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IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION DEMONSTRATION PROJECT

IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION DEMONSTRATION PROJECT. WHAT IS THE EVIDENCE? HOW ARE WE DOING? HOW CAN WE DO BETTER?. Karl Hammermeister, MD January 11, 2005. 1. CARDIOVASCULAR RISK REDUCTION. Risk for Cardiovascular Disease (CVD)

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IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION DEMONSTRATION PROJECT

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  1. IHS SDPI COMPETITIVE GRANT PROGRAM CVD RISK REDUCTION DEMONSTRATION PROJECT WHAT IS THE EVIDENCE? HOW ARE WE DOING? HOW CAN WE DO BETTER? Karl Hammermeister, MD January 11, 2005 1

  2. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 2

  3. WHAT IS CVD RISK REDUCTION? • REDUCING MAJOR VASCULAR EVENTS • ACUTE CORONARY SYNDROMES • ACUTE MYOCARDIAL INFARCTION • UNSTABLE ANGINA • CORONARY REVASCULARIZATION • STROKE & TIA • CEREBRAL REVASCULARIZATION • ACUTE LIMB ISCHEMIA AND AMPUTATION • AORTIC AND PERIPHERAL REVASCULARIZATION PROCEDURES 3

  4. CVD RISK FACTORS • REVERSIBLE RISK FACTORS • Smoking • Hypertension • Dyslipidemia • Sedentary life style • Diabetes? • NON-REVERSIBLE RISK FACTORS • Genes • Age • Gender • NOVEL RISK FACTORS • Infection/Inflammation (c-reactive protein) • Homocysteine 4

  5. DROP IN CAD MORTALITY Unal B, et al. Circulation 2004;109:1101-1107 5

  6. MECHANISMS OF IMPROVED OUTCOMES: I Unal B, et al. Circulation 2004;109:1101-1107 6

  7. MECHANISMS OF IMPROVED OUTCOMES: II Unal B, et al. Circulation 2004;109:1101-1107 7

  8. AGE-ADJUSTED HEART DISEASE MORTALITY Trends in Indian Health, 2000 From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives 8

  9. CVD MORTALITY IN AMERICAN INDIANS 9 Howard BV, et al. Circulation 1999;99:2389-2395

  10. RISK FACTORS FOR CVD IN AMERICAN INDIANS 10 Howard BV, et al. Circulation 1999;99:2389-2395

  11. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 11

  12. Distribution of Systolic Blood Pressure in Diabetic and Non-diabetic American Indians Diabetic Systolic blood pressure (mmHg) Nondiabetic Systolic blood pressure (mmHg) Diabetic From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives 12

  13. NHANES III: Survey of 16,095 U.S. Adults 1992 - 1994 13 Hyman DJ, et al. NEJM 2001;345:479 - 86

  14. BP Control: Trend over Time in Cardiovascular Health Study 5,888 Adults >65 Years 5,888 Adults >65 Years 14 Psaty BM, et al. Arch Intern Med 2002;162:2325 - 2332

  15. Treating Hypertension with ACE Inhibitors Neal B. Lancet 2000;355:1955-1964 15

  16. Meta-analysis of 62,605 Hypertensive Patients 16 Staessen JA, et al. Lancet 2001;358:1305-15

  17. Meta-analysis of 62,605 Hypertensive Patients 17 Staessen JA, et al. Lancet 2001;358:1305-15

  18. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 18

  19. RR for Total Cholesterol in Framingham vs Strong Heart Study From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives 19

  20. HEART PROTECTION STUDY* • Entry criteria (20,536 patients randomized) • Age 40 – 80 • Total cholesterol >135 mg/dl • CAD or CAD equivalent (diabetes or other vascular disease) • Intervention: simvastatin 40 mg QD • Vascular events per 5 years • Placebo arm: 25.2% • Simvastatin arm: 19.8% 21.4% reduction *Lancet 2002;360:7 20

