Results of System Dynamics Model for Preventing and Managing Cardiovascular Disease MAIN MENU

Results of System Dynamics Model for Preventing and Managing Cardiovascular Disease

MAIN MENU

Individual Intervention Results

ComparingIntervention Areas

Summary Results

Disparities

Air Quality

Preventing CVD Risk Factors

UnderstandingBase case

Healthcare Interventions

To CVD Risk Causal Map

Physical Access& Nutrition

East Travis Results

To Project Contributors

Overview of model causal structure

Smoking

Obesity

Secondhandsmoke

Healthinessof diet

Extent ofphysical activity

Psychosocialstress

Diagnosisand control

First-time CVevents and

deaths

Access to and marketingof smoking quit products

and services

Access to andmarketing of mental

health services

Sources ofstress

Access to andmarketing of healthy

food options

Access to andmarketing of physical

activity options

Access to andmarketing of weight

loss services

Access to andmarketing ofprimary care

Particulate airpollution

Utilization ofquality primary

care

Tobacco taxes andsales/marketing

regulations

Smoking bans atwork and public

places

Junk food taxes andsales/marketing

regulations

Downwardtrend in CV

event fatality

Quality of primarycare provision

Chronic Disorders

Costs from CV and other riskfactor complications and

from utilization of services

Anti-smokingsocial marketing

High BP

Highcholesterol

Diabetes Populationaging

Air pollutioncontrol regulations

A Base Case Scenario for Comparison Assumptions for Input Time Series through 2040

• A plausible and straightforward scenario– Assume no further changes in

contextual factors affecting risk factor prevalences

– Any changes in prevalences after 2004 are due to “bathtub” adjustment process and population aging

– Provides an easily-understood basis for comparisons

• Prior to 2004, model reflects declining …– Fraction workplaces allowing smoking

(1990-2003)– Air pollution (1990-2001)– CV event fatality (1990-2003)– Youth smoking (rise 1991-99, decline

1999-2003)

Total RF Complication Costs per Capita

2,000

1,000

0

1990 2000 2010 2020 2030 2040

More resultsBase case

Complication Costs per 1000 if all risk factors = 0

Also note: Cost minimum if all proximal risk factor prevalences were zero.

3,000

No Further Changes in Drivers

Base run behaviors

CVD & Risk Factor Complication Costs and CVD Mortality

0.6

0.3

01990 2000 2010 2020 2030 2040

Smoking Prevalence

Air Pollution PM2.5

Diabetes Prevalence

High BP Prevalence

High Cholesterol Prevalence

CV Risk Factor Prevalences30

15

0

Obese Adults

Newly obeseadults

Becoming non-obese or

dying

20400

0.4% Obese

1990

Next Base caseResult

Previous Base caseResult

Result: Past trends level off after 2004, after which results reflect only slow “bathtub” adjustments in risk factors

• Increasing obesity, high BP, and diabetes

• Decreasing smoking• High cholesterol mixed bag by

age/sex, flat overall• Increases in risk factors and

population aging lead to eventual rebound in deaths

(Air

pollu

tion

only

)

1990 2000 2010 2020 2030 2040

4

3

2

1

0

Deaths from CVD per 1000 if all risk factors = 0

Deaths from CVD per 1000

Complication Costs per 1000

Complication Costs per 1000 if all risk factors = 0

3,000

2,250

1,500

750

0

Smoking

Obesity

Secondhandsmoke

Healthinessof diet


Psychosocialstress



deaths


and services


health services

Sources ofstress


food options


activity options


loss services




care


regulations


places


regulations

Downwardtrend in CV

event fatality


Chronic Disorders




High BP

Highcholesterol


Base case behavior for 1990-2040

1

0Use of Primary Care Services

0.3

0

Stress Prevalence

0.8

0

Poor DietFraction

0.8

0Inadequate

Physical Activity

Previous Base caseResult

4

0

0.3

0Smoking

Prevalence

0.4

0

Obesity Prevalence

0.6

0

Secondhand Smoke

Exposure

0.6

0Diabetes

High BP

High cholesterol

30

0

Particulate Air Pollution

PM2.5

3,000

0

CVD & Risk factorcosts per capita

Uncontrolled

CVD Deaths per 1000

Prevalences

mcg per m3

Age 65+ fraction of the population

CV event fatality multiplier

0.3

0

1.5

0

New quality ofprimary care

PRIMARY CARE INTERVENTIONS

PHYSICAL ACTIVITY INTERVENTIONS

AIR QUALITY INTERVENTIONS

TOBACCO INTERVENTIONS

NUTRITIONAL INTERVENTIONS

INTERVENTIONS AFFECTING STRESS

New PC servicesmarketing

New access toprimary care svcs

New multiplier onair pollution

New multiplier onworkplaces allowing

smoking

New social marketingfor healthy diet

New access tohealthy diet

New junk food taxand sales restrict

New socialmarketing for PA New access to PA

New WL servicesmarketing

New access toweight loss svcs

New socialmarketing

against smoking

New tobacco taxand sales restrict

New SQ servicesmarketing

New access tosmoking quit svcs and

products

New multiplier onsources of stress

New MH servicesmarketing

New access tomental health svcs

INDIVIDUAL INTERVENTIONS SELECTOR

WEIGHT LOSS INTERVENTIONS

Area of effect

and type of intervention– Increasing access – Marketing of

services– Social marketing – Taxes and/or sales

restriction– Others

More resultsAdult population

Intervention Options

Interpreting Cost Results• Complication costs are for CV and

non-CV related complications, both direct and indirect

• Management costs include– Annual costs for services

provided – Medication costs

• When these costs are less than baseline, the difference is the per capita health cost savings per year – the maximum economically justifiable spending for the intervention

Complication & Management Costs per Capita

3,000

2,000

1990 2000 2010 2020 2030 2040

*Average annual savings of

*$ 49 per capita from interventions to increase access to physical activity

options from 2010 - 2040.

