Si l ti th D i Simulating the Dynamics of Cardiovascular Health and Related Risk Factors Related Risk Factors Work in Progress Presented by Patricia L. Mabry, Ph.D. Office of Behavioral and Social Sciences This work was funded by the CDC’s Division for Heart Disease and Stroke Prevention and by the National Institutes of Health’ s Office of Behavioral and Social Science Research The Sciences National Institutes of Health the National Institutes of Health s Office of Behavioral and Social Science Research. The work was done in collaboration with the Health and Human Services Department of Austin/Travis County, Texas, and with Integrated Care Collaboration of Central Texas. The external contractors are Sustainability Institute and RTI International.
Transcript
Si l ti th D iSimulating the Dynamics of Cardiovascular Health and
Related Risk FactorsRelated Risk Factors
Work in ProgressPresented by Patricia L. Mabry, Ph.D.
Office of Behavioral and Social Sciences
This work was funded by the CDC’s Division for Heart Disease and Stroke Prevention and by the National Institutes of Health’s Office of Behavioral and Social Science Research The
Sciences
National Institutes of Health
the National Institutes of Health s Office of Behavioral and Social Science Research. The work was done in collaboration with the Health and Human Services Department of
Austin/Travis County, Texas, and with Integrated Care Collaboration of Central Texas. The external contractors are Sustainability Institute and RTI International.
Chronic Disease Dynamics Modeling Team Core Contributors
System Dynamics Modelers• Jack Homer*• Kris Wile*
Project Coordinators• Bobby Milstein*• Diane Orenstein*
Economists• Justin Trogdon*• Amanda Honeycutt*
CDC & NIH Subject Matter ExpertsBishwa Adhikari, Nicole Blair, Kristen Betts, David Buchner, Michele Casper, Lawton Cooper, Michael Dalmat, Alyssa Easton, Joyce Essien, Roseanne Farris, Larry Fine, Deb Galuska, Kathy Gallagher Judy Hannon Jan Jernigan Darwin Labarthe* Patty Mabry AnnKathy Gallagher, Judy Hannon, Jan Jernigan, Darwin Labarthe , Patty Mabry, Ann Malarcher, Marilyn Metzler, Rob Merritt, Barbara Park, Terry Pechacek, Michael Schooley, Nancy Williams, Nancy Watkins
External Subject Matter ExpertsCynthia Batcher*, Margaret Casey, Phil Huang*, Kristen Lich, Karina Loyo*, David Matchar, Jessie Patton-Levine*, Ella Pugo*, John Robitscher, Rick Schwertfeger*
* Core design team members
CDC partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the overall US, but is informed by the experience and data of the
Austin team, which has been supported by the CDC’s “STEPS” program since 2004.`
An (Inter) Active Form of Policy Planning/Evaluation
System Dynamics is a methodology to…
M th f th t t ib t t• Map the forces that contribute to a persistent problem;
• Convert the map into a computer simulation model, using the best information and insight available;
• Compare results from simulated “What If…” experiments to identify interventions that may improve performance;
• Bring together diverse stakeholders to g gparticipate in model-supported “Action Labs,” which allow participants to discover for themselves the likely consequences of different policy scenariosdifferent policy scenarios
Cardiovascular Disease and Risks Remain Among the Leading Causes of DeathAmong the Leading Causes of Death
*US: CDC/National Center for Health Statistics, Vol. 56, No.10, April 2008; TX: TX Dept. of State Health Services Preliminary Vital Statistics Table 16
4 levels of prevention correspond to 4 States of Cardiovascular Health:
Disability andA CVDI dL
4 States of Cardiovascular Health:
Disability and Risk of CVD Recurrence
Acute CVD Events
Increased CVD Risk
Low CVD Risk
Preventing and Managing Risk Factors for CVD
L l it f Disability andA CVDI dL
NUTRITION, PHYSICAL
COSTS (CVD & NON-CVD) ATTRIBUTABLE TO
RISK FACTORS
Local capacity for leadership & organizing
LOCAL ACTIONS
Disability and Risk of CVD Recurrence
Acute CVD Events
Increased CVD Risk
Low CVD Risk
NUTRITION, PHYSICAL ACTIVITY & STRESS
• Salt intake• Saturated/Trans fat intake• Fruit/Vegetable intake• Net caloric intake CVD RISK FACTOR
• Obesity• Smoking• Secondhand smoke• Air pollution exposure
UTILIZATION OF SERVICES
• Behavioral change• Social support• Mental health• Preventive health
Purpose of the Cardiovascular Risk Model
• How do local conditions affect multiple risk factors for CVD, and how do those risks affect population health Access to and marketing
of smoking quit products
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulationsQuality of primary
care provision Anti-smokingsocial marketing
p pstatus and costs over time?
