Frequently Asked Questions

The conditions highlighted within the 6|18 Initiative are: Tobacco Use, High Blood Pressure, Healthcare-Associated Infections, Asthma, Unintended Pregnancies, and Type 2 Diabetes. CDC selected these conditions and the associated interventions because:

• They affect large numbers of people
• They are associated with high health care costs
• The evidence-based interventions can be implemented by the health care delivery system – health care purchasers, payers, and providers.

The initiative specifies interventions associated with each of the 6 conditions that health care purchasers, payers, or providers can implement. CDC used a standardized process to select and identify the interventions. CDC identified health conditions that affect large numbers of people, are associated with high health care costs and have evidence-based interventions that may improve health and reduce health care costs. CDC then prioritized interventions with a high potential health impact, with evidence of effectiveness among certain population/payer groups that address gaps in coverage or low utilization, and that payers or providers could deliver. Input from the following sources further refined the list: individual public health and health care delivery system experts, health and medical databases, the Guide to Community Preventive Services, United States Preventive Services Task Force, and the Agency for Healthcare Research and Quality. Finally, CDC used two frameworks* to define level and types of evidence. Only interventions with moderate or higher level of evidence were included as defined in CDC’s, “Seeking Best Practices: A Conceptual Framework for Planning and Improving Evidence-Based Practices.” For moderate level of evidence, intervention studies that did not mention case size or that used small case sizes were excluded.

• Moderate level includes intervention evaluations without peer review of practice or publication that have evidence of impact (eg, case studies with appropriate evaluation, evaluation reports, peer-reviewed abstracts and presentations).
• Strong level includes case-control or cohort analytic studies; peer-reviewed journal publications; published reports from consensus panels such as the Advisory Committee on Immunization Practices (eg, nonsystematic review of published intervention evaluations with peer review of practices that have evidence of impact).
• Rigorous level includes intervention evaluations or studies with systematic review that have evidence of impact (eg, meta-analyses, Guide to Community Preventive Services).

Using criteria from the “CDC Policy Analytical Framework,” interventions were prioritized if they are feasible, have public health impact, and have available economic and budgetary impact information. Feasibility is defined as likelihood that the policy can be successfully adopted and implemented.

(* Spencer LM, Schooley MW, Anderson LA, Kochtitzky CS, DeGroff AS, Devlin HM, et al. Seeking Best Practices: A Conceptual Framework for Planning and Improving Evidence-Based Practices. Prev Chronic Dis 2013;10:130186, and Centers for Disease Control and Prevention. CDC’s Policy Analytical Framework. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.)

Evidence demonstrates that the 6|18 Initiative interventions can improve health and control costs of the 6 conditions. The 6|18 Initiative promotes adoption of these evidence-based interventions by health care purchasers, payers, and providers. Additional health conditions and associated evidence based interventions may be added in the future when interventions are identified that demonstrate health improvement and cost control related to common, preventable health conditions.

This initiative links the health care and public health sectors by providing a shared focus on evidence-based interventions that can improve health and control costs across a spectrum of prevention interventions, from traditional clinical settings to care outside the clinical setting. Innovative clinical preventive interventions are clinical and patient-focused, but they occur outside a doctor’s office. CDC’s strength in identifying and analyzing scientific evidence complements the purchaser, payer, and provider role of financing and delivering care. CDC provides evidence related to the interventions to health care purchasers, payers, and providers to inform their decisions when considering coverage, access, utilization and quality and when deciding where they can have the greatest impact on population health outcomes and controlling costs.

CDC is working with a variety of organizations across the purchaser, payer, and provider landscape to improve health and control health care costs. CDC’s partner list includes other federal agencies, state Medicaid Agencies, State Behavioral Health Authorities, commercial insurers, employers, large health systems, providers and provider networks (physician and non-physician), health centers, health insurance exchanges, and other key stakeholders with expertise in health care or health care financing. In particular, CDC is working directly with payers to evaluate their implementation of interventions. CDC is also working to promote provider uptake of best practices including aligning interventions to payment incentives; documenting the operational steps needed to deliver care; and providing sufficient information for initiative adoption. CDC has partnered with the Centers for Health Care Strategies, Association for State and Territorial Health Officials, National Association of State Medicaid Directors, National Association for Chronic Disease Directors, and a number of other national organizations.