  21. SIMVASTATIN: CAUSE-SPECIFIC MORTALITY Cause of SIMVASTATIN PLACEBO Rate ratio & 95% CI death (10269) (10267) STATIN better PLACEBO better Vascular Coronary 587 707 Other vascular 194 230 ANY VASCULAR 781 937 17% SE 4 reduction (7.6%) (9.1%) (2P<0.0001) Non-vascular Neoplastic 359 345 Respiratory 90 114 Other medical 82 90 Non-medical 16 21 NON-VASCULAR 547 570 5% SE 6 reduction (5.3%) (5.6%) (NS) ALL CAUSES 1328 1507 13% SE 4 reduction (12.9%) (14.7%) (2P<0.001) 0.4 0.6 0.8 1.0 1.2 1.4 21 MRC/BHF Heart Protection Study. Lancet 2002;360:7-22

  22. SIMVASTATIN: STROKE INCIDENCE SIMVASTATIN PLACEBO Rate ratio & 95% CI (10269) (10267) STATIN better PLACEBO better Type Ischaemic 290 409 Haemorrhagic 51 53 Unknown 103 134 Severity Fatal 96 119 Severe 42 51 Moderate 107 155 Mild 138 189 Unknown 61 71 ALL STROKES 444 585 25% SE 5 reduction (4.3%) (5.7%) (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4 MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 22

  23. SIMVASTATIN: CORONARY EVENTS & REVASCULARISATION SIMVASTATIN SIMVASTATIN PLACEBO PLACEBO Rate ratio & 95% CI Rate ratio & 95% CI (10269) (10269) (10267) (10267) STATIN better STATIN better PLACEBO better PLACEBO better Major coronary event Major coronary event Non-fatal MI Non-fatal MI 357 357 574 574 Coronary death Coronary death 587 587 707 707 CORONARY EVENTS CORONARY EVENTS 898 898 1212 1212 27% SE 4 27% SE 4 reduction reduction (8.7%) (8.7%) (11.8%) (11.8%) (2P<0.00001) (2P<0.00001) Revascularisation Revascularisation Coronary Coronary 513 513 725 725 Non-coronary Non-coronary 450 450 532 532 REVASCULARISATIONS REVASCULARISATIONS 939 939 1205 1205 24% SE 4 24% SE 4 reduction reduction (9.1%) (9.1%) (11.7%) (11.7%) (2P<0.00001) (2P<0.00001) 0.4 0.4 0.6 0.6 0.8 0.8 1.0 1.0 1.2 1.2 1.4 1.4 MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 23

  24. SIMVASTATIN: MAJOR VASCULAR EVENTS Vascular SIMVASTATIN PLACEBO Rate ratio & 95% CI event (10269) (10267) STATIN better PLACEBO better Major coronary 898 1212 Any stroke 444 585 Revascularisation 939 1205 ANY OF ABOVE 2033 2585 24% SE 3 reduction (19.8%) (25.2%) (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4 MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 24

  25. SIMVASTATIN: MAJOR VASCULAR EVENT by LDL & TOTAL CHOLESTEROL Lipid levels SIMVASTATIN PLACEBO Rate ratio & 95% CI at entry (10269) (10267) STATIN better PLACEBO better LDL cholesterol (mmol/l) < 3.0 (116 mg/dl) 598 (17.6%) 756 (22.2%) ³ 3.0 < 3.5 484 (19.0%) 646 (25.7%) ³ 3.5 (135 mg/dl) 951 (22.0%) 1183 (27.2%) Total cholesterol (mmol/l) < 5.0 (193 mg/dl) 360 (17.7%) 472 (23.1%) ³ 5.0 < 6.0 744 (18.9%) 964 (24.5%) > 6.0 (323 mg/dl) 929 (21.6%) 1149 (26.8%) ALL PATIENTS 2033 (19.8%) 2585 (25.2%) 24% SE 3 reduction (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4 MRC/BHF Heart Protection Study. Lancet 2002;360:7-22 25