Base Case

Increased Access to Physical Activity options

Next Adult PopulationResult

Previous Adult PopResult

Sensitivity range for all interventions

2015 2040

Mort Cost Mort Cost

Uncertainties at minimum impact 15.1% 9.6% 14.2% 17.2%Nominal results 20.3% 12.3% 19.3% 23.0%Uncertainties at maximum impact 28.1% 18.4% 26.2% 29.9%

% Decrease from Base case Deaths from CVD per 1000

CV & Risk FactorComplication Costs per Capita



4

2

0

1990 2000 2010 2020 2030 2040

All 19 Interventionswith range of uncertainty

Base Case

Deaths from CVD if all risk factors = 0

20.3%

19.3%

1990 2000 2010 2020 2030 2040

3,000

2,000

0

1,000All 19 Interventions

with range of uncertainty

Base Case

Complication costs if all risk factors = 0

23.0%12.3%There are significant gains

even at the least effective end of the uncertainty range.

Impact of Multiple Intervention Areas on Adult Population

Primary Care interventions: • Increase the quality of primary care from 54% to 75%• Increase primary care services marketing from 0 to 100%• Increase access to primary care from 84% to 100%

+ Tobacco interventions• Tobacco tax and sales restriction from 50% to 100%• Social marketing against smoking from 0 to 100%• Smoke quit services marketing from 0 to 100% • Access to smoke quit services from 50% to 100%

+ Air Quality interventions• Air pollution cut to half of existing• Workplaces allowing smoking cut to zero

% Change vs. Base Run



Deaths Costs Deaths Costs Base run -- -- -- --Primary care -11.5% -1.9% -9.2% -0.3%Primary care + Tobacco -14.3% -10.0% -12.6% -16.3%Primary care + Tobacco + Air quality -18.8% -12.5% -15.4% -18.2%15 interventions -20.2% -15.7% -18.9% -25.7%

Three areas of interventions together provide – 80-90% of benefit of all

beneficial interventions in short-term,

– 70-80% in long term.

Intervention Results for All Adults • Intervention areas are:

– Primary care – Primary care + Air quality– Primary care + Air quality +

Tobacco– All 15 beneficial interventions

• Note increasing cost gains over time, for Tobacco and remaining six interventions:– Physical activity– Nutrition– Stress

2,000

1,000

0

1990 2000 2010 2020 2030 2040



2

0

1990 2000 2010 2020 2030 2040



Base casePC3 PC3 + AirQ2

PC3 + AirQ2 + Tob4 Beneficial 15

If all risk factors = 0

Base case

PC3

PC3 + AirQ2

PC3 + AirQ2 + Tob4

Beneficial 15


Average annual cost savings of $ 351 per capitaFor PC + AQ + Tob

Effects of Interventions on Preventable Deaths (2010-2040 cumulative)



Cumulative deaths 2010-2040 (in non-CVD population) from CV and other risk factor complications, in millions

From From Other CV Complications CombinedBase 19.59 18.72 48.18PC3 17.74 18.34 45.94PC3AirQ2 17.11 18.22 45.19PC3AirQ2Tob4 16.62 14.78 41.26All19 16.06 14.42 40.34

Over 30 years, the “Tob4” intervention cluster reduces CV deaths by 0.5m, and reduces other deaths (cancers & respiratory) by 3.4m, for a

total reduction of 3.9m. Primary care reduces CV deaths by 1.8 m.

Note that the CV deaths are based on the Framingham methodology, whereas the smoking-related deaths from other complications are based on the SAMMEC methodology.

6.92 million lives saved due to primary care,

air quality & tobacco

interventions

1.85 m

0.49 m0.63 m

3.44 m

0

• Quick two interventions: – Increase Primary Care Quality

from 54% to 75%– Cut Air Pollution by half

• Long three interventions:– Increase Social Marketing Against

Tobacco from 0 to 100% of maximum.

– Increase Tobacco Tax and Sales Restrictions from 50% to 100%

– Increase Access to Physical Activity from 70% to 100%

• These five interventions provide: ~ 77% of cost reduction

achieved by 15 interventions, and

~ 57% of mortality reduction

Interventions for immediate and longer term effects

1990 2000 2010 2020 2030 2040

4

2

3,000

1,000

0

1990 2000 2010 2020 2030 2040



77%

100%

Base CaseQuick two

Quick two + Long three

Beneficial 15



57%

100%

Base CaseQuick two

Quick two + Long threeBeneficial 15


Average annual cost savings of $ 350 per capitaFor Quick 2 + Long 3

More resultsHealthcare Infrastructure

Healthcare Infrastructure Intervention Effects• Intervention areas are:

– Primary Care– PC plus Smoke Quit Services– PC plus SQ plus Mental Health

Services– PC plus SQ plus MH plus Weight

Loss Services• Primary Care has greatest impact

on mortality but also has substantial cost.

• Risk factor treatment costs are based on MEPS data and are medication and oversight.


2

01990 2000 2010 2020 2030 2040

Risk Factor Management Costs per Capita1,000

500

0

1990 2000 2010 2020 2030 2040

Deaths if all risk factors = 0

Base case

PC3 + SQ2

PC3 + SQ2 + MH2

PC3 + SQ2 + MH2 + WL2

PC3

PC3 + SQ2PC3 + SQ2 + MH2

PC3 + SQ2 + MH2 + WL2

PC3

Base case

Primary Care infrastructure interventions

Previous HealthcareInfrastructure Result

• Cardiovascular & Risk factor complication cost savings are greater than increases in ongoing RF management costs.

• This presents opportunities for innovative implementation options.