No. CDC is not funding state Medicaid Agency-Public Health teams participating in the 6|18 Initiative. However, the Robert Wood Johnson Foundation is supporting the Center for Health Care Strategies in providing targeted technical assistance to the nine states, helping to identify and overcome barriers in implementing one or more of the 18 interventions. The six current conditions currently include strategies and interventions that are within program scope of the corresponding CDC cooperative agreements which fund public health departments in state, local, tribal and/or territorial jurisdictions.

CDC is leading the 6|18 Initiative with support from Centers for Medicare and Medicaid Services, Health Resources and Services Administration, and Office of the Assistant Secretary for Health. CMS will offer 6|18 interventions as an option for integrating population health with delivery system transformation and payment reforms through programs such as the State Innovation Model. In addition, CDC and CMS will evaluate state use of specific 6|18 interventions (e.g., self-measured blood pressure monitoring) to determine how they can be implemented within Medicare and Medicaid. CDC, CMS, and OASH, along with HRSA, the Association of State and Territorial Health Officials, and the National Association of Medicaid Directors, are collaborating to support and provide technical assistance to state Medicaid programs.

The HI-5 Initiative is the community-wide, population-oriented complement to the 6|18 Initiative. 6|18 targets six common and costly health conditions – tobacco use, high blood pressure, healthcare-associated infections, asthma, unintended pregnancies, and diabetes – and, initially, 18 proven interventions that form the starting point of discussions with purchasers, payers, and providers. The number of interventions may fluctuate over time. HI-5 highlights evidence-based community-wide interventions proven to have an impact on health within five years and with evidence reporting cost effectiveness and/or cost savings over the lifetime of the population or earlier. In some situations, the 6|18 Initiative conditions align well with HI-5 such as asthma and tobacco use. For example HI-5 addresses tobacco use (one of the 6|18 high-burden conditions) through effective tobacco control interventions such as tobacco price increases, high-impact anti-tobacco mass media campaigns, and comprehensive smoke-free policies. HI-5 also addresses asthma through home improvement loans and grants that cover weatherization to improve insulation, air quality, and dampness that are associated with reducing asthma symptoms, particularly where household member(s) suffer from existing chronic respiratory disease. In other situations, HI-5 evidence highlighted the effectiveness of interventions for additional health conditions such as low birth weight, injuries, and HIV.

The 6|18 Initiative is designed to complement other CDC initiatives like the Winnable Battles and Million Hearts. Each of these initiates highlights common and preventable health conditions where scalable evidence-based interventions are available. Distinct characteristics of 6|18 are that it is specifically tailored for health care purchasers, payers, and providers, and it focuses on accelerating evidence into action.

CDC will work with health care purchasers (employers responsible for employee health and insurance coverage), payers (public and private health insurers), and providers (health systems, physicians, and providers of ancillary services) who are implementing the specific interventions to monitor the quantitative, qualitative, and health and cost impact changes that occur as a result of this initiative. CDC and implementing partners will broadly share these qualitative, quantitative, and impact changes, along with facilitators and barriers to adoption of these interventions, for others to consider implementing.

The following CDC websites include more information on the conditions and interventions that are included in the 6|18 Initiative:

• Reduce Tobacco Use: Office on Smoking and Health
• Control High Blood Pressure: Division of Heart Disease and Stroke Prevention
• Improve Antibiotic Use: Division of Healthcare Quality Promotion
• Control Asthma: Division of Environmental Hazards and Health Effects
• Prevent Unintended Pregnancy: Division of Reproductive Health
• Prevent Type 2 Diabetes: Division of Diabetes Translation

The 6|18 Initiative is led by CDC’s Population Health and Healthcare Office in CDC’s Office of the Associate Director for Policy and Strategy, in collaboration with CDC Centers, Institutes, and Offices (CIOs). For more information about the 6|18 Initiative contact sixeighteen@cdc.gov

The Three Buckets of Prevention framework categorizes interventions according to three discrete approaches on a continuum of prevention from health care to public health. Buckets 1 and 2 are patient-oriented and focus on both traditional and innovative clinical prevention approaches. These clinical interventions may occur in a doctor’s office or in the community and provide services to individual patients. In contrast, Bucket 3 focuses on population-oriented interventions that are intended as community-wide measures to protect and improve the health of populations and the community as a whole. The 6|18 Initiative focuses on Buckets 1 and 2, and can be valuable to health care purchasers, payers, and providers by highlighting preventive interventions that improve health and reduce costs.