Accountability February Jack Lewin, M.D., CEO The American College of Cardiology

Transcription

1 Professionalism Accountability 2011 Saudi Arabia February 2011 Jack Lewin, M.D., CEO The American College of Cardiology

2 Health Care Costs Skyrocketing According to estimates, in the GCC (Gulf States) region alone, health care costs are expected to grow five-fold from now to $60 billion by Demand for overall health care is projected to grow 240 percent in the next 15 years with cardiovascular treatment poised to grow 419 percent. Cardiology will make for 24 percent of the health care costs. Source:

3 Background: As in the Middle East, Health Care Costs in the US have been rising i

4 Globally, people see health as central to sustainability 89% 79% 65% 63% 59% 68% 66% 64% 70% 64% 47% 49% Global US Canada Mexico Brazil UK France Italy Germany India China Japan Emerging Markets Developed Countries Japan From Edelman and Strategy One s 2010 Health Engagement Barometer

5 Background: US spends twice as much per capita on healthcare as any other country $500 $486 $400 $300 $243 $200 $195 $190 $184 $139 $100 $96 $93 $74 $67 $32 $0 US FRA SWITZ* NETH GER CAN NZ AUS* OECD SWED DEN (7.2%) (7.0%) (4.8%) (5.6%) (5.4%) (3.8%) (3.9%) (3.1%) Median (3.4%) (2.1%) (0.9%)

6 Years Background: This expenditure does not lead to superior health indicators Female Male FRA SWITZ AUS SWED CAN* GER OECD NETH NZ UK* DEN US* Median Data: OECD Health Data 2008 (June 2008).

7

8 U.S. Health Reform: Accountable Care Act of 2010 Expanded access: 35 million people Insurance reform Prevention and disease management

9 BUT: Improving quality Slowing cost increases Revitalizing primary care and care coordination

10 ACC Quality Approach An end-to-end, system that translates science into practice Improvement D2B H2H FOCUS ACT PLAN Education and Training Guidelines/Standards Guidelines AUC / PM DO Measurement NCDR STUDY Implementation - Bridge Quality Practice Assessment Clinical Decision Support Operation Management Tools

11 Registries for Evidence Development and ddisseminationi

12 Registries are an essential solution Science tells us what we can do; Guidelines what we should do; Registries what we are actually doing.

13 Influence of NCDR Research Public Policy Quality Improvement: Guideline Adherence Reducing door to balloon times Clinical indications & outcomes Quality Improvement: Translational Research Post-Market Surveillance Adverse events in closure devices New technologies and effectiveness Diffusion of new technology

14 National CV Data Registry Imaging Registry Number of sites and patient records Cath PCI 1376, 10 M ICD 1554, >250K ACTION Registry- CARE GWTG 170, >9K 688, >120K ICD Long IMPACT Registry PINNACLE 169, >849K Afib Ablation Registry PAD Registry HF Registry beyond

15 Non-Evidence-Based Implantable Cardioverter-Defibrillator (ICD) Implantations in the United States Published in JAMA on Jan. 5, 2011 Authored by Fred Morady, M.D., F.A.C.C. Study concluded that approx. one-fourth of ICD implants for primary prevention of SCD in the United States are not in accord with practice guidelines.

16

17 CREST Trial Shows Stenting Equally as Safe and Effective as Surgery (March 2010) The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) Randomized clinical trial of surgery vs. stenting in 2,502 patients at more than 100 hospitals in the U.S. and Canada Showed comparable safety and efficacy for the two methods Results highlight hli ht importance of participating i in the CARE Registry to collect and report data on both CAS and CEA procedures

18 COURAGE Moderate/Severe Ischemia Endpoints

19 D2B Strategies Reduce MI Deaths (December 2009) Seventy five percent of participating hospitals in ACC s Door-to-Balloon (D2B) Alliance by 2008 were able to treat ST-segment elevation myocardial infarction patients within 90 minutes This data shows that the way care for heart attack patients is delivered can make a life or death difference F th t d i th D b i f JACC For more on the study, view the December issue of JACC. The study findings were also covered in The Boston Globe (12/2, Kowalczyk), USA Today (12/3, Sternberg) and HealthDay (12/2, Edelson).

