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Shape aha 2005

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Shape aha 2005

  1. 1. Developing Cost EffectiveDeveloping Cost Effective CHD Screening StrategiesCHD Screening Strategies Leslee J. Shaw, PhDLeslee J. Shaw, PhD Department of Imaging and MedicineDepartment of Imaging and Medicine Cedars-Sinai Medical CenterCedars-Sinai Medical Center Los Angeles, CaliforniaLos Angeles, California
  2. 2. CHD Detection In Asymptomatic Women & MenCHD Detection In Asymptomatic Women & Men Traditional approach to detection of CHD risk =Traditional approach to detection of CHD risk = assessment of typical risk factorsassessment of typical risk factors Despite many available risk assessmentDespite many available risk assessment approaches, there’s aapproaches, there’s a detection gapdetection gap forfor asymptomatic individuals w/ subclinicalasymptomatic individuals w/ subclinical atherosclerosis.atherosclerosis. Framingham & European risk scores - usefulFramingham & European risk scores - useful ““guidesguides.”.” – to predict long term risk of CHD events into predict long term risk of CHD events in healthy populations.healthy populations. – Target Population for Screening:Target Population for Screening: 40% of the US Adult Population (or 3640% of the US Adult Population (or 36 million) = Intermediate Riskmillion) = Intermediate Risk Majority of 1st MIsMajority of 1st MIs Source: Abrams, Pasternak, Greenland, Houston-Miller, Smaha. BC #34: Taskforce #1 - Identification of CHD and CHD Risk. JACC 2003., Blumenthal, Becker, Yanek, Aversano, Moy, Kral, Becker. Detecting occult coronary disease in a high-risk asymptomatic population. Circulation 2003;107(5):702- 707., Wilson, D’Agostino, Levy, Belanger, Silbershatz, Kannel. Prediction of CHD using risk factor categories. Circulation 1998;97:1837-1847.
  3. 3. Source: Fletcher et al., 33rd Bethesda Conf: Preventive Cardiology: How Can We Do Better? JACC 2002;40:4:579-651., Wilson et al. Abdominal aortic calcific deposits are an important predictor of vascular morbidity and mortality. Circulation 2001;103:1529-34., Jaffer et al. Age and Sex Distribution of Subclinical Aortic Atherosclerosis - A Magnetic Resonance Imaging Examination of the Framingham Heart Study Art, Thromb, Vasc Biol 2002;22:849. X
  4. 4. Estimated 10 Yr. Hard CHD Risk FraminghamEstimated 10 Yr. Hard CHD Risk Framingham Offspring & Cohort Women and MenOffspring & Cohort Women and Men Source: Abrams, Pasternak, Greenland, Houston-Miller, Smaha. Bethesda Conference #34: Identification of CHD and CHD risk: Is there a detection gap? JACC 2003 0% 20% 40% 60% 80% 100% 30-39 40-49 50-59 60-69 70-79 30-39 40-49 50-59 60-69 70-79 >20% 10-20% 6-10% <6% PercentPercent Age (years)Age (years) WomenWomen MenMen
  5. 5. CCS=0 CCS 1-99 CCS 100-399 CCS≥400 40 50 60 70 80 90 100 89 74 65 59 Source: Nasir K, Michos ED, Blumenthal RS, Raggi P. Detection of High-Risk Young Adults and Women by Coronary Calcium and National Cholesterol Education Panel-III Guidelines. JACC 2005 (in press). % Not Qualifying For Pharmacotherapy by CACS% Not Qualifying For Pharmacotherapy by CACS Women as well as young individuals were less likely to be considered candidates for pharmacotherapy vs. men & older individuals. Shaw Atherosclerosis (in press) - 45% low risk reclassified based on CAC
