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A Coordinated Approach to Cardiovascular Care

A Coordinated Approach to Cardiovascular Care. Delivering Health and Economic Value to Patients and Purchasers. Sharon Levine MD Associate Executive Director The Permanente Medical Group Kaiser Permanente Bay Area Council June 9, 2008. The Impact of Cardiovascular Disease.

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A Coordinated Approach to Cardiovascular Care

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  1. A Coordinated Approach to Cardiovascular Care Delivering Health and Economic Value to Patients and Purchasers Sharon Levine MD Associate Executive Director The Permanente Medical Group Kaiser Permanente Bay Area Council June 9, 2008

  2. The Impact of Cardiovascular Disease • In 2008 Americans will suffer: • 1.2 million heart attacks • 800,000 strokes • 1.5 million new cases of diabetes • 6 million hospitalizations for CVD,1.3 million angioplasties and 500,000 bypass surgeries • An American dies from CVD every 35 seconds. • Heart disease and stroke are leading causes of disability among working adults. • The cost of heart disease and stroke in the United States is estimated at $450 billion in 2008. It includes direct medical costs and lost productivity from death and disability. • Improved care decreased CVD mortality 25% from 1994 to 2004.

  3. Translating Evidence Into Benefit Evidence Benefits • Abundant Body of Evidence • A 13 point reduction in blood pressure can lower deaths due to CVD by 25%. • 4 generic meds can reduce CV event risk by 50%. • 7 interventions during the ED/Hospital can reduce mortality. • Managing transition of HF patients from hospital to home can reduce readmissions and prevent catastrophic declines.

  4. Translating Evidence Into Benefit: The Quality Chasm Evidence Benefits The “Chasm” • Quality Chasm • In US only 55% of indicated care is provided • Diabetes patients received 45% of indicated care. • Hyperlipidemia patients received 49% of indicated care. • CAD patients received 68% of indicated care. • HTN patients received 65% of indicated care. Source: Rand

  5. What’s the Problem? I’m doing everything as I was trained to do -- I can’t work faster! The Traditional Model Of Care • One patient at a time • Only know about patients who appear in your office • No use of IT • Limited use of “extenders” New Model Elements • Accountability for panel/population • Transparency • Use of EMR, registries, internet • Team care (including pt) • Moving care out of Dr. office

  6. Turning Evidence Into Health Benefit Evidence Benefits • Success Factors: • Integrated delivery system; organized medical group • Process redesign • Use of advanced information technology • Aligned incentives (Pre-payment; salaried physicians) • Clinical Leadership • Patient Engagement

  7. Our Systematic Approach Primary Prevention Secondary Prevention AcuteCare Chronic Care …and accountability across the Continuum of Cardiovascular Disease and from “cradle to grave”.

  8. Investing in Primary Prevention Primary Prevention Secondary Prevention AcuteCare Chronic Care • Delivering the Benefits: • Modify Lifestyle • Increase HTN control • Smoking Cessation • Decrease LDL Cholesterol levels

  9. Increase Hypertension Control Primary Prevention What we did: leadership priority • Clinical Champions • Academic “detailing” • “Revealing Reports” • Where the opportunity is • “Data that Drives” • Tools to pinpoint gaps in blood pressure testing, treatment or documentation • Process Redesign • “Check, Treat, Repeat” • Treatment intensification to target • Medical Assistant BP Checks

  10. Increase Hypertension Control Primary Prevention Making the process clearer and easier…

  11. Increase Hypertension Control Primary Prevention …led to significant gain. 2001 2005 KP at HEDIS 90%tile Trends in Hypertension Control Rates 2001-2006

  12. We are in the Top 5 Secondary Prevention

  13. Decrease Smoking Primary Prevention …Reducing smoking rates over time. Adult Smoking Prevalence 2002 vs. 2005

  14. Crossing the Chasm – Secondary Prevention Primary Prevention Secondary Prevention AcuteCare Chronic Care • Delivering the Benefits: • Heart protective meds: Aspirin, Statin, ACE-I, and Beta-blocker • Lifestyle changes:Tobacco Cessation, Physical Activity, Healthy Eating and Weight Management • Risk factor control: Blood Pressure, Cholesterol and Blood Sugar

  15. PHASE Population Secondary Prevention Approximately 300,000 members or 11% of membership. Composition of population is displayed below:

  16. Diabetes Secondary Prevention Revealing report on adherence… Poor Adherence N=14,568 (24%) Potential Targets for DM Intervention DM Population N=143,858 Poor control N=59,633 (49%) Good adherence, NO Tx Int. N=17,908 (30%) Good Adherence, Tx Int. N=27,157 (46%) Good control N=86,609 (51%)

