Preventing Chronic Disease Dialogue

ESSAY

Jeffrey R. Harris, MD, MPH, MBA; Robert B. Wallace, MD, MSc

Suggested citation for this article: Harris JR, Wallace RB. The Institute of Medicine’s New Report on Living Well With Chronic Illness. Prev Chronic Dis 2012;9:120126. DOI: http://dx.doi.org/10.5888/pcd9.120126.

In the United States, chronic illnesses such as heart disease, cancer, diabetes, stroke, and chronic lung disease account for 70% of deaths and 75% of health care costs (1,2) and have received attention in the professional and lay literature. Although efforts in managing chronic illness typically originate in the health care system, governmental and community-based public health organizations play an important role in helping people with chronic illness maintain optimal health. To help advance the chronic illness programs and policies of public health organizations, the Institute of Medicine (IOM), with the sponsorship of the Arthritis Foundation and the Centers for Disease Control and Prevention (CDC), has produced a new report, “Living Well With Chronic Illness: A Call for Public Health Action” (3). In this essay, we highlight findings from the report related to the consequences of chronic illness, the need for enhanced surveillance, the state of interventions and policies to decrease the effects of chronic illness, and the need for coordinated action in both health care and community-based settings. We close with a discussion of the report’s implications for public health organizations.

James S. Marks, MD, MPH; Risa Lavizzo-Mourey, MD, MBA

Suggested citation for this article: Marks JS, Lavizzo-Mourey R. Philadelphia Freedom. Prev Chronic Dis 2012;9:120182. DOI: http://dx.doi.org/10.5888/pcd9.120182.

The song “Philadelphia Freedom” became popular in 1976, the bicentennial of our nation’s birth. That was also about the time that the obesity rate in our young people began to rise (1). And it has done so inexorably since then — until now.

That’s what makes the report from Philadelphia so exciting. It’s the latest in a small but growing series of studies that point to the first signs of declining rates of obesity among children in places like New York City and California (2,3). In New York City, declines were seen citywide, but the largest changes were among white and Asian students, who already had the lowest rates (2). In California, the state had a significant overall decline, but progress was uneven. Although counties like Los Angeles, which had been at the forefront of making healthy changes, succeeded in reducing childhood obesity rates, more than half of the state’s counties showed continued increases (3).

Thomas E. Kottke, MD, MSPH; Courtney Jordan Baechler, MD, MCE; Emily D.
Parker, PhD

Suggested citation for this article: Kottke TE, Baechler CJ, Parker ED. Accuracy of Heart Disease Prevalence Estimated from Claims Data Compared With an Electronic Health Record. Prev Chronic Dis 2012;9:120009.
DOI: http://dx.doi.org/10.5888/pcd9.120009.

PEER REVIEWED

Abstract

Introduction

We developed a decision support tool that can guide the development of heart disease prevention programs to focus on the interventions that have the most potential to benefit populations. To use it, however, users need to know the prevalence of heart disease in the population that they wish to help. We sought to determine the accuracy with which the prevalence of heart disease can be estimated from health care claims data.

Methods

We compared estimates of disease prevalence based on insurance claims to estimates derived from manual health records in a stratified random sample of 480 patients aged 30 years or older who were enrolled at any time from August 1, 2007, through July 31, 2008 (N = 474,089) in HealthPartners insurance and had a HealthPartners Medical Group electronic record. We compared randomly selected development and validation samples to a subsample that was also enrolled on August 1, 2005 (n = 272,348). We also compared the records of patients who had a gap in enrollment of more than 31 days with those who did not, and compared patients who had no visits, only 1 visit, or 2 or more visits more than 31 days apart for heart disease.

Results

Agreement between claims data and manual review was best in both the development and the validation samples (Cohen’s κ, 0.92, 95% confidence interval [CI], 0.87–0.97; and Cohen’s κ, 0.94, 95% CI, 0.89–0.98, respectively) when patients with only 1 visit were considered to have heart disease.

Conclusion

In this population, prevalence of heart disease can be estimated from claims data with acceptable accuracy.

Miriam Lutski, MSc; Varda Shalev, MD; Avi Porath, MD; Gabriel Chodick, PhD

Suggested citation for this article: Lutski M, Shalev V, Porath A, Chodick G. Continuation With Statin Therapy and the Risk of Primary Cancer: A Population-Based Study. Prev Chronic Dis 2012;9:120005. DOI: http://dx.doi.org/10.5888/pcd9.120005.

PEER REVIEWED

Abstract

Introduction

Studies have suggested that statins may inhibit tumor cell growth and possibly prevent carcinogenesis. The objective of this study was to investigate the association between persistent statin use and the risk of primary cancer in adults.

