ihs sdpi competitive grant program cvd risk reduction demonstration project what is the evidence?...

IHS SDPI COMPETITIVE GRANT IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION PROGRAM CVD RISK REDUCTION

DEMONSTRATION PROJECTDEMONSTRATION PROJECT

WHAT IS THE EVIDENCE?

HOW ARE WE DOING?

HOW CAN WE DO BETTER?

Karl Hammermeister, MDJanuary 11, 2005

1

CARDIOVASCULAR RISK CARDIOVASCULAR RISK REDUCTIONREDUCTION

Risk for Cardiovascular Disease (CVD) What Is the Evidence that Treating Risk Factors

Lowers CVD?– Blood pressure control– Lipid management– Smoking cessation– Diabetes

How Are We Doing? How Can We Do Better? Summary Discussion

2

WHAT IS CVD RISK REDUCTION?WHAT IS CVD RISK REDUCTION?

REDUCING MAJOR VASCULAR EVENTS– ACUTE CORONARY SYNDROMES

ACUTE MYOCARDIAL INFARCTION UNSTABLE ANGINA

– CORONARY REVASCULARIZATION

– STROKE & TIA

– CEREBRAL REVASCULARIZATION

– ACUTE LIMB ISCHEMIA AND AMPUTATION

– AORTIC AND PERIPHERAL REVASCULARIZATION PROCEDURES

3

CVD RISK FACTORSCVD RISK FACTORS REVERSIBLE RISK FACTORS

– Smoking– Hypertension– Dyslipidemia– Sedentary life style– Diabetes?

NON-REVERSIBLE RISK FACTORS– Genes– Age– Gender

NOVEL RISK FACTORS– Infection/Inflammation (c-reactive protein)– Homocysteine

4

DROP IN CAD MORTALITYDROP IN CAD MORTALITY

Unal B, et al. Circulation 2004;109:1101-1107 5

MECHANISMS OF IMPROVED OUTCOMES: IMECHANISMS OF IMPROVED OUTCOMES: I


MECHANISMS OF IMPROVED OUTCOMES: IIMECHANISMS OF IMPROVED OUTCOMES: II


AGE-ADJUSTED HEART DISEASE MORTALITYAGE-ADJUSTED HEART DISEASE MORTALITY

0

50

100

150

200

250

300

1973 '7

5

'77

'79

'81

'83

'85

'87

'89

'91

'93

'95

US All Races AI/AN Actual AI/AN Adjusted

Trends in Indian Health, 2000

From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives 8

CVD MORTALITY IN AMERICAN INDIANSCVD MORTALITY IN AMERICAN INDIANS

Howard BV, et al. Circulation 1999;99:2389-2395 9

RISK FACTORS FOR CVD IN RISK FACTORS FOR CVD IN AMERICAN INDIANSAMERICAN INDIANS

Howard BV, et al. Circulation 1999;99:2389-2395 10





11

Distribution of Systolic Blood Pressure in Distribution of Systolic Blood Pressure in Diabetic and Non-diabetic American Indians Diabetic and Non-diabetic American Indians

Diabetic

Nondiabetic

Systolic blood pressure (mmHg)

Systolic blood pressure (mmHg)

Diabetic

From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives12

NHANES III: Survey of 16,095 U.S. Adults 1992 - 1994NHANES III: Survey of 16,095 U.S. Adults 1992 - 1994

Hyman DJ, et al. NEJM 2001;345:479 - 86 13

BP Control: Trend over Time in Cardiovascular Health StudyBP Control: Trend over Time in Cardiovascular Health Study

5,888 Adults >65 Years

5,888 Adults >65 Years

Psaty BM, et al. Arch Intern Med 2002;162:2325 - 2332 14

Neal B. Lancet 2000;355:1955-1964

Treating HypertensionTreating Hypertension with ACE Inhibitorswith ACE Inhibitors

15

Staessen JA, et al. Lancet 2001;358:1305-15

Meta-analysis of 62,605 Hypertensive PatientsMeta-analysis of 62,605 Hypertensive Patients

