NCPP Update: Projects on Clinical and Community Preventive Services

Jennifer Jenson, Partnership for Prevention

Michael Maciosek, HealthPartners Research Foundation

July 6 and July 13, 2010

Outline for Today’s Update

• Quick update on analysis for clinical rankings• Focus on work on community preventive services

– Scope of work and decisions from last year’s meeting– Literature review– Defining interventions for quantitative modeling– Estimating costs for community interventions– Update on quantitative modeling– Presenting results, including qualitative information for decision-

makers

• NCPP meeting scheduled for Wednesday, October 27, in Washington, DC (group dinner on Tuesday, October 26)

Clinical Update: Overview

• Study objective

– Increase use of high-value, evidence-based clinical preventive services

• Study strategies

– Provide comparable information on the health impact and cost effectiveness of evidence-based services

– Draw attention to high-value services by publishing a ranking based on health impact and cost-effectiveness

– Assist decision-makers by providing as much information on population groups as practical

– Develop and implement a dissemination strategy to make key audiences aware of the study results

Clinical Update: Vaccinations

• Human Papillomavirus vaccine– New service; Markov model complete – Results pending cancer cost update

• Zoster vaccine– New service; Markov model structure and primary data collection

complete

• Influenza vaccine (adults)– Update of prior model complete

• Pneumococcal vaccine (adults) – Update of prior model complete

Clinical Update: Vaccinations

• Meningicoccal conjugate vaccine – New service; to be completed in 2011

• DTaP booster (adolescents) – New service; to be completed in 2011

• DTaP/Td booster– Update to be completed in 2011

• Childhood immunization series– Includes new vaccines (rotavirus, hepatits A); to be started and

completed in 2010

Clinical Update: Cardiovascular Disease

• Screening for high blood pressure,• Screening for lipid disorders in adults,• Aspirin for the primary prevention of cardiovascular events,

and• Screening for type-2 diabetes mellitus in adults

– New Markov model under construction to evaluate all services– Completed substantial work on literature review and model structure,

including plan for integration with tobacco, physical activity and diet models

– Applying for Framingham Heart Study data from NHLBI, with back-up plan to use data from literature

Clinical Update: Health Behaviors

• Counseling to prevent tobacco use, • Screening for obesity in adults, • Screening for obesity in children & adolescents (new service), &• Counseling for a healthy diet (adults at high risk for CHD)

– New Markov models under construction– Intermediate outcomes to be modeled in 2010– Integrated with cardiovascular model, cancer models, and other health

outcomes modeled in 2011

• Screening for alcohol misuse– Literature update complete– Model update to be completed in 2010

Clinical Update: Cancers

• Screening for breast cancer,

• Screening for cervical cancer, and

• Screening for colorectal cancer

– New Markov models complete for all cancer screenings (and HPV vaccine)

– Results pending updated cancer costs (data from NHI-funded study expected in 2011)

Clinical Update: STDs

• Screening for Chlamydial infection– New agent-based model substantially complete

• Screening for gonorrhea– New service; literature review underway– Agent-based model, based on Chlamydia model, to be completed in 2010

• Screening for syphilis– New service; new agent-based model to be completed in 2010

• Screening for HIV infection– New service; to be completed in 2011

• Behavioral counseling to prevent sexually transmitted infections– New service; to be completed in 2011

Clinical Update: Other Services

• Screening for depression (adults), and• Screening for depression in children and adolescents

– Literature update started; expected completion in 2010

• Screening for osteoporosis– New Markov model substantially complete

• Other services not yet started– Folic acid supplementation to prevent neural tube defects (update)– Screening for abdominal aortic aneurysms (high risk adults, new service)– Screening for hearing impairment in older adults (pending USPSTF update)– Screening for visual impairment in children younger than 5 (update)

Community Update: Overview

• Big picture objective– Improve population health by increasing the use of high-value,

evidence-based community interventions

• Other goals– “Proof of concept” research to develop methods for comparing

the value of community interventions– Develop information and measures that

• Are useful for decision-makers, and• Could be used to help improve public health accountability

– Provide tools to complement information in the Guide to Community Preventive Services

