11

Improving Chronic Care Improving Chronic Care ManagementManagement

David M. CutlerDavid M. Cutler

Presented at Alliance for Health ReformPresented at Alliance for Health ReformNovartis/NIHCM BriefingNovartis/NIHCM Briefing

March 28, 2008March 28, 2008

22

Hypertension is not well controlled Hypertension is not well controlled (1999-2004)(1999-2004)

Unaware, 24%

Aware, Not Treated, 11%

Treated, Not Controlled, 34%

Controlled, 31%

33

High cholesterol is better treated but still High cholesterol is better treated but still not very successfullynot very successfully

Unaware, 61%

Aware, not Treated,

28%

Treated, not Controlled,

8%

Controlled, 4%

Unaware, 37%

Aware, not Treated,

22%

Treated, not Controlled,

16%

Controlled, 25%

1988-94 1999-2004

44

What difference does treatment make?What difference does treatment make? What would be the impact of doing better still?What would be the impact of doing better still?

Analyze the treatment of hypertensionAnalyze the treatment of hypertension

Important QuestionsImportant Questions

55

U.S. age-adjusted death rates from coronary heart U.S. age-adjusted death rates from coronary heart disease have fallen by two-thirds since the 1960sdisease have fallen by two-thirds since the 1960s

Age-Adjusted Death Rates for Coronary Heart Disease, U.S., 1950-2003

0

100

200

300

400

500

600

1950 1960 1970 1980 1990 2000 2010

Dea

ths

per

100

,000

Po

pu

lati

on

Source: Vital Statistics of the United States, NCHS.

Deaths per 100,000 Population

66

70% of the improvement in life expectancy over 70% of the improvement in life expectancy over this period was due to cardiovascular disease this period was due to cardiovascular disease

improvementimprovementCauses of increases in U.S. life expectancy in newborns: 1960-2000

7.0

4.9

1.4

0.4

0.3

0.2

0 1 2 3 4 5 6 7 8

Total increase in life expectancy

Death from CVD

Death in infancy

Death from external causes

Death from pneumonia or influenza

Death from cancer

Change in Life Expectancy (in years)

Source: Calculations from D Cutler, A Rosen, S Vijan. The Value of Medical Spending in the United States, 1960-2000. N Engl Med 2006 Aug;355:920-27.

77

ApproachApproachPredict untreated BP and compare to observed BP for 1999-00Predict untreated BP and compare to observed BP for 1999-00

Calculate impact of improvement in BP on risk and number of deaths Calculate impact of improvement in BP on risk and number of deaths (2001), heart attack and stroke hospitalizations (2002)(2001), heart attack and stroke hospitalizations (2002)

See David M. Cutler, Genia Long, Ernst R. Berndt, Jimmy Royer, Andrée-Anne See David M. Cutler, Genia Long, Ernst R. Berndt, Jimmy Royer, Andrée-Anne Fournier, Alicia Sasser, and Pierre Cremieux, “The Value Of Antihypertensive Drugs: Fournier, Alicia Sasser, and Pierre Cremieux, “The Value Of Antihypertensive Drugs: A Perspective On Medical Innovation”, A Perspective On Medical Innovation”, Health AffairsHealth Affairs, January/February 2007; , January/February 2007; 26(1): 97-110. 26(1): 97-110.

88

Results: antihypertensive therapy reduced Results: antihypertensive therapy reduced average BP by 10 – 13%average BP by 10 – 13%

617

82010

22

5

1917

29

10

2140

21

37

27

2711

40

13

0

20

40

60

80

100

Predicted Actual Predicted Actual

Optimal Normal High Normal Stage I Stage II

Definitions: Optimal: SBP<120, DBP<80; Normal: SBP 120-129, DBP 80-84; High Normal: SBP 130-139, DBP 85-89; Stage I: SBP 140-159, DBP 90-99; Stage II Hypertension: SBP>=160, DBP>= 100

Men, 60-69 Women, 60-69

99

Impact on health outcomesImpact on health outcomes

Predicted and Observed Deaths, 2001, and Hospital Discharges for Stroke and MI, 2002, Men and Women

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

Deaths from MajorCardiovascular Disease: 2001

Hospital Discharges for Stroke:2002

Hospital Discharges forMyocardial Infarction: 2002

Observed Predicted Without Antihypertensives Predicted if All at Guidelines

86,000 excess premature deaths from CVD avoided

(2001)

572,000 hospital discharges for stroke

avoided (2002)

261,000 hospital discharges for heart attack avoided (2002)

Hospital Discharges for Stroke (2002)

Hospital Discharges for Myocardial Infarction (2002)

Observed Predicted Without Antihypertensives Predicted if All at Guidelines

Deaths from Major Cardiovascular Disease (2001)

1010

How significant are these estimated reductions How significant are these estimated reductions relative to some other causes of mortality? relative to some other causes of mortality?

Would have approached all deaths from accidents Would have approached all deaths from accidents (98,000, the 5th largest cause of death in 1999-00)(98,000, the 5th largest cause of death in 1999-00)

Would have exceeded all deaths from influenza and pneumonia (64,000, the 7th Would have exceeded all deaths from influenza and pneumonia (64,000, the 7th largest cause of death)largest cause of death)

Roughly equivalent to the number of people who are estimated to die of medical Roughly equivalent to the number of people who are estimated to die of medical errors annuallyerrors annually

Would have exceeded all deaths from motor vehicle accidents (42,000 in 2001)Would have exceeded all deaths from motor vehicle accidents (42,000 in 2001)

1111

There are still significant There are still significant opportunities for improvementopportunities for improvement

If all untreated patients with Stage I or II hypertension had been treated If all untreated patients with Stage I or II hypertension had been treated and all achieved normal blood pressuresand all achieved normal blood pressures

An additional An additional 89,000 fewer excess premature deaths from major 89,000 fewer excess premature deaths from major cardiovascular diseasecardiovascular disease in the U.S. in 2001 in the U.S. in 2001

An estimated An estimated 278,000 fewer US hospital discharges for stroke278,000 fewer US hospital discharges for stroke and and 142,000 142,000 fewer discharges for myocardial infarctionsfewer discharges for myocardial infarctions in 2002 than actually occurred in 2002 than actually occurred

So far, we have achieved approximately half of the potential health gains

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Cost benefit: we calculate an approximate benefit-Cost benefit: we calculate an approximate benefit-to-cost ratio of 10:1 for men and 6:1 for womento-cost ratio of 10:1 for men and 6:1 for women

Assume each year of additional life in good health is worth $90,000 a yearAssume each year of additional life in good health is worth $90,000 a year

Compare discounted lifetime costs for antihypertensive drugs with discounted Compare discounted lifetime costs for antihypertensive drugs with discounted benefits of additional years of lifebenefits of additional years of life

Including benefits other than extended life would increase calculated net Including benefits other than extended life would increase calculated net benefits further:benefits further:

–Reduced hospitalizations for stroke and MI Reduced hospitalizations for stroke and MI

– Impact of antihypertensive drugs on quality of life, work productivityImpact of antihypertensive drugs on quality of life, work productivity

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ImplicationsImplications

Under-utilization of effective, cost-efficient Under-utilization of effective, cost-efficient therapies continues to be a major public health therapies continues to be a major public health challengechallenge