Using	
  BC	
  and	
  Canadian	
  Data	
  to	
  Improve	
  
Health	
  and	
  Healthcare	
  

What	
  are	
  the	
  best	
 ...
 
BC	
  Data	
  and	
  Diabetes	
  
Diabetes	
  Control	
  
•  Major	
  test	
  used	
  to	
  monitor	
  control	
  is	
  
hemoglobin	
  A1C	
  –	
  measures	...
Annual	
  cost	
  of	
  A1C	
  tests	
  performed	
  in	
  BC	
  
2005-­‐2011	
  
Annual	
  number	
  of	
  A1C	
  tests	
  performed	
  
in	
  VCHA	
  
Annual	
  cost	
  of	
  A1C	
  tests	
  performed	
  in	
  
VCHA	
  
Annual	
  number	
  of	
  A1C	
  tests	
  performed	
  
in	
  FHA	
  
Annual	
  cost	
  of	
  A1C	
  tests	
  performed	
  in	
  
FHA	
  
One-­‐third	
  of	
  all	
  A1C	
  tests	
  are	
  repeated	
  
within	
  3	
  months	
  	
  
 

BC	
  Data	
  and	
  Asthma	
  
Improving Asthma Management
  3	
  million	
  Canadians	
  live	
  with	
  
asthma	
  
	
  

  Asthma	
  is	
  the	
  #1	
...
The	
  Opportunity:	
  	
  
	
  Bri<sh	
  Columbia’s	
  Data	
  

Medical	
  
Service	
  
Plan	
  

PharmaNet	
  

Dischar...
 

Asthma	
  Regimen	
  Op<mality	
  Classifica<on	
  (Pa<ent	
  Ages	
  5-­‐11	
  Years)	
  
Inhaled Corticosteroid Use
(B...
Emergency	
  Department	
  Visits	
  

Suboptimal regimen
use

Optimal regimen use
Hospital	
  Admissions	
  

Suboptimal regimen
use

Optimal regimen
use
Family	
  Prac<<oner	
  Visits	
  

60	
  –	
  80	
  
90	
  –	
  100	
  
100	
  –	
  120	
  
120	
  –	
  130	
  
>	
  130	...
Emergency	
  Department	
  Visits	
  

1	
  -­‐	
  5	
  
5	
  -­‐	
  10	
  
10	
  -­‐	
  15	
  
15	
  -­‐	
  20	
  
20	
  ...
Hospital	
  Admissions	
  

0	
  –	
  0.4	
  
0.4	
  –	
  0.8	
  
0.8	
  –	
  1.2	
  
1.2	
  –	
  1.6	
  

Children	
  0	
...
Costs	
  per	
  Pa<ent	
  (by	
  region)	
  

ED Service
Use

*ED	
  Costs	
  are	
  based	
  on	
  BCCH	
  Data,	
  Physi...
Urban	
  vs.	
  Rural	
  

Bubble Size: Estimated number of physicians in the area
Cost	
  per	
  pa*ent	
  according	
  to	
  op*mality	
  of	
  asthma	
  drug	
  
regimens	
  (2009)	
  
1200

1,067.23

C...
Daily	
  vs.	
  Intermikent	
  (Seasonal)	
  Use	
  of	
  Inhaled	
  An<-­‐
inflammatory	
  Asthma	
  Drugs	
  

1.  Interm...
 

BC	
  Data	
  and	
  Prostate	
  Cancer	
  
Using BC Data to Develop a New
Approach to Prevent Prostate Cancer
Metastasis
  Prostate	
  Cancer	
  is	
  the	
  most	
 ...
Prostate	
  Cancer	
  Mortality	
  
•  Most	
   of	
   the	
   <me,	
   prostate	
  
cancer	
   is	
   a	
   chronic	
   d...
The	
  opportunity:	
  	
  
	
  Bri<sh	
  Columbia’s	
  Data	
  

BC	
  Cancer	
  
Registry	
  

BC	
  Cancer	
  
Agency	
...
Relevance	
  
 	
   If	
  blockade	
  of	
  specific	
  calcium	
  channels	
  decreases	
  metastases,	
  

then	
   men	
...
 
