Cardiovascular Disease Risk Reduction: Individual vs' Community Approaches

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Cardiovascular Disease Risk ReductionIndividual
vs. Community Approaches
University of Wisconsin Population Health
Institute Translating Research into Policy and
Practice
Patrick Remington, MD, MPH
Current Concepts in Nutrition and Aging September
22, 2005 Madison, WI
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Outline

• Review trends
• Whats worked in the past 50 years
• Challenges for the future
• Individual versus community-based approaches

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Ten Great Public Health Achievements -- United
States, 1900-1999

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and
  stroke

• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

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Ten Great Public Health Achievements -- United
States, 1900-1999

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and
  stroke

• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

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Causes of Death, 1900
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Causes of Death 2000
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Trends in Mortality in the U.S., 1950-1995
Age-adjusted rate/100,000
Year
Health U.S., 1996
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Trends in Mortality in the U.S., 1950-1995
Age-adjusted rate/100,000
Year
Health U.S., 1996
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What worked for CVD?

• Improved diet
• Public education, food labels
• Reductions in smoking
• Public education, clean indoor air policies
• More clinical preventive services
• high blood pressure detection / treatment
• Secondary prevention (since 1990)
• Thrombolytics / aspirin

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What are the current challenges?

• Improve diets
• Fast foods, diet mania
• Increase physical activity
• TV, computers, automobiles
• Reduce smoking
• The tobacco industry is not dead yet!
• High cost of health care
• Prevention costs, no incentives
• Too little, to late

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Roles and Responsibilities

• Governmental public health
• Academics
• Schools
• Urban planners
• Employers
• Health care providers
• Advocates

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Public Health Partners

• Lead the assessment activities
• Monitor health outcomes, esp. disparities
• Monitor risk factors, esp. in schools
• Monitor community environments

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Adult Obesity Rates, 1994-2003
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Academic Partners

• Define the evidence base
• Assess costs and benefits of policies
• Evaluate progress

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A Tool for Getting the Most from Investments in
Prevention

www.thecommunityguide.org
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The Community Guide Answers the Questions

• What strategies work to
• Promote healthy lifestyles?
• Prevent disease?
• Increase the number of people who receive
  appropriate preventive counseling and screening?

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What topics are/will be reviewed?
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What topics are/will be reviewed?
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What Works Community Interventions

• Community water fluoridation
• School-based dental sealant delivery programs
• Community-wide education campaigns to increase
  physical activity
• Early childhood development programs
• Mass media campaigns to reduce tobacco use
• Tobacco cessation telephone support systems

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What Works Education and Behavior Change

• Distribution and education programs for child
  safety seats
• Individually-adapted behavior change programs to
  increase physical activity
• School-based physical education
• Publicly funded, center-based comprehensive early
  childhood development programs for children 3 - 5
  years old

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What WorksEnvironmental Interventions

• Create or enhance access to places for physical
  activity combined with informational outreach
• Use of tenant-based rental assistance vouchers
  improves household safety by giving qualified
  families a choice in moving to neighborhoods that
  offer reduced exposure to violence

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What WorksHealthcare System Interventions

• Diabetes disease management and case management
  programs
• Tobacco cessation provider reminders provider
  education
• Reduce patients out-of-pocket costs for
  vaccinations
• Client and provider reminder systems for
  vaccinations
• Standing orders for vaccinations

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What WorksLegislation/Regulation/Enforcement

• Sobriety checkpoints
• Reduce legal blood alcohol levels (BAC) to
  lt0.08
• Maintain legal drinking age at 21 years
• Child safety seat laws
• Safety belt laws
• Increase the unit price of tobacco products
• Smoking bans and restrictions

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School Partners

• Create health school policies
• Improved nutrition
• More physical activities

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Schools in central Wisconsin have become focal
points in the fight against obesity, bad food
and inactivity.
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June 2005 issue
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Urban Planners

• Provide safe walking routes
• Improve bike safety
• Promote public transportation

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Envisioning Change
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Envisioning Change
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Envisioning Change
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Employers / Worksites

• Healthy worksite policies
• Insurance incentives

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Health Care Providers

• The system has perverse incentives
• Paid more to provide more care
• Prevention does not pay
• Need to align incentives with desired outcome
• Pay to keep people healthy

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The Clinical Box
People with health problems (patients)
The health care system (clinicians)
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The Population Health Box
People with health problems (patients)
The health care system (clinicians)
Healthy Individuals
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Determinants of Population Health
Social Environment
Physical Environment
Genetic Endowment
Individual Response -Behavior -Biology
Disease
Health Care
Health Function
Prosperity
Well-Being
(Evans and Stoddart, 1994)
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Population Health

• Published in 1997 by David Kindig, MD, PhD
• Improve measures of health
• Align incentives to purchase a healthy
  population

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The Power of Partnerships

• Advocates
• Governmental public health
• Academics
• Schools
• Urban planners
• Employers
• Health care providers