  6. 6. Estimated Direct & Indirect Costs ofEstimated Direct & Indirect Costs of Cardiovascular Diseases & StrokeCardiovascular Diseases & Stroke United States: 2005United States: 2005 Source: Heart Disease and Stroke Statistics – 2005 Update. 254.8 142.1 56.8 59.7 27.9 393.5 0 50 100 150 200 250 300 350 400 450 Heart Disease Coronary Heart Disease Stroke Hypertensive Disease Congestive HeartFailure TotalCVD* BillionsofDollars
  7. 7. Current State of Health Care SystemCurrent State of Health Care System ~50% of health care costs are for end-stage or~50% of health care costs are for end-stage or hospital care.hospital care. – Avg yrly health expenditure for end stage careAvg yrly health expenditure for end stage care is ~5-x higher vs. non-end stage care.is ~5-x higher vs. non-end stage care. Shifting care to early, diagnostic or outpatientShifting care to early, diagnostic or outpatient sector potential to reduce cost.sector potential to reduce cost. Source: CMS, Office of the Actuary, National Health Statistics Group. Access date: March 2, 2004. 0 50 100 150 200 250 300 350 400 450 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%
  8. 8. Source: Medicare Standard Analytic File, 1999. 5+ Chronic Conditions 66% 0 Chronic Conditions 1% 2 Chronic Conditions 7% 3 Chronic Conditions 10% 4 Chronic Conditions 13% 1 Chronic Condition 3% - 2/3rds of Spending = 5+ Chronic Conditions - 1/5th of Spending = 3+ Chronic Conditions Medicare SpendingMedicare Spending
  9. 9. The Most Expensive Conditions In America:The Most Expensive Conditions In America: MEPS Population EstimatesMEPS Population Estimates Billion Billion 1. Ischemic Heart Disease $21.5 9. Cerebrovascular Dz $8.3 2. Motor Vehicle Accidents $21.3 10. Dysrythmias $7.2 3. Acute Resp. Infections $17.9 11. Peripheral Vascular $6.8 4. Arthropathies $15.9 12. COPD $6.4 5. Hypertension $14.8 13. Asthma $5.7 6. Back Problems $12.2 14. CHF $5.2 7. Mood Disorders $10.2 15. Lung Cancer $5.0 8. Diabetes $10.1
  10. 10. The Most Expensive Conditions In America:The Most Expensive Conditions In America: MEPS Population EstimatesMEPS Population Estimates Billion Billion 1. Ischemic Heart Disease $21.5 9. Cerebrovascular Dz $8.3 2. Motor Vehicle Accidents $21.3 10. Dysrythmias $7.2 3. Acute Resp. Infections $17.9 11. Peripheral Vascular $6.8 4. Arthropathies $15.9 12. COPD $6.4 5. Hypertension $14.8 13. Asthma $5.7 6. Back Problems $12.2 14. CHF $5.2 7. Mood Disorders $10.2 15. Lung Cancer $5.0 8. Diabetes $10.1
  11. 11. Upfront Test CostUpfront Test Cost 0 200 400 600 800 1000 ABI TM ET C-IM TEBT /C T EchoO therC T SPEC T IVU S M R C ath CholPanelHsC R PO P VisitAdv Lipid Low Cost Lab / Office Visit Cardiac Imaging Source: Mark DB, Shaw LJ, et al. Bethesda Conference #34- Taskforce #5 - Is atherosclerotic imaging cost effective? JACC 2003;41:1906. Affected by MD Labor, Lab Volume, +/- Add-Ons (Contrast or Radiopharmaceutical), Equipment (Lease, Age, Shared)
  12. 12. Average Cost Inputs for Adverse Sequelae of CVDAverage Cost Inputs for Adverse Sequelae of CVD – Out-of-Hospital SCD – Lost ProductivityOut-of-Hospital SCD – Lost Productivity – In-Hospital Death – in excess of $50k-$100kIn-Hospital Death – in excess of $50k-$100k – End-Stage Care for CHF – 80% of lifetime care costsEnd-Stage Care for CHF – 80% of lifetime care costs – AMI or ACSAMI or ACS ≅≅ $15-20k$15-20k – Chest Pain HospitalizationChest Pain Hospitalization ≅≅ $6k$6k – StrokeStroke ≅≅ $50k$50k – Anti-Ischemic RxAnti-Ischemic Rx ≅≅ $1,500 - $5,000 / yr$1,500 - $5,000 / yr – Out-of-PocketOut-of-Pocket ≅≅ $2,000 / yr$2,000 / yr – ……..
