Coronary heart disease risk factors in Canada: a Microsimulation predictive model Doug Manuel, MD, MSc, William M. Flanagan, BM, Meltem Tuna, PhD, Anya Okhmatovskaia, PhD, Philippe Finès, PhD; Carol Bennett, MSc

Simulated Technology for Applied Research (STAR)  Behnam Sharif, MSc,  Jacek A. Kopec, MD, PhD,  Hubert Wong, PhD,  Aslam Anis, PhD,  Eric C. Sayre, PhD, M.  Mushfiqur Rahman, MSc,  David Buckeridge, MD, PhD,  Jillian Oderkirk, MSc,  Michal Abrahamowicz, PhD,  Sam Harper, PhD,  Michael C. Wolfson, PhD A Canadian Institute for Health Research New Emerging Team including:

Chronic Diseases  Major cause of death and disability worldwide.  Reason of more than 55 thousand deaths in Canada so far this year.  57% of those under 65 live with at least one chronic condition.  An additional chronic disease raises the risk of hospitalization by 44% among people under age 60.

Risk Factors  Behavioural Smoking Physical Inactivity  Biophysical Obesity Elevated Cholesterol Blood Pressure

POHEM: Population Health Model ModGen (Developed in C++) Interacting Agent models Child Vaccination (CVMM) HIVMM Non-Interacting Agent models LifePaths PopSim POHEM Micro-simulation at Statistics Canada

Characteristics of POHEM  case-by-case, longitudinal, continuous time, stochastic, Monte Carlo microsimulation  directly encompasses competing risks and comorbidity  longitudinal risk factor and disease sub-modules  projects population forward in continuous time  generates plausible health biographies over the life course of synthetic individuals from empirical observations

Process for projecting coronary heart disease risks in Canada, 2001 to 2020 Initialize a predictive model by creating a cohort of Canadians, 2001, age 20 years and older. Each year from 2001 to 2009, update population characteristic and CAD risks Compare predictive demographic characteristics and CAD risks from 2001 and 2009 Continue yearly updates to project CAD risks from 2010 to 2020 Canadian population (2001) Canadian Community Health Survey (2001) Update yearly (2002 – 2009) Update for births, deaths, immigration, emigration and change in CAD risks Validate (2002 – 2009) Compare births, deaths, immigration, emigration and prevalence of CAD. Generate predictive estimates (2010 – 2020)

Data sources Canadian Community Health Survey Canadian Heart Health Survey Initial Population

Births and Deaths Yearly Updates Projected total fertility rate and death rate from Statistics Canada Data Sources National population projections Update Method Canadian population estimated, Statistics Canada adjusted census counts Validation

Immigration and Emigration Yearly Updates Projected immigration and emigration from Citizen and Immigration Canada (CIC) Data Sources Projected immigration based on Canadian government policy. Emigration based on CIC projections. Update Method Vital Statistics (Statistics Canada) Validation

Socioeconomic Yearly Updates Projected education and family income from Statistics Canada Data Sources From LifePaths, a microsimulation model used for social planning. Update Method Canadian population estimates, Statistics Canada adjusted census counts Validation

CAD Risks Yearly Updates National Population Health Survey Data Sources Kaplan Meier survival functions by sex, based on observed change during 1994 to Update Method CCHS 2003 – 2009 (biannually) Canadian Health Measures Survey ( ) Validation

Coronary heart disease risk factors, prevalence in 2001 SexMillion% Blood Pressure Million% Male Optimal Female Normal High-normal MeanMedian Hypertensive Stage I Age Hypertensive Stage II-IV SmokingMillion%Total CholesterolMillion% Current Low Former Low-Medium Never Medium Medium-High High

Observed vs. Predicted

Multiple Risk Factors: Diabetes – Obesity - Smoking

Predicted and observed risk factors, 2009 Canada ProjectedObserved Diabetes Obesity Smoking

References  M.C. Wolfson, POHEM—a framework for understanding and modelling the health of human populations. Wld. Hlth. Statist. Quart. 47 (1994), pp. 157–176  Statistics Canada. Canadian Community Health Surveys, Cycles ,