Cardiovascular Disease Prevention in an Era of Global HIT Spread

Sonia Angell, MD, MPH Deputy Commissioner

February 25, 2016 Crystal City, Virginia Innovative Policy in Cardiovascular Non-Communicable Disease Prevention

American College of Preventive Medicine

CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of DOHMH is strictly prohibited

We are more similar than not…

Leading Causes of Death Globally, 2013

Adapted from: Naghavi M, et al. Lancet 2015, 385(9963), 117-171.

*Includes all other non-communicable disease, and injuries

Cardiovascular Disease

32%

Cancer 15%

Diabetes 2%

Chronic Respiratory

Disease 8%

Other* 22%

Communicable, Maternal,

Neonatal, and Nutritional Diseases

21%

Leading Causes of Death in New York City, 2013

*Includes all other natural and external causes (including communicable disease) Source: Summary of Vital Statistics 2013, The City of New York Appendix A, Table M1. February 2015. Can be accessed at: http://www.nyc.gov/html/doh/downloads/pdf/vs/appendixa-2013.pdf

Cardiovascular Disease

37%

Cancer 25%

DM 4%

Chronic Lower Respiratory

Disease 3%

Other* 31%

Still, Place Matters: Premature Death in NYC

Poverty and Race/Ethnicity in NYC

6

Sources: Neighborhood poverty (based on zip code) defined as percent of residents with incomes below 100% of the Federal Poverty Level, per American Community Survey 2007-2011. Population (based on zip code) defined as percent of non-Hispanic black and Hispanic residents, per 2010 Census.

Prevention is a Space Shared by Both Clinical Medicine and Public Health

Clinical

Community

Improved Population

Health

Electronic Health Record Use: Global Growth

8

Available at: http://www.businesswire.com/news/home/20140224005325/en/Global-Market-Electronic-Health-Records-EHR-Expected

EHR Use Has More Than Tripled Since 2001 in the US

Percentage of office-based physicians with EMR/EHRs systems: United States, 2001-2013

Hsiao C-J, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2013. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics. 2014. Available at: http://www.cdc.gov/nchs/data/databriefs/db143.pdf

Electronic Health Records (EHRs) Make Medical Record Information Actionable

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70

80

Oct

-09

Dec-

09

Feb-

10

Apr-

10

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-

11

Jun-

11

Aug-

11

Oct

-11

Data Gives PHDs the tools we need to improve Community Health

Hub Population Health Network

Secure exchange of aggregate data through a distributed model

Send out queries Receive patient counts

overnight Currently covers:

• 700+ practices • 2.1 M patients in 2014 • 6 M patients since 2009

Scope of the Hub’s Coverage: Total Geographical Reach

4,000+ Patients Per Neighborhood 18% of all NYC in 2013

HTN Control Varies by Practice Location

13 Data were obtained from the Hub Population Health System. Buck MD, Anane S, Taverna J, Amirfar S, Stubbs-Dame R, Singer J. The Hub Population Health System: distributed ad hoc queries and alerts. J Am Med Inform Assoc. 2012 Jun;19(e1):e46-50. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392869/

Diabetes: A Social Determinants Lens

• Access to quality health care – Hemoglobin A1C – Public health detailing

• Improving the community food environment – Neighborhood Programs – Citywide Policies

• Improved everyday life – Health – Housing – Income

A1C Registry Data

• Established 2006 by Board of Health • All A1C laboratory tests from clinical

laboratories for NYC residents are electronically reportable to the Health Department

• ~132,000 individuals with diabetes had annual tests between 2006-2012

• Nearly 2/3 did not consistently maintain A1C <8

A1C Point Density Mapping Analysis

Source: NYC A1C Registry, 2006 - 2012

Community Health Worker Initiative – Harlem Health Advocacy Partners

Targets Residents of 5 NYCHA Developments Goals:

• Improve health of Harlem NYCHA residents

• Decrease existing disparities chronic diseases: diabetes, hypertension, asthma

• Policy agenda to advocate for CHW certification & reimbursement

Design Components

• Community Engagement

• Wellness Activities

• Health Insurance Navigation

• Health Coaching

Hotspot map display represents 900 people with uncontrolled diabetes per A1C registry (>9)

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Potential of Aligning Mutually Reinforcing Strategies in both Environments

Clinical • Prescribing Statins • Public Health

Detailing in clinics on Tobacco

• Improved diabetes management

• A1C Registry

Community • Restricting trans fat

use in restaurants • Tobacco media

campaigns • Scale up of National

Diabetes Prevention Program

• CHW Programming

21.6 21.7 21.5

19.2 18.3

18.9

17.5 16.9

15.8 15.8

14 14.8

15.5 16.1

13.9

Smoke-free parks & beaches

1993-2001, smoking prevalence was

stable, 21.5%-21.7%

% o

f adu

lts

NYC & NYS tax increases

Smoke-free Air Act (SFAA)

Free patch programs

start

Hard-hitting media

campaigns

Adult Smoking in New York City

NYS tax increase

Federal tax

increase, NYC

banned flavored sales, & SFAA

extended to include hospital

entrances NYS tax

increase

Source: CDC Behavioral Risk Factor Surveillance Survey; NYC Community Health Survey

SFAA extended to e-cigs, Sensible Tobacco

Enforcement & Tobacco 21 laws

implemented

In Conclusion

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• The world is more similar than different – Lessons learned everywhere have value – Don’t overlook the potential value of HIT anywhere

• Place matters – Look for precision when advancing population

health • Prevention is a shared space by clinical

medicine and public health – Innovate to integrate!

Thank you!

Sonia Angell, MD, MPH

Deputy Commissioner for Prevention and Primary Care

sangell@health.nyc.gov Innovative Policy in Cardiovascular Non-Communicable Disease Prevention

American College of Preventive Medicine CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of DOHMH is strictly prohibited