2015 2040CV & RF Compl Costs

RF Mgmt Costs

Combined Costs

(Savings)

CV & RF Compl Costs

RF Mgmt Costs

Combined Costs

(Savings)

Base case -- -- -- -- -- --

Quality of Primary Care $ (88.00) $ 56.44 $ (31.56) $ (79.00) $ 62.80 $ (16.20)

Quality + Access to Primary Care $ (151.00) $ 113.24 $ (37.76) $ (137.00) $ 126.8 $ (10.20)

Quality + Access + Marketing of PC $ (184.00) $ 141.82 $ (42.18) $ (167.00) $ 159.50 $ (7.50)

Cost differences from Base case

Next Healthcare InfrastructureResult

Economicallyjustifiable level of

investment per capita: $24 over 30 years

Primary Care Infrastructure Intervention Effects• Increasing Primary Care Quality

primarily increases treatment - the diagnosis and control of high BP, high cholesterol, and diabetes – targeting the 84% of the population who have access to primary care.

• Increasing Access to Primary Care provides healthcare options to the 16% without coverage.

2030 2040

CV & RF Complication Costs per 1000

1990 2000 2010 2020

3,000

0

Base case

Quality of Primary CareQuality + Access to Primary Care

Quality + Access + Marketing of Primary Care

Complication costs if all risk factors=0

Risk Factor Management Costs per Capita1,000

500

0

1990 2000 2010 2020 2030 2040

Base case

Quality of Primary Care

Quality + Access to Primary Care

Quality + Access + Marketing of Primary Care

CV events or dying

CV events or dying

UncontrolledHigh BP

ControlledHigh BP

TreatmentHigh BP onset



Why some interventions may not be cost effective for CV endpoints• When considering

– medical management costs– CV and non-CV complication cost

savings– CV benefits only

• With respect to CV endpoints, mental health interventions are quite costly and provide little CV benefit.

• Additionally, weight loss interventions increase costs overall and provide little CV benefit.

• However, there may be other compelling reasons for these interventions.

Complication + Management Costs per Capita

3,000

0

1990 2000 2010 2020 2030 2040

PC3 + SQ2

PC3 + SQ2 + MH2

PC3 + SQ2 + MH2 + WL2

PC3

Basecase

PC – Primary careSQ – Smoke quitMH – Mental healthWL – Weight loss

If all risk factors were = 0



Smoking

Obesity

Secondhandsmoke

Healthinessof diet


Psychosocialstress



deaths


and services


health services

Sources ofstress


food options


activity options


loss services




care


regulations


places


regulations

Downwardtrend in CV

event fatality


Chronic Disorders




High BP

Highcholesterol


Base case behaviors and 15 Beneficial interventions 1990-2040

1

0Use of Primary Care Services

0.3

0

Stress Prevalence

0.8

0

0.8

0

Previous Health InfrastructureResults

4

0

0.3

0

Smoking

Prevalence

0

Obesity Prevalence

0.6

0

0.5

0Diabetes

High BP

High cholesterol

30

0

Air PollutionPM2.5

3,000

0

CVD & Risk factorcosts per capita

Uncontrolled

Prevalences

mcg per m3

Age 65+ fraction of the population

CV event fatality multiplier

0.3

0

1.5

0

CVD Deaths per 1000

Secondhand Smoke Exp.

Poor Diet Fraction

Inadequate

Physical Activity

0.4

High cholesterol

HighBP

Diabetes

0.6

0Control rates

Baseline CV Risk Factors

• Historical trends through 2003 of particular concern:– Obesity– High BP– Diabetes

• Future trajectories represent no change in contextual factors, and are not predictive.

More resultsRisk Factor Reduction

0.6

0.3

01990 2000 2010 2020 2030 2040

Smoking Prevalence

Air Pollution PM2.5

Uncontrolled Diabetes Prevalence

Uncontrolled High BP Prevalence

Uncontrolled High Cholesterol Prevalence

CV Risk Factor Prevalences30

15

0

(Air

pollu

tion

only

)

Obesity Prevalence

0.6

0.4

0.2

0

1990 2000 2010 2020 2030 2040

Stress Prevalence

More CV Risk Factor Prevalences

Fraction Nonsmokers SHS Exposure

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 1990

No Data <4% 4%-6% 6%-8% 8%-10% >10%


(Includes Gestational Diabetes) BRFSS 1991-92


No Data <4% 4%-6% 6%-8% 8%-10% >10%




No Data <4% 4%-6% 6%-8% 8%-10% >10%



Source: Mokdad et al., Diabetes Care 2001;24:412.

No Data <4% 4%-6% 6%-8% 8%-10% >10%



Source: Mokdad et al., J Am Med Assoc 2001;286:10.

No Data <4% 4%-6% 6%-8% 8%-10% >10%



Source: Mokdad et al., J Am Med Assoc 2001;286:10.Back to Risk FactorResults

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Hypertension Statistics• And …

– Almost one third of the people with high blood pressure don't know that they have it.

– About 28% of American adults have prehypertension.

• Hypertension and its complications will continue to increase given these facts.

Overall 30.0%

Women: All Women White African American Mexican American

30.6%28.5%43.5%27.9%

Men: All Men White African American Mexican American

28.8%27.6%40.6%26.8%

Poverty Status: Poor Near Poor Non–Poor

33.9%33.5%28.2%

Percent of Adults With Hypertension 1999–2002

Source: Health, United States, 2005. Back to Risk FactorResults

Other Hypertension stats

Fraction of people ever told they had high blood pressure, 2003

Source: CDC, Behavioral Risk Factor Surveillance System.

Back to Risk FactorResults

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Back to Risk FactorResults

Effects of Intervention Areas on High BP

Uncontrolled High Blood Pressure Prevalence

0.25

0.2

0.15

0.1

1990 2000 2010 2020 2030 2040

Stress

Tobacco

PhysicalActivity

PrimaryCare

Weight LossBase case

• Decreasing Tobacco use increases uncontrolled High BP – due to stress related eating!

• Primary care interventions have a major immediate impact.

• Physical Activity and other interventions take longer to reduce uncontrolled prevalence, but have increasing improvement over time.

• Other chronic conditions have similar pattern.