16

Staessen JA, et al. Lancet 2001;358:1305-15

Meta-analysis of 62,605 Hypertensive PatientsMeta-analysis of 62,605 Hypertensive Patients

17





18

Men Men Women Women

FHS SHS FHS SHS

160-199 Ref Ref Ref Ref

200-239 1.19 1.63 1.23 1.09

240-279 1.66 2.31 1.28 1.55

> = 280 1.93 2.87 1.71 2.57

RR for Total Cholesterol in RR for Total Cholesterol in Framingham vs Strong Heart StudyFramingham vs Strong Heart Study

From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives

19

HEART PROTECTION STUDY*HEART PROTECTION STUDY*

Entry criteria (20,536 patients randomized)– Age 40 – 80– Total cholesterol >135 mg/dl– CAD or CAD equivalent (diabetes or other

vascular disease)

Intervention: simvastatin 40 mg QD Vascular events per 5 years

– Placebo arm: 25.2%– Simvastatin arm: 19.8%

21.4% reduction

*Lancet 2002;360:7 20

SIMVASTATIN: CAUSE-SPECIFIC MORTALITYSIMVASTATIN: CAUSE-SPECIFIC MORTALITY

(10269) (10267)

SIMVASTATIN PLACEBO Rate ratio & 95% CI

STATIN better PLACEBO better

Cause ofdeath

Vascular

587 707Coronary194 230Other vascular

(7.6%) (9.1%)17% SE 4reduction

781 937

(2P<0.0001)

ANY VASCULAR

Non-vascular

359 345Neoplastic90 114Respiratory82 90Other medical16 21Non-medical

(5.3%) (5.6%)5% SE 6reduction

547 570

(NS)

NON-VASCULAR

(12.9%) (14.7%)13% SE 4reduction

1328 1507

(2P<0.001)

ALL CAUSES

0.4 0.6 0.8 1.0 1.2 1.4

MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 21

SIMVASTATIN: STROKE INCIDENCESIMVASTATIN: STROKE INCIDENCE

(10269) (10267)



Type

290 409Ischaemic51 53Haemorrhagic

103 134Unknown

Severity

96 119Fatal42 51Severe

107 155Moderate138 189Mild

61 71Unknown

(4.3%) (5.7%)25% SE 5reduction

444 585

(2P<0.00001)

ALL STROKES

0.4 0.6 0.8 1.0 1.2 1.4


(10269) (10267)



Major coronary event

357 574Non-fatal MI587 707Coronary death

(8.7%) (11.8%)27% SE 4reduction

898 1212

(2P<0.00001)

CORONARY EVENTS

Revascularisation

513 725Coronary450 532Non-coronary

(9.1%) (11.7%)24% SE 4reduction

939 1205

(2P<0.00001)

REVASCULARISATIONS

0.4 0.6 0.8 1.0 1.2 1.4

SIMVASTATIN: CORONARY EVENTS & REVASCULARISATIONSIMVASTATIN: CORONARY EVENTS & REVASCULARISATION

(10269) (10267)



Major coronary event

357 574Non-fatal MI587 707Coronary death

(8.7%) (11.8%)27% SE 4reduction

898 1212

(2P<0.00001)

CORONARY EVENTS

Revascularisation

513 725Coronary450 532Non-coronary

(9.1%) (11.7%)24% SE 4reduction

939 1205

(2P<0.00001)

REVASCULARISATIONS

0.4 0.6 0.8 1.0 1.2 1.4


SIMVASTATIN: MAJOR VASCULAR EVENTSSIMVASTATIN: MAJOR VASCULAR EVENTS

(10269) (10267)



Vascularevent

898 1212Major coronary

444 585Any stroke

939 1205Revascularisation

(19.8%) (25.2%)24% SE 3reduction

2033 2585

(2P<0.00001)

