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Economic And Humanistic Outcomes Of Post Acs In Cardiac Rehabilitation Program At Sarawak General Hospital For Nham 2010
 

Economic And Humanistic Outcomes Of Post Acs In Cardiac Rehabilitation Program At Sarawak General Hospital For Nham 2010

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Cardiac Rehabilitation Program in Cardiac Center, Sarawak General Hospital.

Cardiac Rehabilitation Program in Cardiac Center, Sarawak General Hospital.

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  • Testing
  • BRUM study. Nonadherence to prescribed medications bypatients with coronary heart disease (CHD) is associated with an increased incidence of adverse cardiovascular events, but it is not known whether self-reported nonadherence can identify patients at greatest risk of such events. Nonadherence to physician treatment recommendations is an increasingly recognized cause of adverse outcomes and increased health care costs, particularly among patients with cardiovascular disease
  • Clinical & Physical Characteristic
  • Several dimensions of HRQOL measures were found inproved in MCRP. Comparison of mean difference from baseline MCRP (+10.57; 95%CI: -2.09, 23.23) Reported less bodily pain (BP) than CCRP (+3.72, 95%CI:-8.94, 16.39) and Control (-4.16, 95%CI: -14.92, 6.59).
  • Results For a 0-100 score and MCID values from -40 to -10, the difference in success rate between arms ranges from 7.9% to 9.9% (ES = 0.25) and from 15.9% to 19.7% (ES = 0.50). For PASS values from 20 to 50, the difference in success rate between arms ranges from 7.1% to 9.9% (ES = 0.25) and from 15.6% to 19.7% (ES = 0.50).Conclusion The MCID or PASS value has a low impact on the difference in the success rate between the arms in a trial. Tubach, F., Giraudeau, B., & Ravaud, P. (2009). The variability in minimal clinically important difference and patient acceptable symptomatic state values did not have an impact on treatment effect estimates. Journal of Clinical Epidemiology, 62(7), 725-728. The minimal important difference (MID), from the patient perspective, can be defined as "the smallest difference in score in the domain of interest which patients perceive as beneficial and which would cause clinicians to consider a change in patient's management". (Jaeschke et al., 1989; Fayers & Machin, 2007).
  • BRUM study. Nonadherence to prescribed medications bypatients with coronary heart disease (CHD) is associated with an increased incidence of adverse cardiovascular events, but it is not known whether self-reported nonadherence can identify patients at greatest risk of such events. Nonadherence to physician treatment recommendations is an increasingly recognized cause of adverse outcomes and increased health care costs, particularly among patients with cardiovascular disease

Economic And Humanistic Outcomes Of Post Acs In Cardiac Rehabilitation Program At Sarawak General Hospital For Nham 2010 Economic And Humanistic Outcomes Of Post Acs In Cardiac Rehabilitation Program At Sarawak General Hospital For Nham 2010 Presentation Transcript

