1. 1 Population Health Model (POHEM) AMI Acknowledgements: CCORT for collaboration and funding.

2. 2 2001 …….. POHEM example Starting Population: Canadian Community Health Survey 2001 (CCHS) cross-sectional representation of the Canadian population aged 18+ VARIABLE age sex province health region immigration status education level income quartile body mass index smoking status diabetic status HUI total cholesterol* HDL* blood pressure* Survey sample weight *imputed from Canadian Heart Health Surveys (1986-1992) VALUE 44 male Ontario York non-immigrant post-secondary Q4 (richest) 32.2 kg/m2 (obese) smoker non-diabetic 0.96 high low high 100.32 At beginning of each year: update risk factor profile evaluate hazard of developing disease  none in 2001 evaluate hazard of dying  2051

3. 3 AMI at age 45.3 Now at risk of 2 nd AMI, CHF, UA,... 2001 …….. POHEM example 2002 …….. Starting Population: Canadian Community Health Survey 2001 (CCHS) cross-sectional representation of the Canadian population aged 18+ AMI age sex province health region immigration status education level income quartile body mass index smoking status diabetic status HUI total cholesterol HDL blood pressure 2002.3 CHF UA AMI2

4. 4 CHF period of comorbidity from living with OA and CHF Osteoarthritis at age 69.4 in year 2028 … …….. 2001 …….. POHEM example 2002 …….. Starting Population: Canadian Community Health Survey 2001 (CCHS) cross-sectional representation of the Canadian population aged 18+ 2003 …….. Death at age 71.2 AMI CHFOA Congestive Heart Failue at age 66.1 in year 2023 2023.12028.4 2002.3 UA AMI2

5. 5 2001 …….. POHEM example 2002 …….. Starting Population: Canadian Community Health Survey 2001 (CCHS) cross-sectional representation of the Canadian population aged 18+ 2003 …….. … Death >100,000 records on CCHS representing over 20 million Canadians in 2001 Plus New Immigrants and New 18 year olds in subsequent years = 1 hour on a PC New 18 year olds New Immigrants

6. 6 Data Sources Canadian Community Health Survey (2000/01) –cross-sectional –representative of household population –starting population for POHEM (2001) National Population Health Survey –longitudinal from 1994-2004 (6 cycles) –model individual’s change in BMI, Smoking Many other data sources –survey, administrative, census, registry, vital, literature

7. 7 Data Sources Survey Data –Canadian Community Health Survey (2001, 2003, 2005, …) starting population for POHEM –National Population Health Survey (1994-2004…) models of change in BMI and smoking –Canadian Heart Health Survey (1986 to 1992) measured risk factors (cholesterol, blood pressure…) –Canadian Health Measures Survey(2009? …) Census and Registry Data –Census (population, immigration) (2002 to 2026) –Vital Statistics (mortality, births)(1872 to 2026) –Canadian Cancer Registry (incidence)(1997 to 1999) Administrative Data –Health Person-Oriented Information (1992/93 to 2001/02…) AMI incidence rates by province, Stroke, Arrhythmias? –Ontario Registered Person database (1988/89 to 2001/02) survival analysis –British Columbia Linked Hospital Admin Db (1991/92 to 2003/04) Osteoarthritis incidence rate, time to hip/knee surgery Other –CIHI cost data, Chart Abstractions, OHIP, other country data, published literature (e.g., relative risks, risk-incidence functions, sensitivity/specificity of screening tests), expert opinion…

8. 8 Coronary Heart Disease: Acute Myocardial Infarction (AMI) Upstream health determinants Intermediate risk factors Intermediate diseases SequalaeDeath AMI* Health Person-Oriented Information (HPOI) (HIRD) incidence rates by province, age and sex 2 nd AMI Congestive Heart Failure Unstabl e Angina Death Registered Persons database for Ontario (ICES) (CCORT I) survival data for each transition *incidence-risk equation based on Framingham risk function (Wilson 1998) for “index” AMI events competing risk of death from other causes Vital statistics (and other POHEM disease modules) initial values & transition models Diabetes Total cholesterol & HDL blood pressur e Cdn Heart Health Surveys 1986-92 age (time) initial values Obesity Smoking Nutrition Physical activity Alcohol Income Education Region Sex CCHS 2001 transition models NPHS 1994- 2004 S(t) Causal pathway

9. 9 Data Analysis and Input to POHEM: 1.incidence rates ( I ) are estimated from administrative data by age, sex and province 2.Framingham risk function, obtained from literature, relates risk factors to incidence  (beta coefficients from Wilson 1998) vary by risk factor categories α represents baseline risk by age, sex, province, calibrated to reproduce observed incidence rates ( I ) and takes into account the distribution of the risk factors in the population 4.initial values of risk factors from national surveys 5.models of change in risk factors based on trends from national surveys How POHEM Generates an Incident Case of AMI 1)POHEM selects a record from CCHS in simulation year 2001: male, age 44, Ontario, smoker, non-diabetic, high total cholesterol, low HDL, medium blood pressure... 2)Lookup baseline risk and risk factor coefficients from input parameter table. 3)Evaluate the probability (p) of AMI using the Framingham risk function (with rescaling): p = F/(1+F) = 0.877 4)Convert p to an annualized hazard (h): h = -ln(1-p) = 2.09 5)Generate a uniform random number (u) between 0 and 1 u = 0.975 6)Convert u to an annualized hazard (h*): h* = -ln(1-u) = 3.69 7)Transform the proportional hazards to a waiting time: t = ( h* / h ) = 1.76 years 8)AMI does not occur at age 44 in year 2001. 9)POHEM ages the person forward to next birthday and re- evaluates risk of AMI (steps 2-8). 10)Repeated for every record on CCHS, births and new immigrants α male,44,ON = 0.00138 β smoker = 0.523 β non-diab = 0 β chol-high = 0.657 β HDL-low = 0.497 β BP-med = 0.283

10. 10 Data source: HPOI (hospital discharge abstract database); POHEM projections superimposed Trends in overnight hospitalizations for new AMI cases (External Validation) POHEM projections of AMI, Ontario

11. 11 First AMIs projected* to increase in all provinces *POHEM projections

12. 12 Age-standardized rate of AMI projected to decline  reduced impact from risk factors

13. 13

14. 14 Chart 1 Percentage of current smokers, Canada excluding territories, 2000 to 2006 % Sources: Population Health Model (POHEM); Canadian Tobacco Use Monitoring Survey (CTUMS); Canadian Community Health Survey cycles 1.1, 2.1, 3,1 (CCHS) POHEM (age 18+) CCHS (age 18+) CTUMS (age 15+)

15. 15 Nutrition Diabetes Kidney Disease Diabetic Retinopathy Osteoarthritis Coronary Heart Disease Peripheral Vascular Disease Stroke Obesity Physical activity Alcohol 25 Cancers Region Smoking Cholesterol Blood pressure Hyper- tension Ethnicity Upstream health determinants Intermediate risk factors Intermediate diseases DiseasesTreatment Initial state assigned from CCHS (+CHHS) Death competing risk of death from other causes Amputation Dialysis ABS Surgery, Drugs Surgery, Radio/Chemo/H ormonal therapy Cataract surgery... Surgery, Drug, Lifestyle POHEM: Overall causal flow TIME (AGE and YEAR) other risk factors other diseases Income Education Health-related Quality of life (e.g., HUI) Depression Age Sex Death Obesity Age Sex Region Income Education