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A Coordinated Approach to Cardiovascular Care
Sharon Levine MDAssociate Executive Director
The Permanente Medical GroupKaiser Permanente
Bay Area CouncilJune 9, 2008
Delivering Health and Economic Value to Patients and Purchasers
2
The Impact of Cardiovascular Disease In 2008 Americans will suffer:
– 1.2 million heart attacks– 800,000 strokes– 1.5 million new cases of diabetes– 6 million hospitalizations for CVD,1.3 million angioplasties and
500,000 bypass surgeries
An American dies from CVD every 35 seconds.
Heart disease and stroke are leading causes of disability among working adults.
The cost of heart disease and stroke in the United States is estimated at $450 billion in 2008. It includes direct medical costs and lost productivity from death and disability.
Improved care decreased CVD mortality 25% from 1994 to 2004.
3
Translating Evidence Into Benefit
Evidence Benefits
Abundant Body of Evidence A 13 point reduction in blood pressure can lower
deaths due to CVD by 25%. 4 generic meds can reduce CV event risk by 50%. 7 interventions during the ED/Hospital can reduce
mortality. Managing transition of HF patients from hospital to home
can reduce readmissions and prevent catastrophic declines.
4
Translating Evidence Into Benefit: The Quality Chasm
The “Chasm”
Quality Chasm
In US only 55% of indicated care is provided Diabetes patients received 45% of indicated care.
Hyperlipidemia patients received 49% of indicated care.
CAD patients received 68% of indicated care.
HTN patients received 65% of indicated care.
Source: Rand
Evidence Benefits
5
What’s the Problem? I’m doing everything as I was trained to do -- I can’t work faster!
Accountability for panel/population
Transparency Use of EMR, registries,
internet Team care (including pt) Moving care out of Dr. office
The Traditional Model Of Care
One patient at a time Only know about patients
who appear in your office No use of IT Limited use of “extenders”
New Model Elements
6
Turning Evidence Into Health Benefit
Evidence Benefits
Success Factors:
Integrated delivery system; organized medical group
Process redesign
Use of advanced information technology
Aligned incentives (Pre-payment; salaried physicians)
Clinical Leadership
Patient Engagement
7
Our Systematic Approach
…and accountability across the Continuum of Cardiovascular Disease and
from “cradle to grave”.
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
8
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Investing in Primary Prevention
Delivering the Benefits:
Modify Lifestyle
Increase HTN control
Smoking Cessation
Decrease LDL Cholesterol levels
9
Increase Hypertension Control
What we did: leadership priority Clinical Champions
– Academic “detailing”
“Revealing Reports” – Where the opportunity is
“Data that Drives”– Tools to pinpoint gaps in blood pressure testing,
treatment or documentation
Process Redesign – “Check, Treat, Repeat”– Treatment intensification to target – Medical Assistant BP Checks
Primary Prevention
10
Action Description Outcome
CheckWas BP taken and recorded? Documentation
Was BP high? (Determines denominator for measure 3)
Treat Was treatment intensified ? Upward titration of dose and/or medication type
Repeat
Was there another BP taken within 4 weeks?
Follow up care
Was the f/u BP lower than the initial BP?
Better Control of BP
Was the f/u BP in control? Controlling BP
Increase Hypertension ControlPrimary Prevention
Making the process clearer and easier…
11
Increase Hypertension Control
KP at HEDIS 90%tile
Primary Prevention
Trends in Hypertension Control Rates 2001-2006
…led to significant gain.
2001 2005
12
We are in the Top 5Secondary Prevention
13
23.0%
16.4%
12.2%
20.9%
15.2%
9.2%
12.0%
0%
5%
10%
15%
20%
25%
United States California Kaiser PermanenteNorthern California
Healthy People 2010 Target
Survey Population
% A
dult
popu
latio
n wh
o cu
rren
tly s
mok
e
2002
2005
10%
7.5%
25%
Adult Smoking Prevalence 2002 vs. 2005
Decrease SmokingPrimary Prevention
…Reducing smoking rates over time.
14
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Crossing the Chasm – Secondary Prevention
Delivering the Benefits: Heart protective meds: Aspirin, Statin, ACE-I, and Beta-blocker
Lifestyle changes: Tobacco Cessation, Physical Activity, Healthy Eating and Weight Management
Risk factor control: Blood Pressure, Cholesterol and Blood Sugar
15
PHASE Population
68%
11% 9% 6% 2%
32%
0%
20%
40%
60%
80%
Diabetes CAD Stroke PAD CKD AAA
Secondary Prevention
Approximately 300,000 members or 11% of membership. Composition of population is displayed below:
16
Poor control N=59,633 (49%)
Good Adherence, Tx Int.N=27,157 (46%)
Poor AdherenceN=14,568 (24%)Good adherence, NO Tx Int.N=17,908 (30%)
DM PopulationN=143,858
Good controlN=86,609 (51%)
Diabetes
Potential Targets for DM Intervention
Secondary Prevention
Revealing report on adherence…
17
30
40
50
60
70
2004Q4
2005Q1
2005Q2
2005Q3
2005Q4
2006Q1
2006Q2
2006Q3
2006Q4
2007Q1
2007Q2
% o
n ta
rget
med
icatio
n
Statin Use ACEI Use BB Use All Meds
All PHASE Rx meds (composite metric)improved 30.3%
Secondary Prevention
Members on PHASE Medications Improvement from Q4 2004-Q2 2007
PHASE Results
18
Results
BP Control <139/89 (for DM and CKD 129/79) improved 29.6%
(1) HbA1c Control represented on this graph is A1C < 8.0. A1C < 7.0 and A1C > 9.0 are also measured
(2) Lipid Control measure represents the percentage of PHASE patients with most recent test of LDL < 100 mg/dl in last 12 months.
