Improving Healthcare Value in Coronary Artery Disease John Beltrame University of Adelaide Central Adelaide Health Network The ICHOM Standard Set in Australia
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