Community-Based Initiatives in NCD

Prevention and Control

in North Carolina, USA

Eric D. Peterson, MD, MPH

Fred Cobb, MD Distinguished Professor of Medicine

Duke University School of Medicine

Director, Duke Clinical Research Institute (DCRI)

1990 2020

Lower Respiratory Infection 1 Ischemic heart disease

Diarrheal Disease 2 Depression

Perinatal 3 Road Traffic Accidents

Depression 4 Cerebrovascular

Ischemic Heart Disease 5 COPD

Cerebrovascular 6 Lower Respiratory Infection

Tuberculosis 7 Tuberculosis

Measles 8 War

Road Traffic Accidents 9 Diarrhoeal Disease

Congenital Diseases 10 HIV

Malaria 11 Perinatal Disease

COPD 12 Violence

Falls 13 Congenital

Iron-deficiency anemia 14 Self-inflicted injury

Protein calorie malnutrition 15 Bronchial and Lung Cancer

GLOBAL BURDEN OF CV DISEASE

Evolving View of CV Quality of Care:

Need for a Longitudinal Perspective

Getting Better Living w/ Illness/Disability (T1)

Coping w/ End of Life (T2)

Staying Healthy

Post Acute/

Rehabilitation

Phase

20 Prevention

Episode begins –

onset of symptoms

Post AMI Trajectory 2 (T2)

Adult with multiple co-morbidities

Focus on:

• Quality of Life

• Functional Status

• 20 Prevention Strategies

• Advanced Care Planning

• Advanced Directives

• Palliative Care/Symptom Control

Assessment of

Preferences

Acute

Phase

PHASE 1

PHASE 2 PHASE 3 PHASE 4

Episode ends –

1 year post AMI

20 Prevention (CAD with prior AMI)

Advanced Care Planning

Population at Risk

10 Prevention (no known CAD)

20 Prevention (CAD no prior AMI)

Post AMI Trajectory 1 (T1)

Relatively healthy adult

Focus on:

• Quality of Life

• Functional Status

• 20 Prevention Strategies

• Rehabilitation

• Advanced care planning

Targets for Implementation

Aware Applicable Able Acted On Agreed Adhered To Accepted

Providers: Evidence-based

Systems Improvement

Patients: engaged, adherent

Glasziou, et al. Evid. Based Nurs. 2005

Types of Implementation

Provider and patient education

Performance feedback

IT (monitors, reminders, decision-support)

Behavioral strategies (incentives)

New care models (team-based)

Community support/social networks

Policy change

Improving CV Care in NC

Across the Spectrum

Acute MI Care

CRUSADE/ACTION: Hospital feedback

RACE/Mission Lifeline: STEMI Systems

Smoothing Care Transitions

Patient Adherence: TRANSLATE ACS

Predictive/personalized interventions: GWTG

Primary Prevention

Ambulatory provider profiling

Engaging patients

Geospatial mapping and community

engagement

Participation in provider-led quality improvement (QI) efforts can improve CV care! NRMI, CRUSADE

AHA GWTG

ACC-NCDR

Means to Achieve better care Motivated local champions

Timely, valued feedback

Simple tools Standard orders, CPOE Pt-MD contract Chart documentation

Collaborative Teams

Provider Led Feedback

and QI Works

Concept

Outcomes

Clinical

Trials

Guidelines

Performance

Indicators

Measurement

Provider Led

Quality Improvement

Safe, Effective,

Long-term Use

Improvements in Guidelines Adherence And

Rates of Drug Overdosing Over Time

Mehta RH, et al AHJ 2007

27.5

24.9

22.1

0

5

10

15

20

25

30

35

Q4 2005 Q1 2006 Q2 2006R

ate

of

Exc

es

s D

osin

g

Co

mp

osit

e A

dh

ere

nce

Ra

tes

60%

70%

80%

90%

Q1

'02

Q1

'03

Q2

'04

Q3

'05

Q4

'06

Acute DischargeAlexander K, et al AHA 2007

Hospital Link Between Overall Guidelines

Adherence and Mortality

Peterson et al, JAMA 2006;295:1863-1912

5.95

5.16 4.97

4.16

5.064.63

4.15

6.31

0

1

2

3

4

5

6

7

<=25% 25 - 50% 50 - 75% >=75%

Hospital Composite Quality Quartiles

% I

n-H

osp

Mo

rtali

ty

Adjusted Unadjusted

Every 10% in guidelines adherence

10% in mortality (OR=0.90, 95% CI: 0.84-0.97)

The Need for Integrated Community Systems Door-to-Balloon w/ and w/o Transfer

Transfer in DTB Times Non-Transfer in DTB Times

96

114

145

53 61

68

Q3 10

98

117

141

55 62 69

Q4 10

93

114

145

57 64

Q1 11

97

119

149

57 64 71

Q2 11

Tim

e (

min

)