Next Risk FactorResults

Previous RiskFactor Results

Primary care intervention effects on proximal risk factors

Uncontrolled Diabetes Prevalence0.08

0.04

0

1990 2000 2010 2020 2030 2040

Uncontrolled High Cholesterol0.6

0.3

0

1990 2040

Smoking Prevalence0.3

0.2

01990 2000 2010 2020 2030 2040

Uncontrolled High BP Prevalence0.3

0.2

0.1

0

1990 2040

• An example of synergy:– Increasing Quality

of Primary Care increases both diagnosis and control rates for all those receiving care.

– Increasing Access to Primary Care provides the option to those having higher morbidity.

– Together, they provide more effective care to a larger population.

Next Risk FactorResult

Previous Risk FactorResult

0.10.1

Base case

Quality + Access to Primary CareQuality + Access + Marketing

Quality of Primary Care

Adults with Access

to Primary Care

Please note different y-axis scaling. Different risk factors have different prevalences.

CV events or dying

Implications of interventions to decrease risk factors

1. Primary care interventions increase diagnosis and treatment – so people live longer and total prevalence increases.

2. Physical activity, weight loss and stress reduction reduce high BP onset, reducing the total prevalence, albeit slowly.

Next Risk FactorResult


High BP Prevalence (Controlled + Uncontrolled)

0.4

0.3

0.2

1990 2000 2010 2020 2030 2040

CV events or dying

UncontrolledHigh BP

ControlledHigh BP

Treatment

Primary CareTobacco

Base case

Weight Loss

PhysicalActivity

Stress

High BP onset

1.

2.


0.25

0.2

0.15

0.1

1990 2000 2010 2020 2030 2040

Stress

Tobacco

PhysicalActivity

PrimaryCare


2. 1.

Investment in interventions to decrease risk factors• Accounting for

– Medical management costs– CV and non-CV complication cost

savings• Better intervention opportunities

to reduce high blood pressure, high cholesterol, and diabetes are:– Primary care – Physical activity– Stress reduction

• Tobacco interventions increase chronic conditions a bit, but are very cost effective for smoking and CV endpoints.



Complication + Management Costs per Capita

3,000

1,500

1990 2000 2010 2020

2030 2040

0.25

0.2

0.15

0.1

1990 2000 2010 2020 2030 2040

Stress

Tobacco

PhysicalActivity

PrimaryCare


Stress

Tobacco

PhysicalActivity

Primary CareWeight Loss

Base case

2,500

2,000

Access and Stress Interventions – A proxy for disparity

• The model represents averages of communities throughout the nation.

• However we know that people lower on the socioeconomic scale have– Higher burden of disease– Higher prevalence of risk factors, and – Fewer viable options for healthcare, healthy food, and

physical activity• So interventions targeting local conditions to

affect these options would likely have a greater impact on endpoints than these averaged results indicate.

Next Access and StressResults

Access and Stress intervention results • Includes 5 of 15 interventions:

– Increases Access to physical activity, nutritious food, primary care, and smoke quit services

– Cut stress by half. • Reduces risk factors more than 40% of the

effect of all15 beneficial interventions. • Improvements in highly burdened segments

of population would be even higher.

Next Access & StressResults

Previous Access & Stress Results

Uncontrolled High BP Prevalence0.3

0

Increase Access + Decrease Stress


0.04

0

Uncontrolled High Cholesterol Prev.0.6

0.3

0

1990 2000 2010 2020 2030 2040



Change from Base case: 2015 2040

Beneficial 15 Interventions -100.0% -100.0%

5 Access & Stress Unctrl High Blood Pressure

Prevalence -31.5% -46.7%

Unctrl Diabetes Prevalence -31.7% -53.0%Unctrl High Cholesterol

Prevalence -28.2% -42.5%

Obesity Prevalence -77.6% -77.5%

100%

Base case

Beneficial 15

100%

100%

47%32%

53%32%

43%28%

Access and Stress intervention results • These 5 of 19 interventions to

increase access and decrease stress also reduce complication and management costs for the risk factors by > 25%.

• By 2040, an estimated 1.52 million lives would be saved cumulatively.



Management + Complication Costs per Capita


15 Beneficial Interventions -100.0% -100.0%

Five Access & Stress Interventions:

CV Deaths per Capita -22.8% -32.2%

RF Complication Costs per Capita (CV & non-CV) -17.8% -26.7%

2,000

1,000

0

1990 2000 2010 2020 2030 2040

4

2

0

Base caseIncrease Access + Decrease Stress

1990 2000 2010 2020 2030 2040

Next Access & StressResults

All 19 interventions

100%

100%

100%

Base case

All 19 interventions


100%

Average annual cost savings of $ 109 per capita

For 5 Access & Stress

32%

27%

23%

18%

Access and Stress intervention results • By 2040, Cardiovascular and risk factor

complication costs are reduced by $160 per capita.

• And the increase in RF management costs is modest.

• So, these improvements in health and costs are primarily due to increasing quality of local living conditions – not a large investment in healthcare.


CV & RF Complication Costs per 1000

Difference from Base run 2015 2040Five Access & Stress Interventions:

Complication Costs $ -88.00 $ -160.00

RF Management Costs $ 25.74

$ 8.93

Risk Factor Management Costs per Capita

1990 2000 2010 2020 2030 2040

1,000

500

0

Base case


2,000

1,000

0

Base case

Beneficial 15 interventions


1990 2000 2010 2020 2030 2040


-$160-$88

+$26 +$9

Physical Activity and Nutrition Interventions

• Some interventions may be correlated with one another, such as improvements in physical activity and nutrition.

• Also individual lifestyle changes can have reinforcing bandwagon effects in a community.

• However, bandwagon are not included in the model, so expected improvements are conservative estimates.

Next PA & NutritionResults

Physical Activity and Nutrition intervention results

• Almost all potential obesity reduction can be achieved through physical activity and nutrition interventions. (More info)

• High BP and cholesterol are improved, but the preventative effects on diabetes prevalence are greatest.


