developing cost effective chd screening strategies

Developing Cost Effective Developing Cost Effective CHD Screening StrategiesCHD Screening Strategies

Leslee J. Shaw, PhDLeslee J. Shaw, PhDDepartment of Imaging and MedicineDepartment of Imaging and Medicine

Cedars-Sinai Medical CenterCedars-Sinai Medical CenterLos Angeles, CaliforniaLos Angeles, California

CHD Detection In Asymptomatic Women & CHD Detection In Asymptomatic Women & MenMen

Traditional approach to detection of CHD risk = Traditional approach to detection of CHD risk = assessment of typical risk factors assessment of typical risk factors Despite many available risk assessment Despite many available risk assessment approaches, there’s a approaches, there’s a detection gapdetection gap for for asymptomatic individuals w/ subclinical asymptomatic individuals w/ subclinical atherosclerosis. atherosclerosis. Framingham & European risk scores - useful Framingham & European risk scores - useful ““guidesguides.” .” – to predict long term risk of CHD events in to 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 36 40% 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.

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

Estimated 10 Yr. Hard CHD Risk Estimated 10 Yr. Hard CHD Risk Framingham Offspring & Cohort Women Framingham Offspring & Cohort Women

and Menand 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%

Perc

ent

Perc

ent

Age (years)Age (years)

WomenWomen MenMen

CCS=0 CCS 1-99 CCS 100-399 CCS400

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 % Not Qualifying For Pharmacotherapy by CACSCACS

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

Estimated Direct & Indirect Costs of Estimated Direct & Indirect Costs of Cardiovascular Diseases & StrokeCardiovascular Diseases & StrokeUnited States: 2005United States: 2005

Source: Heart Disease and Stroke Statistics – 2005 Update.

254.8

142.1

56.8 59.727.9

393.5

0

50

100

150

200250

300

350

400

450

Hea

rtD

isea

se

Cor

onar

yH

eart

Dis

ease

Str

oke

Hyp

erte

nsiv

eD

isea

se

Con

gest

ive

Hea

rt F

ailu

re

Tot

al C

VD

*

Bil

lio

ns

of

Do

llar

s

Current State of Health Care SystemCurrent State of Health Care System

~50% of health care costs are for ~50% of health care costs are for end-stage or hospital care.end-stage or hospital care.– Avg yrly health expenditure for Avg yrly health expenditure for

end stage care is ~5-x higher end stage care is ~5-x higher vs. non-end stage care.vs. non-end stage care.

Shifting care to early, Shifting care to early, diagnostic or outpatient sector diagnostic or outpatient sector potential to reduce cost.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 BillionMedicare pays 31%










Source: Medicare Standard Analytic File, 1999.

5+ Chronic Conditions

66%

0 Chronic Conditions

1%


7%


10%


13%

1 Chronic Condition

3%

- 2/3rds of Spending = 5+ Chronic Conditions

- 1/5th of Spending = 3+ Chronic Conditions

Medicare SpendingMedicare Spending

The Most Expensive Conditions In The Most Expensive Conditions In America: America:

MEPS Population Estimates MEPS 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

Upfront Test CostUpfront Test Cost

0

200

400

600

800

1000

ABI

TMET

C-IMT

EBT / CT

Echo

Oth

er C

T

SPECTIV

USM

RCat

h

Chol P

anel

HsCRP

OP V

isit

Adv L

ipid

Low CostLab / 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)

Average Cost Inputs for Adverse Average Cost Inputs for Adverse Sequelae of CVDSequelae 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 ACS AMI or ACS $15-20k $15-20k– Chest Pain Hospitalization Chest Pain Hospitalization $6k $6k– Stroke Stroke $50k $50k– Anti-Ischemic Rx Anti-Ischemic Rx $1,500 - $5,000 / yr $1,500 - $5,000 / yr– Out-of-Pocket Out-of-Pocket $2,000 / yr $2,000 / yr– ……..

Medicare Payment Advisory Commission Medicare Payment Advisory Commission (MedPAC) - Growth in Physician Services(MedPAC) - Growth in Physician Services

0

5

10

15

20

25

30

35

40

45

MajorProcedures

Evaluation &Management

OtherProcedures

Tests Imaging

22%

Growth of All Physician Services

%

Includes all Services in the Physician Fee ScheduleSource: MEDPAC Analysis of Medicare Claims DataMarch 17, 2005, Executive Director, Medicare Payment Advisory Commission, Mark Miller,.htm

Trends in CV Operations & ProceduresTrends in CV Operations & Procedures

United States: 1979-2000United States: 1979-2000

Unfolding a Body of EvidenceUnfolding a Body of Evidence

Observational Data

•Risk identification•Costs

Clinical TrialData•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):62E65E.

