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我国心血管病防治：挑战、成因和对策

我国心血管病防治：挑战、成因和对策. 中国医学科学院 阜外心血管病医院 国家心血管病中心 医学研究统计中心 杨进刚. China P atient-centered E valuative A ssessment of C ardiac E vents. Trends in Characteristics, Treatment and. Outcomes Among Patients With AMI. in China from 2001 to 2011. China PEACE-Retrospective AMI Study.

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我国心血管病防治：挑战、成因和对策

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  1. 我国心血管病防治：挑战、成因和对策 中国医学科学院 阜外心血管病医院 国家心血管病中心 医学研究统计中心 杨进刚

  2. ChinaPatient-centered Evaluative Assessment of Cardiac Events TrendsinCharacteristics,Treatmentand OutcomesAmongPatientsWithAMI inChinafrom2001to2011 ChinaPEACE-RetrospectiveAMIStudy onbehalfofChinaPEACEinvestigators FuwaiHospital,NationalCenterforCardiovascularDiseases,China

  3. ChinaPEACE-RetrospectiveAMIStudy Three time points over a decade: 2001, 2006, 2011 A nationally representative sample of hospitalizations for AMI using two-stage random sampling. Standardized central medical chart abstraction (accuracy >98%) Rigorous data quality monitoring at each stage 4

  4. HospitalizationRateforAMI 20 15

  5. TrendsinTesting 2001 2006 2011 * P<0.001 * 100 * * % 50 0 Troponin Creatinine Echocardiogram

  6. TrendsinMedications * P<0.001 2001 2006 2011 100 * * * P=0.13 P=0.24 %50 0 Aspirin* Clopidogrel* Statins BB* ACE-I/ARB

  7. TrendsinReperfusionTherapy

  8. Trends:In-hospitalOutcomes

  9. Summary:AMIinChina2001-2011 MarkedincreasesinrateofAMIhospitalization Morefrequentuseofproceduresandtesting Persistentgapsinqualityofcare Nosignificantimprovementinmortality EvidenceforFutureQualityImprovementStrategies

  10. N=2432

  11. Hospital Distribution throughout mainland of China • Hospitals • 30 Provincial level • 44 Prefecture level • 31 County level N=12999 NINGXIA Provincial level Prefecture level County level

  12. Times from symptom onset to hospital arrival STEMI NSTEMI

  13. Percentage of Reperfusion in pts with STEMI

  14. In-hospital mortality rate in pts with AMI

  15. 三个级别医院就诊患者的差别

  16. Conclusion • Findings from the China Acute Myocardial Infarction Registry provide an overview of the treatment that patients actually receive and the outcome, providing the opportunity to assess daily practice in a large population of patients with AMI in China. • The variation in the management and outcome in patients with AMI by region and by type of hospitals reported in this study in China merit further investigation to reduce the observed disparities.

  17. Cost-effectivenessofoptimaluseofAMI treatmentsandimpactonCHDmortalityin China DongZhao CapitalMedicalUniversityBeijingAnzhenHospital BeijingInstituteofHeart,Lung&BloodVesselDiseases

  18. 2

  19. StrategiesofreducingAMImortality Primaryprevention Acutetreatment Secondaryprevention 5

  20. Increasingsurvivalfromimprovingtreatment

  21. KeytreatmentstrategiesofAMI recommendedbytheguidelines 11

  22. Questions&Hypotheses: 1.Whichoftheserecommendedtreatment strategieswouldbecost-effectiveinChinaif theutilitiesofeachorcombinationsofthem wereoptimalto100%. 2.Iftheopitmaluseofrecommenedtreatment haveremarkableimpactontotalCHDmortality inChina? 17

  23. Treatmentsstrategiesinacuteperiod A1RisingtheuseofAspirin, β-blockers,statinsandACEIduring Thefirst30daysafteronsetfromcurrentutilityrateto100% A2Rising theuseofclopidogrelinpatientswithAMIto100% B RisingtheuseofunfractinatedheparininpatientswithNSTEMIto100% C1RisingtheuseofprimaryPCIintertiaryhospitalandthrombolysis insecondaryhospitalinpatientswithSTEMI (withconsideration oftheavailibilityofPCItechnology)to100% C2RisingtheuseofprimaryPCIinallpatientswithSTEMIto100% C3RisingtheuseofprimaryPCI inhighriskpatientswithNSTEMIintertiary hospitalto100% 20

  24. Cost-effectivenessmeasurements •Incrementalcost-effectivenessratioswereusedtoevaluate thecost-effectivenessofoptimaluseofthekeytreatments. ICERswerecalculatedbydividingtheincrementalchanges intotalhealthcarecostsbytheincrementalchangesin QALYs. •WHO-CHOICEcriteriawereusedtoassessthedegreeof cost-effectiveness. •Highlycost-effective:ICERlessthantheGDPpercapita. •Moderatelycost-effective:ICERswerebetween1to3times ofGDPpercapita. •Notcost-effective:ICERmorethan3timesofGDPper 21 capita.