  • 3 Lawrence Anchah , 1, 2 Prof. Dr. Sim Kui Hian, 4 Prof. Dr. Mohd. Izham Mohd Ibrahim, 1, 2 Dr. Alan Fong Yean Yip , 3 Yanti Nasyuhana Sani, 3 Tiong Lee Len, 3 Bibi Faridha Mohd Salleh, 4 Dr Mohd. Azmi Ahmad Hassali, 4 Prof. Dr. Yahaya Hassan, 5 Karen Tang Siew Lang, 1 Hii Ai Ching, 1 Sii Lik Ngoh   1 Dept of Cardiology, Sarawak General Hospital 2 Clinical Research Centre, Sarawak General Hospital 3 Dept of Pharmacy, Sarawak General Hospital 4 School Pharmaceutical Sciences, Universiti Sains Malaysia 5 Dept of Physiotherapy, Sarawak General Hospital The Economic and Humanistic Outcomes of Post Acute Coronary Syndrome in Cardiac Rehabilitation Program: A Quasi-experimental Design of 12-months Follow-up  
  • Background
    • The World Health Organization (WHO) defines cardiac rehabilitation as 1 :
    • “ the sum of activities * required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community.”
    • Cardiac rehabilitation uses a multidisciplinary team approach toward lifestyle modification with the thought that optimal outcomes are achieved when rehabilitative strategies are combined
    • * Activities includes: medical evaluation, prescribed exercise, patient education and counseling
    • World Health Organization. Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD. Geneva: WHO regional Office for Europe, 1993
    • National Heart Foundation of Australia & Australian Cardiac Rehabilitation Association. Recommended Framework for Cardiac Rehabilitation ’04
  • General Phases in Cardiac Rehabilitation
    • Phase I - Inpatient Program
    • begins soon after a cardiac events – CCU/CTW/Gen Med
    • end when the patient is ready to go home
    • low-level exercise and education for the patient and family.
    • Phase II - Outpatient Hospital-based
    • > 2 weeks after discharge ( 1 day, 1 week to 8 weeks)
    • dietitians, social workers, pharmacists, clinicians & others
    • emphasizes monitored exercise
    • education and lifestyle management.
    • Phase III - Community-based Or Clinic Or Polyclinic
    • ongoing exercise & education – health facilities
    • maintenance program
    • Phase IV - Community-based
    • without supervision – community centre
    • patients continue to apply what they have learned
    American Association of Cardiovascular & Pulmonary Rehabilitation. AACVPR Cardiac Rehabilitation Resource Manual (2006). USA, Human Kinetics, Library of Congress. Web site: http://www.humakinetics.com/
  • The Innovative Model – M odified CRP
    • Door-to-balloon time improvement & combine with many other components of care process or measures that can affect outcomes *
    • The interdisciplinary teamwork
      • coincide with the existing Conventional model CRP (CCRP)
      • differ from the conventional model
      • different levels of intervention structures
    • We developed a service models, Phase I CRP is intensified and improved
      • in-patient based education intervention
      • counselling for patients and family
    • The cost effectiveness and humanistic outcomes studies in phase I and short course phase II of CRP are lacking in our local setting.
    * Wang TY, et al. The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes . Arch Intern Med 2009; 169:1411-1419.
  • Measurement for Interventional Outcomes
    • A patient perspective: quantitative surveys such as health status, work performance, symptom burden, and satisfaction.
    • Health status can be measured using disease specific or general instruments
    • General instrument measuring health-related quality of life (HRQoL)
      • patients’ perceptions of health status
      • the preference-based weights
      • calculate QALYs (Tradeoff in incremental costs and gains in health)
    • Examples: SF-36, EQ-5D
    Brazier, J. E., Dixon, S., & Ratcliffe, J. (2009). The role of patient preferences in cost-effectiveness analysis: a conflict of values? PharmacoEconomics, 27(9), 705-712. Van Stel, H., & Buskens, E. (2006). Comparison of the SF-6D and the EQ-5D in patients with coronary heart disease. Health and Quality of Life Outcomes, 4(1), 20
  • Objectives
    • To evaluate the modified phase I and short course of phase II cardiac rehabilitation.
    • To measure the quality of life outcomes in patients who undergo variety of interventions after the post acute coronary syndrome (ACS).
    • To evaluate the cost-effectiveness of cardiac rehabilitation program.
  • METHODOLOGY
  • Methodology: Data collection
    • Approved by MREC, MOH. Written informed consent was obtained
    • Design & Setting:
    • ACS cases on January 2008 to Dec 2009
    • An interview (one to one) session while patients on admission.
    • In-patient intensive cardiac care unit (CCU) and the cardiothoracic ward (CTW) at Sarawak General Hospital , east Malaysia.
    • Inclusion Criteria:
    • Consented for the trial
    • No other chronic comorbidities
    • Below 75 years old
    • Able to talk in Bahasa and English and local dialect
    • STEMI, NSTEMI and UA
    • "nonequivalent" because in this design we do not explicitly control the assignment and the groups were nonequivalent
  • CCRP CONTROL MCRP Inpatient Outpatient
  • SF-36
    • The SF-36 is a generic health questionnaire that measure eight dimensions (scales) of health status. Scores range from 0–100
    • P hysical C omponent S ummary (PCS)
      • Physical functioning (PF)
      • Role limitation-physical (RP)
      • Bodily pain (BP), and
      • General health perception (GH)
    • M ental C omponent S ummary (MCS)
      • Energy and vitality (VT)
      • Social functioning ( SF )
      • Role limitation-emotional ( RE )
      • Mental health ( MH )
    Ware, EJ. SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Center; 1993. p. 4:3.
  • Statistical Analysis
    • Minimal Clinically Important Difference (MCID) to indentify clinical significant of HRQoL outcomes.
      • Population Norms Comparison as Anchor-Based Methods to Determine Changes
