Creating Health: Finding the Path from Here to There

By Thomas Kottke, MD, MSPH and Nico Pronk, PhD

The advances in the treatment of cardiovascular disease in the past 50 years are remarkable. Automated external defibrillators (AEDs), the devices you see in airports and other public places, change out-of-hospital cardiac arrest from a death sentence to an event with some chance of survival. Coronary angioplasty (ballooning the blockages in the arteries that feed the heart) during a heart attack reduces deaths by about 50%. Implantable devices that pace and shock the heart when a life-threatening heart beat occurs reduce the risk of death by more than 40%.¹

These statistics and the current emphasis on individualized medicine might suggest that, if a community can afford high tech health care, it doesn’t need to invest in parks, bikeways, tobacco-free homes and workplaces, access to affordable fruits and vegetables, and the other health promoting environments.² But the data demonstrate that the path to health for every community and every individual, rich and poor alike requires health-promoting physical and social environments.

Let’s do the math for the high tech treatments of heart disease and two of the fundamental determinants of health--physical activity and healthy food. The best estimate of what will happen to an individual is what will happen to others in their community. It is simple to calculate the community impact of any intervention if just four parameters are known: (1) the extent to which an intervention will reduce “event rates,” (2) the event rate for eligible individuals who participate in the intervention, (3) the number of eligible individuals who have not yet taken part in the intervention, and (4) the number of people in the community who are eligible for the intervention.

For example, using deaths that might be prevented or postponed (DPP) as “the event,” we can calculate the impact of meeting the physical activity guideline for healthy Americans.

For a population of 30-84 year-old Americans:

• The mortality rate of physically active individuals is 30% lower than the mortality rate for inactive individuals;
• The death rate is 1,007/100,000;
• 70% of those able to be active are currently not active;
• In a population of 100,000, the number of apparently healthy individuals is 90,024. 

Therefore, the DPP that could be achieved if the entire healthy population were to become physically active is 0.30 x 0.01007 x 0.7 x 90,024, or 190.

In 2009, we published the expected DPPs for nutrition, physical activity, tobacco and several heart disease treatments.¹ We calculated the impact of improving performance from current levels to achieving 100% goal attainment.  We found that the number of deaths that might be prevented or postponed in a community of 100,000 adults ages 30-84 would be:

• 1.9 if AEDs were placed in all public places and people who worked there were trained in their use,
• 15.1 if all individuals with heart attacks received angioplasty,
• 63 if all individuals who met the criteria received an implantable defibrillator or biventricular pacemaker,
• 158 if everyone met the dietary goal of 5 servings of fruits and vegetables every day,
• 159 if no one smoked and no one were exposed to second-hand smoke, and
• 334 if everyone met the physical activity goal of 150 minutes per week.

We found that improving care for acute heart disease events could at most prevent or postpone 8% of deaths in the U.S. population ages 30-84. Taking full advantage of the benefits of good nutrition, adequate physical activity, and elimination of tobacco would prevent or postpone 49% of all deaths.  If our calculations considered the impact of all community determinants of health on all ages, the predicted impact would be considerably larger.

It is indisputable that access to medical care saves lives, but the math demonstrates that, regardless of the resources that might be committed to health care, there is only one path to significantly healthier communities.  That path is mobilizing action to improve the physical and social environments in which we live.

Thomas Kottke, MD, MSPH is Medical Director for Population Health with HealthPartners in Bloomington, MN.

Nico Pronk, Ph.D. is Vice President and Health Science Officer with HealthPartners in Bloomington, MN.

 

References

1. Kottke TE, Faith DA, Jordan CO, Pronk NP, Thomas RJ, Capewell S. The comparative effectiveness of heart disease prevention and treatment strategies. Am J Prev Med. Jan 2009;36(1):82-88 e85.

2. Mobilizing Action Toward Community Health (MATCH): Population Health Metrics, Solid Partnerships, and Real Incentives 2012; http://uwphi.pophealth.wisc.edu/. Accessed December 20, 2012.