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USING                     MICROSIMULATION TO                     INFORM TARGETED                     CARDIOVASCULAR       ...
Presentation Outline1) Brief Project Background2) Description of the CVD Prevention Policy Model3) Brief Description of Re...
Project BackgroundContext: Need to identify priority areas for prevention (NCPP)    1) Evidence driven    2) Consistent a...
Project BackgroundCardiovascular Clinical Preventive Services (USPSTF):1) Screening for lipid disorders in adults     Men...
CVD Prevention Policy ModelDesign Overview:   “Microsimulation” model: start with an individual and    predict lifetime p...
CVD Prevention Policy ModelDesign Overview:Demographic characteristics: Age 20 to 100 Sex: Male, Female Race/ethnicity:...
CVD Prevention Policy ModelDesign Overview:Cardiovascular disease events:   Myocardial infarction (MI)   Ischemic stroke...
CVD Prevention Policy Model
CVD Prevention Policy Model             Model Initialization:                NHANES (1999-2008)                 • Sex    ...
CVD Prevention Policy Model             Eligibility for Prevention:                USPSTF                 Recommendations...
CVD Prevention Policy Model             Eligibility for Treatment:                Based on National                 Clini...
CVD Prevention Policy Model             Treatment Effects:                Meta-analyses and                 literature re...
CVD Prevention Policy Model             CVD Event Risk:                Customized 1yr risk                 equations esti...
CVD Prevention Policy Model             Risk of Death:                CVD-death risk estimated                 using Fram...
CVD Prevention Policy Model             Progression of Risk Factors:                Estimated using a two-step           ...
CVD Prevention Policy ModelCosts:1) Costs of disease     First-year and ongoing costs estimated from MEPS      (1999-2008...
Simulation ResultsEvaluation of USPSTF Recommendations :Preliminary estimates (2012):1) Screening for lipid disorders in a...
Simulation Results:  DisparitiesHypertension Reference Case, No Screening, Rates per 100k                  Total   Men    ...
Conclusion     Questions/Comments?
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Using Microsimulation to inform Targeted Cardiovascular Disease Prevention Policy DEHMER

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Using Microsimulation to inform Targeted Cardiovascular Disease Prevention Policy DEHMER

