Improving Healthcare Value in Coronary Artery Disease€¦ · ‘Holostic’ Stable Angina Management Disease Coronary Heart Disease Symptoms Angina Functional Limitation Physical

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