  25. Numberofdeathpreventedduring Comparisonofoptionsofoptimaluseoftreatment strategiesforeffects,costandcost-effectiveness pPCI inSTEMI pPCI+ Thrombolysis Four medications PCIin NSTEMI Clopidogrel inAMI Unfractionated heparin (C2) inSTEMI(C1) (A1) (C3) (A2) (B) 0 -1900.00 -10000 acuteperiod -3300.00 -3200.00 -9800.00 -20000 -30000 ICER B A1 C1 C2 A2 C3 -40000 -50000 -60000 1200 1000 800 600 -36300deaths -53600deaths $1099millions $610millions $2800 $3100 $9000 $10700 $17600 $23400 (Increasedacutetreatmentcostinmillions) 400 $152millions$112millons 200 $34millions Four medications (A1) $5millions Unfractionated heparin23 (B) 0 pPCI inSTEMI (C2) pPCI+ Thrombolysis inSTEMI(C1) PCIin NSTEMI (C3) Clopidogrel inAMI (A2)

  26. Numberofdeathpreventedduring Cost-effectivenessofcombinedstrategies pPCI inSTEMI pPCI+ Thrombolysis Four medications PCIin NSTEMI Clopidogrel inAMI Unfractionated heparin (C2) inSTEMI(C1) (A1) (C3) (A2) (B) 0 -1900.00 -10000 acuteperiod -3300.00 -3200.00 -9800.00 -20000 -30000 -40000 -50000 -60000 1200 -36300deaths -53600deaths A1+B A1+B+A2 A1+B+C1 Highlycost-effective Notcost-effective Moderatecosteffective (Increasedacutetreatmentcostinmillions) $1099millions A1+B+C1+C3Notcost-effective 1000 800 $610millions 600 400 $152millions $112.millions 200 $34millons $5millons Unfractionated heparin24 (B) 0 pPCI inSTEMI (C2) pPCI+ Thrombolysis inSTEMI(C1) PCIin NSTEMI (C3) Clopidogrel inAMI (A2) Four medications (A1)

  27. ImpactonCHDmortalitybyoptimaluseofthe treatmentstrategies pPCI inSTEMI pPCI+ Thrombolysis Four medications PCIin NSTEMI Clopidogrel inAMI Unfractionated heparin Numberofdeathpreventedduring (C2) inSTEMI(C1) (A1) (C3) (A2) (B) 0 -1900.00 -10000 -3300.00 -3200.00 -9800.00 -20000 -30000 acuteperiod -40000 -50000 -60000 0 -1 -36300deaths -53600deaths -0.3% -0.4% -0.4% -1.3% -2 (Percentageofreductionin -3 -4 A1+B+C1+C3Maximuma10% reductioninmortalityrateofCHD. -5 -6 -7 -8 -5% mortalityrate -7.5% pPCI inSTEMI (C2) pPCI+ Thrombolysis inSTEMI(C1) PCIin NSTEMI (C3) Clopidogrel inAMI (A2) Four medications (A1) Unfractionated heparin25 (B)

  28. Conclusions oMosthospital-basedAMItreatmentstrategies recommendedbytheguidelineswouldbehighlyor moderatelycost-effectiveinChina; o Full and simultaneous improvements of all standard hospital based AMI treatment strategies assessed in this study would only attributed to 9.6% reduction in the CHD mortality rate; oGiventhetrendtowardhigherabsolutenumbersandrates ofCHDinChina,prehospitalemergencycare, public educationonsymptomsofAMIandavailabilityof treatmentsforAMIshouldbeimproved. 26

  29. ExplainingthefallinCHDdeathsinUSA 1980-2000:RESULTS NEJM2007;356:2388. RiskFactorsworse+17% Obesity(increase) Diabetes(increase) +7% +10% 10000 RiskFactorsbetter-65% PopulationBPfall-20% Smoking-12% Cholesterol(diet)-24% Physicalactivity-5% -10000 Treatments-47% AMItreatments-10% Secondaryprevention-11% Heartfailure-9% Angina:CABG&PTCA-5% Hypertensiontherapies-7% Statins(primaryprevention)-5% Unexplained-9% 341,745 -30000 -50000 fewerdeaths in2000 1980 2000

  30. Explainingthefallincoronaryheartdisease deathsinEngland&Wales1981-2000 RiskFactorsworse+13% Obesity(increase)+3.5% Diabetes(increase)+4.8% Physicalactivity(less)+4.4% RiskFactorsbetter-71% Smoking-41% Cholesterol-9% PopulationBPfall-9% Deprivation-3% Otherfactors-8% 0 -20000 -40000 68,230 fewerdeaths in2000 2000 Treatments-42% AMItreatments-8% Secondaryprevention-11% Heartfailure-12% Angina:CABG&PTCA-4% Angina:Aspirinetc-5% Hypertensiontherapies-3% Unal,Critchley&Capewell Circulation2004109(9)1101 -60000 -80000 1981

  31. 2007-2009年北京市男女两性 急性冠心病事件院前死亡构成比（%） 院前死亡构成比（%） 女性 男性 39 孙佳艺，等. 《中华心血管病杂志》，2012

