuals with HTN

• Support Measurement and Accountability

Hypertension Prevention and Control• Expand Access to Care and Treatment

• Decrease out of pocket costs of HTN and cholesterol medications (e.g., bulk purchase)

• Integrate HTN with other chronic disease efforts (e.g., nutrition, diabetes, physical activity, obesity)

• Implement/expand use of auxiliary health workers• Promote High Quality Services

• Increase reimbursement of clinical and community-based services

• Enhance Clinical/ Community-based Social Supports• Improve adherence to guidelines• Quitline or other counseling/cessation

* Green BB et al. JAMA 2008;299:2857-67

Cholesterol• Having high blood cholesterol puts one at risk for heart

disease.• 1 in 6 six adults- 16.3% of U.S. adult population- has high

cholesterol (240 mg/dL and above); approximately twice the risk for heart disease.

• High LDL-Cholesterol (160 mg/dL and above )=

“Bad" cholesterol• LDL-lowering therapy reduces total mortality, coronary

mortality, major coronary events, coronary artery procedures, and stroke in persons with established CHD.

Smoking

• Smoking causes CVD.• Cigarette smokers are 2–4 times more

likely to develop coronary heart disease than nonsmokers.

• Cigarette smoking approximately doubles a person's risk for stroke.

• Nonsmokers exposed to secondhand smoke at home or work increase heart disease risk by 25–30% and lung cancer risk by 20–30%.

Clinical Smoking Cessation Guidelines• Tobacco dependence is a chronic condition that often

requires repeated intervention.• Evaluate tobacco use of every patient at every visit.• Every patient who uses tobacco should be offered tobacco

cessation services– 3-5 minutes of counseling can increase quit rates– Medications are effective and should be offered to every

patient attempting to quit• Only 6 states cover all proven treatment through Medicaid

at present.

Fiore MC et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. 2008.

Quitline Counseling Alone or with Medication Increases 6-Month Abstinence Rates

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Source: Clinical Practice Guideline Meta-Analysis Results. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May.

Community-Level Interventions Reduce Costs

• Change Environment – Healthy Choice is Default Choice

• Scalable• Evidence-Based• Measureable• Support Peer-to-Peer Learning

Lifestyle Intervention(s)

Assessment of Lifestyle Behaviors and Readiness to

Change

Women Recruited from NBCCEDP Program

Abnormal

Medical Referral

and diagnosis

Heart Disease and Stroke Risk Factor Screening

Risk Reduction Counseling and Referral

Risk Factors Prevented or Reduced

WISEWOMAN: Flow of Services

The Asheville (NC) Project

• Employer sponsored Chronic Disease Self- Management Program • Trained Health Educators and

Pharmacists• Reimbursement/ Co-pay reduction

• Increase in blood pressure and cholesterol control

• Decrease in CVD event rates• Decrease in CVD related costs• Decrease in costs of CVD events, to

$9,931 from $14,343 or $4412 per event

Annual cost:

$486

Usual care:

$624

No care:

$534

Critical SHAPP Components • Easy enrollment • Dedicated staff • Affordable medication • Evidence-based treatment protocols• Patient follow-up and monitoring. • Nurse-driven treatment program.

• ABCS Initiative

• Evidence-based policy and systems change strategies (clinical/community)

• Implement models for rural chronic disease prevention and health promotion

• Develop and implement an integrated chronic disease collaborative model

• Robust surveillance, including direct biological measurement

• Leveraging other federal and non-federal resources.

Mississippi Delta Health Collaborative

Community Health Workers (CHW’s)CHWs add value to health care systems and improve care because they support:

• Self-management strategies• Compliance with treatment • Lifestyle changes• Patient education• Access to health care, medications, and other

services• Navigation of the healthcare system• Cultural competence of service delivery• Patient and community advocacy

What Actions Have Other States Taken? (CHW)

•Stakeholder Consortium develops standard workforce curriculum (“scope of practice”) and identifies CHW supervisors•Stakeholders advocate for reimbursement structures•2008 State legislation authorizes hourly reimbursement of CHW services (billable to Medicaid)

Minnesota

• MA Association of CHWs forms in 2000•2006 MA Health Care Reform language includes CHWs and tasks MA Department of Public Health to conduct CHW workforce study• Study released in 2010 and includes recommendations for workforce sustainability

Massachusetts

African American Men & High Blood Pressure Control (Barbershop Initiative)

Tools & Resourceswww.cdc.gov/dhdsp

http://www.cdc.gov/dhdsp

CHW Guide Provides

• Evidence on effectiveness of CHWs as a strategy to improve the prevention and management of chronic conditions (especially HTN)

• Information on existing resources to support the work and development of CHWs

• Guidance and examples to public health practitioners about policy and systems strategies

A barber-based intervention for hypertension in African American men: Design of a group randomized trialAmerican Heart Journal, Volume 157, Issue 1, January 2009, Pages 30-36Ronald G. Victor, Joseph E. Ravenell, Anne Freeman, Deepa G. Bhat, Joy S. Storm, Moiz Shafiq, Patricia Knowles, Peter J. Hannan, Robert Haley, David Leonard

A Closer Look at African American Men and High Blood Pressure Control

http://www.sciencedirect.com/science?_ob=GatewayURL&_method=citationSearch&_uoikey=B6W9H-4V3ST77-5&_origin=SDEMFRHTML&_version=1&md5=27a07efd0512f9b3de9d24c41b46ba82

Moving Into Action Guides

• Update to 2005 Guides built to accompany Action Plan

• Purpose: Suggest policy actions across goal areas at federal, state, and local levels

• Targeted Guides: • State legislators• Governors• Employers• Local (leaders)

Atlases of Heart Disease and Stroke

On-line Interactive Atlas: Heart Disease & Stroke

http://apps.nccd.cdc.gov/giscvh

http://apps.nccd.cdc.gov/giscvh

• ABCS• Control tobacco in every community• Food environment that promotes healthy eating• Physical environment that promotes physical

activity• Prevention-oriented clinical care• Cut heart disease and stroke deaths dramatically

Heart Healthy Future

evidence-based policy & systems interventions for the prevention of heart disease and stroke...

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