3rd Congress on Preconception Health and Care Uppsala February PEACE Tool

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1 Department of Public Health and Caring Sciences (IFV) 3rd Congress on Preconception Health and Care Uppsala February 2016 PEACE Tool Population Estimates of Attributable Fraction for Congenital Conditions Everywhere Pierpaolo Mastroiacovo and Lorenzo Botto

2 Foreword The aim of Preconception Health and Care: to decrease the prevalence of adverse reproductive outcomes (AROs) Mastroiacovo - Botto 2

3 To reach this aim we need to decrease the prevalence of preconception risk factors Risk Factor Nutrition Over- & under-weight Insufficient Folic acid Smoking Alcohol Illicit substances Stress Chronic disease Infectious disease Medications Chemicals Age at conception Mastroiacovo - Botto 3

4 By decreasing the prevalence of a preconceptional risk factor we can, yes, WE CAN decrease several AROs, including some adult diseases Risk Factor Infertility Pregnancy Disease Malformation Develop Disability Preterm Birth Nutrition X X X X X X Over- & under-weight X X X X X X X Insufficient Folic acid X X X X X X Smoking X X X X X X X Alcohol X X X X X X Illicit substances X X X X X X Stress X X X X Chronic disease X X X X X X Infectious disease X X X X X X Medications X X X X Chemicals X X X X X X X Age at conception X X X X X X IUGR Evidence of the causal link between risk factor and outcome is variable Adult Disease Mastroiacovo - Botto 4

5 Key Challenge Poor visibility of primary prevention opportunities offered by Preconception Health and Care In particular for Health Policy Makers Mastroiacovo - Botto 5

6 The metric, typically provided by research articles, is the relative increase of risk of a particular outcome associated with a particular risk factor [RR (Relative Risk) or its approximation, the OR (Odds Ratio)] this metric represents the strength of the association between risk factor and outcome 1.60 ( ) 1.43 ( ) 1.49 ( ) 12.7 ( ) Mastroiacovo - Botto 6

7 Fine... but policy makers want to know How many cases does this risk factor cause in my country? How many cases could be prevented if the prevention program is implemented? How much money could I save? Mastroiacovo - Botto 7

8 The answer to these questions needs Population Attributable Fraction (PAF) to start from: The proportion (%) of adverse outcomes that would be prevented if the risk factor was eliminated Outcome Incidence before the preconception program Exposure eliminated [Before ] [After] [Before] Outcome Incidence after the preconception program Mastroiacovo - Botto 8

9 How the PAF is computed? Two metrics are needed PAF = ( OR 1 ) x P exposure [(OR 1) + 1] x P exposure Note: this is one way to compute the PAF, using OR as estimate of risk Mastroiacovo - Botto 9

10 The Odds Ratio is provided by a suitable study, preferably a well-done meta-analysis of several high quality studies Simeone RM et al. Diabetes and congenital heart defects: a systematic review, meta-analysis, and modeling project. Am J Prev Med Feb;48(2): Mastroiacovo - Botto 10

11 The prevalence of exposure (P exp ) is given by a well-done survey not too difficult to do Before pregnancy During pregnancy Soon after birth After birth Mastroiacovo - Botto 11

12 or, better, by an ongoing surveillance program for example, the PRAMS system in the United States After delivery Includes Preconception Indicators Mastroiacovo - Botto 12

13 Population Attributable Fraction (PAF) Knowing the two metrics (OR and P exp ) for a risk factor, we can estimate its Population Impact : the Population Attributable Fraction (PAF) 100% 90% OR: 20 OR: 10 80% OR: 5 70% OR: 3 60% 50% OR: 2 40% 30% 20% 10% 0% 0% 1% 10% 100% Population Prevalence of Risk Factor (logarithmic scale) Mastroiacovo - Botto 13

14 Population Attributable Fraction (PAF) Examples 100% 90% 80% 70% As you can see even a small OR may have a great impact, with sufficiently high risk factor prevalence OR: 20 OR: 10 OR: 5 OR: 3 Insufficient FA & NTDs Pr= 100% OR= 3.57 PAF= 72% N= % 50% 40% 30% OR: 2 Obesity & SB Pr= 40% OR= 2.24 PAF= 33% N= % 10% 0% 0% 1% 10% 100% Population Prevalence of Risk Factor (logarithmic scale) Valproate & SB Pr= 0.1% OR= 12.7 PAF= 1.2% N= 6 In this example, in 1 million births N of spina bifida is 503 Number of cases (N) computed on 1 million births Mastroiacovo - Botto 14

15 Now how much time left? I m going to turn on a light Mastroiacovo - Botto 15

16 and introduce to you the PEACE Tool Free! Yours for. 999 Euros (1,091 USD) 499 Euros (545 USD) 99 Euros (108 USD) With one stipulation. Mastroiacovo - Botto 16

17 What does PEACE mean? Population Estimates of Attributable fraction for Congenital conditions Everywhere Mastroiacovo - Botto 17

18 How is the PEACE Tool organized? Excel file with 8 spreadsheets 1. Frequently asked questions about the tool 2. Data entry dashboard 3. Results for Smoking 4. Results for Diabetes 5. Results for Obesity 6. Summary of results dashboard 7. Examples of exposure prevalence 8. Examples of outcome prevalence Mastroiacovo - Botto 18

19 How the PEACE Tool is organized? Excel file with 8 spreadsheets 1. Frequently asked questions about PEACE 2. Data entry dashboard 3. Results for Smoking 4. Results for Diabetes 5. Results for Obesity 6. Summary of results dashboard 7. Examples of exposure prevalence 8. Examples of outcome prevalence Mastroiacovo - Botto 19

20 Click & Learn Button 52 outcomes Enter local To correct the Enter local prevalence. estimate if prevalence. If unavailable, bias is If unavailable, can use suspected PEACE estimates provides estimates, with reference Mastroiacovo - Botto 20

21 How the PEACE Tool is organized? Excel file with 8 spreadsheets 1. Frequently asked questions about PEACE 2. Data entry dashboard 3. Results for Smoking 4. Results for Diabetes 5. Results for Obesity 6. Summary of results dashboard 7. Examples of exposure prevalence 8. Examples of outcome prevalence Mastroiacovo - Botto 21

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23 The most significant (and ongoing) work and contribution of the PEACE team: 1. Search and systematic review of meta-analyses for the risk factors in the tool 2. Selected the Overall Odds Ratio of the best meta-analysis (evaluated via AMSTAR score) 3. However, the Overall Odds Ratio can be changed when better data appears in the literature Mastroiacovo - Botto 23

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26 How the PEACE Tool is organized? Excel file with 8 spreadsheets 1. Frequently asked questions about PEACE 2. Data entry dashboard 3. Results for Smoking 4. Results for Diabetes 5. Results for Obesity 6. Summary of results dashboard 7. Examples of exposure prevalence 8. Examples of outcome prevalence Mastroiacovo - Botto 26

27 Next slide wide Mastroiacovo - Botto 27

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29 Strongly hope Lorenzo Myself Population Estimates of Attributable fraction for Congenital conditions Everywhere be with you Mastroiacovo - Botto 29

30 Pierpaolo Mastroiacovo MD Professor of Pediatrics Director ICBD and ICBDSR Centres Via Carlo Mirabello 14, Rome Mastroiacovo - Botto 30

31 Support World Birth Defects Day: Join Thunderclap Google: Thunderclap World Birth Defects Day 2016