A Coordinated Approach to Cardiovascular Care

Sharon Levine MDAssociate Executive Director

The Permanente Medical GroupKaiser Permanente

Bay Area CouncilJune 9, 2008

Delivering Health and Economic Value to Patients and Purchasers

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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.

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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.

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Translating Evidence Into Benefit: The Quality Chasm

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

Evidence Benefits

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What’s the Problem? I’m doing everything as I was trained to do -- I can’t work faster!

Accountability for panel/population

Transparency Use of EMR, registries,

internet Team care (including pt) Moving care out of Dr. office

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

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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

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Our Systematic Approach

…and accountability across the Continuum of Cardiovascular Disease and

from “cradle to grave”.

Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care

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Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care

Investing in Primary Prevention

Delivering the Benefits:

Modify Lifestyle

Increase HTN control

Smoking Cessation

Decrease LDL Cholesterol levels

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Increase Hypertension Control

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

Primary Prevention

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Action Description Outcome

CheckWas BP taken and recorded? Documentation

Was BP high? (Determines denominator for measure 3)

Treat Was treatment intensified ? Upward titration of dose and/or medication type

Repeat

Was there another BP taken within 4 weeks?

Follow up care

Was the f/u BP lower than the initial BP?

Better Control of BP

Was the f/u BP in control? Controlling BP

Increase Hypertension ControlPrimary Prevention

Making the process clearer and easier…

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Increase Hypertension Control

KP at HEDIS 90%tile

Primary Prevention

Trends in Hypertension Control Rates 2001-2006

…led to significant gain.

2001 2005

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We are in the Top 5Secondary Prevention

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23.0%

16.4%

12.2%

20.9%

15.2%

9.2%

12.0%

0%

5%

10%

15%

20%

25%

United States California Kaiser PermanenteNorthern California

Healthy People 2010 Target

Survey Population

% A

dult

popu

latio

n wh

o cu

rren

tly s

mok

e

2002

2005

10%

7.5%

25%

Adult Smoking Prevalence 2002 vs. 2005

Decrease SmokingPrimary Prevention

…Reducing smoking rates over time.

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Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care

Crossing the Chasm – Secondary Prevention

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

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PHASE Population

68%

11% 9% 6% 2%

32%

0%

20%

40%

60%

80%

Diabetes CAD Stroke PAD CKD AAA

Secondary Prevention

Approximately 300,000 members or 11% of membership. Composition of population is displayed below:

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Poor control N=59,633 (49%)

Good Adherence, Tx Int.N=27,157 (46%)

Poor AdherenceN=14,568 (24%)Good adherence, NO Tx Int.N=17,908 (30%)

DM PopulationN=143,858

Good controlN=86,609 (51%)

Diabetes

Potential Targets for DM Intervention

Secondary Prevention

Revealing report on adherence…

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30

40

50

60

70

2004Q4

2005Q1

2005Q2

2005Q3

2005Q4

2006Q1

2006Q2

2006Q3

2006Q4

2007Q1

2007Q2

% o

n ta

rget

med

icatio

n

Statin Use ACEI Use BB Use All Meds

All PHASE Rx meds (composite metric)improved 30.3%

Secondary Prevention

Members on PHASE Medications Improvement from Q4 2004-Q2 2007

PHASE Results

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Results

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.

Multiple Risk Factor Management - A1c control (<8.0) has improved along with tight measures of LDL and Blood Pressure 2004-2007

Secondary Prevention

HbA1c <8.0 improved 10.6%

LDL <100 improved 31.0%

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Impact of 2007 Improvements: 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

Secondary Prevention

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Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care

Crossing the Chasm – Acute Care

Delivering the Benefits: 7 Joint Commission Core Measures

Provide revascularization to appropriate patients

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Reducing variation and improving quality

Reducing variation and improving quality over time at all NCAL Med Centers

Acute Care

Inpatient Quality Performance: All Core Measures, Rolling Year

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Heart attack mortality is declining

Standardized MI Mortality

50

60

70

80

90

100

1 2 3 4 5 6 7

year

ind

ex

Acute Care

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Cardiac Procedures

Cardiac Procedures

-

1,900

3,800

5,700

7,600

9,500

2001 2002 2003 2004 2005 2006 2007

Year

Pro

ce

du

re V

olu

me

CV Surgery PCIDx Cath

2001 – 2007 Volume Trends, KPNC

Acute Care

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Coronary Procedures – Less PCIs, CABG, CATHAcute Care

National 50th Percentile Rate Kaiser Permanente Rate

2006 Data

8.2

2.4

12.3

4.8

1.7

4.4

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

PCI CABG CATH PCI CABG CATH

Procedures/ Thousand Males aged 45-64

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Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care

Crossing the Chasm – Chronic Care

Delivering the Benefits: Stratification by patient status

Integration across conditions

Panel management to offload algorithm-driven care

Member engagement: Self-management skills

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Level 3 – Intensive or Case Management – 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.

Self Care Support

35,000 pts

Assisted Careor

Care Management

5,000 pts

Case Mngmt2,000 pts

Prevention is part of every member’s care

Intensiveor

42,000 HF pts

Chronic Care

Chronic Conditions Management Program for Heart Failure in NCAL

Heart Failure

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Trends in HF Mortality CHF Outcome Data

Chronic Care

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100.698.2

175.5 162.2144.4

137.6109.6

366.7377.1

579.4 561.6

500.4 506.4

390

212.6217.8

244.3 236.7 243.1 240.9 238.2

0

100

200

300

400

500

600

700

1999Q4 2000Q4 2001Q4 2002Q4 2003Q4 2004Q4 2005Q1

Rat

e/10

00 H

F R

egis

try Day Rate

ED Visits

Discharge-44.0%

Utilization Due to Heart Failure is Decreasing for Registry Members

Heart FailureChronic Care

-13.0%

-36.7%

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Total and ST Elevated MIs are declining

0

0.5

1

1.5

2

2.5

3

3.5

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Ag

e/S

ex

Ad

jus

ted

Ra

te p

er

10

00

ST Elevated MI Non ST Elevated MI MI

Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates for Kaiser Permanente, 1998 - 2007

Full Spectrum of Care

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Strokes are declining

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Ag

e/S

ex

Ad

jus

ted

Ra

te p

er

10

00

Strokes Intracerebral Hem

Stroke and Intracerebral Hemorrhage – Hospitalization Rates in Kaiser Permanente – 1998 - 2007

Full Spectrum of Care

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Trends in Heart Disease Mortality in the population of Kaiser Permanente (N. California) and the rest of California, age-sex agjusted*, 1995-2004

183

136

188

274

100

150

200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

year

de

ath

s/1

00

,00

0

KP-rateNon-Kp rate

* 2004 KP is the standard pop for the adjustment

Heart disease mortality declining

30% less chance of dying due to HD if

you are a Kaiser Permanente

Member

Full Spectrum of Care

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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