Community Update: Overview

• Study strategy– Develop quantitative information on the health impact and cost-

effectiveness of community interventions– Provide complementary information and tools to help decision-

makers evaluate interventions with their community context in mind

• Scope of work– 15 interventions in two core topic areas: tobacco (7) and physical

activity (8)– Selected from recommended interventions in the Community Guide– Sought mix of intervention types and actors

Community Update: 2009 Decisions

• Defining interventions for quantitative modeling– Because interventions are broadly defined and may vary

considerably– NCPP recommended analysis on more than one example,

including case-studies and prototype interventions

• Measuring health impact and intermediate outcomes– Because of data limitations, NCPP recommended

• Modeling final outcomes, where possible• Presenting information on intermediate outcomes, always• Conducting “what-if-analyses” when evidence or data are

insufficient for linking intermediate and health outcomes

Community Update: 2009 Decisions

• Estimating costs & resource requirements– In response to staff ideas on collecting cost information– NCPP recommended a practical approach

• Don’t use focus groups as a primary strategy• Don’t complicate data collection by adding other objectives

• Providing qualitative information for decision-makers– Because estimates of health impact and cost effectiveness will

have significant limitations– NCPP agreed on the need to develop “qualitative” information to

help decision-makers interpret and consider quantitative results with their own communities in mind

Community Update: Literature Review

• Literature more extensive than anticipated

• Goals of our review include:– Understanding the character of the evidence-base– Defining interventions in adequate detail for modeling– Collecting different types of data, including information on

intervention effectiveness, costs, and resource requirements

• Community Guide staff have offered to help reduce the burden of literature review– Challenges include timing and logistics

Community Update: Defining Interventions for Modeling

• Our experience to date suggests:– For some interventions, a prototype intervention will be most

useful – For other interventions, a case-study makes more sense– Both approaches have some value for all recommendations– Some health impacts are likely to be very small

• Next: several examples to illustrate what we mean

Community Update: Defining Interventions

• Example 1: Increasing the unit price of tobacco– Variety of studies using different data sources covering many states

• Prototype intervention-Median increase in tobacco tax from a median base level (median level for US states)– Shows the impact of a politically feasible tax increase in a state with a

moderate existing tax– Approximates the typical impact of a tax increase

• Case studies-Estimate the impact of recent tax increases in low-tax and high-tax states– Shows potential variation and helps decision makers think about the

likely impact of a tax change in their state

Community Update: Defining Interventions

• Example 2: Point-of-decision prompts to increase physical activity– Many small-scale studies of 1 or 2 prompts within one of 3 location

types: malls, transit stations, and office buildings

• Case studies from different locations are likely to show– Minimal impact on physical activity levels and health– Little practical variation

• A hypothetical prototype of a larger-scale, community-wide intervention (involving multiple locations in a city)– Would show the potential impact of point-of-decision prompts

Community Update: Defining Interventions

• Example 3: School-based interventions to increase physical activity– Two major types of studies:

• PE curriculum changes & programs to increase walking or biking to school (typical measure is change in activity from commuting itself)

• Broader curriculum changes & after school programs to promote activity (broader measures of change in activity, such as activity logs, BMI)

• Prototype intervention-Has been elusive due to high variation

• Case studies- Broader curriculum change and more extensive after-school programs are likely to be more informative

Community Update: Estimating Costs

• Example 1: Increasing the unit price of tobacco

• Virtually impossible to estimate– Cost of advocating for legislative change

• Databases of costs for lobbying are neither specific nor complete• Success rate of lobbying may be difficult to determine

– Cost of implementing policy change• Incremental costs for changing systems to collect and remit taxes may be

small or large, depending on scale• Tax enforcement budget may not change with policy change

– “Welfare loss” from taxes causing shift of consumption• Not clear if welfare loss is relevant for addictive products

• Can estimate change in state revenue with data from effectiveness literature

Community Update: Estimating Costs

• Example 2: Point of decision prompts to increase physical activity

• Literature includes very little data on costs or resource use• But ballpark estimate is possible from:

– National data on the number and size of shopping malls, commercial buildings, and transit stations

– Reported estimates of meeting time for decision-making– Internet estimates on the cost of signs– Assumptions about the cost of maintaining signs

