translating epidemiologic research to improve population health through global engagement

Translating epidemiologic research to improve population

health through global engagement

Graham A Colditz, MD DrPHNiess-Gain Professor

Chief, Division of Public Health Sciences

AEA 30th Anniversary, Sydney Uni, 30 September, 2017

Department of SurgeryDivision of Public Health Sciences

High School:Newington College,Stanmore


BScMed

S&P


Economic costs of diabetes: JAMA 1989

JAMA 1989


BMI and Relative Risk of incident diabetes over 8 years, NHS Colditz et al Am J Epidemiol 1990


June 26, 1995

Every Woman’s delemma

THE ESTROGEN DILEMMAAMERICA'S NO. 1 DRUG IS AN ELIXIER OF YOUTH, BUT WOMEN MUST DECIDE IF IT'S WORTH THE RISK OF CANCER


Selected Causes of Death –1970–72 AND 2002–04, Australia


Doll and Peto 1979

Now IARC 2016 many prospective cohorts for obesity as a cause of cancer


Workgroup reviewed measures of adiposity; animal models; mechanisms; and epidemiologic evidence.Concluded lack of body fatness lowers risk, or obesity causes cancer.

NEJM August 25, 2016


Evidence, 2016

RiskIncreaseAssociatedwithObesity LevelofEvidence

Small(RR1.09-1.34)

Moderate(RR1.35-1.99)

Large(RR2.0-4.9)

VeryLarge(RR5.0+)

Convincing Ovary Colon Breast Esophagus Thyroid Gastriccardia

LiverKidney Uterus

Gallbladder Pancreas

MeningiomaMultiplemyeloma

Probable Malebreast

Fatalprost.DiffuseLargeB-celllymphoma

IARC Report NEJM 2016


Current situationWe are not implementing proven chronic disease prevention and treatment interventions.

Instead we allow millions of people to develop and die from highly preventable diseases.

By not implementing these interventions in ways that reach populations with greatest need, we are permitting disparities to persist.38M deaths each year from NCDs, and 74% of them are in low & middle income countries.

Emmons and Colditz, NEJM 2017


Global NCD burden as cause of death


NCD burden and ageing population –costs of care outstrip budget

Allocation cannot keep up with cost of care, even in high income countries

Economist Sept 10, 2016


Chan, et al…Hu JAMA 2009SEA – includes IndiaWestern Pacific – China, Australia etc.


Over 80% CHD and Diabetes can be prevented through lifestyle!1.Healthy diet (high cereal fiber, low glycemic

load, high polyunsaturated fat), 2.Physical activity (>30 minutes per day), and 3.Not being overweight or obese (BMI<25)

• Hu, .. Colditz,… Willett NEJM 2001• Stampfer, et al NEJM 2000


Estimated new cancer cases, World, 1975 to 2050: Region

Bray and Moller Nat Rev Cancer 2006

2012 – 14 M cases

1.7 M breast(1 in 4 cancersin women)


Sept 14 2017


Malik et al Nat Rev Endocrinol 2013

Excess energy è Obesity è NCDs


WHO priorities:population-wide interventions – Prevention § Reducing tobacco use (a best buy)§ Promoting healthy diets§ Promoting physical activity§ Reducing harmful alcohol use§ Cancer specific strategies

§ Hepatitis B vaccine (a best buy)§ HPV vaccine§ Cervical cancer screening§ Not currently recommended in low income countries – colon

cancer screeningWHO: Global status report on non-communicable diseases, 2010


Best buys for 4 risk factors§ Reduce tobacco use:

§ Protect from exposure§ Warning dangers§ Enforce bans on advertising§ Raise taxes

§ Promote healthy eating§ Reduce harmful alcohol§ Increase physical activity


Kirby Lancet Oncol 2016


Best buys for 4 risk factors§ Reduce tobacco use

§ Promote healthy diet:• Reduce salt/sodium in food• Replace trans-fat with unsaturated fatty acids• Reduce saturated fats• Reduce content of free sugars in food and drinks• Eat plants not animal products