50

220

210

60

70

80

90

110

100

120

130

140

150

160

170

200

180

190

240

230

71

40

30

20

250

10

0

ACTION Registry-GWTG DATA: July 1, 2010 – June 30, 2011

Coordinated Systems of STEMI Care

Region

PCI hospital

Non PCI hospital strategy Transfer for PCI Lytics Mixed

New PCI hospitals New regions

Circulation Outcomes 2011

Direct to PCI Centers EMS 1st Medical Contact to Device Times

p<0.0001

• 60% used EMS

• EMS-transported patients had significantly shorter delays in both symptom onset-

to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion

time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-

to-needle time, 23 versus 29 minutes; P�0.0001).

• Subsequent study demonstrated that a plan of ‘bypassing’ hospitals without

capacity to do primary PCI reduced time to reperfusion and had trends towards

lower mortality

Circulation 2011

Mortality

The Need for Better Post Event Transitions

A ‘Voltage Drop’ in Secondary Prevention

Kramer, JM et al AHJ 2006

Trends in Post MI Discharge

Beta-blocker Use

1

Months

3 6 12 15 Index MI

Hospitalization

STEMI/NSTEMI

PCI

DCRI FOLLOW-UP - rehospitalizations

- medication use

- collect bills and records

validate events

q assess care costs

SITE - consent patient for follow-up

- enter data from index hospitalization

After the patient goes home…

In-hospital

Persistence of Evidence-based

Therapies Post Discharge

60

70

80

90

100

Aspirin ADP inhibitor Statin B-blocker ACE/ARB

Discharge 6 wk 6 mo 12 mo

Evolution of Duke Medicine

Duke University Health System

Duke University Health Research

School Clinics

Federally Qualified Health Center

Local Primary Care Practices and Practice Networks

Local Medicaid Network

Durham Public Health System

DUKE Community Engagement Model

Social Integrators Universities DTMI Community Engagement

Data architecture and analytics (who, what, where)

COMMUNITY PARTNERSHIP ZONE CLINICAL CARE

Accountability: real-time monitoring and evaluation (weight, HbA1C, blindness, amputation, foot ulcers, nephropathy, retinopathy, stroke, MI,

sudden death, heart failure)

Decision support systems

Insurers Employers

Informed, activated population Strong community organizations

Healthy public policy Supportive env’ts/families

Public sector Media and other institutions

Proactive practice team Informed, activated

patients

Community based clinical care Activated patients Lifestyle programs

Regular glucose monitoring

Medication adherence Knowledge generation & transfer

Ongoing mobilization, capacity-bldg Advocacy

Fee

db

ack

loo

p

Fee

db

ack

loo

p

Readmission: An Opportunity!

15

.34

14

.51

17

.26

11.9

8

15

.63

15

.96

15

.00

10

.34

18

.10

13

.61

12

.70

13

.75

14

.20

15

.14

13

.32

13

.37

12

.54

11

.07

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

2008-4 2009-1 2009-2 2009-3 2009-4 2010-1 2010-2 2010-3 2010-4

AMI All Cause 30-Day Readmission Rates

AMI - DUKE

AMI - US N&W Heart

How to Reduce Readmissions

Characterize variation in readmissions following ACS

and Heart Failure

Identify modifiable MD, hospital and system factors

associated with readmission

Duke Interventions

Phone calls at 72 hours after discharge for all cardiac patients

Address medications compliance, verify follow-up schedule, identify and address

complications or concerns

On-call cardiologist schedule

Attending on-call 24/7 for any patient or referring provider calls

7-day appointment scheduling with Primary Care or Cardiology

New scheduling process to improve appointment scheduling prior to discharge

Electronic discharge paperwork

Cardiology use near 70% and CT Surgery in process

Pharmacists support medication-related education and follow-up

AMI: Medicare patients with a) h/o non-adherence to CV meds; or b) perceived

poor understanding of medication regimen

Predictive Modeling*

at the point of care

i

What is the patient’s risk of readmission

within 30 days?

What is the patient’s risk of death?

* Compliments of Zubin Eapen

“The future of hypertension control may be getting

more encouraging. This optimism doesn’t stem from

the discovery of a new drug, but rather from the dawning

of the information age in ambulatory medicine.”