Previous PA & Nutrition Results



5 Physical Activity & Nutrition Interventions

Obesity -95.1% -96.0%

Uncontrolled Diabetes -15.4% -51.8%

Uncontrolled High Cholesterol -12.0% -38.6%

Uncontrolled High BP -10.0% -31.5%

Obesity Prevalence0.4

0.2

0

1990 2000 2010 2020 2030 2040

Base case

Nutrition

Nutrition + Physical activity


0.04

01990 2000 2010 2020 2030 2040

Base caseNutrition


Beneficial 15

Beneficial 15

Physical Activity and Nutrition intervention results • Physical activity and nutrition interventions are

preventative.

• Primary prevention interventions reduce onset, and therefore total diabetes prevalence by 13.9% by 2040.

• All 15 beneficial interventions result in higher non-

CVD prevalence, mainly because improved primary care is reducing CV events – an outflow of prevalence!


Previous PA & Nutrition Results

Total Diabetes Prevalence0.1

0.07

0.04

1990 2000 2010 2020 2030 2040Time (Year)

CV events or dying

CV events or dying

UncontrolledDiabetes

ControlledDiabetes

TreatmentDiabetes onset

Base caseNutrition


Beneficial 15

Total Diabetes Prevalence = Uncontrolled + Controlled

Physical Activity and Nutrition intervention results

• The effects of these preventative interventions is cost savings in both complication costs, and management costs.


Cost difference from Base run 2015 2040Five Nutrition and PA Interventions:

RF Complication Costs $ -33 $ -110

RF Management Costs $ -12 $ -31

Total $ -45 $ -141


3,000

0

1990 2000 2010 2020 2030 2040

Base runNutrition

Nutrition + PA

Beneficial 15

Average annual cost savings of $ 94 per capitaFor PA & Nutrition

That’s healthcare cost avoidance.

∆ $141

Air Quality Interventions

Next Air QualityResults

• There is no ‘safe level’ of particulate matter with respect to cardiovascular risk. Less is better.

• Because air pollution increases CV risk for entire populations, improvements to average particulate matter – through air pollution standards, traffic mitigation, public smoking bans – make a big difference.

http://kassandraproject.files.wordpress.com/2007/12/air-pollution-systems.jpg

http://www.google.com/imgres?imgurl=http://news.bbc.co.uk/olmedia/145000/images/_149716_traffic_pollution_300_(12-08-98)_elvis.jpg&imgrefurl=http://news.bbc.co.uk/1/hi/health/149716.stm&h=70&w=116&sz=12&tbnid=jFS7V9kUd6oJ:&tbnh=70&tbnw=116&prev=/images?q=traffic+pollution+pic&sa=X&oi=image_result&resnum=1&ct=image&cd=3

Air Quality intervention results • Two air quality interventions include:

– Reducing PM2.5 by half– Increasing smoking bans in public

places to 100%• Air quality has a marked, direct

impact on coronary heart disease events especially.

Previous Air Quality Results



Two Air Quality Interventions:

CHD Events only -59.8% -51.4%

All Cardiovascular Events -38.6% -28.8%

Next Air QualityResults

CV Events per 1000 (CHD, Stroke, CHF, PAD)

20

10

0

1990 2000 2010 2020 2030 2040

CHD Events per 10008

4

0

1990 2000 2010 2020 2030 2040

Base case


Air Quality interventions

Base caseAir Quality interventions

100%100%


100%100%

51%60%

39% 29%

-17%

Air Quality intervention results • Air quality interventions are

relatively fast acting. By 2015, RF management and complication costs would be reduced by $73 per capita.

• By 2040, 710 thousand cumulative deaths would be prevented.

Previous Air Quality Results


2,000

1,000

0

1990 2000 2010 2020 2030 2040


2

0

1990 2000 2010 2020 2030 2040



Two Air Quality Interventions:

CV Deaths per Capita -25.6% -16.7%

Management and All Complication Costs per

Capita -20.7% -12.0%


For 2 Air Quality

-26%

-21%

-12%

Next Intervention AreaResults

New quality ofprimary care

PRIMARY CARE INTERVENTIONS

PHYSICAL ACTIVITY INTERVENTIONS

AIR QUALITY INTERVENTIONS

TOBACCO INTERVENTIONS

NUTRITIONAL INTERVENTIONS

INTERVENTIONS AFFECTING STRESS

New PC servicesmarketing

New access toprimary care svcs

New multiplier onair pollution

New multiplier onworkplaces allowing

smoking

New social marketingfor healthy diet

New access tohealthy diet

New junk food taxand sales restrict

New socialmarketing for PA New access to PA

New WL servicesmarketing

New access toweight loss svcs

New socialmarketing

against smoking

New tobacco taxand sales restrict

New SQ servicesmarketing

New access tosmoking quit svcs and

products

New multiplier onsources of stress

New MH servicesmarketing

New access tomental health svcs

INDIVIDUAL INTERVENTIONS SELECTOR

WEIGHT LOSS INTERVENTIONS

RESULTS FOR INTERVENTION AREAS

Primary Care

Nutritional

Physical Activity

Weight Loss

Tobacco

Air Quality

Stress

ComparativeResults

Cumulative effects of Primary Care interventions• Interventions are:

– Increase Quality from 54% to 75%– Increase Access from 85% to 100%– Increase Marketing from zero to

maximum (100%)

• CVD mortality is reduced by 11.5% in 2015 and 9.2% in 2040.

• 2.09M lives would be saved cumulatively by 2040.


2

0

1990 2000 2010 2020 2030 2040

Base casePC QualityPC Quality + AccessPC Quality + Access + Marketing

Complication & Mgmt Costs per Capita3,000

01990 2000 2010 2020 2030 2040

Main Intervention Area Results

More Intervention AreaResults


For all 3 PC

Cumulative effects of Healthy Diet interventions• Interventions are:

– Access to healthy diet from 70% to 100%

– Social marketing for healthy diet from 0 to maximum (100%)

– Junk food tax and sales restrictions from 0 to max

• CVD mortality is reduced by 1.6% by 2040.

