MD Conference Express AHA 2013 - (Page 12)

FEATURE in the area of systems prevention including the National Collaborative on Childhood Obesity Research's project Envision (http://nccor.org/projects/envision.php), which seeks to gain insight into the most effective ways of preventing obesity by examining the effects of individual, socio-cultural, economic, environmental, and policy forces on children's diet, physical activity, energy balance, and body weight [Story M et al. Annu Rev Public Health 2008]. Another example is a program at Johns Hopkins University that aims to reduce the impact of CVD disparities on vulnerable populations in Baltimore, Maryland, USA [Cooper LA et al. Am J Pub Health 2013]. Dr. Robinson also proposed another model that builds on existing epidemiologic studies through the collection of new data on community, transportation, air and water quality, socioeconomic trends, and social networks. Finally, she suggested that these quantitative systems should be complemented by qualitative studies, not only to add new data but also to facilitate the advance of new interventions. Evidence-based practice guidelines are issued and updated regularly in most specialties. They are the result of many hours of work on the part of clinical specialists- but to be effective they must be implemented. Using the Kaiser Permanente system as an example, Wiley Chan, MD, Kaiser Permanente Care Management Institute, Oakland, California, USA, discussed some of the important factors in the clinical implementation of practice guidelines. Effective implementation of practice guidelines begins with a culture that supports patient-centered, evidencebased care and a leadership structure that encourages and funds the activities called for in the guidelines. Within this environment, it then becomes possible to establish an infrastructure that promotes coordinated multifaceted implementation strategies that are based on an integrated set of data systems and registries, care/case management programs, pharmacy initiatives, and electronic health record (EHR) clinical decision support systems. Use of the system is encouraged through a system of metrics to which clinicians, staff, and the organization are held accountable as well as incentives for performance. Patient-facing tools can enhance patient engagement, and their use is associated with significant improvement in nine Healthcare Effectiveness Data and Information Set (HEDIS) measures (Figure 1) [Zhou YY et al. Health Aff (Millwood) 2010]. Most discussions of CVD-related morbidity and mortality focus on their relationship to lifestyle issues (diet, physical activity, tobacco use) and/or the availability of, and access to, quality of care. While these are essential issues, Dorairaj Prabhakaran, MD, Center for Chronic Disease Control and Center for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, New Delhi, India, suggested that socioeconomic status (SES), genetics, and fetal programming are also very important 12 December 2013 conditioning factors for disease risk and that when these are considered, there is a strong argument in favor of a lifecourse perspective on CVD. Such a perspective would take into account two major drivers of CVD: the early critical period during which an exposure leads to lasting/lifelong adverse effects on body systems and the longitudinal accumulation of risk across the life-span from biological and social factors. 1. CV Figure 1: Impact of Patient Facing Tools on Quality of Care Figure 1. Impact of Patient Facing Tools on Quality of Care: Selected Measures Post: Nonusers 100 Post: Users 90 80 70 60 0 HbA1C Screening HbA1C <9% LDL-C Screening LDL-C BP BP <100 mg/dL <140/90 mm Hg <130/80 mm Hg BP=blood pressure; LDL-C=low-density lipoprotein cholesterol. According to the 1000 Days Partnership (http://www. thousanddays.org/about/), the right nutrition during the 1000 days between conception and a child's second birthday can have a profound impact on a child's ability to grow, learn, and rise out of poverty (Figure 2) [Victora CG et al. Pediatrics 2010; Stein AD et al. Am J Hum Biol 2010]. The mechanism fetal programming is depicted in Figure 2. Importantly for CVD, >100 publications from several countries have documented the relationship between low birth weight and rebound adiposity, hypertension, coronary heart disease, stroke, type 2 diabetes, and insulin resistance in later life. 1. CV Figure 2. Effects of Fetal Undernutrition Figure 2: Effects of Fetal Undernutrition Uteroplacental blood flow Maternal diet Placental transfer Fetal genome Nutrient demand exceeds supply FETAL UNDERNUTRITION Brain sparing Impaired development: blood vessels, liver, kidneys, pancreas Down regulation of growth Insulin/IGF-1 secretion and sensitivity Hyperlipidemia Hypertension Early Altered body maturation composition Cortisol Central obesity Muscle ? Fat Insulin resistance Type 2 diabetes and CHD CHD=coronary heart disease; IGF-1=insulin-like growth factor 1. Reproduced with permission from D Prabhakaran, MD. www.mdconferencexpress.com  http://www.nccor.org/projects/envision.php http://www.thousanddays.org/about/ http://www.thousanddays.org/about/ http://www.mdconferencexpress.com

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