• How do different local interventions affect cardiovascular health and
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisand control
of smoking quit productsand services
Access to andmarketing of mental
health services
Sources ofstress
Access to andmarketing of healthy
p y
Particulate airpollution
Utilization ofquality primary
care
Smoking bans atwork and public
places
Downwardtrend in CV
event fatalityChronic Disorders
social marketing
Air pollutioncontrol regulations
related expenditures in the short- and long-term?
• How might local health leaders better
Obesity
Healthinessof diet
Extent ofphysical activity
First-time CVevents and
deaths
marketing of healthyfood options
Access to andmarketing of physical
activity options
Access to andmarketing of weight
loss services
Junk food taxes andsales/marketing
regulations
Costs from CV and other riskfactor complications and
from utilization of services
High BP
Highcholesterol
Diabetes Populationaging
balance their policy efforts given limited resources?
The CDC has partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the
overall US, but is informed by the experience and data of the Austin team, which has been supported by the CDC’s “STEPS” program since 2004.
Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008;5(2). Available at http://www.cdc.gov/pcd/issues/2008/apr/07_0230.htm
Direct Risk Factors
Smoking
Secondhandsmoke Particulate airParticulate air
pollutionDownwardtrend in CV
event fatalityChronic Disorders
High BP
First-time CVevents and
deaths
High BP
Highcholesterol
Diabetes Populationaging
Indirect Risk Factors
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l Particulate air
Utilization ofquality primary
care
Healthiness
and control Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deaths
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Tobacco InterventionsTobacco taxes and
Access to and marketingof smoking quit products
and services
Tobacco taxes andsales/marketing
regulationsAnti-smokingsocial marketing
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l Particulate air
Utilization ofquality primary
care
Healthiness
and control Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deaths
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Air Quality InterventionsTobacco taxes and
Access to and marketingof smoking quit products
and services
Tobacco taxes andsales/marketing
regulations
Smoking bans at
Anti-smokingsocial marketing
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosis and Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
control Particulate airpollution
Downward trend inCV event fatality
Chronic Disorders
Hi h BP
Obesity
Healthinessof diet
First-time CVevents and deaths
High BPHigh
cholesterol
Diabetes Populationaging
Extent ofphysical activity
Health Care InterventionsTobacco taxes and
Access to and marketingof smoking quit products
and services
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulationsQuality of primary
care provision Anti-smokingsocial marketing
Smoking bans at
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
and control Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deaths
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Interventions Affecting StressTobacco taxes and
Access to and marketingof smoking quit products
and servicesSources ofstress
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulationsQuality of primary
care provision Anti-smokingsocial marketing
Smoking bans at
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l
Access to andmarketing of mental
health services
Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
and control Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deaths
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Healthy Diet InterventionsTobacco taxes and
Access to and marketingof smoking quit products
and servicesSources ofstress
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulationsQuality of primary
care provision Anti-smokingsocial marketing
Smoking bans at
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l
Access to andmarketing of mental
health services
Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
and control
Access to andmarketing of healthy
food options
Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deathsJunk food taxes and
sales/marketingregulations
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Physical Activity & Weight Loss InterventionsTobacco taxes and
Access to and marketingof smoking quit products
and servicesSources ofstress
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulations
Smoking bans at
Quality of primarycare provision Anti-smoking
social marketing
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisd t l
Access to andmarketing of mental
health services
Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
and control
Access to andmarketing of healthy
food options
Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
High BP
Obesity
of dietFirst-time CVevents and
deathsJunk food taxes andsales/marketing
regulations
High BP
Highcholesterol
Diabetes Populationaging
Extent ofphysical activity
Access to andmarketing of physical
activity options
Access to andmarketing of weight
loss servicesactivity options
Adding Up the CostsTobacco taxes and
Access to and marketingof smoking quit products
and servicesSources ofstress
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulations
Smoking bans at
Quality of primarycare provision Anti-smoking
social marketing
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosis
Access to andmarketing of mental
health services
Particulate air