Community Update: Estimating Costs

• Example 3: School-based interventions to increase physical activity

• Journal articles provide some indication of time requirements and needed professional skills in health and education– National salary surveys can be used to estimate cost of labor resources

• Will need to supplement literature with interviews to– Estimate the cost of developing, testing, and producing educational

materials, and– Understand variation in costs

Community Update: Quantitative Modeling

• Generally, quantitative modeling for this project includes– Modeling health and health behaviors over the lifespan, using national data sets– Modeling how community interventions affect health behaviors and other

intermediate outcomes– Modeling how changes in behaviors and intermediate outcomes impact health

• We’re close to completing work to model the natural history of relevant behaviors (smoking, physical activity, diet) over the lifespan

• Clinical models provide a foundation for modeling the relationship between intermediate outcomes and health

• In October, we’ll show the effect of community interventions on health behaviors (the change from natural history)

Community Update: Information for Decision-makers

• General strategy– Provide different types of information and tools that decision-makers can

use as they prefer– Accomplish this by developing an online tool

• Quantitative information– On health impact and contributing factors

• Descriptive information, by topic– About community interventions, health burden, and risk factors

• Tools for self-assessment by decision-makers – To help them think about the likely impact of specific interventions in

their own communities

Community Update: Quantitative Information (1 of 2)

• Table with summary information on health impact and contributing factors

– Evidence of effectiveness (strong or sufficient)• What is the strength of evidence that the intervention works?

– Intermediate outcome affected (high, medium, low)• How common is the behavior, disease/condition, or environmental

exposure in the population?

– Effect size, intermediate outcome (high, medium, low)• By how much will the intervention change the behavior,

disease/condition, or environmental exposure?

Community Update: Quantitative Information (2 of 2)

• Health outcome affected (high, medium, low)– How much of a problem is the condition, disease, or injury that the

intervention affects?

• Effect size, health outcome (high, medium, low)– What is an individual’s expected reduction in risk following a change in

behavior or environmental exposure?

• Reach (high, medium, low)– What proportion of individuals or households will come into contact with

the intervention, assuming full-scale implementation?

• Health impact (high, medium, low)– What is the overall impact on community health?

Community Update: Descriptive Information about Interventions

• Organized by topic to provide a menu of interventions for decision-makers to choose from– For example, for physical activity interventions:

• Community-scale urban design land use policies and practices• Places for physical activity combined with informational outreach activities• Enhanced school-based physical education, etc.

• Reference table includes– More complete descriptive information – Information about

• Intervention type (built environment, education/information, etc.)• Actor (community organizations, employers, policymakers, educators, etc.) • Evidence of effectiveness (from the Community Guide)

Community Update: Descriptive Info About Health Burden & Risk Factors

• Reference information about– Relevant diseases and conditions

• For example, for physical activity interventions:– National and state data on the prevalence of cardiovascular disease, diabetes,

and obesity– For different population groups (children, adults, older adults; Black, White,

Hispanic, American Indian/Native Alaskan, Asian/Pacific Islander)

– Relevant health behaviors• For example, for physical activity interventions:

– National and state data on the population share that “met physical activity recommendations,” or “engaged in no leisure time physical activity”

– For different population groups (children, adults; Black, White, Hispanic)

– Healthy People 2020 Objectives

Community Update: Tools for Self-Assessment by Decision-makers

• To help decision-makers account for the unique characteristics of their own communities

• For example, questions to consider when planning an intervention– Reach (What are barriers you foresee that will limit your ability to successfully

reach your intended population?)– Effectiveness (What are the potential unintended consequences that may result

from this program?)– Adoption (What percent of your organization will be involved in supporting or

delivering this program?)– Implementation (How confident are you that the program can be consistently

delivered as intended?)– Maintenance (What resources are available to provide long-term support to

program participants?)

• Other questions to assess population characteristics

What We Expect to Discuss in October

• Clinical– Analytic results– Preliminary plan for disseminating findings, given health reform

• Communities– More on defining interventions (choosing prototypes and case

studies) for community services– Behavior models– Preliminary quantitative results (pending updates to intervention

definitions) for intermediate outcomes, from behavior models– Qualitative/supplemental information, and how we propose to

present it– Preliminary plan for disseminating findings, given health reform