Improving Healthcare Value in Coronary Artery Disease

John Beltrame University of Adelaide

Central Adelaide Health Network

The ICHOM Standard Set in Australia

Australian Healthcare - Journals

Elshaug et al (2012) MJA 197: 556

Duckett et al (2015) MJA 203:183e

Australian Healthcare - NHMRC

Australian Healthcare - NHMRC

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

Australian Healthcare Reform

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)

International Consortium for Health Outcomes Measurement

• Non-profit Organisation

• Value-based Healthcare

• Standard Datasets

• Global Comparisons

Founding Partners

Coronary Disease Work Group What are the key outcomes?

2330hrs 1930hrs 1500hrs 1000hrs 0800hrs

ICHOM Coronary Artery Disease Standard Set

Conditions: •  Asymptomatic CAD •  Stable Angina •  Acute Coronary Syndrome

Treatments: •  Lifestyle Modification •  Drug Therapy •  PCI •  Coronary Artery Bypass

Outcomes

ICHOM – CAD Standard

McNamara (2015) J Am Heart Assoc 4:5

Cardiology 101

Stable Angina

•  Chest Pain with exercise •  Myocardial infarct risk 1%/yr

Stable Angina Management

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)

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

Angina Improvement

Weintraub et al (2008) N Engl J Med 359: 677-87

‘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

PCI Appropriateness

Patel (2012) J Am Coll Cardiol 59:857-81

PCI Appropriateness Acute Coronary Syndrome

Patel (2012) J Am Coll Cardiol 59:857-81

Appropriate

Uncertain

Inappropriate

PCI Appropriateness Stable Angina

Patel (2012) J Am Coll Cardiol 59:857-81

Improving PCI Appropriateness

Bradley (2015) Circulation 132:20-6

COURAGE Trial

Stable Angina Management

‘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)

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) ?

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

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

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

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%

Angina Improvement

Weintraub et al (2008) N Engl J Med 359: 677-87

PCI Appropriateness Stable Angina

Value-based Health Care

Stable Angina

Angiography ± PCI

12-month PROMs

Clinician Feedback

Future Value Healthcare for Stable Angina

International learning