• Management and complication costs are reduced by – $15 per capita by 2015– $49 per capita by 2040.


2

0

1990 2000 2010 2020 2030 2040


01990 2000 2010 2020 2030 2040

Base caseHealthy Diet AccessHealthy Diet Access + MarketingHealthy Diet Access + Marketing + Junk food tax

Base caseHealthy Diet AccessHealthy Diet Access + MarketingHealthy Diet Access + Marketing + Junk food tax



Average annual cost savings of $ 36 per capitaFor all 3 Nutrition

Cumulative effects of Physical Activity interventions• Interventions include:

– Access to Physical activity options from 70% to 100%

– Social marketing of Physical activity from 0 to maximum


• Management plus complication costs are reduced by – $32 per capita by 2015 and – $94 per capita by 2040

(4.3% of base)


2

0

1990 2000 2010 2020 2030 2040


01990 2000 2010 2020 2030 2040

Base casePhysical Activity AccessPhysical Activity Access + Social Marketing

Base casePhysical Activity AccessPhysical Activity Access + Social Marketing




For both Physical Activity

Cumulative effects of Weight Loss interventions• Interventions are:

– Increase access to weight loss services from 50% to 100%

– Increase social marketing for weight loss services from 0 to maximum


• Management plus complication costs are increased by – $18 per capita by 2015 and – $1 per capita by 2040


2

0

1990 2000 2010 2020 2030 2040


01990 2000 2010 2020 2030 2040

Base caseWeight loss AccessWeight loss Access + Social Marketing

Base caseWeight loss AccessWeight loss Access + Social Marketing



Average annual cost increase of

$ 9 per capitaFor both Weight Loss

Cumulative effects of Tobacco interventions• Interventions include:

– Increase social marketing against smoking from 0 to 100% (maximum possible)

– Increase tobacco tax and sales restrictions from 50% to 100%

– Increase Marketing of smoking quit services from 0 to 100%

– Increase Access to smoke quit services from 50% to 100%


• Management plus complication costs are decreased by – $183 per capita by 2015 and – $361 per capita by 2040


2

0

1990 2000 2010 2020 2030 2040

Base caseAnti smoke marketingAnti smoke mktg + tobacco tax Anti smoke mktg + tobacco tax + smoke quit mktg


01990 2000 2010 2020 2030 2040

Anti smoke mktg + tobacco tax + smoke quit mktg + smoke quit access

Base caseAnti smoke marketingAnti smoke mktg + tobacco tax Anti smoke mktg + tobacco tax + smoke quit mktgAnti smoke mktg + tobacco tax + smoke quit mktg + smoke quit access




For all Tobacco

Cumulative effects of Air Quality interventions• Interventions:

– Reducing PM2.5 by half.– Cut smoking in public places

completely

• CVD mortality is reduced by 5.2% by 2015 and 3.2% by 2040.

• Management plus complication costs are decreased by – $72 per capita by 2015 (3.2% of

base) – $68 per capita by 2040 (3.1% of

base)


2

0

1990 2000 2010 2020 2030 2040

Base caseAir pollution reductionAir pollution reduction + Workplace smoking ban


01990 2000 2010 2020 2030 2040

Base caseAir pollution reductionAir pollution reduction + Workplace smoking ban



Average annual cost savings of $ 72 per capitaFor both Air quality

Cumulative effects of interventions affecting Stress• Interventions:

– Cut Sources of Stress by half– Increase Access to mental

health services from 25% to 100%

– Increase Marketing of mental health services from 0 to 100%


• Management plus complication costs are increased by – $28 per capita by 2015 – $16 per capita by 2040


2

0

1990 2000 2010 2020 2030 2040

Base caseStress ½ Stress ½ + Access to mental health servicesStress ½ + Access + Marketing ofmental health services


01990 2000 2010 2020 2030 2040

Base caseStress ½ Stress ½ + Access to mental health servicesStress ½ + Access + Marketing ofmental health services



Average annual cost increase of $ 16 per capita

For 3 Stress interventions

Comparing intervention area costsComplication & Mgmt Costs per Capita

3,000

2,500

2,000

1,500

1990 2000 2010 2020 2030 2040

Base caseWeight lossStressPrimary careAir quality


2,500

2,000

1,500

1990 2000 2010 2020 2030 2040

Base caseTobacco Physical activityHealthy diet

Slower acting intervention areas, Tobacco, Physical activity, and Healthy diet have increasing gains, with Tobacco providing the greatest cost advantage by far.

Of the rapid acting interventions, Air quality provides the greatest short and long term cost benefit.



Please note non-zero y-axes.

Comparing intervention area mortality

Death rates for slower acting intervention areas, Tobacco, Physical activity, and Healthy diet have increasing gains, with Tobacco providing earlier return on health investment.

Of the rapid acting interventions, both Primary care and Air quality interventions provide substantial short and long term mortality benefits.



3

2

1990 2000 2010 2020 2030 2040


3

2

1990 2000 2010 2020 2030 2040

Base caseWeight lossStressPrimary careAir quality

Base caseTobacco Physical activityHealthy diet

Please note non-zero y-axes.

