improving healthcare value in coronary artery disease€¦ · ‘holostic’ stable angina...
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Improving Healthcare Value in Coronary Artery Disease
John Beltrame University of Adelaide
Central Adelaide Health Network
The ICHOM Standard Set in Australia
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Australian Healthcare - Journals
Elshaug et al (2012) MJA 197: 556
Duckett et al (2015) MJA 203:183e
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Australian Healthcare - NHMRC
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Australian Healthcare - NHMRC
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Australian Healthcare - Media ‘Wasted Healthcare’
Dr Norman Swan (2015)
• Australia Healthcare spend = $155b • Unnecessary spending = $46b • Rewards procedures not outcomes
• ‘Surgery – the ultimate placebo’ • Questionable benefit for procedures
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Australian Healthcare Reform
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Value Healthcare
Focus on:
• improved value, not just reduce cost
• value for patients (i.e. patient outcomes)
• medical conditions over full cycle of care
• regional & national comparisons
• reward innovations that increase value
Porter & Olmsted Telsberg (2006)
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International Consortium for Health Outcomes Measurement
• Non-profit Organisation
• Value-based Healthcare
• Standard Datasets
• Global Comparisons
Founding Partners
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Coronary Disease Work Group What are the key outcomes?
2330hrs 1930hrs 1500hrs 1000hrs 0800hrs
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ICHOM Coronary Artery Disease Standard Set
Conditions: • Asymptomatic CAD • Stable Angina • Acute Coronary Syndrome
Treatments: • Lifestyle Modification • Drug Therapy • PCI • Coronary Artery Bypass
Outcomes
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ICHOM – CAD Standard
McNamara (2015) J Am Heart Assoc 4:5
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Cardiology 101
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Stable Angina
• Chest Pain with exercise • Myocardial infarct risk 1%/yr
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Stable Angina Management
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Clinical Outcomes Utilising Revascularisation and Aggressive Guideline-driven drug Evaluation
Boden et al (2007) New Engl J Med
Patients • Angina • Suitable for Stent
Death / Heart Attack
Post-PCI Angina
Medications Only
Meds + Stent (PCI)
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Major Adverse Cardiac Events
Number at Risk Medication Only 1138 1017 959 834 638 408 192 30 Meds + PCI 1149 1013 952 833 637 417 200 35
Years 0 1 2 3 4 5 6
0.0
0.5
0.6
0.7
0.8
0.9
1.0
Medications + Stent
Medications Only
Hazard ratio: 1.05 95% CI (0.87-1.27) P = 0.62
7
Sur
viva
l Fre
e of
A
ll-C
ause
Dea
th/M
I
Boden et al (2007) New Engl J Med
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Angina Improvement
Weintraub et al (2008) N Engl J Med 359: 677-87
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‘Real World’ COURAGE: TQEH
Beltrame et al (2008) N Engl J Med
Angina Frequency
30
40
50
60
70
80
90
100
-3 0 3 6 9 12
Time after angiography (months)
Mea
n S
AQ
Sco
re
COURAGE-PCI (n=939) COURAGE-Medical (n=939)
TQEH-PCI (n=118) TQEH-Medical (n=229)
Better
Worse
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PCI Appropriateness
Patel (2012) J Am Coll Cardiol 59:857-81
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PCI Appropriateness Acute Coronary Syndrome
Patel (2012) J Am Coll Cardiol 59:857-81
Appropriate
Uncertain
Inappropriate
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PCI Appropriateness Stable Angina
Patel (2012) J Am Coll Cardiol 59:857-81
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Improving PCI Appropriateness
Bradley (2015) Circulation 132:20-6
COURAGE Trial
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Stable Angina Management
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‘Holostic’ Stable Angina Management
Disease
Coronary Heart Disease
Symptoms
Angina
Functional Limitation
Physical Emotional
Social
Quality of Life
Discrepancy in actual & desired health
Patient-focused Disease- focus
Patient-related outcome measures (PROM’s)
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2060 Patients (median 10/GP)
207 Active GP Participation
2,031 Stable Angina Patients Clinical details + Quality of life questionnaire
535 GP Expressions of Interest Mailout 19,817 GP’s
Prevalence of Weekly Angina in Stable Angina Patients attending GP’s
How many patients have persistent angina (>1/wk) ?
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Cluster-Stratification
0
10
20
30
40
50
NSW VIC QLD SA WA TAS ACT NT
Freq
uenc
y (%
)
Active GPs Practicing GPs Population
Beltrame et al (2009) Arch Intern Med 169:1491-99
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Data Collection GP Assessment Patient Assessment
Beltrame et al (2009) Arch Intern Med 169:1491-99
Angina Assessment • GP: “Optimal Control” = 80% • Patient: “Angina Free” = 52%
“not limit enjoyment of life” = 47%
29% stable angina patients experience angina ≥ 1/week
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Clinical Outcomes Follow-up (Death & Re-admission at 12 mths)
Coronary Angiogram Database of South Australia
Health-Outcomes Follow-up (Patient Outcomes 1 & 12 mth)
In-Hospital Status • Clinical Outcomes Registry (ICHOM & Am College Cardiology)
• Health Outcomes Registry (ICHOM Questionnaires)
• A quality assurance and outcomes research project • Clinical characteristics & outcomes of SA Teaching Hospital angio pts • Since 2012, enrolled >20,000 Diagnostic Angiograms + PCI
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Coronary Artery Disease Outcomes
• ICHOM Data Collection: Ø Survival (linkage) Ø Complications Ø Disease Progression Ø PROMs
• Current Status: Ø 1,062 patients Ø Psyche Liaison 50pts Ø 12-mth follow-up 90%
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Angina Improvement
Weintraub et al (2008) N Engl J Med 359: 677-87
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PCI Appropriateness Stable Angina
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Value-based Health Care
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Stable Angina
Angiography ± PCI
12-month PROMs
Clinician Feedback
Future Value Healthcare for Stable Angina
International learning