  17. PHASE Results Secondary Prevention Members on PHASE Medications Improvement from Q4 2004-Q2 2007 All PHASE Rx meds (composite metric) improved 30.3%

  18. Results Secondary Prevention Multiple Risk Factor Management - A1c control (<8.0) has improved along with tight measures of LDL and Blood Pressure 2004-2007 HbA1c <8.0 improved 10.6% LDL <100 improved 31.0% BP Control <139/89 (for DM and CKD 129/79) improved 29.6% (1) HbA1c Control represented on this graph is A1C < 8.0. A1C < 7.0 and A1C > 9.0 are also measured (2) Lipid Control measure represents the percentage of PHASE patients with most recent test of LDL < 100 mg/dl in last 12 months. (3) Blood Pressure Control is defined as BP <= 129/79 for patients with Diabetes and CKD and BP <= 139/89 for all other PHASE patients.

  19. Impact of 2007 Improvements: Secondary Prevention • Additional 9,600 patients at LDL target • 300 heart attacks/strokes prevented • Additional 2,000 patients on statins • 170 heart attacks/strokes prevented • Additional 1,600 patients on ACEI • 70 heart attacks/strokes prevented • Additional 4,700 People with Diabetes at A1c <9 • 188 adverse outcomes prevented • Additional 13,447 People with Diabetes have BP < 129/ 79 • 1200 CV events prevented

  20. Crossing the Chasm – Acute Care Primary Prevention Secondary Prevention AcuteCare Chronic Care • Delivering the Benefits: • 7 Joint Commission Core Measures • Provide revascularization to appropriate patients

  21. Reducing variation and improving quality Acute Care Reducing variation and improving quality over time at all NCAL Med Centers Inpatient Quality Performance: All Core Measures, Rolling Year

  22. Heart attack mortality is declining Acute Care

  23. Cardiac Procedures Acute Care 2001 – 2007 Volume Trends, KPNC

  24. Coronary Procedures – Less PCIs, CABG, CATH Acute Care National 50th Percentile Rate Kaiser Permanente Rate Procedures/ Thousand Males aged 45-64

  25. Crossing the Chasm – Chronic Care Primary Prevention Secondary Prevention AcuteCare Chronic Care • Delivering the Benefits: • Stratification by patient status • Integration across conditions • Panel management to offload algorithm-driven care • Member engagement: Self-management skills

  26. Heart Failure Chronic Care Level 3 – Intensive or CaseManagement – Heart Failure patients who are at high risk due to complicated and/or unstable condition, poor functional status and/or psychosocial problems. High intensity management of the patient’s care is required. Level 2 – Assisted Care or Care Management –Heart Failure patients with moderate symptoms, sub-optimal medication management, poor self-care skills. Also include patients who are unable to achieve or maintain self-care skills despite appropriate education and support from the APC team. Level 1 – Self Care Support – Heart Failure patients supported by routine APC team care. Members have mild symptoms & appropriate medication management. Members who may benefit from basic self-care education. Prevention - The foundation of basic care for all levels. Intensive or Case Mngmt 2,000 pts Prevention is part of every member’s care Assisted CareorCare Management 5,000 pts Self Care Support 35,000 pts Chronic Conditions Management Program for Heart Failure in NCAL 42,000 HF pts

  27. Trends in HF Mortality Chronic Care CHF Outcome Data

  28. Heart Failure Chronic Care Utilization Due to Heart Failure is Decreasing for Registry Members 700 579.4 561.6 600 506.4 500.4 Day Rate 500 -36.7% 390 400 377.1 ED Visits 366.7 Rate/1000 HF Registry 300 -13.0% 243.1 240.9 244.3 236.7 238.2 217.8 212.6 200 -44.0% 175.5 162.2 Discharge 144.4 100.6 100 137.6 98.2 109.6 0 1999Q4 2000Q4 2001Q4 2002Q4 2003Q4 2004Q4 2005Q1

  29. Total and ST Elevated MIs are declining Full Spectrum of Care Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates for Kaiser Permanente, 1998 - 2007

  30. Strokes are declining Full Spectrum of Care Stroke and Intracerebral Hemorrhage – Hospitalization Rates in Kaiser Permanente – 1998 - 2007

  31. Heart disease mortality declining Full Spectrum of Care 30% less chance of dying due to HD if you are a Kaiser Permanente Member

  32. Summary Using our • integrated system, • advanced IT systems, • process redesign • financial alignment and • patient engagement, we’ve made it easier to “do the right thing” across the spectrum of cardiovascular disease, so that cardiovascular disease is no longer the number one cause of death for KP members

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