Date of Award

January 2017

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Brita Roy

Second Advisor

Bradley Richards

Abstract

Cardiovascular Disease remains the number one cause of mortality in the United States with atherosclerotic cardiovascular disease (ASCVD) being a major component. Lifestyle interventions remain the first line treatment for the prevention of ASCVD, and clinic- based interventions effectively improve rates of healthy lifestyle choices. However, these programs require additional resources and there is currently no guidance for clinic directors to understand what lifestyle intervention(s) have the highest value for their unique population. We propose a novel application of the 10-year ASCVD risk calculator to a clinic patient cohort, thereby acting as a tool for providers and administrators to develop lifestyle intervention programs that will have the greatest risk reduction for their clinic population.

We first defined the ASCVD 10-year risk for patient cohorts from four different primary care clinics in New Haven, CT by normalizing and aggregating individual patient 10- year ASCVD risk scores. We then calculated changes to this normalized aggregate risk by modeling the effects of evidence-based interventions found in Cochrane Reviews of different efficacy to each of four modifiable risk factors used in the 10-year ASCVD risk calculator. The four different modifiable risk factors include systolic blood pressure, total cholesterol, HDL cholesterol and smoking status. A resulting change in each cohort’s normalized aggregate risk was calculated.

The clinic cohorts had different levels of modeled risk reduction from the same interventions. The magnitude of reduction was dependent on baseline normalized aggregate risk and prevalence of risk factor(s) targeted in the interventions. The three clinics where the baseline normalized aggregate risk was above 100 events per 1,000, patients had a greater risk reduction from an organizational intervention aimed at improving the quality of treatment for hypertensive patients compared to all other evidence-based interventions found in Cochrane Reviews. In the clinic that had a lower baseline normalized aggregate risk, the highest yield intervention was dietary advice by providers. Our data demonstrate that the highest yield lifestyle intervention for any clinic may vary depending on the makeup of the populations and its risk factors.

The tool created in this study can be used by clinic providers and administrators to estimate the effects of various interventions on the ASCVD risk of their clinic cohort. The models generated by this tool can be used to guide strategy and prioritize clinic resources based on the extrapolated effects of evidence based interventions to specific clinic populations. Furthermore, it may also guide interventions planned to address needs identified by community health assessments. Because the tool predicts outcomes for specific patient populations it has the potential to foster the application of evidence-based practices to population health management.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 01/01/2021

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