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Aeha cea- shaw

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Aeha cea- shaw

  1. 1. Framing the Public Policy DebateFraming the Public Policy Debate on Screening for CVD:on Screening for CVD: Forming a FoundationForming a Foundation with Clinical & Cost Effective-Based Medicinewith Clinical & Cost Effective-Based Medicine Leslee J. ShawLeslee J. Shaw Associate ProfessorAssociate Professor Director, Outcomes ResearchDirector, Outcomes Research Cardiovascular Research InstituteCardiovascular Research Institute
  2. 2. Presenter Disclosure Information Disclosure Information... The following relationships exist related to this presentation: Leslee J. Shaw, PhD No relationships to disclose
  3. 3. U.S. Preventive Services Task Force:U.S. Preventive Services Task Force: Screening for CHDScreening for CHD (Release Date: February 2004)(Release Date: February 2004)  Recommendation:Recommendation: TF recommendsTF recommends againstagainst routine screening with rest or Exroutine screening with rest or Ex ECG, or EBT for detection of severe coronary stenosis or predicting CHD eventsECG, or EBT for detection of severe coronary stenosis or predicting CHD events in low risk asymptomatic adults.in low risk asymptomatic adults.  Rationale:Rationale: TF found insufficient evidence for or against routine screening.TF found insufficient evidence for or against routine screening.  ……Absence of evidence that detection improves outcomes, TF concluded thatAbsence of evidence that detection improves outcomes, TF concluded that potential harms exceed benefitspotential harms exceed benefits..  ……evidence is inadequate to determine how testing changes treatment!evidence is inadequate to determine how testing changes treatment! • False + tests are common among asymptomatic adults, especially women, &False + tests are common among asymptomatic adults, especially women, & lead to unnecessary diagnostic testing, over-treatment, and labeling.lead to unnecessary diagnostic testing, over-treatment, and labeling. • False + results, cause psychological distress & anxiety, often lead toFalse + results, cause psychological distress & anxiety, often lead to invasive tests, such as angio or treatment with unnecessary meds.invasive tests, such as angio or treatment with unnecessary meds. • Test sensitivity is limited, screening could result in False - results. False -Test sensitivity is limited, screening could result in False - results. False - results can mislead those with CHD and result in delayed rx.results can mislead those with CHD and result in delayed rx. Source: http://www.ahrq.gov/clinic/uspstf/uspsacad.htm, Access date: March 2, 2004.
  4. 4. What is the real potentialWhat is the real potential value to society for CVDvalue to society for CVD screening?screening? Common arguments have been employed for all screening tests: false -/+Common arguments have been employed for all screening tests: false -/+ costs, anxiety, labeling, …costs, anxiety, labeling, … Source: Belch JJF, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management. Arch Int Med 2003;163:884-892.
  5. 5. Technology HierarchyTechnology Hierarchy
  6. 6. Current State of Health Care SystemCurrent State of Health Care System  ~50% of health care costs~50% of health care costs are for end-stage or hospitalare for end-stage or hospital care.care. • Avg yrly health expenditureAvg yrly health expenditure for end stage care is ~4.6 foldfor end stage care is ~4.6 fold higher than non-end stagehigher than non-end stage care.care.  Shifting care to OP sectorShifting care to OP sector reduces cost.reduces cost. • Although prescription drugAlthough prescription drug costs are rising, only 3.3% ofcosts are rising, only 3.3% of change is due to increasedchange is due to increased utilization.utilization. Source: CMS, Office of the Actuary, National Health Statistics Group. Access date: March 2, 2004. 0 50 100 150 200 250 300 350 400 Medical Durables Other Nondurables Home Health Other Personal Health Other Professionals Dental Nursing Home Drug MD / Clinical Services Hospital Personal Health Spending (Billions of Dollars) Medicare Spending Other Payers $412 Billion Medicare pays 31% $286 Billion Medicare pays 21% $122 Billion Medicare pays 2% $92 Billion Medicare pays 10% $39 Billion Medicare pays 12% $60 Billion Medicare pays 0% $37 Billion Medicare pays 0% $31 Billion Medicare pays 4% $32 Billion Medicare pays 29% $19 Billion Medicare pays 25%
