New Opportunities in the Changing Landscape of Prevention

Yach, Derek; Calitz, Chris

doi:10.1001/jama.2014.8900

Cited by 19 publications

(13 citation statements)

References 6 publications

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“…The Affordable Care Act created new opportunities to implement changes such as these elsewhere and to measure their effects on noncommunicable diseases and health care costs. 51 Among them are requirements that tax-exempt hospitals assess the health needs of their communities and develop implementation strategies to meet those needs. 52 In 2009, US hospitals spent 7.5% of their operating expenses on community benefits, but largely on charity care.…”

Section: Discussionmentioning

confidence: 99%

Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010

Record

Onion

Prior

et al. 2015

JAMA

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IMPORTANCE Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality. OBJECTIVE To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community. DESIGN, SETTING, AND PARTICIPANTS Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22 444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages. INTERVENTIONS Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians. MAIN OUTCOMES AND MEASURES Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age. RESULTS More than 150 000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7%(95%CI, 21.6%–27.7%) from 18.3%to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95%CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed − expected [O − E], 11.3%; 95% CI, 5.5%–17.7%; P < .001), 1996–2000; these differences later disappeared when Maine’s overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994–2006 (O − E, −17 discharges/1000 residents; 95% CI −20.1 to −13.9; P < .001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970–1989 and 1990–2010 (O − E, −60.4 deaths/100 000; 95%CI, −97.9 to −22.8; P < .001, and −41.6/100 000; 95% CI, −77.3 to −5.8; P = .005, respectively). CONCLUSIONS AND RELEVANCE Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county’s population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.

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Section: Discussionmentioning

confidence: 99%

Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010

Record

Onion

Prior

et al. 2015

JAMA

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“…7 As policies evolve, new strategies to complement these approaches can be implemented by employers, institutions, and retailers to promote healthier food choices. 2,3,14,15 …”

Section: Introductionmentioning

confidence: 99%

Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial

Thorndike

Riis²,

Levy

2016

Preventive Medicine

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Population-level strategies to improve healthy food choices are needed for obesity prevention. We conducted a randomized controlled trial of 2,672 employees at Massachusetts General Hospital who were regular customers of the hospital cafeteria with all items labeled green (healthy), yellow (less healthy), or red (unhealthy) to determine if social norm (peer-comparison) feedback with or without financial incentives increased employees’ healthy food choices. Participants were randomized in 2012 to three arms: 1) monthly letter with social norm feedback about healthy food purchases, comparing employee to “all” and to “healthiest” customers (feedback-only); 2) monthly letter with social norm feedback plus small financial incentive for increasing green purchases (feedback-incentive); or 3) no contact (control). The main outcome was change in proportion of green-labeled purchases at end of 3-month intervention. Post-hoc analyses examined linear trends. At baseline, the proportion of green-labeled purchases (50%) did not differ between arms. At end of the 3-month intervention, the percentage increase in green-labeled purchases was larger in the feedback-incentive arm compared to control (2.2% vs. 0.1%, P=0.03), but the two intervention arms were not different. The rate of increase in green-labeled purchases was higher in both feedback-only (P=0.04) and feedback-incentive arms (P=0.004) compared to control. At end of a 3-month wash-out, there were no differences between control and intervention arms. Social norms plus small financial incentives increased employees’ healthy food choices over the short-term. Future research will be needed to assess the impact of this relatively low-cost intervention on employees’ food choices and weight over the long-term. Trial Registration: Clinical Trials.gov NCT01604499

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“…Despite a health care landscape that advocates for incentivizing prevention science 44 and associated campaigns such as the Millions Hearts Initiative, 45 the surgical literature has, until recently, remained largely focused on outcomes directly attributable to the surgical encounter, thereby unintentionally separating the perioperative health care experience from broader national efforts to improve public health through the provision of high quality preventive medical care. Our finding that more than one in four patients demonstrated elevated ambulatory clinic blood pressures in the year after surgery provides evidence to support the notion that the public health opportunity for anesthesiologists to reduce long-term morbidity by assuring timely follow-up care for poorly controlled blood pressure is significant.…”

Section: Discussionmentioning

confidence: 99%

Balancing Model Performance and Simplicity to Predict Postoperative Primary Care Blood Pressure Elevation

Schonberger

Dai²,

Brandt

et al. 2015

Anesthesia &Amp; Analgesia

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Background Because of uncertainty regarding the reliability of perioperative blood pressures and traditional notions downplaying the role of anesthesiologists in longitudinal patient care, there is no consensus for anesthesiologists to recommend postoperative primary care blood pressure follow-up for patients presenting for surgery with an elevated blood pressure. The decision of whom to refer should ideally be based on a predictive model that balances performance with ease-of-use. If an acceptable decision-rule were developed, a new practice paradigm integrating the surgical encounter into broader public health efforts could be tested, with the goal of reducing long-term morbidity from hypertension among surgical patients. Methods Using national data from United States veterans receiving surgical care, we determined the prevalence of poorly controlled outpatient clinic blood pressures ≥ 140/90mmHg, based on the mean of up to four readings in the year after surgery. Four increasingly complex logistic regression models were assessed to predict this outcome. The first included the mean of two preoperative blood pressure readings; other models progressively added a broad array of demographic and clinical data. After internal validation, the C-statistics and the Net Reclassification Index between the simplest and most complex models were assessed. The performance characteristics of several simple blood pressure referral thresholds were then calculated. Results Among 215,621 patients, poorly controlled outpatient clinic blood pressure was present postoperatively in 25.7% (95%CI 25.5%-25.9%) including 14.2% (95%CI 13.9%-14.6%) of patients lacking a prior hypertension history. The most complex prediction model demonstrated statistically significant, but clinically marginal, improvement in discrimination over a model based on preoperative blood pressure alone (C-statistic 0.736 (95% CI 0.734-0.739) vs 0.721 (95% CI 0.718-0.723); p for difference <0.0001). The Net Reclassification Index was 0.088 (95%CI 0.082-0.093), p < 0.0001. A preoperative blood pressure threshold ≥ 150/95mmHg, calculated as the mean of two readings, identified patients more likely than not to demonstrate outpatient clinic blood pressures in the hypertensive range. Four of five patients not meeting this criterion were indeed found to be normotensive during outpatient clinic follow-up (Positive Predictive Value 51.5%, 95% CI 51.0-52.0; Negative Predictive Value 79.6%, 95% CI 79.4-79.7). Conclusions In a national cohort of surgical patients, poorly controlled postoperative clinic blood pressure was present in more than 1 of 4 patients (95%CI 25.5%-25.9%). Predictive modeling based on the mean of two preoperative blood pressure measurements performed nearly as well as more complicated models and may provide acceptable predictive performance to guide postoperative referral decisions. Future studies of the feasibility and efficacy of such referrals are needed to assess possible beneficial effects on long-term cardiovascular morbidity.

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New Opportunities in the Changing Landscape of Prevention

Cited by 19 publications

References 6 publications

Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010

Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010

Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial

Balancing Model Performance and Simplicity to Predict Postoperative Primary Care Blood Pressure Elevation

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