  26. 30% REDUCTION IN CHD FOR 30 MG/DL REDUCTION IN LDL 26 Grundy SM, et al. Circulation 2004;110:227-239

  27. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 27

  28. SMOKING CESSATION SAVES LIVES • Male smoker quits at age 35 • Adds 2.3 years additional life • Female smoker quits at age 35 • Adds 1.5 years additional life 28

  29. SMOKING CESSATION INTERVENTION IS COST-EFFECTIVE Cost per Life-Year Added Tsevat J., et al. 1992;93:43S – 47S 29

  30. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 30

  31. PREVALENCE OF DIABETESStrong Heart Study, by Gender and Center From Howard BV, Raymer T. Overview of Cardiovascular Disease in American Indians and Alaskan Natives 31

  32. Diabetes Markedly Increases Risk of Myocardial Infarction 32 Sowers, JR. Arch Intern Med 2004;164:1850-57

  33. Beneficial Effects of Tight Blood Pressure Control in Diabetics Sowers, JR. Arch Intern Med 2004;164:1850-57 33

  34. Beneficial Effects of Tight Blood Pressure Control in Diabetics 34 Sowers, JR. Arch Intern Med 2004;164:1850-57

  35. Treatment Algorithm for Hypertensive Diabetics Sowers, JR. Arch Intern Med 2004;164:1850-57 35

  36. ARBs Slow Progression of Renal Disease In Type II Diabetes Sowers, JR. Arch Intern Med 2004;164:1850-57 36

  37. EFFECTS OF SIMVASTATIN ON CV OUTCOMES Armitage J, et al. Cuur Opin Lipidol 2004;15(4):439-446. 37

  38. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 38

  39. 153,305 VHA Primary Care Patients from Four Facilities CAD EQUIVALENT 39

  40. LDL LOWERING: MVEs PREVENTED 40

  41. BLOOD PRESSURE LOWERING: MVEs PREVENTED 41

  42. COST ESTIMATES 42

  43. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 43

  44. PCMM Assignment: • blank - Patient is assigned to and had a visit with provider PC-xx • None - Patient has been seen by provider PC-xx, but is not assigned to any primary care provider • Name – Patient has been seen by provider PC-xx, but is assigned to other named primary care provider (PCP) • (*) – Patient is assigned to PC-xx, visited with one or more other care providers, but did not see assigned care provider PC-xx in the evaluation time frame • Color coding for LDL and BP measurements: • Gray – Measurement listed for reference only, VA-DoD IHD Guideline and/or VAH Performance Measures do not apply • Green – Performance measure applicable and patient concordant • Bold – Patient non-concordant with either VA-DoD guideline or VHA performance measure • Bold – Systolic pressure >160 mm Hg PC-xx None (*) assigned PCP Marked patients are used for calculating performance rankings Patient had a visit in the evaluation time frame with provider PC-xx and patient is either assigned to PC-xx or was not yet assigned as of 6/30/2003 A - Patient has active prescription for medication O - Medication ordered VHA Performance Measures are grouped into 3 columns,non-concordance is highlighted Problems identified on CPRS Problem List, outpatient reason for visit (OPC), or discharge summary (PTF) Concordance/non-concordance with VA-DoD IHD Guideline, non-concordance is highlighted 44 Legend for Performance Measure Alerts 8/4/2003

  45. CARE PROVIDER RANKING 45

  46. Doe, John 123-45-6789 EBMR 46 EBMR

  47. EBMR CONCORDANCE SUMMARY TAB 47

  48. EBMR CONCORDANCE ASSESSMENT: ALL PATIENTS 48

  49. EBMR RESULTS: PRELIMINARY ANALYSIS OF BLOOD PRESSURE 49

  50. CARDIOVASCULAR RISK REDUCTION • Risk for Cardiovascular Disease (CVD) • What Is the Evidence that Treating Risk Factors Lowers CVD? • Blood pressure control • Lipid management • Smoking cessation • Diabetes • How Are We Doing? • How Can We Do Better? • Summary • Discussion 50

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