BC	
  and	
  Canadian	
  Data	
  and	
  Hepa<<s	
  C	
  
Standard	
  HCV	
  Drug	
  Therapy	
  
•  Recommended	
  treatment:	
  	
  
•  	
  PEG-­‐IFN-­‐α	
  +	
  Ribavirin	
  (48-...
New	
  drugs	
  available	
  and	
  on	
  pipeline	
  
	
  	
  Direct	
  Ac*ng	
  An*virals	
  
 

New Therapeutic Options for
HCV Drug Therapy

•  High	
  Rates	
  of	
  ADRs	
  

•  Boceprevir/telaprevir	
  decreased...
Can we determine the	
  op*mal	
  HCV	
  
treatment	
  prior	
  to therapy?
Pa*ent	
  

IL28B	
  	
  
Genotype	
  
&	
  
C...
1.	
  Triple	
  therapy	
  
	
  
IL28B	
  
offers	
  modest	
  
	
  C/C	
  
improvement	
  for	
  
	
  
IL28B	
  C/C patien...
2. Triple therapy
IL28B	
  
significantly
	
  C/C	
  
improves SVR in
IL28B T/T patients 70-­‐86%	
  SVR	
  
with	
  $$,	...
The	
  opportunity:	
  	
  
	
  Build	
  the	
  Dataset	
  in	
  Canada	
  

Ac<ve	
  
Surveillance	
  with	
  
CPNDS	
  a...
Chronic	
  Hepa**s	
  C	
  treatment	
  goal:	
  	
  
Biomarker	
  and	
  Stepwise	
  Approach	
  
PegIFN	
  +	
  RBV	
  
...
HCV	
  Treatment	
  Algorithm	
  
Patient with HCV genotype 1
No previous HCV treatment

Predicted good responder to
dual ...
Hepa<<s	
  C	
  Treatment	
  
•  The	
  right	
  treatment	
  for	
  every	
  pa<ent,	
  avoiding	
  
unnecessary	
  risk	...
This	
  is	
  Beau<ful,	
  Bri<sh	
  Columbia	
  
	
  

•  BC	
  has	
  the	
  BEST	
  health	
  data	
  in	
  North	
  Am...
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Using BC and Canadian Data to Improve Health and Healthcare What are the best ways to improve health outcomes and system sustainability? - Dr. Bruce Carleton

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Using BC and Canadian Data to Improve Health and Healthcare What are the best ways to improve health outcomes and system sustainability? - Dr. Bruce Carleton