Peterson ED Arch Int Med 2008;168:259-60

Preventing Disease:

The Next Frontier

All Rights Reserved, Duke Medicine 2008

02

46

810

Num

ber

of

Pro

viders

0 10 20 30 40 50% of Patients with Uncontrolled Hypertension

Distribution of Rates of Uncontrolled HypertensionBy Provider

Overall: 27.2% Patients

not controlled

All Rights Reserved, Duke Medicine 2008

Distribution of Provider-Specific Rates of Uncontrolled Hypertension

0

10

20

30

40

50

60

70

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46

Provider Rank

Pe

rce

nt

Un

co

ntr

olle

d

After adjusting for predictors:

Provider variability significant (p<0.001)

Threefold variability across providers

All Rights Reserved, Duke Medicine 2008

42%

3%

7%

5%

43%

Medication Change

No ChangesRecommended

Follow Up with OtherProvider

Recommend HomeMonitoring

Diet and Exercise Changes

Response to Uncontrolled Blood Pressure

57%

Target

for QI

All Rights Reserved, Duke Medicine 2008

Future Directions – Improving HTN Control

• Provider feedback

– Starting July 15, 2011

– Providers receive quarterly clinician-specific feedback reports via Duke Heart Center

– Measure Pre- Post-intervention BP Control vs concurrent control group

– Move to multi-specialty, multi system intervention (primary care and UNC)

• Patient feedback

– Identify a cohort of patients with uncontrolled BP

– Randomize to feedback vs. no feedback

– Assess: patient provider satisfaction, responses, BP control rates

NEJM Oct 28 2010;383:18:

The Office Should Not Be the End of Care!

Home-Based Health Care

Model for Home-based Health

Consumer Electronics

Gateway

World Wide Web

Web Interfaces for

EMR / PHR / HIE

Health Monitoring

Devices

Family

Interactivity

and Alerts

Provider Portal,

Alerts and Tools

Interactive

Communication

33

Blood Pressure Monitoring Application

• Store, analyze, and/or share Blood

Pressure data

• Medication hx, refill information

• Accessible by patient, MD or case

manager

“Patient Portal” “Provider Portal”

• Data inputs

• Reports

• Risk Tools

• Trackers

• AHA Content

• Patient Monitoring

• Enhanced

Communication

• Notification

• Reporting

Heart360 Cardiovascular Wellness Center

35

SPRITE Evaluation: Randomized Trial

Enrolled

Randomization

Control

ARM 1 ARM 2 ARM 3

H360 H360 +

Disease Manager

Excluded

• Same as BPMC +

• DM: Nurse/MD who

monitors and responds to

BPMC data

• Keeps primary MD

informed of care changes

• Home BP monitoring

• Link BP data, meds, to

patient and provider

Primary Outcome: BP Control

Secondary Outcomes: Med Adherence, Other CRF Control, Patient Satisfaction

• Usual standard of care

• Printed Education tools

• Assessment of endpoints

(BP, med use, etc)

at routine intervals

Multiple Clinics

CICI Team: Nancy Allen LaPointe, Midge Bowers, Khadijah Breathett, Cedric

Bright, Robert Califf, Katrina Damon, Sharon Elliott-Bynum, Olivia Fu, Bradi

Granger, Karol Harshaw-Ellis, Elaine Hart-Brothers, Carolyn Lekavich, Robin

Mathews, Vincent Miller, John Middleton, Sahar Naderi, Eric D. Peterson, Beth

Phillips, Maria Small, Bimal R. Shah, Kevin L. Thomas, Kristin D. Thomas, Elyse

Thompson, Patrick Wayte

Check It, Change It: The Durham Blood Pressure Challenge

A public-private partnership

to improve our community’s

health

37

Target

Population

Community

Connected

Care

Enrollment & Individual

Assessment w/ provider

Remote

Monitoring

Community

Ambassador

APC

Outcomes:

• ↓ BP

• ↓ admissions for CVD

• Process & Impact metrics

Measurement &

Evaluation*:

•Heart360®

•Chart audits

•DSR

Provider

Engagement

Durham County residents with HTN

Pharmacies

Program Overview: Vascular Intervention Project)

DOC CAARE & Samaritan Lincoln Private

Patient Engagement

Patient empowered to begin

disease management behaviors-

tracking health factors,

medications, lifestyle changes;

receiving patient education;

and partnering with their

provider.

Collaborative Community Care

American Heart Association 38 Confidential

Patient OnBoarding

Clinic

Pharmacy

Employer

Community

Center

Community

Clinic

Provider

Provider

and/or

Kiosks

Patient Coach

Website

Kiosks

Health Assessment

Kiosks

Campaign Website

Kiosks

and/or

Pharmacist

Provider Engagement

Provider Connection enabled

regardless of recruitment channel.

•Motivational/Engagement Effort

• Improved Standard of Care

Intervention Channel

“Humanity’s greatest advances are not in its discoveries – but in how those discoveries are applied ...”

Bill Gates, June 7, 2007

Harvard Commencement Address