Simulation results for individual interventions - grouped by area

Single InterventionTest value

Deaths/ thou 2015

Complic $/capita

2015

Mgmt + Complic

$/cap 2015

% Δ Complc $/ thou 2015

% Δ Deaths/

thou 2015

% Δ Comp & Mgmt $/

thou 2015Deaths/

thou 2040

Complic $/capita

2040

Mgmt + Complic

$/cap 2040


% Δ Deaths/

thou 2040

% Δ Comp & Mgmt $/

thou 2040

Base case - 2.657 1,928 2,216 - - - 3.228 1,897 2,196 - - -Quality of Primary Care 0.75 2.510 1,840 2,184 -4.6% -5.5% -1.4% 3.088 1,818 2,181 -4.2% -4.3% -0.7%Primary care services marketing 1 2.627 1,911 2,217 -0.9% -1.1% 0.0% 3.200 1,881 2,201 -0.8% -0.9% 0.2%Access to primary care 1 2.586 1,886 2,219 -2.2% -2.7% 0.1% 3.161 1,859 2,209 -2.0% -2.1% 0.6%Social marketing healthy diet 1 2.654 1,926 2,213 -0.1% -0.1% -0.1% 3.217 1,889 2,186 -0.4% -0.3% -0.5%Junk food tax & sales restrict 1 2.656 1,927 2,215 -0.1% 0.0% 0.0% 3.224 1,894 2,193 -0.2% -0.1% -0.1%Access to healthy diet 1 2.646 1,920 2,206 -0.4% -0.4% -0.5% 3.193 1,870 2,162 -1.4% -1.1% -1.5%Social marketing for physical activity 1 2.652 1,924 2,211 -0.2% -0.2% -0.2% 3.213 1,885 2,181 -0.6% -0.5% -0.7%Access to physical activity 1 2.635 1,910 2,192 -0.9% -0.8% -1.1% 3.160 1,841 2,125 -3.0% -2.1% -3.2%Weight loss services marketing 1 2.656 1,927 2,219 -0.1% 0.0% 0.1% 3.225 1,894 2,196 -0.2% -0.1% 0.0%Access to weight loss services 1 2.654 1,925 2,229 -0.2% -0.1% 0.6% 3.213 1,884 2,197 -0.7% -0.5% 0.0%Social marketing against smoking 1 2.617 1,810 2,097 -6.1% -1.5% -5.4% 3.142 1,629 1,928 -14.1% -2.7% -12.2%Tobacco tax & sales restrict 1 2.627 1,862 2,149 -3.4% -1.1% -3.0% 3.177 1,754 2,053 -7.5% -1.6% -6.5%Smoke quit services marketing 1 2.653 1,923 2,215 -0.3% -0.2% 0.0% 3.223 1,888 2,190 -0.5% -0.2% -0.3%Access to smoke quit services 1 2.647 1,916 2,213 -0.6% -0.4% -0.1% 3.216 1,875 2,181 -1.2% -0.4% -0.7%

Air pollution multiplier 0.5 2.531 1,876 2,165 -2.7% -4.7% -2.3% 3.135 1,860 2,163 -2.0% -2.9% -1.5%Workplaces allowing smoking multiplier 0 2.644 1,906 2,194 -1.1% -0.5% -1.0% 3.218 1,860 2,160 -2.0% -0.3% -1.6%Multiplier on sources of stress 0.5 2.643 1,916 2,185 -0.6% -0.5% -1.4% 3.2 1,868 2,145 -1.5% -0.9% -2.3%Access on mental health services 1 2.655 1,926 2,311 -0.1% -0.1% 4.3% 3.224 1,892 2,288 -0.3% -0.1% 4.2%Mental health services marketing 1 2.657 1,928 2,223 0.0% 0.0% 0.3% 3.227 1,896 2,203 -0.1% 0.0% 0.3%

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More IndividualIntervention Results

Previous Individual Intervention Results

More Effective Individual Interventions for US

After 10 years (2015) After 35 years (2040)

CVD DeathsPer 1000

1. Quality of Primary Care (-5.5%)

2. Air Pollution Multiplier (-4.7%)

3. Access to Primary Care (-2.7%)

4. Social Mktg Against Smoking (-1.5%)

5. Tobacco Tax and Sales Restrictions (-1.1%)



3. Social Mktg Against Smoking (-2.7%) 4. Access to Physical Activity (-2.1%)


Complication and Management Costs





5. Stress Reduction (-1.4%)



3. Access to Physical Activity (-3.2%)


5. Access to Healthy Diet (-1.5%)


13% 14%

73%

14%

44% 42%

Black Hispanic Other

US

E. Travis

More E. TravisResults

E. Travis population relative to USE. Travis has higher percentage of Latinos who are younger and smoke less than US average.

Sources: U.S. Census Bureau, Geolytics

E. Travis status quo case relative to USInitial conditions that play out over time given ‘inertia’ of the system:

+ ET has a younger population than US average. + High cholesterol and smoking prevalences are

slightly lower.+ Air pollution is slightly lower. – High blood pressure, obesity, and diabetes

prevalences are higher than US average.– Service usage rates are lower.– Less physical activity and lower quality diet than

US average.

Previous E. Travis Results


E. Travis status quo has key drivers differentiating from US

Younger population

Fewersmokers

More obesity &diabetes

Somewhat lower CV event

and death rates

Slightly higher complication and

management costs

Less high cholesterol

Lower air pollution

Moreunhealthy behavior

More High BP

Better than US average Worse than US average

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CO

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NS





More Effective Individual Interventions for E. Travis


CVD DeathsPer 1000











Complication and Management Costs













Comparing E. Travis to US: More Effective Individual Interventions


CVD Death Rate

Compl + Mgmt Costs

CVD Death Rate

Compl + Mgmt Costs

ET US ET US ET US ET US

Social Marketing Against Smoking 4 4 1 1 4 3 1 1

Quality of Primary Care 1 1 3 1 1

Tobacco Tax an Sales Restrictions 5 2 2 2 2

Air Pollution 3 2 4* 3 5 2 4

Access to Primary Care 2 3 4 4 2 4

Access to Physical Activity 5 2 4 3 3

Access to Healthy Diet 4 4

Stress Reduction 4 5

*Duplicates ranks indicate ties.

Intervention Results for Adults in E. Travis• Intervention areas are:

– Primary care – Primary care + Air quality– Primary care + Air quality +

Tobacco– All 15 beneficial interventions

• Note increasing cost gains over time, for Tobacco and remaining six interventions:– Physical activity– Nutrition– Stress

3,000

1,000

0

1990 2000 2010 2020 2030 2040



2

0

1990 2000 2010 2020 2030 2040

Next E. TravisResult

Previous E. TravisResult

Base casePC3 + AirQ2

PC3 + AirQ2 + Tob4 Beneficial 15


Base case

PC3 + AirQ2 + Tob4

Beneficial 15


Average annual cost savings of $ 377 per capitaFor PC + AQ + Tob

PC3

PC3 + AirQ2

PC3

0

• Quick three interventions: – Increase Primary Care Quality

from 54% to 75%– Increase Access to Primary Care

from 74% to 100%– Cut Air Pollution by half

• Long three interventions:– Increase Social Marketing Against

Tobacco from 0 to 100% of maximum.