  13. 13. Medicare Payment Advisory Commission (MedPAC) -Medicare Payment Advisory Commission (MedPAC) - Growth in Physician ServicesGrowth in Physician Services 0 5 10 15 20 25 30 35 40 45 Major Procedures Evaluation & Management Other Procedures Tests Imaging 22% Growth of All Physician Services % Includes all Services in the Physician Fee Schedule Source: MEDPAC Analysis of Medicare Claims Data March 17, 2005, Executive Director, Medicare Payment Advisory Commission, Mark Miller,.htm
  14. 14. Trends in CV Operations & ProceduresTrends in CV Operations & Procedures United States: 1979-2000United States: 1979-2000
  15. 15. Unfolding a Body of EvidenceUnfolding a Body of Evidence Observational Data •Risk identification •Costs Clinical Trial Data •Vs. Comparators Building Building Cost Effectiveness •High Risk CEA •Reimbursement Disease Management •Risk Identification •Cost Efficiency •Outcomes – Improve Process of Care Quality Standards: Benchmarking / Profiling •Cost / Charges •Guiding Providers •Adherence Guidelines Practice Guidelines / Critical Pathways Source: Shaw LJ, Redberg RF. From clinical trials to public health policy: The path from imaging to screening. Am J Cardiol 2001 Jul 19;88(2-A):62E 65E.
  16. 16. Basics of CEABasics of CEA CEA – technique for selecting among competing choices when resources are limited.CEA – technique for selecting among competing choices when resources are limited. ““Value for Money”Value for Money” Technique comparing relative value of various clinical strategies. Commonly, a newTechnique comparing relative value of various clinical strategies. Commonly, a new strategy is compared w/ current practice (i.e., "low-cost alternative") in calculation of CEstrategy is compared w/ current practice (i.e., "low-cost alternative") in calculation of CE ratio:ratio: Result = "price" of an additional outcome purchased by switching from current practice toResult = "price" of an additional outcome purchased by switching from current practice to new strategy (e.g., $10,000 / life year). If the price is low enough, new strategy isnew strategy (e.g., $10,000 / life year). If the price is low enough, new strategy is considered "cost-effective.“considered "cost-effective.“ Source: http://www.acponline.org/journals/ecp/sepoct00/primer.htm =Standard: <$50,000 / LYS
  17. 17. Critical Cost Effectiveness (CE) QuestionsCritical Cost Effectiveness (CE) Questions 1. Vs. usual care—i.e., no screening—what is the CE of CHD screening of asymptomatic adults to reduce risk for CHD-specific morbidity / mortality? 2. What is the CE of selective screening adults at increased risk for CHD — e.g., those with a family history of premature CHD, w/ risk factors — vs. routine screening & usual care? 3. How will differences in rx effectiveness affect CE estimates for CHD screening? 4. Among individuals w/ subclinical disease on initial screening exam, what is the CE of periodic surveillance vs. one-time screening? 5. Among individuals w/out subclinical CAD on initial screening exam, what is the CE of re-screening at varying intervals vs. onetime screening?
