ICSI Guideline: Primary Prevention of Chronic Disease Risk Factors

Transcription

1 ICSI Guideline: Primary Prevention of Chronic Disease Risk Factors Thomas Kottke, MD, MSPH Work group leader Melissa Marshall, MBA Clinical Systems Improvement Facilitator October 30th, Institute for Clinical Systems Improvement

2 ICSI Guideline: Primary Prevention of Chronic Disease Risk Factors Objectives: Overview of ICSI guideline process Rationale for guideline selection Overview of guideline components Rationale for preventing chronic disease Outline four lifestyle behaviors that impact chronic disease 2

3 Use of This Presentation This power point presentation is the property of the Institute for Clinical Systems Improvement (ICSI). ICSI member organizations may use and adapt this presentation for the use with their own staff and patients. Any other use of the presentation would need specific permission from ICSI. 3

4 Who is ICSI? Founded in 1993 as a non-profit, independent organization Sponsored by six MN health plans 50 medical groups and hospitals, representing 9,000 providers Creating Patient-Centered and Value Driven Care. 4

5 What are guidelines? Evidence-based documents outlining most appropriate practices for prevention, detection, or treatment of specific health conditions Consensus -based foundation for improvement initiatives 5

6 Guideline Purpose Improve the effectiveness, efficiency and consistency of patient care. 6

7 Use of Guideline Health Care Organizations system design and implementation Clinicians as a resource and reference 7

8 Guideline Development Process Charter document developed Work group members recruited from member groups Guideline drafted Member groups critically review draft guideline Guideline reviewed by work group and changes incorporated as appropriate Steering Committee approves for release to member groups and public 8

9 Why PPCD? Continuum of health care delivery Evidence around behaviors Involves employers, community, patients and providers Used as a resource for Governors task force 9

10 Work group members Thomas Kottke, MD, HealthPartners Cardiology Aaron Kelly, PhD, St Paul Heart Stephen Kopecky, MD, Mayo Clinic Exercise Physiology Kim Seibert, CES, RCEP, St Paul Heart General Internist Martha Stanford, MD, Stillwater Medical Group Nursing Melissa Magstadt, MS, CNP, Sanford Health Family Medicine Patrick O Connor, MD, HealthPartners Michael Schoenleber, MD, HealthPartners John Wilkinson, MD, Mayo Clinic Mary Winnett, MD, MPH, Minnesota Department of Health Health Education Trina Ford, RD, MSN, Marshfield Clinic Molly Soeby, MPA, MT Altru Health System Employer Charles Montreuil Carlson Companies 10

11 Scope and Target Population All adults (18 and older) in the community 11

12 Clinical Highlights Four lifestyle behaviors are associated with a decade or more of increased life expectancy. Adequate physical activity Diet that emphasizes fruits and vegetables Abstinence from tobacco and avoidance of tobacco smoke Avoidance of hazardous and harmful drinking 12

13 Clinical Highlights Medical Groups cannot be given the sole responsibility for effecting lifestyle change- community networks, physical and social environments and public policy Broad approach necessary-requires individual change,health care redesign, community, employer and payer support 13

14 Clinical Highlights Health Risk Assessments are most effective when combined with interventions aimed at risk reduction and support Collaborative decision-making and brief, combined interventions are effective in helping motivate and engage patients in healthier lifestyles. 14

15 15

16

17 40% of all deaths in US attributed to four behaviors (Mokdad, 2004) Poor nutrition Inadequate levels of physical activity Smoking and Exposure to tobacco Hazardous drinking 17

18 18

19 Expected Age at Death by Lifestyle High risk Low risk Vegetarian Exercise Nuts BMI Past Smoker Fraser GE and Shavlik DJ. Arch Intern Med 2001;161:

20 Expected Age at Death by Lifestyle High risk Low risk Vegetarian Exercise Nuts BMI Past Smoker Fraser GE and Shavlik DJ. Arch Intern Med 2001;161:

21 Expected Remaining Years of Life at Age 65 Vegetarian Adventists All California Adventists Japan Men Women Iceland United States Finland United Kingdom Fraser GE and Shavlik DJ. Arch Intern Med 2001;161:

22 22

23 Khaw KT. PLoS Medicine 2008;5(1):e12

24 Though relatively modest and achievable, their combined impact was associated with an estimated 4-fold difference in mortality risk, equivalent to 14 y in chronological age. Notably, the differences in survival were also observed in people with existing chronic disease. Khaw KT. PLoS Medicine 2008;5(1):e12