  1. 1. Using  BC  and  Canadian  Data  to  Improve   Health  and  Healthcare   What  are  the  best  ways  to  improve  health  outcomes     and  system  sustainability?   Dr.  Bruce  Carleton   University  of  Bri<sh  Columbia   Child  &  Family  Research  Ins<tute   BC  Children’s  Hospital  
  2. 2.   BC  Data  and  Diabetes  
  3. 3. Diabetes  Control   •  Major  test  used  to  monitor  control  is   hemoglobin  A1C  –  measures  glucose  control   over  4  months  by  analyzing  the  amount  of   glucose  on  the  red  blood  cell   •  CDA  recommends  tes<ng  every  3  months;    Test   at  6-­‐month  intervals  when  glycemic  targets   are  consistently  achieved     •  No  evidence  to  suggest  tes<ng  more  oPen   than  every  4  months  is  necessary  
  4. 4. Annual  cost  of  A1C  tests  performed  in  BC   2005-­‐2011  
  5. 5. Annual  number  of  A1C  tests  performed   in  VCHA  
  6. 6. Annual  cost  of  A1C  tests  performed  in   VCHA  
  7. 7. Annual  number  of  A1C  tests  performed   in  FHA  
  8. 8. Annual  cost  of  A1C  tests  performed  in   FHA  
  9. 9. One-­‐third  of  all  A1C  tests  are  repeated   within  3  months    
  10. 10.   BC  Data  and  Asthma  
  11. 11. Improving Asthma Management   3  million  Canadians  live  with   asthma       Asthma  is  the  #1  chronic   condi<on  in  children       6  out  of  10  people  living  with  asthma   do  not  have  it  under  control     250  people  die  each  year  in  Canada   from  asthma  (and  most  are   preventable)  
  12. 12. The  Opportunity:      Bri<sh  Columbia’s  Data   Medical   Service   Plan   PharmaNet   Discharge   Abstracts   Database   Vital   Sta<s<cs  
  13. 13.   Asthma  Regimen  Op<mality  Classifica<on  (Pa<ent  Ages  5-­‐11  Years)   Inhaled Corticosteroid Use (Beclomethasone Equivalents) Inhaled  Short-­‐ac<ng  Bronchodilator   Use     (Salbutamol  Equivalents)   0  µg/day   >  250  &  ≤   500  µg/day     ≤ 1  inhaler   /  year   >0  &  ≤  250   µg/day     1  -­‐  2  inhalers  /   year   2  -­‐  4  inhalers  /   year   >  4  inhalers  /   year   Green  =  Op<mal  regimen,  n=6,155  (67%)   Yellow  =  Unclassified  regimen,  n=2,162  (23%)    Red  =  Subop<mal  regimen,  n=913  (10%)   >  500     µg/day  
  14. 14. Emergency  Department  Visits   Suboptimal regimen use Optimal regimen use
  15. 15. Hospital  Admissions   Suboptimal regimen use Optimal regimen use
  16. 16. Family  Prac<<oner  Visits   60  –  80   90  –  100   100  –  120   120  –  130   >  130   Children 0 -18 years/ Asthma related visits/ 2009 Per  100  pa<ents  
  17. 17. Emergency  Department  Visits   1  -­‐  5   5  -­‐  10   10  -­‐  15   15  -­‐  20   20  -­‐  25   Children  0  -­‐18  years/  Asthma  related  visits/    2009   Per  100   pa<ents  
  18. 18. Hospital  Admissions   0  –  0.4   0.4  –  0.8   0.8  –  1.2   1.2  –  1.6   Children  0  -­‐18  years/  Asthma  related  visits/    2009   1.6  -­‐  2   Per  100   pa<ents  
  19. 19. Costs  per  Pa<ent  (by  region)   ED Service Use *ED  Costs  are  based  on  BCCH  Data,  Physician  Visits  Costs  from  MSP   All  Costs  based  on  2009  Data/Dollars  
  20. 20. Urban  vs.  Rural   Bubble Size: Estimated number of physicians in the area
  21. 21. Cost  per  pa*ent  according  to  op*mality  of  asthma  drug   regimens  (2009)   1200 1,067.23 Cost per patient 1000 800 600 Pts with optimal regimens 471.98 Pts with suboptimal regimens 400 180.28 200 47.59 0 ED visits Hospital admissions Health Services The costs of ED services was 2.3X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen The costs of hospital admission was 4X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen
  22. 22. Daily  vs.  Intermikent  (Seasonal)  Use  of  Inhaled  An<-­‐ inflammatory  Asthma  Drugs   1.  Intermikent   users   of   ICS   are   28%   more   likely   to   have   hospital   admissions  than  regular  users.     2.  Intermikent  users  of  ICS  are  19%  more  likely  to  have  ED  visits   than  regular  users.  
  23. 23.   BC  Data  and  Prostate  Cancer  
  24. 24. Using BC Data to Develop a New Approach to Prevent Prostate Cancer Metastasis   Prostate  Cancer  is  the  most   commonly-­‐diagnosed  cancer   among  Canadian  men       23,600  Canadian  men  will  be   diagnosed  with  prostate   cancer  this  year       In  2013,  3,900  Canadians  will   die  from  Prostate  Cancer  
  25. 25. Prostate  Cancer  Mortality   •  Most   of   the   <me,   prostate   cancer   is   a   chronic   disease   with  low  mortality     •  Unfortunately,   when   the   disease  became  metasta<c,  it   has  a  high  mortality  rate     •  There   is   evidence   to   suggest   that     blocking   a   specific   type   of   calcium   channel   can   prevent    metastases    
  26. 26. The  opportunity:      Bri<sh  Columbia’s  Data   BC  Cancer   Registry   BC  Cancer   Agency   Pharmacy   Data   PharmaNet   Medical   Services   Plan  