  18. 18. Screening Criteria DiscussedScreening Criteria Discussed BurdenBurden – Prevalence of diseasePrevalence of disease – Years of life lostYears of life lost – Disability or quality of lifeDisability or quality of life – Economic burdenEconomic burden Effectiveness and EfficacyEffectiveness and Efficacy Cost effectivenessCost effectiveness Current delivery ratesCurrent delivery rates Feasibility of increasing delivery ratesFeasibility of increasing delivery rates
  19. 19. Cost Effective CHD ScreeningCost Effective CHD Screening 1. Detection of Risk1. Detection of Risk 2. Early Rx2. Early Rx 3. Improved Outcome3. Improved Outcome Resulting in Reduction in More Costly, End-Stage CareResulting in Reduction in More Costly, End-Stage Care Improved Societal ProductivityImproved Societal Productivity
  20. 20. Evaluation CriteriaEvaluation Criteria Burden of diseaseBurden of disease – Single measure incorporating mortality & morbiditySingle measure incorporating mortality & morbidity Effectiveness of ScreeningEffectiveness of Screening Cost effectivenessCost effectiveness Feasibility of Increasing Delivery RatesFeasibility of Increasing Delivery Rates
  21. 21. CHD Screening FrameworkCHD Screening Framework Two Steps:Two Steps: 1.1. Burden and Effectiveness into single measure ofBurden and Effectiveness into single measure of Clinically Preventable BurdenClinically Preventable Burden (CPB)(CPB) 2.2. Cost EffectivenessCost Effectiveness included to account for resourceincluded to account for resource consumptionconsumption
  22. 22. Clinically Preventable BurdenClinically Preventable Burden CPB = Burden x EffectivenessCPB = Burden x Effectiveness – Burden includes all disease targeted by CHDBurden includes all disease targeted by CHD – Effectiveness = % of burden reducedEffectiveness = % of burden reduced Measures burden of CHD preventableMeasures burden of CHD preventable Burden measured in Quality-Adjusted Life YearsBurden measured in Quality-Adjusted Life Years Saved (QALYS) -- approximatedSaved (QALYS) -- approximated Uses effectiveness from RCTUses effectiveness from RCT – Range of Therapeutic Risk ReductionRange of Therapeutic Risk Reduction
  23. 23. Clinically Preventable BurdenClinically Preventable Burden Qualitative assessment of CHD screeningQualitative assessment of CHD screening should consider:should consider: – CPB - not burden and effectiveness separatelyCPB - not burden and effectiveness separately focus on fatal or high-prevalence, nonfatal conditionsfocus on fatal or high-prevalence, nonfatal conditions – Costs of service: medical care, out-of-pocketCosts of service: medical care, out-of-pocket – Potential for cost savingsPotential for cost savings
  24. 24. Cost Effectiveness (CE) AnalysisCost Effectiveness (CE) Analysis CECE == costs of screening – costs avertedcosts of screening – costs averted Net Effectiveness**Net Effectiveness** ICER =ICER = – CHD Screening vs. No Testing / Usual CareCHD Screening vs. No Testing / Usual Care – CHD Screening vs. Global Risk ScoreCHD Screening vs. Global Risk Score – CHD Screening vs. Alternative TestingCHD Screening vs. Alternative Testing CAC vs. C-IMTCAC vs. C-IMT CAC vs. BARTCAC vs. BART CAC vs. ….CAC vs. …. ** Clinically Preventable Burden reduced** Clinically Preventable Burden reduced