20 Impact to date 87% of patients in member hospitals now receive PCI in 90 min or less STEMI Patients with D2B less than 90 minutes, US Percent of non transfer in patients 55 receiving PCI in member hospitals National median D2B time for qualifying STEMI patients, US 1 Minutes Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Year ~1,400 US hospitals No. of member in total potentially hospitals in ~200 ~1,000 ~1,100 eligible for D2B, D2B (US) i.e., conducting primary PCI for AMI 1 National median, Including both D2B member hospitals and non-members SOURCE: D2B report; Cath-PCI registry; ACC

21 Quality can save money! Emergency Dept. Activation of Cath Lab and Immediate Transfer Door-to-balloon time from 113 to 75 minutes Transfer time from 147 to 85 minutes Infarct size (creatinine kinase) Hospital stays by 2-3 days Cost by over 30 percent U. M. Khot et. Al. Circulation. 2007; 116

22 Trends : Age & PCI Mortality 1.4 Elective PCI Patients 1.2 (%) 1.0 Mort tality ( Age Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26 Years

23 Registries Can Define QI Targets 27% Pre-hospital ECG Door to reperfusion times Risk-adjusted mortality J Am Coll Cardiol, 2009; 53:

24 What is H2H? Goal: Reduce all-cause readmission rates among patients discharged with HF or AMI by 20 percent by 2012 National rallying point Catalyze action Leverage other initiativesi i i Rapid learning community Building on success

25 H2H Core Concepts Post-discharge medication management. Access to the proper medications and proper education on use Early follow-up. Follow-up visit scheduled with means of transportation within one week of discharge Symptom management. Recognize the signs and symptoms that require medical attention Recognize the signs and symptoms that require medical attention and appropriate contact if they appear

26 Safety and Efficacy of PCI Without On-site Surgical Back-up Risk Adjusted Outcomes Odds Ratio (OR): outcomes for patients at On-Site (vs. Off-Site) facilities adjusting for site correlations and potential confounding variables

27 Risk of Local Adverse Effects Following Cardiac Catheterization by Hemostasis Device and Gender A Report from the NCDR in Partnership with the FDA Dale Tavris, Syamal Dey, Albrecht Gallauresi, Richard Shaw, William Weintraub, Kristi Mitchell, Ralph Brindis Grant from Office of Women s Health, Food and Drug Administration

28 Outcomes Following Coronary Stenting: A National Study of Long Term, Real-World Outcomes of Bare-Metal and Drug-Eluting Stents Pamela S. Douglas, J. Matthew Brennan, Kevin J. Anstrom, Eric L. Eisenstein, David Dai, Ghazala Haque, David F. Kong, Ralph Brindis, Art Sedrakyan, David Matchar, Eric D. Peterson Duke Clinical Research Institute Duke University Medical Center

29 DES & BMS Event Rates:30-month Adjusted BMS DES patients Rate / Death MI Revasc Bleeding Stroke

30 Existing AUC SPECT-MPI CCT/MRI TTE/TEE Stress Echocardiography Coronary Revascularization: PCI/CABG SPECT-MPI Update In Progress: CT, TEE/TTE and Stress Echo Updates; Peripheral Vascular Disease, Diagnostic Cath

31 Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: i The ACCF and United Healthcare SPECT Pilot Study Inappropriate 13% Uncertain 14% Unclassifed 7% APPROPRIATENESS CLASSIFICATION (n = 6,351) Appropriate 66%

32 Low-Risk Findings on Noninvasive Imaging Study And Asymptomatic (Patients Without Prior Bypass Surgery) Noninvasive testing Symptoms/Rx Burden of disease

33 The Case for Prevention

34 Distribution of Cost-Effectiveness Ratios for Preventive Measures and Treatments for Existing Conditions. Opportunities for efficient investment in health care programs are roughly equal lfor prevention and dtreatmentt t Cohen JT et al. N Engl J Med 2008;358:

35 Diabetes Screening and Cost Effectiveness Type 2 diabetes screening in US population is cost effective when started between age years with screening repeated every 3 5 years Headline from The Lancet (2010) Study by Dr. Richard Kahn, ADA and colleagues including David Eddy

36 ALL Initiative: Aspirin, Lisinopril and Lipid-Lowering Medication Bundling 3 Generic Low-Cost Drugs Prevents Heart Attack and Stroke in Large, Diverse Population, Observational Clinical Study Shows Kaiser s Archimedes Model forecasted that bundled cardioprotective medications aspirin, lisinopril, and lovastatin would reduce the risk of heart attack and stroke in a high-risk population by 71 percent. Dudl, M.D., Bellows, Ph.D., Wang, Ph.D., M.P.H., Wong, M.P.H., M.P.P., AJMC, Oct. 2009

37 The Case for Chronic Disease Management

38 The PINNACLE Registry First office-based Quality Improvement program in U.S. Data collection system Assessments and continuous feedback Clinical decision support tools Financial and daily operation management tools Opportunity for recognition Potential basis for new payment model

39 The PINNACLE Dashboard

40 Rapid PINNACLE Growth Dec 2008 Dec 2009 Dec 2010 Patient Records: 2, ,172 >1 million Approximately 1,000 practices enrolled

41 The Case for Improved Systems of Care D2B H2H

42 Improving Quality is the Bridge to Effective Cost-Containment We must measure to manage healthcare Payment incentives i must align with better Value, Quality, and Efficiency CVD is the biggest cost burden (43%) in Medicare CV care has the most science, performance measures, and opportunity for cost containment and savings

43 In Health Care, We Must Measure to Manage

44 JAMA article on Patient Selection for ICD Implantation 111,707 patient records evaluated ated for guideline adherence in ICD implantation decisions ICD implantations were not in accordance with practice guidelines in 22.5 percent of patients ACC and HRS respond

45 The Good News: Systematic improving quality of care is the best way to reduce costs!

46 Registry Collaboration International comparative effectiveness comparisons International quality improvement projects International learning opportunities

47 Global Burden of Cardiovascular Disease Source: World Health Organization,

48 Leading Causes of Mortality and Burden of Disease Mortality % 1. Ischaemic heart disease Cerebrovascular disease Lower respiratory infection COPD Diarrhoeal diseases HIV/AIDS Tuberculosis Trachea, bronchus, lung cancers Road traffic accidents Prematurity, low birth weight 2.0 DALYs % 1. Lower respiratory infections Diarrhoeal diseases Depression Ischaemic heart disease HIV/AIDS Cerebrovascular disease Prematurity, low birth weight Birth asphyxia, birth trauma Road traffic accidents Neonatal infections/other 2.7 Source: World Health Organization,

49 Global projections for selected causes, 2004 to Cancers ns) Dea aths (millio Ischaemic HD Stroke Acute respiratory infections Road traffic accidents Perinatal HIV/AIDS TB Malaria Spurce: Mathers and Loncar, PLoS Medicine, 2006

50 Promoting Global Change Realignment of incentives for all payers, hospitals, physicians, and other clinicians Threats to the status quo health care reform, public reporting/transparency, payment reform, economic forces, population increase, rapid urbanization, lifestyle, difficult to track rural statistics Convincing ggovernments that professional societies can increase quality and reduce unnecessary spending Vision, clarity of intent and leadership Luck (improves considerably with hard work!)

51 How to engage the physician community Valid data Clinical data Quantifiable impact and performance feedback 27% reduced morbidity and mortality from pre-hospital EKG The profession as a trusted source Practice realignment around teams of care Data-driven coordination of care Payment incentives and reform Transparency and public reporting Alignment with government

52 How to engage public policy leaders

53 Opportunities for Partnership on Registries, Quality Improvement and Research

54 The right objective for health care is to increase value for patients, which is the quality of patient outcomes relative to the dollars expended. -- Michael Porter

55 Professional Accountability

56