  27. 27. Relevance       If  blockade  of  specific  calcium  channels  decreases  metastases,   then   men   who   take   these   drugs   for   heart   disease   should   have   lower  rates  of  prostate  cancer  metastases  than  men  who  do  not.       If  an  associa9on  is  found  between  this  par9cular  class  of  calcium   channel   blocker   use   and   survival   or   metastases,   then   calcium   channel  blockers  could  poten9ally  be  prescribed  to  either  prevent   prostate  cancer  metastases  or  prolong  survival.  
  28. 28.   BC  and  Canadian  Data  and  Hepa<<s  C  
  29. 29. Standard  HCV  Drug  Therapy   •  Recommended  treatment:     •   PEG-­‐IFN-­‐α  +  Ribavirin  (48-­‐week  course)   Significant Variability in Response 40-50% clear virus 50-60% do not clear virus Significant ancestry related differences in response rates (European > African response rates) Treatment often poorly tolerated because of ADRs
  30. 30. New  drugs  available  and  on  pipeline      Direct  Ac*ng  An*virals  
  31. 31.   New Therapeutic Options for HCV Drug Therapy •  High  Rates  of  ADRs   •  Boceprevir/telaprevir  decreased  hemoglobin  (9-­‐52%)   •  Telaprevir/boceprevir  neutropenia  and  thrombocytopenia     •  Telaprevir-­‐induced  skin  reac<ons  (56%;    1%  severe)   •  Psychiatric  symptoms  from  boceprevir     Telaprevir  (2012:  4  safety  warnings)   Bocepravir  (2012-­‐13:  5  safety  warnings)  
  32. 32. Can we determine the  op*mal  HCV   treatment  prior  to therapy? Pa*ent   IL28B     Genotype   &   Clinical     Factors   PEG-­‐IFN-­‐RBV   PEG-­‐IFN-­‐RBV     +     Prot.  Inhib.   +  $20,000-­‐40,000  
  33. 33. 1.  Triple  therapy     IL28B   offers  modest    C/C   improvement  for     IL28B  C/C patients 70-­‐86%  SVR   but $$, ADRs Safe  &  Effec*ve   PEG-­‐IFN+RBV   No  Effect   Adverse  Drug  Reac*on   80-­‐90%  SVR   PEG-­‐IFN+RBV     +     Prot.  Inhib.   +  $20-­‐40k   Safe  &  Effec*ve   No  Effect   Adverse  Drug     Reac*on   “An  individual   with  a  CC   genotype  could   be  spared  the   expense  and   adverse  events,   and  would   achieve  similarly   excellent  results   with  PEG-­‐IFN/ RBV  alone”   -­‐  Jenson  &  Pol,  Liver   Intl,  2012  
  34. 34. 2. Triple therapy IL28B   significantly  C/C   improves SVR in IL28B T/T patients 70-­‐86%  SVR   with  $$,  ADRs   IL28B    T/T   25-­‐40%  SVR   Safe  &  Effec*ve   Safe  &  Effec*ve   PEG-­‐IFN+RBV   No  Effect   No  Effect   Adverse  Drug  Reac*on   80-­‐90%  SVR   PEG-­‐IFN+RBV     +     Prot.  Inhib.   +  $20-­‐40k   Adverse  Drug  Reac*on   60-­‐75%  SVR   Safe  &  Effec*ve   Safe  &  Effec*ve   No  Effect   No  Effect   Adverse  Drug     Reac*on   Adverse  Drug     Reac*on  
  35. 35. The  opportunity:      Build  the  Dataset  in  Canada   Ac<ve   Surveillance  with   CPNDS  across   Canada  
  36. 36. Chronic  Hepa**s  C  treatment  goal:     Biomarker  and  Stepwise  Approach   PegIFN  +  RBV   Pa<ents  with  predictors     of  good  response:    IL  28  C/C    IFN  4    Clinical  factors     PegIFN  +  RBV  +  DAA   Pa<ents  with  NO  predictors   of  good  response     Pa<ents  without    an   increased  risk  to  develop   toxicity  to  DAA     Pa<ents  with  failure  or   relapse    to  PegIFN/RBV   DAA  combina<on  (IFN  Free)   Future  treatment???     Pa<ents  at  higher  risk   to  develop  toxicity  to   Peg-­‐RBV   Pa<ents  at  higher  risk  to  develop   toxicity  to  DAA   Op<mizing  Cost:    Each  Pa<ents  receives  the  appropriate  medica<on   Op<mizing  Safety:    Clearly  iden<fied  risk-­‐benefit  profile  for  each  drug   SVR  
  37. 37. HCV  Treatment  Algorithm   Patient with HCV genotype 1 No previous HCV treatment Predicted good responder to dual therapy Genetic testing for IL28B/IFNL4 gene region variants Predicted poor responder to dual therapy ITPA genetic testing for RBV-induced anemia risk Low Risk ITPA genetic testing for RBV-induced anemia risk High Risk Treat with dual therapy: PegIFN/RBV Treat with dual therapy + early erythropoietin + enhanced monitoring for anemia Low Risk High Risk Treat with triple therapy: PegIFN/RBV + telaprevir or boceprevir Treat with triple therapy + Reduce RBV dose by 50% (to 600mg/day) + enhanced monitoring for anemia
  38. 38. Hepa<<s  C  Treatment   •  The  right  treatment  for  every  pa<ent,  avoiding   unnecessary  risk  and  providing  the  best   possible  care.   •  Op<mize  healthcare  expenses  for  Hepa<<s  C   treatment  
  39. 39. This  is  Beau<ful,  Bri<sh  Columbia     •  BC  has  the  BEST  health  data  in  North  America   •  Rich  informa<on  on  collec<ve  health  experiences   •  Can  help  us  find  solu<ons  to  health  and  health   system  problems   •  Not  just  about  research,  but  USE  of  findings  to   increase  system  efficiencies  and  improve  care  of   pa<ents   •  Preserve  health  benefits  for  Bri<sh  Columbians  in   the  next  and  future  genera<ons    

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