  25. 25. Treatment-Eligible US-PopulationTreatment-Eligible US-Population under NCEP II, NCEP III, CAC Screeningunder NCEP II, NCEP III, CAC Screening 0 2.5 5 7.5 10 12.5 15 40-59 60-79 40-59 60-79 Millionsofpeople Men Women % Increase 142.5 184.3 124.9 85.9 65.0 50.0 65.0 50.0 NCEP II NCEP III Age (y) Source: Fedder DO et al., Circulation 2002;105:152-156, Nasir K, Michos ED, Blumenthal RS, Raggi P. Detection of High-Risk Young Adults and Women by Coronary Calcium and National Cholesterol Education Panel-III Guidelines. JACC 2005 (in press). CAC
  26. 26. Treatment Est. 10-Yr Costs from NCEP IIITreatment Est. 10-Yr Costs from NCEP III to CAC Screeningto CAC Screening $0 $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 40-59 60-79 40-59 60-79 Millionsof$ Men Women NCEP III Source: Fedder DO et al., Circulation 2002;105:152-156, Nasir K, Michos ED, Blumenthal RS, Raggi P. Detection of High-Risk Young Adults and Women by Coronary Calcium and National Cholesterol Education Panel-III Guidelines. JACC 2005 (in press). CAC
  27. 27. CACS RR (95% CI) p ValueSummary RR Ratio 1.5 (0.8-2.9) 24 / 6931 18 / 8503 0.18 0.01 0.01 0.1 0.1 1 1 10 10 100 100 Higher Risk Low Risk Events / N Low Risk 2.1 (1.3-3.3) 46 / 2670 26 / 4600 0.003 Moderate Risk 4.1 (2.9-6.0) 102 / 4,428 44 / 9,977 <0.0001 High Risk 6.7 (4.8-9.4) 179 / 3,550 44 / 6,839 <0.0001 Very High Risk* 1,000 10.8 (4.2-27.7) 14 / 196 6 / 905 <0.0001 Very Low Risk 1-44 1-112 100-400 400-999 Lower Risk Higher Risk Low Risk includes Arad, Greenland, LaMonte Moderate Risk includes Arad, Greenland, LaMonte, Taylor, Vliegenthart High Risk includes Arad, Greenland, Kondos, LaMonte, Vliegenthart Very High Risk includes Vliegenthart Very Low Risk includes Kondos, LaMonte, Taylor Relative Risk (RR) Ratios (95% CI) by CACS RiskRelative Risk (RR) Ratios (95% CI) by CACS Risk When c/w FRS event rates, Δ LYS with CACS ≅≅ 0.58 for 35% RR Reduction w/ Rx (0-0.83)
  28. 28. CPB Model Inputs – Disease BurdenCPB Model Inputs – Disease Burden 20022002 CurrentCurrent Post-ScreeningPost-Screening CHD DeathsCHD Deaths 697,000697,000 ↓↓10% (5%-25%)10% (5%-25%) MIMI 2,100,0002,100,000 ↓↓ 25% (5%-35%)25% (5%-35%) Chest Pain SymptomsChest Pain Symptoms 12,000,00012,000,000 ↓↓ 5% (2.5%-25%)5% (2.5%-25%) Hospital D/C for 1Hospital D/C for 100 DiagnosisDiagnosis of CVDof CVD 6,373,0006,373,000 ↑↑ 10% (5%-25%)10% (5%-25%) Hospital D/C for 1Hospital D/C for 100 DiagnosisDiagnosis of CHFof CHF 970,000970,000 ↓↓ 10% (5%-25%)10% (5%-25%) Source: MI rates were extrapolated from ARIC, 1987-2000 & does not include silent MIs. CVA data also not included.
  29. 29. CPB Model Inputs – Disease BurdenCPB Model Inputs – Disease Burden CurrentCurrent Post-Post- ScreeningScreening Post-ScreeningPost-Screening CHD DeathsCHD Deaths 697,000697,000 ↓↓10%10% ($697 m)($697 m) MIMI 2,100,0002,100,000 ↓↓ 15%15% ($3.7 b)($3.7 b) Chest Pain SymptomsChest Pain Symptoms 12,000,00012,000,000 ↓↓ 10%10% ($7.2 b)($7.2 b) Hospital D/C for 1Hospital D/C for 100 DiagnosisDiagnosis of CVDof CVD 6,373,0006,373,000 ↑↑ 10%10% $3.8 b$3.8 b Hospital D/C for 1Hospital D/C for 100 DiagnosisDiagnosis of CHFof CHF 970,000970,000 ↓↓ 10%10% ($9.9 b)($9.9 b) Source: MI rates were extrapolated from ARIC, 1987-2000 & does not include silent MIs. CVA data also not included.
  30. 30. CPB Model Inputs – Procedure BurdenCPB Model Inputs – Procedure Burden Pre-Pre- ScreeningScreening Post-Post- ScreeningScreening Stress ImagingStress Imaging 8,700,0008,700,000 ↑↑ 10%10% (5%-25%)(5%-25%) AngiographyAngiography 6,800,0006,800,000 ↑↑ 15% - CTA15% - CTA (2.5%-25%)(2.5%-25%) PCIPCI 657,000657,000 ↓↓ 10%10% (5%-50%)(5%-50%) CABSCABS 515,000515,000 ↓↓ 5%5% (2.5%-50%)(2.5%-50%) Source: CDC/NCHS for 2002. http://www.acc.org/advocacy/word_files/2005ProposedPhysicianPmtRulev3%20web.xls.