  7. 7. Cost Effective ScreeningCost Effective Screening  Cost effective screening may beCost effective screening may be defined as …defined as … ∆∆ CostCost ∆∆ Life Years SavedLife Years Saved Source: Mark DB, Shaw LJ, Lauer MS, O’Malley P, Heidenreich P. 34th Bethesda Conference: Task force #5 – Is atherosclerotic imaging cost effective? J Am Coll Cardiol 2003;41:1906-17., Shaw LJ, Raggi P, Berman DS et al. Cost effectiveness of screening for CVD with measures of coronary calcium. Prog Cardiov Dis 2003;46:171-84. CV Imaging Costs Ankle Brachial Index $61 Ex ECG $67 Carotid Ultrasound $71 EBT / CT Coronary Ca $87 Rest Echo $91 Other CT $283 SPECT $296 MR $873 IVUS $712 PET $1,272 Rt / Lt Heart Cath $1,810 Comparative Costs Cholesterol panel $13 CRP $13 Outpatient Office Visit $39 Advanced lipid analysis $247 Decreased Effectiveness Improved Effectiveness Decreased Cost Need to determine whetherNeed to determine whether cost savings are worthcost savings are worth decreased effectivenessdecreased effectiveness Cost effectiveCost effective Increased Cost Not cost effectiveNot cost effective Need to determine whetherNeed to determine whether increased effectiveness worthincreased effectiveness worth increased costincreased cost
  8. 8. Shifting the Paradigm to ScreeningShifting the Paradigm to Screening  Early detection leads to:Early detection leads to: • ……improved life expectancy.improved life expectancy. • ……less costly, less invasive care, less hospitalizations with shorter lengthsless costly, less invasive care, less hospitalizations with shorter lengths of stayof stay • ……improved societal productivityimproved societal productivity  Cost – Benefit Ratio is:Cost – Benefit Ratio is: • Does a more productive,Does a more productive, asymptomatic individualasymptomatic individual reduce costs of care inreduce costs of care in relation to symptomaticrelation to symptomatic presentation?presentation? • Despite improvements inDespite improvements in CVD mortality, is there stillCVD mortality, is there still a detection gap?a detection gap? Source: Pasternak RC, Abrams J, Greenland P, Smaha LA, Wilson PW, Houston-Miller N. 34th Bethesda Conference: Task force #1--Identification of coronary heart disease risk: is there a detection gap? J Am Coll Cardiol 2003 Jun 4; 41(11): 1863-74. 0 0.5 1 1.5 2 IHD Stroke DM Gains in Life Expectancy After Eliminating Condition
  9. 9. High Risk Cost EffectivenessHigh Risk Cost Effectiveness  Selecting higher risk cohorts results in aSelecting higher risk cohorts results in a more effective test.more effective test. • Risk reduction w/ Rx is greater inRisk reduction w/ Rx is greater in higher risk populations.higher risk populations.  Clinical effectiveness drives costClinical effectiveness drives cost effectivenesseffectiveness • Focus on Intermediate RiskFocus on Intermediate Risk IndividualsIndividuals  Improved Resource AllocationImproved Resource Allocation • Requires Selective Screening withRequires Selective Screening with optimal clinical effectiveness (i.e.,optimal clinical effectiveness (i.e., added value)added value)  Accurate detection of high riskAccurate detection of high risk  Exclusion of treatment in lowExclusion of treatment in low riskrisk • Low cost test that can be widelyLow cost test that can be widely utilizedutilized Source: Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004;291:210-215., Budoff MJ, Blumenthal RS, Carr JJ, et al. Assessment of Coronary Artery Calcification by Electron Beam and Multidetector Computed Tomography. Circulation 2004. Shaw LJ, Raggi P, Schisterman E, et al. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiol 2003;228:826-33., <0.6% / yr risk 2.0% / yr risk 1.0% / yr risk 0.0 2.0 4.0 6.0 8.0 10.0 12.0 $- $100,000 $200,000 $300,000 $400,000 $500,000 $600,000 Cost Effectiveness Analysis DeltaDisability-AdjustedLifeYears
  10. 10. High Risk Cost EffectivenessHigh Risk Cost Effectiveness  Selecting higher risk cohorts results in aSelecting higher risk cohorts results in a more effective test.more effective test. • Risk reduction w/ Rx is greater inRisk reduction w/ Rx is greater in higher risk populations.higher risk populations.  Clinical effectiveness drives costClinical effectiveness drives cost effectivenesseffectiveness • Focus on Intermediate RiskFocus on Intermediate Risk IndividualsIndividuals  Improved Resource AllocationImproved Resource Allocation • Requires Selective Screening withRequires Selective Screening with optimal clinical effectiveness (i.e.,optimal clinical effectiveness (i.e., added value)added value)  Accurate detection of high riskAccurate detection of high risk  Exclusion of treatment in lowExclusion of treatment in low riskrisk • Low cost test that can be widelyLow cost test that can be widely utilizedutilized Source: Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004;291:210-215., Budoff MJ, Blumenthal RS, Carr JJ, et al. Assessment of Coronary Artery Calcification by Electron Beam and Multidetector Computed Tomography. Circulation 2004. Shaw LJ, Raggi P, Schisterman E, et al. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiol 2003;228:826-33., <0.6% / yr risk 2.0% / yr risk 1.0% / yr risk 0.0 2.0 4.0 6.0 8.0 10.0 12.0 $- $100,000 $200,000 $300,000 $400,000 $500,000 $600,000 Cost Effectiveness Analysis DeltaDisability-AdjustedLifeYears

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