(3) Blood Pressure Control is defined as BP <= 129/79 for patients with Diabetes and CKD and BP <= 139/89 for all other PHASE patients.
Multiple Risk Factor Management - A1c control (<8.0) has improved along with tight measures of LDL and Blood Pressure 2004-2007
Secondary Prevention
HbA1c <8.0 improved 10.6%
LDL <100 improved 31.0%
19
Impact of 2007 Improvements: Additional 9,600 patients at LDL target
– 300 heart attacks/strokes prevented
Additional 2,000 patients on statins– 170 heart attacks/strokes prevented
Additional 1,600 patients on ACEI – 70 heart attacks/strokes prevented
Additional 4,700 People with Diabetes at A1c <9– 188 adverse outcomes prevented
Additional 13,447 People with Diabetes have BP < 129/ 79– 1200 CV events prevented
Secondary Prevention
20
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Crossing the Chasm – Acute Care
Delivering the Benefits: 7 Joint Commission Core Measures
Provide revascularization to appropriate patients
21
Reducing variation and improving quality
Reducing variation and improving quality over time at all NCAL Med Centers
Acute Care
Inpatient Quality Performance: All Core Measures, Rolling Year
22
Heart attack mortality is declining
Standardized MI Mortality
50
60
70
80
90
100
1 2 3 4 5 6 7
year
ind
ex
Acute Care
23
Cardiac Procedures
Cardiac Procedures
-
1,900
3,800
5,700
7,600
9,500
2001 2002 2003 2004 2005 2006 2007
Year
Pro
ce
du
re V
olu
me
CV Surgery PCIDx Cath
2001 – 2007 Volume Trends, KPNC
Acute Care
24
Coronary Procedures – Less PCIs, CABG, CATHAcute Care
National 50th Percentile Rate Kaiser Permanente Rate
2006 Data
8.2
2.4
12.3
4.8
1.7
4.4
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
PCI CABG CATH PCI CABG CATH
Procedures/ Thousand Males aged 45-64
25
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Crossing the Chasm – Chronic Care
Delivering the Benefits: Stratification by patient status
Integration across conditions
Panel management to offload algorithm-driven care
Member engagement: Self-management skills
26
Level 3 – Intensive or Case Management – Heart Failure patients who are at high risk due to complicated and/or unstable condition, poor functional status and/or psychosocial problems. High intensity management of the patient’s care is required.
Level 2 – Assisted Care or Care Management – Heart Failure patients with moderate symptoms, sub-optimal medication management, poor self-care skills. Also include patients who are unable to achieve or maintain self-care skills despite appropriate education and support from the APC team.
Level 1 – Self Care Support – Heart Failure patients supported by routine APC team care. Members have mild symptoms & appropriate medication management. Members who may benefit from basic self-care education. Prevention - The foundation of basic care for all levels.
Self Care Support
35,000 pts
Assisted Careor
Care Management
5,000 pts
Case Mngmt2,000 pts
Prevention is part of every member’s care
Intensiveor
42,000 HF pts
Chronic Care
Chronic Conditions Management Program for Heart Failure in NCAL
Heart Failure
27
Trends in HF Mortality CHF Outcome Data
Chronic Care
28
100.698.2
175.5 162.2144.4
137.6109.6
366.7377.1
579.4 561.6
500.4 506.4
390
212.6217.8
244.3 236.7 243.1 240.9 238.2
0
100
200
300
400
500
600
700
1999Q4 2000Q4 2001Q4 2002Q4 2003Q4 2004Q4 2005Q1
Rat
e/10
00 H
F R
egis
try Day Rate
ED Visits
Discharge-44.0%
Utilization Due to Heart Failure is Decreasing for Registry Members
Heart FailureChronic Care
-13.0%
-36.7%
29
Total and ST Elevated MIs are declining
0
0.5
1
1.5
2
2.5
3
3.5
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Ag
e/S
ex
Ad
jus
ted
Ra
te p
er
10
00
ST Elevated MI Non ST Elevated MI MI
Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates for Kaiser Permanente, 1998 - 2007
Full Spectrum of Care
30
Strokes are declining
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Ag
e/S
ex
Ad
jus
ted
Ra
te p
er
10
00
Strokes Intracerebral Hem
Stroke and Intracerebral Hemorrhage – Hospitalization Rates in Kaiser Permanente – 1998 - 2007
Full Spectrum of Care
31
Trends in Heart Disease Mortality in the population of Kaiser Permanente (N. California) and the rest of California, age-sex agjusted*, 1995-2004
183
136
188
274
100
150
200
250
300
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
year
de
ath
s/1
00
,00
0
KP-rateNon-Kp rate
* 2004 KP is the standard pop for the adjustment
Heart disease mortality declining
30% less chance of dying due to HD if
you are a Kaiser Permanente
Member
Full Spectrum of Care
32
Summary
Using our
integrated system,
advanced IT systems,
process redesign
financial alignment and
patient engagement,
we’ve made it easier to “do the right thing” across the spectrum of cardiovascular disease, so that cardiovascular disease is no longer the number one cause of death for KP members