Utilization ofquality primary
care
Smoking bans atwork and public
placesAir pollution
control regulations
Healthiness
and control
Access to andmarketing of healthy
food options
Particulate airpollution
Downwardtrend in CV
event fatalityChronic Disorders
Hi h BP
Obesity
Healthinessof diet
First-time CVevents and
deathsJunk food taxes and
sales/marketingregulations
High BPHigh
cholesterol
Diabetes Populationaging
Extent ofphysical activity
Access to andmarketing of physical
activity options
Access to andmarketing of weight
loss services
Costs from CV and other riskfactor complications and from
utilization of services
activity options
A Base Case Scenario for ComparisonAssumptions for Input Time Series through 2040
• A plausible and straightforward scenario– Assume no further changes in
– Any changes in prevalences after 2004 are due to “bathtub” adjustment process and population aging
Total RF Complication Costs per Capita
2 000
3,000
p p p g g– Provides an easily-understood basis
for comparisons
2,000
1,000
No Further Changes in Drivers
• Prior to 2004, model reflects declining …– Fraction workplaces allowing
smoking (1990-2003)
0
1990 2000 2010 2020 2030 2040
g ( )– Air pollution (1990-2001)– Youth smoking (rise 1991-99, decline
1999-2003)CV f li (1990 2003)– CV event fatality (1990-2003)
Adding Up the CostsCardiovascular event costs
• Medical costs (ER, inpatient, rehab)—for non-fatal & fatal events• Productivity (morbidity) losses* from non-fatal eventsy ( y)• Productivity (premature mortality) losses* from fatal events
Non-cardiovascular complications of risk factors• Hospital costs due to non-CV complications of diabetes (e.g., kidneys, p p ( g y
eyes, feet), high BP, & smoking• Productivity (morbidity) losses* from non-fatal complications of diabetes,
high BP, smoking, & obesity• Productivity (mortality) losses* from fatal complications of smoking (e g• Productivity (mortality) losses from fatal complications of smoking (e.g.,
cancer, COPD), diabetes, high BP, & obesity
Costs of managing risk factors• Medications & visits for diabetes high BP high cholesterol—by level ofMedications & visits for diabetes, high BP, high cholesterol by level of
care (high quality = 2 – 2.5x cost of mediocre care)• Other services: Mental health services, Weight loss services, Smoking
quit services & products
Human capital approach based on: Haddix, Teutsch, Corso, Prevention Effectiveness, 2003 (2nd ed, Tables 1.1b and 1.1c).
Base run behaviorsCV Risk Factor PrevalencesResult: Past trends level off after
0.6
High BP Prevalence
High Cholesterol Prevalence
30Result: Past trends level off after 2004, after which results reflect only slow “bathtub” adjustments in risk factors
• Increasing obesity high BP and on o
nly)
0.3
0
Smoking Prevalence
Air Pollution PM2.5
Diabetes Prevalence
15
0
Increasing obesity, high BP, and diabetes
• Decreasing smoking and air pollution
• Increases in risk factors and
(Air
pollu
ti
CVD & Risk Factor Complication Costs and CVD Mortality
01990 2000 2010 2020 2030 2040
0
Obese
Increases in risk factors and population aging lead to eventual rebound in deaths
Costs and CVD MortalityObese Adults
Newly obeseadults
Becoming non obese or
4
3
Deaths from CVD per 1000
Complication Costs per 1000
3,000
2,250
adults non-obese or dying
0
0.4% Obese
2
1
0
Deaths from CVD per 1000 if all risk factors = 0
Complication Costs per 1000 if all risk factors = 0
1,500
750
204001990
1990 2000 2010 2020 2030 204000
T b t d
Base case behavior for 1990-2040
Access to and marketingof smoking quit products
and servicesSources ofstress
Access to andmarketing ofprimary care
Tobacco taxes andsales/marketing
regulations
Smoking bans at
Quality of primarycare provision Anti-smoking
social marketing
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisand control
Access to andmarketing of mental
health services
Particulate airpoll tion
Utilization ofquality primary
care
gwork and public
places1
0Use of Primary Care Services
0.3
0
Stress Prevalence
0.3
0Smoking
Prevalence0.6
0
Secondhand Smoke
Exposure
30Particulate
Air Pollution PM2.5
mcg per m3
Healthinessof diet
Access to andmarketing of healthy
food options
pollutionDownwardtrend in CV
event fatalityChronic Disorders
High BP0.8
Poor Diet 4
0 Exposure
0.6
High cholesterol
0PM2.5
Uncontrolled
Prevalences
CV event fatality multiplier
1.5
0
Obesity
E t t f
First-time CVevents and
deathsJunk food taxes andsales/marketing
regulations
C t f CV d th i k
Highcholesterol
Diabetes Populationaging
0Fraction
0 8
4
0
0.4
0
Obesity Prevalence
0Diabetes
High BP
High cholesterol
3 000
CVD Deaths per 1000
Age 65+ fraction of the population
0.3
0
Extent ofphysical activity
Access to andmarketing of physical
activity options
Access to andmarketing of weight
loss services
Costs from CV and other riskfactor complications and
from utilization of services
0.8
0Inadequate
Physical Activity
3,000
0
CVD & Risk factorcosts per capita
Interpreting Cost Results
• Complication costs are for CV and non-CV related complications, both direct and indirect
Complication & Management Costs per Capita
3,000
• Management costs include– Annual costs for services
provided – Medication costs
• When these costs are less than baseline, the Base Casethan baseline, the difference is the per capita health cost savings per year – the maximum
2,000
1990 2000 2010 2020 2030 2040
*Base Case
Increased Access to Physical Activity options
per year – the maximum economically justifiable spending for the intervention
Average annual savings of *$ 49 per capita from interventions to
i t h i l ti itintervention increase access to physical activity options from 2010 - 2040.