ANY OF ABOVE

0.4 0.6 0.8 1.0 1.2 1.4


SIMVASTATIN: MAJOR VASCULAR EVENTSIMVASTATIN: MAJOR VASCULAR EVENTby LDL & TOTAL CHOLESTEROLby LDL & TOTAL CHOLESTEROL

(10269) (10267)SIMVASTATIN PLACEBO Rate ratio & 95% CI

STATIN better PLACEBO betterLipid levelsat entry

LDL cholesterol (mmol/l)

598 756(17.6%) (22.2%)< 3.0 (116 mg/dl)

484 646(19.0%) (25.7%) 3.0 < 3.5

951 1183(22.0%) (27.2%) 3.5 (135 mg/dl)

Total cholesterol (mmol/l)

360 472(17.7%) (23.1%)< 5.0 (193 mg/dl)

744 964(18.9%) (24.5%) 5.0 < 6.0

929 1149(21.6%) (26.8%)> 6.0 (323 mg/dl)

24% SE 3reduction(2P<0.00001)

2033 2585(19.8%) (25.2%)ALL PATIENTS

0.4 0.6 0.8 1.0 1.2 1.4


30% REDUCTION IN CHD FOR 30 MG/DL 30% REDUCTION IN CHD FOR 30 MG/DL REDUCTION IN LDLREDUCTION IN LDL

Grundy SM, et al. Circulation 2004;110:227-239 26





27

SMOKING CESSATION SMOKING CESSATION SAVES LIVESSAVES LIVES

Male smoker quits at age 35– Adds 2.3 years additional life

Female smoker quits at age 35– Adds 1.5 years additional life

28

SMOKING CESSATION SMOKING CESSATION INTERVENTION IS COST-EFFECTIVEINTERVENTION IS COST-EFFECTIVE

Intervention 35-Year Old Male

35-Year Old Female

Counseling Alone

$700 - 1000 $1200 - 2100

Counseling plus Nicotine Gum

$4000 - 6000 $7000 - 9000

Cost per Life-Year Added

Tsevat J., et al. 1992;93:43S – 47S 29





30

PREVALENCE OF DIABETESPREVALENCE OF DIABETESStrong Heart Study, by Gender and CenterStrong Heart Study, by Gender and Center

From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives

31

Diabetes Markedly Increases Risk of Myocardial InfarctionDiabetes Markedly Increases Risk of Myocardial Infarction

Sowers, JR. Arch Intern Med 2004;164:1850-57 32

Beneficial Effects of Tight Blood Pressure Control in DiabeticsBeneficial Effects of Tight Blood Pressure Control in Diabetics


Treatment Algorithm for Hypertensive DiabeticsTreatment Algorithm for Hypertensive Diabetics


ARBs Slow Progression of Renal DiseaseARBs Slow Progression of Renal DiseaseIn Type II DiabetesIn Type II Diabetes


EFFECTS OF SIMVASTATIN ON CV OUTCOMESEFFECTS OF SIMVASTATIN ON CV OUTCOMES

Armitage J, et al. Cuur Opin Lipidol 2004;15(4):439-446. 37





38

CARDIOVASCULAR DIAGNOSES AND DIABETES IN VA PRIMARY CARE

64

44

2023

6 5

41

71

66

50

12

24

84

37

70

63

47

16

22

5 4

36

6972

39

30

21

76

48

80

56

46

13

23

5 5

36

63

0

10

20

30

40

50

60

70

80

90

100

HTN orHypertensive

Hypertensive CAD Diabetes CVD PVD CAD/CADEquivalent

One or more

Per

cen

t

All

A

B

C

D

153,305 VHA Primary Care Patients from Four Facilities

CAD EQUIVALENT

39

LDL LOWERING: MVEs LDL LOWERING: MVEs PREVENTEDPREVENTED

VHA Patients (Projected)

5-YearMVE Risk

Estimated MVEs Over 5 Years

Meet HPS Criteria 1,193,969

Meet HPS Criteria & No Statin

479,664 0.246 117,786

Initiate Statin 479,664 0.193 92,409

MVEs prevented 25,377

40

BLOOD PRESSURE BLOOD PRESSURE LOWERING: MVEs PREVENTEDLOWERING: MVEs PREVENTED

VHA Patients (Projected)