  32. 2007-2009年合计北京市男女两性各年龄组 急性冠心病事件院前死亡构成比（%） 85+ 75-84 65-74 55-64 45-54 35-44 25-34 男性 女性 40 孙佳艺，等. 《中华心血管病杂志》，2012

  33. ClinicalPathwaysforAcuteCoronarySyndromesinChina Dr.DuXin TheGeorgeInstituteforGlobalHealth BeijingAnzhenHospital,CapitalMedicalUniversity

  34. CPACS:Aqualityofcareimprovement initiativeinChina •Along-termcollaborationbetweenTheGeorgeInstitute, ChineseSocietyofCardiologyandMinistryofHealth •ThestudywassponsoredbySanofi •CPACSPhase1(2004-2006):Prospectiveregisterstudy –51hospitalsacrossthecountry –3000patients •CPACSPhase2(2007-2011):clusterrandomisedtrialof clinicalpathwayforevidence-basedmanagementofACS –75hospitalsacrossthecountry –>16,000patients

  35. CPACS2:clusterrandomisedtrial Implementandevaluateaqualityimprovement initiativeforthecareofhospitalisedACS patientsinChina

  36. Participatingcentres 75participatingcenters 50level3hospitals 25level2hospitals

  37. Intervention:performancemeasurementand feedback Clinicalpathwayimplementationwithcyclical auditfeedbackandpathwaymodification

  38. keyperformanceindicatorsusedin CPACS-2 •%ofreperfusiontherapyforSTEMI •Door-to-needletime •Door-to-balloontime •%diagnosesconsistentwithECGandbiomarkerfindings •%ofhigh-riskpatientsundergoinginvasivetherapy •%oflow-riskpatientsundergoingfunctionaltesting •%onoptimummedicaltherapyondischarge •Lengthofhospitalstay

  39. Primaryandsecondaryoutcomes •Primaryoutcome:8keyperformanceindicators •Secondaryoutcome:inhospitalevents •Death •Cardiacdeath •MajorAdverseCardiovascularEvents(MACE)comprisingall- causemortality,MIandstroke • Majorbleedingepisodes

  40. CPACS-2results Assessedforeligibility:82hospitals Excluded:7hospitals Refusedtoparticipate(4) Otherreason(3) Eligible:75hospitals Pilothospitals:5hospitals Randomised:70hospitals GroupA(earlyintervention):32hospitals Losttofollow-up:0hospital Analysis:32hospitals 50(range50-50)patientsperhospital GroupB(lateintervention):38hospitals Losttofollow-up:0hospital Analysis:38hospitals 50(range50-50)patientsperhospital

  41. Primaryoutcome:ContinuousKPIs Meandifference Control Intervention Favours Favours (n=1900) (n=1600) Control Intervention (95%CI) p-value Lengthofstayindays(ICC=0.107) 12.05(9.03) 11.31(7.43) Un-adjusted Adjusted -0.74(-2.11,0.63) -0.77(-2.15,0.62) 0.290 0.278 -3 0 3 Meandifference(day) Control Intervention Favours Favours Meandifference (n=1900) (n=1600) Control Intervention (95%CI) p-value DTNtimeforSTEMIpatientsundergoingthrombolysisinmin(ICC=0.191) Un-adjusted Adjusted 99.00(81.41) 79.06(66.15) 11.89(-21.3,45.06) 18.06(-13.4,49.54) 0.483 0.261 DTBtimeforSTEMIpatientsundergoingprimaryPCIinmin(ICC=0.114) Un-adjusted Adjusted 130.09(90.98) 141.09(103.69) -10.6(-44.4,23.21) -11.0(-45.2,23.22) 0.539 0.528 -25 025 Meandifference(min)

  42. Primaryoutcome:BinaryKPIs Control (n=1900) Intervention (n=1600) FavoursFavours ControlIntervention Riskratio (95%CI) p-value Patientswithfinaldiagnosis(UAPorMI)consistentwithbiomarkerfinding(ICC=0.08) Un-adjusted Adjusted 1720/1855(92.7%) 1398/1568(89.2%) 0.96(0.91,1.01) 0.95(0.89,1.02) 0.118 0.163 Low-riskpatientsundergoingfunctionaltesting(ICC=0.058) 0.25(0.03,2.07) 9/141(6.4%) 1/90(1.1%) 0.197 Un-adjusted Adjusted High-riskpatientsundergoingcoronaryangiography(ICC=0.462) Un-adjusted Adjusted 689/1504(45.8%) 690/1350(51.1%) 1.14(0.82,1.58) 1.02(0.81,1.29) 0.444 0.849 Patientsdischargedonappropriatemedicaltherapy(ICC=0.112) 932/1822(51.2%) 976/1555(62.8%) 1.23(1.06,1.42) 1.21(1.06,1.37) 0.007 0.004 Un-adjusted Adjusted STEMIpatientsreceivingappropriatereperfusiontherapy(ICC=0.096) 1.24(0.98,1.55) 1.25(0.98,1.59) 10 229/720(31.8%) Un-adjusted Adjusted 290/679(42.7%) 0.069 0.070 1 Riskratio 0.1

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