Methods

This retrospective study was conducted by using the computerized data sets of a large health maintenance organization (HMO) in Israel. The study population was 202,648 enrollees aged 21 or older who purchased at least 1 pack of statin medication from 1998 to 2006. The follow-up period was from the date of first statin dispensation (index date) to the date of first cancer diagnosis, death, leaving the HMO, or September 1, 2007, whichever occurred first. Persistence was measured by calculating the mean proportion of follow-up days covered (PDC) with statins by dividing the quantity of statin dispensed by the total follow-up time.

Results

During the study period, 8,662 incident cancers were reported. In a multivariable model, the highest cancer risk was calculated among nonpersistent statin users. A strong negative association between persistence with statin therapy and cancer risk was calculated for hematopoietic malignancies, where patients covered with statins in 86% or more of the follow-up time had a 31% (95% confidence interval, 0.55-0.88) lower risk than patients in the lowest persistence level (≤12%).

Conclusion

Our study demonstrated that persistent use of statins is associated with a lower overall cancer risk and particularly the risk of incident hematopoietic malignancies. In light of widespread statin consumption and increases in cancer incidence, the association between statins and cancer incidence may be relevant for cancer prevention.

Tim Casper, MA; David A. Kindig, MD, PhD

Suggested citation for this article: Casper T, Kindig DA. Are Community-Level Financial Data Adequate to Assess Population Health Investments? Prev Chronic Dis 2012;9:120066. DOI: http://dx.doi.org/10.5888/pcd9.120066.

PEER REVIEWED

Abstract

The variation in health outcomes among communities results largely from different levels of financial and nonfinancial policy investments over time; these natural experiments should offer investment and policy guidance for a business model on population health. However, little such guidance exists. We examined the availability of data in a sample of Wisconsin counties for expenditures in selected categories of health care, public health, human services, income support, job development, and education. We found, as predicted by the National Committee on Vital and Health Statistics in 2002, that availability is often limited by the challenges of difficulty in locating useable data, a lack of resources among public agencies to upgrade information technology systems for making data more usable and accessible to the public, and a lack of enterprise-wide coordination and geographic detail in data collection efforts. These challenges must be overcome to provide policy-relevant information for optimal population health resource allocation.

Ellen Kersten; Barbara Laraia, PhD, MPH; Maggi Kelly, PhD; Nancy Adler, PhD; Irene H. Yen, PhD, MPH

Suggested citation for this article: Kersten E, Laraia B, Kelly M, Adler N, Yen IH. Small Food Stores and Availability of Nutritious Foods: A Comparison of Database and In-Store Measures, Northern California, 2009. Prev Chronic Dis 2012;9:120023.
DOI: http://dx.doi.org/10.5888/pcd9.120023.

PEER REVIEWED

Abstract

Introduction

Small food stores are prevalent in urban neighborhoods, but the availability of nutritious food at such stores is not well known. The objective of this study was to determine whether data from 3 sources would yield a single, homogenous, healthful food store category that can be used to accurately characterize community nutrition environments for public health research.

Methods

We conducted in-store surveys in 2009 on store type and the availability of nutritious food in a sample of nonchain food stores (n = 102) in 6 predominantly urban counties in Northern California (Alameda, Contra Costa, Marin, Sacramento, San Francisco, and Santa Clara). We compared survey results with commercial database information and neighborhood sociodemographic data by using independent sample t tests and classification and regression trees.

Results

Sampled small food stores yielded a heterogeneous group of stores in terms of store type and nutritious food options. Most stores were identified as convenience (54%) or specialty stores (22%); others were small grocery stores (19%) and large grocery stores (5%). Convenience and specialty stores were smaller and carried fewer nutritious and fresh food items. The availability of nutritious food and produce was better in stores in neighborhoods that had a higher percentage of white residents and a lower population density but did not differ significantly by neighborhood income.

Conclusion

Commercial databases alone may not adequately categorize small food stores and the availability of nutritious foods. Alternative measures are needed to more accurately inform research and policies that seek to address disparities in diet-related health conditions.

Julie A. Jacobs, MPH; Ellen Jones, PhD; Barbara A. Gabella, MSPH; Bonnie
Spring, PhD; Ross C. Brownson, PhD

Suggested citation for this article: Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for Implementing an Evidence-Based Approach in Public Health Practice. Prev Chronic Dis 2012;9:110324. DOI: http://dx.doi.org/10.5888/pcd9.110324. 