Results: Comparing groups of interventionsINDIVIDUAL INTERVENTIONS SELECTOR
Care• Primary Care Quality = 75%• PC Marketing = 100%• PC Access = 100%
New quality ofprimary care
PRIMARY CARE INTERVENTIONS
NUTRITIONAL INTERVENTIONS
New PC servicesmarketing
New access toprimary care svcs
PC Access 100%
Lifestyle• Physical Activity Access =
100%• Physical Activity Social
PHYSICAL ACTIVITY INTERVENTIONS
New social marketingfor healthy diet
New access tohealthy diet
New junk food taxand sales restrict
New social New access to PAPhysical Activity Social Marketing = 100%
• Access to Healthy Nutrition = 100%
• Healthy Nutrition Social M k ti 100%
marketing for PA New access to PA
New WL servicesmarketing
New access toweight loss svcs
WEIGHT LOSS INTERVENTIONS
Marketing = 100%• Stress Multiplier = ½
Air• Tobacco Tax = 100%
TOBACCO INTERVENTIONS
New socialmarketing
against smoking
New tobacco taxand sales restrict
New SQ servicesmarketing
New access tosmoking quit svcs and
products
• Marketing Against Smoking = 100%
• Air Pollution Multiplier = ½ • Smoking Bans = 100%
AIR QUALITY INTERVENTIONS
INTERVENTIONS AFFECTING STRESS
New multiplier onair pollution
New multiplier onworkplaces allowing
smoking
INTERVENTIONS AFFECTING STRESS
New multiplier onsources of stress
New MH servicesmarketing
New access tomental health svcs
Comparing Care, Air & Lifestyle Interventions
• Care providesDeaths from CVD per 1000
4• Care provides – quick and sustained
reduction in CV events, b t littl t i
4Base Case
Care
Care + Air + Lifestyle– but little cost savings.• Air provides
– rapid and growing
2Care + Air
Care + Air + Lifestyle
If all risk factors = 0
p g greduction in CV events,
– and major cost savings.• Lifestyle provides
01990 2000 2010 2020 2030 2040
Complication & Mgmt Costs per CapitaLifestyle provides– Growing CV event
reductions over time, but little immediately
Complication & Mgmt Costs per Capita3,000
Base CaseCare
Care + Airbut little immediately– Substantially increasing
cost savings over timeCare + Air + Lifestyle
01990 2000 2010 2020 2030 2040
If all risk factors = 0
Cost ConclusionsAIR S ki d i lit i t ti• AIR – Smoking and air quality interventions can save lives quickly and can justify intervention spending up to$300 per capita for 30 years ($355 in ET).p p y ( )
• CARE – Improving utilization and quality of primary care services can save lives quickly, but should not be expected to save much on total costs Justifiedexpected to save much on total costs. Justified intervention spending could be up to $25 per capita for 30 years ($35 in ET).
• LIFESTYLE – Improving nutrition and physical activity, and reducing sources of stress take longer to affect CV events though obesity and chronic conditionsaffect CV events though obesity and chronic conditions. However their contribution grows over time and intervention spending of up to $100 per capita could be j tifi d ($177 i ET)justified ($177 in ET).
Comparing All 19 Interventions on Summary Measures of Burden and Cost
Top 8 Highest Leverage Interventions*• Social Marketing Against Tobacco• Social Marketing Against Tobacco• Quality of Primary Care• Tobacco Tax and Sales Restrictions• Reducing Air Pollution (PM2.5)• Access to Primary Care• Access to Physical Activityy y• Access to Healthy Diet• Reduce Psychosocial Stress
Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease 2009 (in press)..