Basics of CEABasics of CEACEA – 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 new Technique comparing relative value of various clinical strategies. Commonly, a new strategy is compared w/ current practice (i.e., "low-cost alternative") in calculation of CE strategy 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 to Result = "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 is new 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

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?

Screening Criteria Discussed Screening 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 rates Feasibility of increasing delivery rates

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

Evaluation Criteria Evaluation 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

CHD Screening Framework CHD Screening Framework

Two Steps:Two Steps:

1.1. Burden and Effectiveness into single measure of Burden and Effectiveness into single measure of Clinically Preventable BurdenClinically Preventable Burden (CPB) (CPB)

2.2. Cost EffectivenessCost Effectiveness included to account for resource included to account for resource consumptionconsumption

Clinically Preventable Burden Clinically Preventable Burden

CPB = Burden x Effectiveness CPB = 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 Years Burden 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

Clinically Preventable BurdenClinically Preventable Burden

Qualitative assessment of CHD screening Qualitative assessment of CHD screening should consider:should consider:

– CPB - not burden and effectiveness separatelyCPB - not burden and effectiveness separatelyfocus 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

Cost Effectiveness (CE) AnalysisCost Effectiveness (CE) Analysis

CE CE = = 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

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

Million

s o

f p

eop

leMen 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

Treatment Est. 10-Yr Costs from NCEP III Treatment 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

Million

s o

f $

Men WomenNCEP 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

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 1-441-112

100-400400-999

Lower Risk Higher Risk

Low Risk includes Arad, Greenland, LaMonte

Moderate Risk includes Arad, Greenland, LaMonte, Taylor, VliegenthartHigh 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)

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 10 0 Diagnosis Diagnosis of CVDof CVD

6,373,0006,373,000 ↑ ↑ 10% (5%-25%)10% (5%-25%)

Hospital D/C for 1Hospital D/C for 10 0 Diagnosis Diagnosis 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.

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 10 0 Diagnosis Diagnosis of CVDof CVD

6,373,0006,373,000 ↑ ↑ 10%10% $3.8 b$3.8 b

Hospital D/C for 1Hospital D/C for 10 0 Diagnosis Diagnosis 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.

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.

CPB Model Inputs – Procedure BurdenCPB Model Inputs – Procedure Burden

Pre-Pre-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.

Markov Model:Markov Model: Health states - ovals; arrows represent allowed transitions. All pts Health 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..

DeathPost-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 thePrimary Prevention of Cardiovascular Disease among Patients without Overt Hyperlipidemia. Am J Med 2003;114:485– 494.

Multi-Attribute Cost Markov Model:Multi-Attribute Cost Markov Model: Comparing FRS vs. CACS Comparing 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.

DeathFRS

Post-MI &AP

Event-Free

DeathCACS

Post-MI &AP

Event-Free

<$50,000 / Events Averted

ConclusionsConclusions

If we can identify w/ a high degree of likelihood pts at risk for If we can identify w/ a high degree of likelihood pts at risk for AMI / SCD, then it is likely that a CV screening-driven approach AMI / SCD, then it is likely that a CV screening-driven approach including prevention (i.e., risk factor modification) can result in including 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 subclinical Preliminary 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 in When 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 of Decision 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.

Potential Evidence for Priority Potential Evidence for Priority SettingSetting

Priority Criteria Measures Impact

Condition Disability, Mortality System Costs, Guideline Adherence,

ErrorsSocietal Indirect Costs

ImprovabilityCondition Cost-Effectiveness, efficacyDisparity Impact on vulnerable subgroupsSystem Effectiveness of quality

improvement

Inclusiveness Diffusion across subpopulations

Many preventive services are Many preventive services are recommendedrecommended

Delivery of effective services is Delivery of effective services is incompleteincomplete

Resources—time and money—are Resources—time and money—are limitedlimited

Preventive services differ in their health Preventive services differ in their health impact and costsimpact and costs

Unmet Expectations & Limitations Unmet Expectations & Limitations to CHD Screeningto CHD Screening

developing cost effective chd screening strategies

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