§ Reduce harmful alcohol§ Increase physical activity


WHO priorities:Individual-based interventions in primary care

• Cardiovascular disease and Diabetes• Multi-drug therapy (including glycaemic control for

diabetes mellitus) to individuals who have had a heart attack or stroke, and to persons with a high risk (> 30%) of a CVD event in the next 10 years;

• Providing aspirin to people having an acute heart attack• Cancer• Smoking cessation, aspirin, blood pressure

treatment, and lipid lowering agents


What skills do we need?• Mentoring• Diversity• Global focus => work life balance


1975 – Jake Najman, medical sociology

1977, Ken Donald B.Sc. (Med) - research

1978-9 Chris Bain “Go to HSPH”

1976-9 Mary Sheehan

medical student research

Mentors


Translating research to practiceImplementation Science• Design • Frameworks• Analysis (what is the unit here)

Let’s also think about de-implementation


Tomorrows leaders• They are here already – being trained• What skills do they need (not something

to think about for the future but we need these skills now!)

• Success is not just getting our trainees to their first jobs!


Reporting•Stats methods•Measurement

Evidence synthesis•BCG team•Methods

Translation to practice•Risk prediction•Implementation science

Arrived Boston, Sept 1981

Core Issues in Moving from Research to Practice


MeasurementExamples include: • Reproducibility of age at menopause• Diet• Physical activity • Biomarkers


Evidence synthesis

IOM examples from Fred’s work: Vaccines“Adverse effects of Pertussis and Rubella vaccines” NAP 1991From mine: “Veterans and Agent Orange”, NAP 1994, 1996


Citations: JAMA 1994 – 1116; Pediatrics 1995 – 428

Methods development: Berkey et al


Aims of Response to CDC RFAProject objectives.As defined in the Request for Proposals released by the Centers for Disease Control and Prevention in the summer of 1992, the specific aims for the study were:

A To review the available literature and data bases for data on BCG efficacy and provide a written report on the data that are amenable to meta-analysis.

B To provide a written proposal for study design and methodology for meta-analysis of the available data. Specific attention will be placed on limitations of methods used for meta-analysis, and estimates of confidence to be placed in the estimates of efficacy.

C To perform the meta-analyses using an agreed upon methodology and report on the efficacy of BCG in subgroups. Specific attention will be placed on analyses to assess the efficacy of BCG in children and adults, and the relative efficacy of different vaccine strains.


Aim so f response to RFA

Citations 377


Translation to Practice: Prediction Models

Evolution from modeling breast cancer incidence to applications in breast, colorectal, ovarian, and other cancers

Move beyond disease etiology to stratify population for interventions


Purposes of Risk Prediction Determine study eligibilityRisk stratification

E.g., to counsel or guide lifestyle modification – prevention

Intervention decisionRisk estimation and classification for eligibility for services, e.g. MRI

Understand disease etiologyModel incidence and temporal relations of risk factors (life-course

models)


To Fulfill PurposesDevelop model

Validate

Implement

Adjust


Cancer Prevention

Reviewed evidenceTranslate to practiceTest pencil and paperDevelop cancer tool on lineExpand to other diseases

ValidateCancer &Heart diseaseEmmons K, et al 1999

Kim D., et al J Clin Epi 2004De Vito L et al 2015


Future: Implementation Sciences

How pragmatic is this trial? See PRECIS criteria?

Designs for interventions in health systems?

Thorpe et al CMAJ A pragmatic–explanatory continuum indicator summary(PRECIS): a tool to help trial designers


Implementation Sciences Methods• Methods for policy research• Methods for large scale studies required for scale up• Methods appropriate for capturing multi-level influences,

given organizational complexities• Choosing the correct unit of analysis, given there are “so

many” at play• Real world random assignment• Rapid launch of natural experiments (investigators adopt,

they’re off and running)


Implementation Sciences Methods (Con’t)• Simulation methods• Long-enough observation to capture de-

implementation• Methods to capture “diagnostic appropriate”

treatment, given the variations of under-use, over-use, and inappropriate use of guidelines/ interventions etc.

• Power estimation for studies when organizational change is the outcome


Wall-eCaptain

Will we all have access to driverless cars?

What will our cancer risk be?

translating epidemiologic research to improve population health through global engagement

Health & Medicine