.. _intervention_crm_mgmt_outreach:

=====================
Outreach Intervention
=====================

.. contents::
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.. list-table:: Abbreviations
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  * - Abbreviation
    - Definition
    - Note
  * - SBP
    - Systolic Blood Pressure
    - 
  * - LDL-C
    - Low-Density Lipoprotein Cholesterol
    - 
  * - CVD
    - Cardiovascular Disease 
    - 


Intervention Overview
---------------------

Primary adherence to SBP and LDL-C lowering therapies would increase through patient outreach. Methods for outreach include 
regular phone calls between provider and patient, a mobile app with reminders and guidance, or a patient support clinic.

Today, few patients receive this support and adherence to medications is often low. This intervention will assess the 
impact of an outreach intervention on risk factors and CVD. 


.. list-table:: Affected Outcome #1 Effect Size
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  * - OR for Primary Adherence
    - Source 
    - Notes
  * - 2.16 
    - [Derose-2013]_ 
    - 


Baseline Coverage and Scenarios
+++++++++++++++++++++++++++++++

**Baseline** is assumed to have no one enrolled in any intervention. 

**Medical Outreach 50% Coverage** assumes 50% of eligible simulants are enrolled in the outreach intervention. Scales 
linearly over 1 year such that there is 0% coverage at baseline (Jan 1, 2023) and 50% at year 1 (Jan 1, 2024). Remain at 50% coverage for the remainder of the simulation. 

**Medical Outreach 100% Coverage** assumes all eligible simulants are enrolled in the intervention. Scales 
linearly over 1 year such that there is 0% coverage at baseline (Jan 1, 2023) and 100% at year 1 (Jan 1, 2024). 


Vivarium Modeling Strategy
--------------------------

Eligibility and Initiation
++++++++++++++++++++++++++

- SBP >=130 mmHg and/or LDL-c >= 1.8 mmol/L 
- Enrollment in the intervention only happens during interactions with healthcare, as shown :ref:`here <us_cvd_concept_model>`


Affected Outcomes
+++++++++++++++++

.. note::
  There is data by age strata in this paper if adherence was separated in the future 


This intervention affects primary adherence to medications, which in turn will affect the simulants exposure to SBP and LDL-C. 


The 2.16 odds ratio listed above will approximately halve the number of simulants that are primary non-adherent 
compared to those who are not receiving the intervention. The changes to adherence are as follows: 

**LDL-C Treatments**

.. list-table:: Adherence Changes 
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  :header-rows: 1

  * - Category
    - Percent of Simulants 
    - Notes
  * - Change from Primary Non-adherence to Adherent 
    - 46.53% 
    - 
  * - Change from Primary Non-adherence to Secondary Non-adherent 
    - 6.95%
    - 
  * - Remain in Primary Non-adherence 
    - 46.52%
    - 


**Blood Pressure Treatments**

.. list-table:: Adherence Changes 
  :widths: 10 10 10 
  :header-rows: 1

  * - Category
    - Percent of Simulants 
    - Notes
  * - Change from Primary Non-adherence to Adherent 
    - 44.55% 
    - 
  * - Change from Primary Non-adherence to Secondary Non-adherent 
    - 6.08%
    - 
  * - Remain in Primary Non-adherence 
    - 49.37%
    - 


Assumptions and Limitations
~~~~~~~~~~~~~~~~~~~~~~~~~~~~

- We assume that all those simulants who become primary adherent are then adherent to the medication moving forward. This is likely to overestimate the effect of the results. 

- Currently the same probability of being adherent is used for all simulants. In future iterations, we will try to separate this by age, sex, race, or other simulant characteristics. 


Validation and Verification Criteria
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

- Intervention coverage among the eligible population should verify to the scenario-specific level
- Intervention coverage should be zero among the non-eligible populations
- SBP or LDL-C effects stratified by intervention coverage should reflect the intervention effect size

References
------------

.. [Derose-2013] Derose, Stephen F., et al. "Automated outreach to increase primary adherence to cholesterol-lowering medications." JAMA internal medicine 173.1 (2013): 38-43.
  https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1399850