5-Year

MVE Risk

Estimated MVEs Over 5 Years

Hypertensive 1,888,462 14% 265,048

12 – 14 mm Hg SBP reduction

1,888,462 10.2% 191,827

MVEs prevented 73,221

41

COST ESTIMATESCOST ESTIMATES

COST ITEM

UNIT

COST ($)

NUMBER PATIENTS

HOSPITAL-IZATIONS

VHA-WIDE COST/5 YR

HCTZ -0.017 1,888,462 –58,589,530

SIMVA-STATIN

–0.479 479,664 –419,310,280

MVEs PREVENTED

$7,911 98,598 779,974,397

NET $302,074,587

42





43

Color coding for LDL and BP measurements:

Gray – Measurement listed for reference only, VA-DoD IHD Guideline and/or VAH Performance Measures do not applyGreen – Performance measure applicable and patient concordant

Bold – Patient non-concordant with either VA-DoD guideline or VHA performance measureBold – Systolic pressure >160 mm Hg

PC-xx

Marked patients are used for calculating performance rankings

Patient had a visit in the evaluation time frame with provider PC-xx andpatient is either assigned to PC-xx or was not yet assigned as of 6/30/2003

Problems identified on CPRS Problem List, outpatient reason for visit (OPC), or discharge summary (PTF)

PCMM Assignment:

blank - Patient is assigned to and had a visit with provider PC-xxNone - Patient has been seen by provider PC-xx, but is not assigned to any primary care providerName – Patient has been seen by provider PC-xx, but is assigned to other named primary care provider (PCP)(*) – Patient is assigned to PC-xx, visited with one or more other care providers, but did not see assigned care provider PC-xx in the evaluation time frame

Concordance/non-concordance with VA-DoD IHD Guideline,non-concordance is highlighted

VHA Performance Measures are grouped into 3 columns,non-concordance is highlighted

A - Patient has active prescription for medicationO - Medication ordered

Legend for Performance Measure Alerts 8/4/2003

None

assigned PCP

(*)

44

CARE PROVIDER RANKINGCARE PROVIDER RANKINGALL PERFORMANCE MEASURES COMBINED

100

72 71 7067 67 66 66

6563 63 62 62 61 61 61 60

58 57 56 56 56 55 5452

47 45

31

61

70

0

10

20

30

40

50

60

70

80

90

100

PC

-25

PC

-16

PC

-26

PC

-09

PC

-14

PC

-01

PC

-25

PC

-12

PC

-08

PC

-23

PC

-11

PC

-22

PC

-06

PC

-21

PC

-19

PC

-10

PC

-13

PC

-24

PC

-04

PC

-15

PC

-17

PC

-07

PC

-20

PC

-02

PC

-03

PC

-24

PC

-05

PC

-18

ME

AN

AB

C

CARE PROVIDER CODE

PE

RC

EN

T C

ON

CO

RD

AN

CE

45

Doe, John123-45-6789

EBMR EBMR

EBMR

46

EBMR CONCORDANCE SUMMARY TABEBMR CONCORDANCE SUMMARY TAB

47

EBMR CONCORDANCE ASSESSMENT: ALL PATIENTSEBMR CONCORDANCE ASSESSMENT: ALL PATIENTS

48

BLOOD PRESSURE <140/90

55%58%

61%

52% 53%

57%60%

65%

59% 58%

52%

61%

0%

20%

40%

60%

80%

100%

1 2 3 4-1 4-2 ALL

Firm Pair

Pe

rce

nt

Co

nc

ord

an

t

Control

Intervention

EBMR RESULTS: PRELIMINARYEBMR RESULTS: PRELIMINARY ANALYSIS OF BLOOD PRESSUREANALYSIS OF BLOOD PRESSURE

49





50





51

ihs sdpi competitive grant program cvd risk reduction demonstration project what is the evidence?...

Documents

cardiovascular disease

cvd mortality

american indians howard

cardiovascular health

alaskan natives

summary discussion

hypertensive patients

bp control