Comparing MS Delta, E. Travis & US: Most Effective Individual InterventionsMost Effective Individual Interventions
*Duplicates ranks indicate ties.
Dynamic Models Support Strategic Action
Local implementationopportunitiesLocal
• Extensions under way include– Borderline conditions, ex-
smokersD t
STRATEGICPRIORITIES
Downstreaminterventions
and costs
opportunitiesLocal implementation
strengths and success
– Downstream interventions and costs
• Transferability to
SYSTEMDYNAMICS MODEL
Smoking
Secondhandsmoke
Psychosocialstress
Diagnosisand control
Access to and marketingof smoking quit products
and services
Access to andmarketing of mental
health services
Sources ofstress
Access to andmarketing ofprimary care
Particulate air
Utilization ofquality primary
care
Tobacco taxes andsales/marketing
regulations
Smoking bans atwork and public
places
Quality of primarycare provision Anti-smoking
social marketing
Air pollutioncontrol regulations
Other chronic di
Political will
yother locales (East Travis, MS Delta)
Tools for wider
Obesity
Healthinessof diet
Extent ofphysical activity
and control
First-time CVevents and
deaths
Access to andmarketing of healthy
food options
Access to andAccess to and
marketing of weight
pollution
Junk food taxes andsales/marketing
regulations
Downwardtrend in CV
event fatalityChronic Disorders
Costs from CV and other riskfactor complications and from
utilization of services
High BPHigh
cholesterol
Diabetes Populationaging
disease endpoints
Health Ability to
• Tools for wider dissemination
• Cost-effectivenessAccess to and
marketing of physicalactivity options
marketing of weightloss services
inequities
Local leadership
yengage all
stakeholdersfor specific interventions
B d li
Implementationactions and costs
leadershipcapacity
Borderline conditions
What we have learned
• The simulator and surrounding dialogue are useful to:– Create alignment among stakeholders
I iti t t i thi ki i i– Initiate systemic thinking, increasing leadership capacity
– Spur people to actionSpur people to action– Identify opportunities and build commitment
to address them– Inform the development of business cases
for investment in interventions
EXTRA SLIDES
Data Sources for Modeling CVD RiskC• Census
– Population, deaths, births, net immigration, health coverage
• AHA & NIH statistical reports– Cardiovascular events, deaths, and prevalence (CHD, stroke, CHF, PAD)Cardiovascular events, deaths, and prevalence (CHD, stroke, CHF, PAD)
• National Health and Nutrition Examination Survey (NHANES) – Risk factor prevalences by age (18-29, 30-64, 65+) and sex (M, F)– Chronic disorder diagnosis and control (hypertension, high cholesterol, diabetes)
B h i l Ri k F t S ill S t (BRFSS)• Behavioral Risk Factor Surveillance System (BRFSS)– Diet & physical activity– Primary care utilization– Lack of needed emotional/social support Psychosocial stress
• Medical Examination Panel (MEPS) / National Health Interview (NHIS)– Medical and productivity costs attributable to smoking, obesity, and chronic disorders
• Research literature– CVD risk calculator and relative risks from SHS air pollution obesity and inactivity– CVD risk calculator, and relative risks from SHS, air pollution, obesity, and inactivity– Medical and productivity costs of cardiovascular events
• Questionnaires for CDC and Austin teams (expert judgment)– Potential effects of social & services marketing on utilization behavior
Eff t f b h i l i ki i ht l t d ti– Effects of behavioral services on smoking, weight loss, stress reduction– Relative risks of stress for high BP, high cholesterol, smoking, and obesity
Calculating First-Time CV Events & DeathsB d ll t bli h d F i h h f l l tiBased on well-established Framingham approach for calculating
probability of first-time events & deaths in individuals• CVD = CHD (MI, angina, cardiac arrest) + Stroke/TIA + CHF + PAD
Modifies individual-level risk calculator for use with populations• Uses prevalences of uncontrolled chronic disorders by sex/age group• Introduces secondhand smoke and pollution as additional risk factors• Combines risks multiplicatively to account for overlapping conditions• Adjustment exponents reproduce synergies seen in individual-level
calculator• Adjustment multipliers reproduce AHA event and death frequencies for
2003
- Anderson et al, Am Heart J 1991 (based on Framingham MA population N=5573, 1968-1987)- Homer “Risk calculation in the CVD model” project document, June 19, 2007- NHANES 1988-94 & 1999-04- AHA Heart Disease and Stroke Statistics – 2006 Update- AHA Heart Disease and Stroke Statistics – 2006 Update