      • Analysing Paired Data as Distribution-based Approach to Determine Changes
    • Manual by using SF-36, range of MID is 2 -20 points and depending to sample size. Walters and Brazier, 2003
    • SPSS 16
    • Paired t-test for continuous dependent
    • One-way ANOVA and post-hoc test for 3 groups over time
    • QALY = Preference based ( EQ5D utility ) X time (year)
  • RESULTS
  • Screening and Recruitment process from Jan-Dec 2008
  • At baseline there were no difference in demographic, socioeconomic background, or physical characteristic data
  • Clinical & Physical Characteristic
    • Overall improvement compare to baseline
    • Poor in physical components & emotional components
    Baseline vs. Malaysian Norms by Azman et al., (2003) * Six months assessment * Azman A.B ., Sararaks S., Rugayah B., Low L.L., Azian A.A., Geeta S., Tiew C.T. (2003). Quality of life of the Malaysian general population: Results from a postal survey using the SF-36. Med J Malaysia, 58(5):694-711
    • Several dimensions of HRQOL measures were found improved in MCRP.
    • BP, GH. VT and MH
    Baseline 12-months assessment
  • Baseline compare with Malaysian Population Norms
  • Six Months Assessment
  • 12 Months Assessment MH BP, GH & VT
  • Nnot MCRP
  • M inimal C linically I mportant D ifference (MCID)
    • MCID is used to report the success rate (proportion of patients improved or in an acceptable state) in trial arms.
    • "the smallest difference in score in the domain of interest which patients perceive as beneficial and which would cause clinicians to consider a change in patient's management". (Jaeschke et al., 1989; Fayers & Machin, 2007).
    • The minimal clinically important difference (MCID) :
      • the patient acceptable symptom state (PASS)
      • cut-offs dichotomizing continuous values
      • improved or not improved
      • 0.5 SD = mean change of the small change (rated by patients on global rating scale) Norman et al., 2003
    • 0.5 SD vs. standardized response mean (Example 0.3 for SF-6D)
    • Walters and Brazier., 2003
    • Manual by using SF-36, range of MID is 2 -20 points and depending to sample size.
    Tubach, F., Giraudeau, B., & Ravaud, P. (2009). The variability in minimal clinically important difference and patient acceptable symptomatic state values did not have an impact on treatment effect estimates. Journal of Clinical Epidemiology, 62(7), 725-728.
  • Mean Differences after 12 months follow up
  • Estimation of the cost of treatment based expenditure (top-down), services, salary, hospital days, medication, procedure cost etc. Admission Cost Stage I, II, III OPD Phase 2 Follow-up Medication Cost COROS TOTAL Cost (Annually) QALY Gain Rx MCRP 1,788.21 43.05 17.21 2,302.72 1,901.24 6,052.43 $7,213.86 CCRP 1,788.21 17.21 2,302.72 1,901.24 6,009.38 $7,162.55 Control 1,788.21 2,302.72 1,901.24 5,992.17 $8,000.23 DES BMS PCI MCRP 16,893.92 43.05 17.21 2,302.72 13,393.92 15,756.90 $18,780.57 CCRP 16,893.92 17.21 2,302.72 13,393.92 15,713.85 $18,729.26 Control 16,893.92 2,302.72 13,393.92 15,696.64 $20,956.79 COROS CABG MCRP 49,341.08 43.05 17.21 2,302.72 1,901.24 53,605.30 $63,891.89 CCRP 49,341.08 17.21 2,302.72 1,901.24 53,562.25 $63,840.58 Control 49,341.08 2,302.72 1,901.24 53,545.04 $71,488.70
  • Utility Score from EQ5D Questionnaire Baseline 12 months
  • Incremental Cost Ratio * CCRP as a reference point Optimised Medical Therapy TOTAL Cost Annually QALY Incremental Cost Ratio (ICR) MCRP 6,052.43 7,213.86 $51.31 CCRP * 6,009.38 7,162.55 - Control 5,992.17 8,000.23 $837.68 PCI (Angiogram) MCRP 15,756.90 18,780.57 $51.31 CCRP 15,713.85 18,729.26 - Control 15,696.64 20,956.79 $2,227.53 CABG (Bypass) MCRP 53,605.30 63,891.89 $51.31 CCRP 53,562.25 63,840.58 - Control 53,545.04 71,488.70 $7,648.12
  • Cost per QALY
    • Without Cardiac Rehabilitation Program:
      • Very poor of patients’ perceptions of health status (utility score)
      • After one-year post ACS the incremental cost (IC) for each patient was;
      • IC = RM 837.68 ( cost per QALY RM 8,032.40 ) in usual care without intervention;
      • IC = RM 2,227.53 ( cost per QALY RM 20,956.79 ) for PCI ; and
      • IC = RM 7,648.12 ( cost per QALY RM 71,488.70 ) for CABG .
  • CONCLUSION
  • Conclusions
        • This study demonstrates post ACS population with SF-36 may aid in the further development and health economic evaluation of CRP.
      • The domains in HRQoL of post ACS patients differ significantly in physical (PCS) and mental (MCS) scores compare with the Malaysian norms.
      • Modified Cardiac rehabilitation have improved quality of life of patients after long period of time in Physical Functioning (PF), Role of Physical (RP), Social Functioning (SF), and Role of Emotion (RE), that clinically difficult to assess with conventional metrics or surrogate makers
      • Cardiac rehabilitation program have improved both PCS in Body Pain and MCS of Social Functioning
      • Without any cardiac rehabilitation for post ACS patients will cause a high impact in annual cost of treatment and poor improvement in quality of life.
  • LIMITATION
  • Suggestion:
    • Multicentre research (Cardiology Centre: PGH, QEH, SAGH, IJN)
    • More investigators, unlimited funding.
    • Recommendation of Improvement in Cardiac Rehabilitation:
    • More time spent in phase I cardiac rehabilitation, in term of;
      • 1. Patient Education on drug –disease counseling
      • 2. Medication adherence & understanding
      • 3. More emphasize the intensive counseling and motivation of phase I CRP by clinical pharmacists.
    • Incremental Cost Ratio (ICR) of modified cardiac rehabilitation program is very minimum in term of operational cost for clinical pharmacy services.
    • MCRP can easily implemented in all hospitals and it is highly cost-effective program.
  • THANK YOU Sarawak General Hospital It is not the number that count, but the heart….
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