  31. 31. CPB Model Inputs – Procedure BurdenCPB Model Inputs – Procedure Burden Pre-Pre- ScreeningScreening Post-Post- ScreeningScreening Post-Post- ScreeningScreening Stress ImagingStress Imaging 8,700,0008,700,000 ↑↑ 10%10% (5%-25%)(5%-25%) $358 m$358 m AngiographyAngiography 6,800,0006,800,000 ↑↑ 15% - CTA15% - CTA (2.5%-25%)(2.5%-25%) $600 m$600 m PCIPCI 657,000657,000 ↓↓ 10%10% (5%-50%)(5%-50%) ($580 m)($580 m) CABSCABS 515,000515,000 ↓↓ 5%5% (2.5%-50%)(2.5%-50%) ($672 m)($672 m) Source: CDC/NCHS for 2002. http://www.acc.org/advocacy/word_files/2005ProposedPhysicianPmtRulev3%20web.xls.
  32. 32. Markov Model:Markov Model: Health states - ovals; arrows represent allowed transitions. All ptsHealth states - ovals; arrows represent allowed transitions. All pts start event-free & can remain, have MI or angina, or die.start event-free & can remain, have MI or angina, or die. Markov model to estimate the benefits, costs, & incremental cost-effectiveness of CHD screening followed by targeted statin rx for high risk subclinical dz, vs. usual care alone, for the primary prevention of CV events among patients ages 45-65 years.. Death Post-MI Post-MI & AP Post-AP Event-Free Source: Blake GJ, Ridker PM, Kuntz KM. Potential Cost-effectiveness of C-Reactive Protein Screening Followed by Targeted Statin Therapy for the Primary Prevention of Cardiovascular Disease among Patients without Overt Hyperlipidemia. Am J Med 2003;114:485– 494.
  33. 33. Multi-Attribute Cost Markov Model:Multi-Attribute Cost Markov Model: Comparing FRS vs. CACSComparing FRS vs. CACS for 5 Yrs. Of Observational Follow-up Estimated LYS in Pts. Ages 45-65 yrs.for 5 Yrs. Of Observational Follow-up Estimated LYS in Pts. Ages 45-65 yrs. Death FRS Post-MI & AP Event-Free Death CACS Post-MI & AP Event-Free <$50,000 / Events Averted
  34. 34. ConclusionsConclusions If we can identify w/ a high degree of likelihood pts at risk forIf we can identify w/ a high degree of likelihood pts at risk for AMI / SCD, then it is likely that a CV screening-driven approachAMI / SCD, then it is likely that a CV screening-driven approach including prevention (i.e., risk factor modification) can result inincluding prevention (i.e., risk factor modification) can result in improved outcomes & aversion of costly hospitalizations.improved outcomes & aversion of costly hospitalizations. Preliminary analyses from the CE models reveal that subclinicalPreliminary analyses from the CE models reveal that subclinical dz screening can be cost effective when applied to “higher risk”dz screening can be cost effective when applied to “higher risk” or appropriate patient candidates.or appropriate patient candidates. – When compared with global risk scores that often underestimate risk inWhen compared with global risk scores that often underestimate risk in key patient subsets: women, young, international cohorts.key patient subsets: women, young, international cohorts. Decision models do not replace RCT comparing an array ofDecision models do not replace RCT comparing an array of imaging modalities, laboratory markers, or global risk scoring.imaging modalities, laboratory markers, or global risk scoring.
  35. 35. Potential Evidence for Priority SettingPotential Evidence for Priority Setting Priority Criteria Measures Impact Condition Disability, Mortality System Costs, Guideline Adherence, Errors Societal Indirect Costs Improvability Condition Cost-Effectiveness, efficacy Disparity Impact on vulnerable subgroups System Effectiveness of quality improvement Inclusiveness Diffusion across subpopulations
  36. 36. Many preventive services areMany preventive services are recommendedrecommended Delivery of effective services isDelivery of effective services is incompleteincomplete Resources—time and money—areResources—time and money—are limitedlimited Preventive services differ in their healthPreventive services differ in their health impact and costsimpact and costs Unmet Expectations & LimitationsUnmet Expectations & Limitations to CHD Screeningto CHD Screening

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