a canadian view on effective use of vads · 2017-11-10 · a canadian view on effective use of vads...
TRANSCRIPT
![Page 1: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/1.jpg)
Value Based Care and the Role of INTERMACS in our Evolving Health Care Environment
A Canadian View on Effective Use of VADS
Anique Ducharme MD, MSc, Montreal Heart Institute, Montreal (Qc), Canada
AND LJ Lambert, G Sas, N Dragieva, LJ Boothroyd, M Carrier, R Cecere,
E Charbonneau, MD, C Sanscartier, AMA, JE Morin, MD, P Bogaty, MD Institut national d’excellence en santé et en services sociaux, (INESSS),
Montréal, Québec, Canada;
![Page 2: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/2.jpg)
Disclosures
• Research grant: St-Jude Medical, Sorin inc. • Adboard: Pfizer • Speaker bureau
– Abbot Vascular – Thoratec – Pfizer – Servier
2
![Page 3: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/3.jpg)
USA versus Canada
USA Canada
![Page 4: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/4.jpg)
About Canada What’s relevant for this audience?
• Land area: 3,855,100 sq mi (2nd largest in the world) • Population : 35,158,300,
– Smaller than California (38,041,430) – Quebec (8, 155 300)
• Canadian Health care system = socialized – Universal access – HF patients: lost leader
• Hospital admission: $ $ $ $ • No DRG-diagnosis reimbursement • Devices therapy (ICD-CRT-MCS): more $
– No possibility for the hospital to “Gain Back” some of the lost”
![Page 5: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/5.jpg)
VAD survival (“DT”) compared to Optimal Medical Therapy (IM 3)
Park SJ. AHA Scientific Sessions, November 2010.
![Page 6: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/6.jpg)
So we had to open up the bank somehow to offer this therapy to a growing number of patients.
![Page 7: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/7.jpg)
• The publicly funded cardiology evaluation unit from INESSS conducted a review
of the evidence,
And recommended to the Québec Ministry of Health that use of long-term left ventricular assist devices (LVAD) should be carefully monitored but not limited to bridge-to-transplant patients. March 2012
![Page 8: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/8.jpg)
A Canadian View on Effective Use of VADS: First the data
• In 2013, many Canadian centers joined CANAMACS –Data non available yet
• INESSS: –Retrospective review of hospital data sources of all LVAD-implanted patients (3 centers) → 2010-12. –Variables, definitions & time points as INTERMACS –Major clinical outcomes (death, transplant, recovery) and adverse events were determined during 1-year follow up.
![Page 9: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/9.jpg)
Patient characteristics at implant: Québec vs INTERMACS
Québec
(2010-2012) N=53
%
INTERMACS* (2010-2011)
N=3,573 %
Age group, years ≤ 39 13 12 40 - 59 53 41
60 - 79 34 46
80+ 0 0.6
Male 77 78†
Mean body mass index, kg/m2 25.7 27.0‡
Mean body surface area, m2 1.9 2.07†
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to September 30, 2013
†Kirklin et al. J Heart Lung Transplant 2012; 31:117-26. ‡Teuteberg et al. JACC Heart Failure 2013;1;5:369-78.
![Page 10: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/10.jpg)
51
30
118
0
25
36 37
0.4 0.70
10
20
30
40
50
60
BTT BTC DT Rescue therapy Bridge torecovery
Perc
ent (
%)
Québec
INTERMACS
N=53 Québec (2010-2012) N=3,573 INTERMACS (2010-2011)*
Initial LVAD implant strategy: Québec vs INTERMACS
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to Sept 30, 2013
![Page 11: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/11.jpg)
13
40
43
4
0 0 0
15
40
27
13
3 2 10
10
20
30
40
50
60
1 2 3 4 5 6 7
Perc
ent (
%)
Québec
INTERMACS
N=53 Québec (2010-2012) N=3,573 INTERMACS (2010-2011)*
INTERMACS clinical profile at time of LVAD implant: Quebec vs INTERMACS
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to Sept 30, 2013
![Page 12: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/12.jpg)
Clinical results at 1 year after LVAD implant: Québec vs INTERMACS
Québec (2010-2012)
N=53 %
INTERMACS * (2006-2012)
N=6,609 %
Alive on LVAD support 57 57
Died on LVAD support 17 18
Transplanted after LVAD and alive 19 24
Transplanted after LVAD and died 6
LVAD explanted / recovery 2 1
*Quarterly Statistical Report 2012; 4rd Quarter; Implant and event dates: June 23, 2006 to December 31, 2012
![Page 13: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/13.jpg)
Adverse events during the first year after implant: Quebec vs INTERMACS
Adverse events Québec (2010-12)
N=53 , % INTERMACS (2006-12)*
N=6,796, %
Device malfunction 13 14
Bleeding 42 38
Infection 43 40
Cardiac arrhythmia 47 26
Right heart failure LLE & high CVP post-op (4)
25 17 14
Neurological dysfunction excluding delirium:
28 18,5 16
Renal dysfunction 26 12
Hepatic dysfunction 9 5
Respiratory failure 19 18 *Quarterly Statistical Report 2012; 4th Quarter; Implant and event dates: June 23, 2006 to December 31, 2012
RVAD/inotrope > 1 week post-op or 2/4 criteria; – CVP> 18 – CI < 2.3 – Ascites/edema –↑ CVP by Echo
TIA or CVA or Seizure or
Encephalopathy or Confusion
![Page 14: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/14.jpg)
Total/average cost of hospital stay for LVAD
implantation according to costing component (2013 $CAN)
Costing component Total cost Average per patient cost
In-hospital drug cost $246,618 $5,075
LVAD implantation cost $300,889 $6,269
Hospital stay cost $2,557,486 $53,282 LVAD acquisition cost $5,365,534 $111,782
Total $ 8,470 527 $ 176 408
Excluding: physicians fees, VAD program structure & staff Devices-related rehospitalization
160,652.46 USD
![Page 15: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/15.jpg)
A Canadian View on Effective Use of VADS Conclusion
• Our implant rate is very low – « US benchmark »: 30/100 000 population – Quebec: 0.67/100 000
• In comparison with INTERMACS patients, Québec LVAD patients are younger but sicker and less likely to be DT.
• Despite low volumes, clinical results in Québec hospitals are similar to those reported for INTERMACS. – More adverse events reported with independent data
abstraction compared to self reporting ? • The cost of initial VAD implant in Canada is cheap.
17
![Page 16: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/16.jpg)
As for DT…
18
• We owe to our patients not to miss the boat – Our volumes will increase, but will remain << USA
• Key for a successfull DT program lies in patients selection.
• Will future policies affect our capacity to offer DT to the Canadian patients? – Some costs are not expected to drop (hospital,…) – The politicians are getter older also…
![Page 17: A Canadian View on Effective Use of VADS · 2017-11-10 · A Canadian View on Effective Use of VADS Conclusion • Our implant rate is very low – « US benchmark »: 30/100 000](https://reader033.vdocument.in/reader033/viewer/2022042606/5f70d123fdcf9f436a664514/html5/thumbnails/17.jpg)
USA vs Canada: The Reality ?
USA Canada