25 25 Among individuals aged 70 to 90 years, adherence to a Mediterranean diet and healthful lifestyle [being physically active, moderate alcohol use, and non smoking] is associated with a more than 50% lower rate of all-causes and cause-specific mortality

26 A model without air leaks 3 states and 3 transitions Apparently Healthy/ No heart disease diagnosis* *includes occult HD Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation

27 Prevalence and mortality Apparently Healthy/ No heart disease diagnosis* N=90,024/907** Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation *includes occult HD **N per 100,000 adults aged 30-84/deaths without improved treatment N=8,335/239 Heart disease without symptomatic LV systolic dysfunction or Heart disease with symptomatic LV systolic dysfunction N=1,641/182 Total deaths=1,328

28 Events and case-fatality rates N=325/309 Apparently Healthy/ No heart disease diagnosis* Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation *includes occult HD **N per 100,000 adults aged 30-84/deaths without improved treatment STEMI=159/19 NSTEMI=599/63 UA/other=1270/135 Systolic heart failure=345/45 N=253/7 Heart disease without symptomatic LV systolic dysfunction or Heart disease with symptomatic LV systolic dysfunction Total deaths=578

29 Results: A case study Company: National defense contractor (~1,700 employees and spouses) Benefit incentive ($35 co-pay difference [$10 vs. $45], or $250 deductible difference) available for participants: Complete Health Assessment (HA) Participate in health management programs if risk factors identified Average Health Assessment participation over 90% in each year for three years (4 measurement periods) 29 29

30 Results (cont d) EXPERIENCE HEALTH & PRODUCTIVITY ROI For every 100 program participants: 93 are very satisfied or satisfied with the program 88 would participate again 85 would recommend the program to a friend Sustained improvement in population health over three years 37% reduction in tobacco prevalence 58% increase in physical activity 89% increase in intake of fruits and vegetables Population-based reduction in BMI of 0.3 kg/m 2 Demonstrated ROI of 3:1 Medical savings of 3.3% of overall expected medical care cost with actual reduction in trend in Year 3 30

31 Preventable/postponable deaths Unavoidable deaths Preventable or postponable deaths Achieved intervention effect = 120 lives/100,000 Hundreds No apparent heart disease Heart Disease without LVSD Heart Disease with LVSD Out of hospital cardiac arrest MI with ST segment elevation MI without ST segment elevation Unstable angina Acute heart failure due to LVSD Ambulatory presentation

32 Community Support for Healthier Lifestyle Improvements in health care systems Education, policy and environmental changes Collaborative partnerships among various stakeholders in communities 32

33 Community Support for Healthier Lifestyle Individual providers Health plans and Employers Educators and schools Faith-based organizations Changes in physical environment Changes in Social Environment Public Policy Initiatives 33

34 Community Support for Healthier Lifestyle Clinical Information Systems Decision Support Systems Delivery System Design Self-Management Support Community Resources 34

35 Health Risk Assessment Identify health risk factors Provide feedback on behavior changes Effective, when combined with timely feedback, education and interventions Administered in many settings 35

36 Increased Physical Activity Minimum goal(any improvement is beneficial) Get additional 10 minutes Healthier behavior goals 30 min x 5 days (moderate intensity) or 20 min x 3 days (vigorous intensity) Optimal healthy goals 300 minutes per week or 10,000 steps per day 36

37 Improved Nutrition Healthier behavior goals Follow US Dietary Guideline Optimal healthy goals Follow Mediterranean Diet 37

38 Decreased tobacco use and exposure Minimum goal(any improvement is beneficial) Provide brief intervention to eliminate or decrease use and exposure Healthier behavior goals In addition systematically offer pharmacotherapy and follow-up Eliminate tobacco advertising and commercial promotion, eliminate tobacco smoke in public areas, eliminate youth access to tobacco products Optimal healthy goals Eliminate all tobacco use and exposure 38

39 Decreased hazardous and harmful drinking/alcohol use Minimum goal(any improvement is beneficial) Provide appropriate intervention Healthier behavior goals In addition, systematically offer interventions and follow-up Optimal healthy goals Discontinue all drinking that has any adverse impact on health 39

40 40 Questions?