  1. 1. USING MICROSIMULATION TO INFORM TARGETED CARDIOVASCULAR DISEASE PREVENTION POLICY STEVEN DEHMER, PHD RESEARCH FELLOW, HEALTHPARTNERS RESEARCH FOUNDATIONMonday, April 30th HMORN 2012 Conference, Seattle WA
  2. 2. Presentation Outline1) Brief Project Background2) Description of the CVD Prevention Policy Model3) Brief Description of Results
  3. 3. Project BackgroundContext: Need to identify priority areas for prevention (NCPP) 1) Evidence driven 2) Consistent and comparable 3) Account for disparities and population-specific effectsPurpose:a) Assess USPSTF recommended cardiovascular clinical servicesb) Assess cardiovascular impacts of other clinical and community services
  4. 4. Project BackgroundCardiovascular Clinical Preventive Services (USPSTF):1) Screening for lipid disorders in adults  Men (35+ or 20-35 at ↑ risk); Women (20+ at ↑ risk)2) Hypertension screening for adults (18 and older)3) Aspirin counseling for primary prevention of CVD  Men ages 45-79 with increased risk from myocardial infarction  Women ages 55-79 with increased risk from stroke  Balance potential CVD benefits with gastrointestinal bleeding risks
  5. 5. CVD Prevention Policy ModelDesign Overview: “Microsimulation” model: start with an individual and predict lifetime progression of health status and outcomes Simulations of many individuals can be aggregated to estimate population-wide impacts Interventions or counterfactuals tested as if in a randomized controlled trial (here: same people and all else held equal) Key benefit of complex design: sub-population effects for informing targeted policy
  6. 6. CVD Prevention Policy ModelDesign Overview:Demographic characteristics: Age 20 to 100 Sex: Male, Female Race/ethnicity:  Non-Hispanic white  Non-Hispanic black/African American  Hispanic/Mexican American  “Other”Health characteristics (change as an individual ages): Body mass index (BMI) Cholesterol: LDL, HDL Systolic blood pressure (SBP) Smoking status Disease status
  7. 7. CVD Prevention Policy ModelDesign Overview:Cardiovascular disease events: Myocardial infarction (MI) Ischemic stroke (IS) Hemorrhagic stroke (HS) Congestive heart failure (CHF) Angina pectoris (AP) Intermittent claudication (IC)Related disease: DiabetesMortality: CVD related death Non-CVD death
  8. 8. CVD Prevention Policy Model
  9. 9. CVD Prevention Policy Model Model Initialization:  NHANES (1999-2008) • Sex • Race/ethnicity • HDL, LDL • SBP  BRFSS (2009) • BMI
  10. 10. CVD Prevention Policy Model Eligibility for Prevention:  USPSTF Recommendations: 1) Lipid screening 2) BP screening 3) Aspirin counseling  Delivery of untested recommendations set at contemporary rates (NHANES, 1999-2008)
  11. 11. CVD Prevention Policy Model Eligibility for Treatment:  Based on National Clinical Guidelines: • ATP III for lipids • JNC-7 for hypertension • USPSTF for aspirin
  12. 12. CVD Prevention Policy Model Treatment Effects:  Meta-analyses and literature reviews (evidence from major clinical trials) • Lipid treatment with statins lowers LDL, raises HDL • Hypertension treatment lowers SBP • Aspirin treatment lowers MI risk in men, ischemic stroke risk in men; raises HS and GI bleeding risk in all
  13. 13. CVD Prevention Policy Model CVD Event Risk:  Customized 1yr risk equations estimated using Framingham Heart Study Data • Includes original and offspring cohorts • About 10,000 people • Longitudinal design from 1950-2003 • Mostly white
  14. 14. CVD Prevention Policy Model Risk of Death:  CVD-death risk estimated using Framingham Heart Study data  Death from other causes estimated using life tables (net of CVD mortality)
  15. 15. CVD Prevention Policy Model Progression of Risk Factors:  Estimated using a two-step process: 1) Determine if there is a change 2) Determine size of change  Cholesterol and BP changes from Framingham Heart Study data  Changes in BMI from BRFSS (2009)
  16. 16. CVD Prevention Policy ModelCosts:1) Costs of disease  First-year and ongoing costs estimated from MEPS (1999-2008)2) Costs of screening/monitoring  Clinic/lab fees from National Fee Analyzer (2005)3) Costs of treatment  Statin and antihypertensive treatment costs from Express Scripts Drug Trend Report (2010)
  17. 17. Simulation ResultsEvaluation of USPSTF Recommendations :Preliminary estimates (2012):1) Screening for lipid disorders in adults  C/E: $50,000 per QALY  CPB: 650,000 QALYs2) Hypertension screening for adults  C/E: $65,000 per QALY  CPB: 500,000 QALYs3) Aspirin counseling for primary prevention of CVD  C/E: $100 saved per person  CPB: 150,000 QALYs
  18. 18. Simulation Results: DisparitiesHypertension Reference Case, No Screening, Rates per 100k Total Men Women White Black Hispanic OtherMyocardial 29,301 38,200 20,091 28,234 33,931 29,864 27,745InfarctionIschemic Stroke 18,247 17,292 19,235 17,838 20,388 18,370 17,188Angina Pectoris 21,355 25,080 17,499 20,948 22,656 21,722 21,256Congestive 29,381 29,404 29,357 27,684 35,004 30,892 28,656Heart FailureIntermittent 10,498 12,204 8,732 10,232 12,200 10,200 10,182ClaudicationCVD-related 38,055 42,758 33,187 37,293 41,653 38,167 37,133DeathLife Expectancy 78.96 76.02 82.01 79.06 78.58 78.96 78.93
  19. 19. Conclusion Questions/Comments?

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