– Increase Tobacco Tax and Sales Restrictions from 50% to 100%

– Increase Access to Physical Activity from 60% to 100%

• These six interventions provide: ~ 78% of cost reduction

achieved by 15 interventions, and

~ 81% of mortality reduction

Interventions for immediate and longer term effects for ET

1990 2000 2010 2020 2030 2040

4

2

3,000

1,000

0

1990 2000 2010 2020 2030 2040


78%

100%

Base Case

Quick three + Long three

Beneficial 15



81%

100%

Base CaseQuick three

Quick three + Long threeBeneficial 15



For Quick 3 + Long 3

Quick three

Next E. TravisResult

Previous E. TravisResult

Single InterventionTest value

Deaths/ thou 2015

Complic $/capita

2015

Mgmt + Complic

$/cap 2015


% Δ Deaths/

thou 2015

% Δ Comp & Mgmt $/

thou 2015Deaths/

thou 2040

Complic $/capita

2040

Mgmt + Complic

$/cap 2040


% Δ Deaths/

thou 2040

% Δ Comp & Mgmt $/

thou 2040

Base case - 2.119 2,034 2,313 - - - 2.787 2,025 2,322 - - -Quality of Primary Care 0.75 2.008 1,935 2,270 -4.9% -5.2% -1.9% 2.672 1,940 2,300 -4.2% -4.1% -0.9%Primary care services marketing 1 2.099 2,016 2,314 -0.9% -0.9% 0.0% 2.766 2,009 2,328 -0.8% -0.8% 0.3%Access to primary care 1 2.028 1,953 2,317 -4.0% -4.3% 0.2% 2.692 1,955 2,347 -3.5% -3.4% 1.1%Social marketing healthy diet 1 2.117 2,032 2,310 -0.1% -0.1% -0.1% 2.781 2,018 2,314 -0.3% -0.2% -0.3%Junk food tax & sales restrict 1 2.119 2,033 2,312 0.0% 0.0% 0.0% 2.785 2,022 2,319 -0.1% -0.1% -0.1%Access to healthy diet 1 2.105 2,020 2,296 -0.7% -0.7% -0.7% 2.740 1,976 2,261 -2.4% -1.7% -2.6%Social marketing for physical activity 1 2.117 2,031 2,310 -0.1% -0.1% -0.1% 2.780 2,017 2,313 -0.4% -0.3% -0.4%Access to physical activity 1 2.089 2,002 2,273 -1.6% -1.4% -1.7% 2.692 1,920 2,193 -5.2% -3.4% -5.6%Weight loss services marketing 1 2.119 2,033 2,315 0.0% 0.0% 0.1% 2.785 2,022 2,322 -0.1% -0.1% 0.0%Access to weight loss services 1 2.116 2,029 2,330 -0.2% -0.1% 0.7% 2.771 2,006 2,321 -0.9% -0.6% 0.0%Social marketing against smoking 1 2.086 1,908 2,186 -6.2% -1.6% -5.5% 2.711 1,736 2,032 -14.3% -2.7% -12.5%Tobacco tax & sales restrict 1 2.095 1,964 2,243 -3.4% -1.1% -3.0% 2.743 1,870 2,167 -7.7% -1.6% -6.7%Smoke quit services marketing 1 2.117 2,030 2,312 -0.2% -0.1% 0.0% 2.784 2,016 2,316 -0.4% -0.1% -0.3%Access to smoke quit services 1 2.110 2,019 2,308 -0.7% -0.4% -0.2% 2.775 1,995 2,301 -1.5% -0.4% -0.9%

Air pollution multiplier 0.5 2.035 1,993 2,273 -2.0% -4.0% -1.7% 2.722 1,997 2,297 -1.4% -2.3% -1.1%Workplaces allowing smoking multiplier 0 2.109 2,011 2,291 -1.1% -0.5% -1.0% 2.778 1,987 2,301 -1.9% -0.3% -0.9%Multiplier on sources of stress 0.5 2.103 2,017 2,281 -0.8% -0.8% -1.4% 2.755 1,982 2,260 -2.1% -1.1% -2.7%Access on mental health services 1 2.117 2,033 2,414 0.0% -0.1% 4.4% 2.783 2,019 2,420 -0.3% -0.1% 4.2%Mental health services marketing 1 2.119 2,032 2,318 -0.1% 0.0% 0.2% 2.787 2,024 2,327 0.0% 0.0% 0.2%

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Individual Intervention Results for E. Travis

Contributors to CV Risk ModelCore Design Team• CDC: Darwin Labarthe, Diane Orenstein, Bobby Milstein, Marilyn

Metzler, Rosanne Farris• Austin: Adolfo Valadez, Phil Huang, Karina Loyo, Rick

Schwertfeger, Cindy Batcher, Ella Pugo, Josh Vest, Jesse Patton-Levine

• NIH: Patty Mabry• Consultants: Jack Homer, Justin Trogdon, Kristina Wile

Organizational Sponsors• Austin/Travis County Health and Human Services Department• CDC Division for Heart Disease and Stroke Prevention• CDC Division of Adult and Community Health• CDC Division of Nutrition, Physical Activity, and Obesity• CDC Division of Diabetes Translation • CDC Office on Smoking and Health• CDC NCCDPHP Office of the Director• Indigent Care Collaborative (Austin, TX)• NIH Office of Behavioral and Social Science Research• RTI International• Sustainability Institute• Texas Department of Health

Results of System Dynamics Model for Preventing and Managing Cardiovascular Disease MAIN MENU

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