PEER REVIEWED 

Abstract

Increasing disease rates, limited funding, and the ever-growing scientific basis for intervention demand the use of proven strategies to improve population health. Public health practitioners must be ready to implement an evidence-based approach in their work to meet health goals and sustain necessary resources. We researched easily accessible and time-efficient tools for implementing an evidence-based public health (EBPH) approach to improve population health. Several tools have been developed to meet EBPH needs, including free online resources in the following topic areas: training and planning tools, US health surveillance, policy tracking and surveillance, systematic reviews and evidence-based guidelines, economic evaluation, and gray literature. Key elements of EBPH are engaging the community in assessment and decision making; using data and information systems systematically; making decisions on the basis of the best available peer-reviewed evidence (both quantitative and qualitative); applying program-planning frameworks (often based in health-behavior theory); conducting sound evaluation; and disseminating what is learned. 

SPECIAL TOPIC

Deborah Cohen, MD, MPH; Lila Rabinovich, MPhil

Suggested citation for this article: Cohen D, Rabinovich L. Addressing the Proximal Causes of Obesity: The Relevance of Alcohol Control Policies. Prev Chronic Dis 2012;9:110274. DOI: http://dx.doi.org/10.5888/pcd9.110274.

PEER REVIEWED

Abstract

Many policy measures to control the obesity epidemic assume that people consciously and rationally choose what and how much they eat and therefore focus on providing information and more access to healthier foods. In contrast, many regulations that do not assume people make rational choices have been successfully applied to control alcohol, a substance — like food — of which immoderate consumption leads to serious health problems. Alcohol-use control policies restrict where, when, and by whom alcohol can be purchased and used. Access, salience, and impulsive drinking behaviors are addressed with regulations including alcohol outlet density limits, constraints on retail displays of alcoholic beverages, and restrictions on drink “specials.” We discuss 5 regulations that are effective in reducing drinking and why they may be promising if applied to the obesity epidemic.

PEER REVIEWED

Alyson J. Littman, PhD, MPH; Edward J. Boyko, MD, MPH; Mary B. McDonell, MS; Stephan D. Fihn, MD, MPH

Suggested citation for this article: Littman AJ, Boyko EJ, McDonell MB, Fihn SD. Evaluation of a Weight Management Program for Veterans. Prev Chronic Dis 2012;9:110267. DOI: http://dx.doi.org/10.5888/pcd9.110267.

Abstract

Introduction

To improve the health of overweight and obese veterans, the Department of Veterans Affairs (VA) developed the MOVE! Weight Management Program for Veterans. The aim of this evaluation was to assess its reach and effectiveness.

Methods

We extracted data on program involvement, demographics, medical conditions, and outcomes from VA administrative databases in 4 Western states. Eligibility criteria for MOVE! were being younger than 70 years and having a body mass index (BMI, in kg/m²) of at least 30.0, or 25.0 to 29.9 with an obesity-related condition. To evaluate reach, we estimated the percentage of eligible veterans who participated in the program and their representativeness. To evaluate effectiveness, we estimated changes in weight and BMI using multivariable linear regression.

Results

Less than 5% of eligible veterans participated, of whom half had only a single encounter. Likelihood of participation was greater in women, those with a higher BMI, and those with more primary care visits, sleep apnea, or a mental health condition. Likelihood of participation was lower among those who were younger than 55 (vs 55-64), widowed, current smokers, and residing farther from the medical center (≥30 vs <30 miles). At 6- and 12-month follow-up, participants lost an average of 1.3 lb (95% confidence interval [CI], −2.6 to −0.02 lb) and 0.9 lb (95% CI, −2.0 to 0.1 lb) more than nonparticipants, after covariate adjustment. More intensive treatment (≥6 encounters) was associated with greater weight loss at 12 months (−3.7 lb; 95% CI, −5.1 to −2.3 lb).

Conclusion

Few eligible patients participated in the program during the study period, and overall estimates of effectiveness were low.

PEER REVIEWED

Garry Egger, PhD, MPH

Suggested citation for this article: Egger G. In Search of a Germ Theory Equivalent for Chronic Disease. Prev Chronic Dis 2012;9:110301. DOI: http://dx.doi.org/10.5888/pcd9.110301.

Abstract

The fight against infectious disease advanced dramatically with the consolidation of the germ theory in the 19th century. This focus on a predominant cause of infections (ie, microbial pathogens) ultimately led to medical and public health advances (eg, immunization, pasteurization, antibiotics). However, the resulting declines in infections in the 20th century were matched by a rise in chronic, noncommunicable diseases, for which there is no single underlying etiology. The discovery of a form of low-grade systemic and chronic inflammation (“metaflammation”), linked to inducers (broadly termed “anthropogens”) associated with modern man-made environments and lifestyles, suggests an underlying basis for chronic disease that could provide a 21st-century equivalent of the germ theory.