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IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION DEMONSTRATION PROJECT WHAT IS THE EVIDENCE?...
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Transcript of 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
Unal B, et al. Circulation 2004;109:1101-1107 6
MECHANISMS OF IMPROVED OUTCOMES: IIMECHANISMS OF IMPROVED OUTCOMES: II
Unal B, et al. Circulation 2004;109:1101-1107 7
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
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
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
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
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)
SIMVASTATIN PLACEBO Rate ratio & 95% CI
STATIN better PLACEBO better
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
MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 22
(10269) (10267)
SIMVASTATIN PLACEBO Rate ratio & 95% CI
STATIN better PLACEBO better
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)
SIMVASTATIN PLACEBO Rate ratio & 95% CI
STATIN better PLACEBO better
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
MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 23
SIMVASTATIN: MAJOR VASCULAR EVENTSSIMVASTATIN: MAJOR VASCULAR EVENTS
(10269) (10267)
SIMVASTATIN PLACEBO Rate ratio & 95% CI
STATIN better PLACEBO better
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
MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 24
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
MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 25
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
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
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
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
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
Sowers, JR. Arch Intern Med 2004;164:1850-57 33
Beneficial Effects of Tight Blood Pressure Control in DiabeticsBeneficial Effects of Tight Blood Pressure Control in Diabetics
Sowers, JR. Arch Intern Med 2004;164:1850-57 34
Treatment Algorithm for Hypertensive DiabeticsTreatment Algorithm for Hypertensive Diabetics
Sowers, JR. Arch Intern Med 2004;164:1850-57 35
ARBs Slow Progression of Renal DiseaseARBs Slow Progression of Renal DiseaseIn Type II DiabetesIn Type II Diabetes
Sowers, JR. Arch Intern Med 2004;164:1850-57 36
EFFECTS OF SIMVASTATIN ON CV OUTCOMESEFFECTS OF SIMVASTATIN ON CV OUTCOMES
Armitage J, et al. Cuur Opin Lipidol 2004;15(4):439-446. 37
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
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
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
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
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
50
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
51