Using  BC  and  Canadian  Data  to  Improve  Health  and  Healthcare  

What  are  the  best  ways  to  improve  health  outcomes    and  system  sustainability?  

Dr.  Bruce  Carleton  University  of  Bri<sh  Columbia  

Child  &  Family  Research  Ins<tute  BC  Children’s  Hospital  

 BC  Data  and  Diabetes  

Diabetes  Control  

•   Major  test  used  to  monitor  control  is  hemoglobin  A1C  –  measures  glucose  control  over  4  months  by  analyzing  the  amount  of  glucose  on  the  red  blood  cell  

•   CDA  recommends  tes<ng  every  3  months;    Test  at  6-­‐month  intervals  when  glycemic  targets  are  consistently  achieved    

•   No  evidence  to  suggest  tes<ng  more  oPen  than  every  4  months  is  necessary  

Annual  cost  of  A1C  tests  performed  in  BC  2005-­‐2011  

Annual  number  of  A1C  tests  performed  in  VCHA  

Annual  cost  of  A1C  tests  performed  in  VCHA  

Annual  number  of  A1C  tests  performed  in  FHA  

Annual  cost  of  A1C  tests  performed  in  FHA  

One-­‐third  of  all  A1C  tests  are  repeated  within  3  months    

 

BC  Data  and  Asthma  

  3  million  Canadians  live  with  asthma    

  Asthma  is  the  #1  chronic  condi<on  in  children    

  6  out  of  10  people  living  with  asthma  do  not  have  it  under  control  

  250  people  die  each  year  in  Canada  from  asthma  (and  most  are  preventable)  

Improving Asthma Management

The  Opportunity:      Bri<sh  Columbia’s  Data  

Medical  Service  Plan  

PharmaNet  

Discharge  Abstracts  Database  

Vital  Sta<s<cs  

Inhaled  Short-­‐ac<n

g  Bron

chod

ilator  

Use    

(Salbu

tamol  Equ

ivalen

ts)  

       

>  500    µg/day  

>  250  &  ≤  500  µg/day  

>0  &  ≤  250  µg/day  

0  µg/day  

>  4  inhalers  /  year  

2  -­‐  4  inhalers  /  year  

1  -­‐  2  inhalers  /  year  

≤ 1  inhaler  /  year  

Inhaled Corticosteroid Use (Beclomethasone Equivalents)

Asthma  Regimen  Op<mality  Classifica<on  (Pa<ent  Ages  5-­‐11  Years)    

Green  =  Op<mal  regimen,  n=6,155  (67%)  Yellow  =  Unclassified  regimen,  n=2,162  (23%)    Red  =  Subop<mal  regimen,  n=913  (10%)  

Suboptimal regimen use

Optimal regimen use

Emergency  Department  Visits  

Suboptimal regimen use

Optimal regimen use

Hospital  Admissions  

Family  Prac<<oner  Visits  

60  –  80  

90  –  100  

100  –  120  

120  –  130  

>  130  

Per  100  pa<ents  Children 0 -18 years/ Asthma related visits/ 2009

Emergency  Department  Visits  

1  -­‐  5  5  -­‐  10  10  -­‐  15  15  -­‐  20  20  -­‐  25  

Per  100  pa<ents  

Children  0  -­‐18  years/  Asthma  related  visits/    2009  

Hospital  Admissions  

0  –  0.4  

0.4  –  0.8  

0.8  –  1.2  

1.2  –  1.6  

1.6  -­‐  2  

Per  100  pa<ents  

Children  0  -­‐18  years/  Asthma  related  visits/    2009  

Costs  per  Pa<ent  (by  region)  

*ED  Costs  are  based  on  BCCH  Data,  Physician  Visits  Costs  from  MSP  All  Costs  based  on  2009  Data/Dollars  

ED Service Use

Urban  vs.  Rural  

Bubble Size: Estimated number of physicians in the area

0

200

400

600

800

1000

1200

ED visits Hospital admissions

471.98

47.59

1,067.23

180.28 Cos

t per

pat

ient

Health Services

Pts with optimal regimens

Pts with suboptimal regimens

Cost  per  pa*ent  according  to  op*mality  of  asthma  drug  regimens  (2009)  

The costs of ED services was 2.3X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen The costs of hospital admission was 4X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen

Daily  vs.  Intermikent  (Seasonal)  Use  of  Inhaled  An<-­‐inflammatory  Asthma  Drugs  

�

1.   Intermikent  users  of  ICS  are  28%  more  likely  to  have  hospital  admissions  than  regular  users.  

 

2.   Intermikent  users  of  ICS  are  19%  more  likely  to  have  ED  visits  than  regular  users.  

 

BC  Data  and  Prostate  Cancer  

  Prostate  Cancer  is  the  most  commonly-­‐diagnosed  cancer  among  Canadian  men    

  23,600  Canadian  men  will  be  diagnosed  with  prostate  cancer  this  year  

  In  2013,  3,900  Canadians  will  die  from  Prostate  Cancer  

 

Using BC Data to Develop a New Approach to Prevent Prostate Cancer

Metastasis

Prostate  Cancer  Mortality  

•   Most   of   the   <me,   prostate  cancer   is   a   chronic   disease  with  low  mortality  

 •   Unfortunately,   when   the  disease  became  metasta<c,  it  has  a  high  mortality  rate  

 •   There   is   evidence   to   suggest  that    blocking  a  specific   type  of   calcium   channel   can  prevent    metastases  

 

The  opportunity:      Bri<sh  Columbia’s  Data  

BC  Cancer  Registry  

BC  Cancer  Agency  

Pharmacy  Data  

PharmaNet  Medical  Services  Plan  

Relevance  

   If  blockade  of  specific  calcium  channels  decreases  metastases,  then  men  who   take   these   drugs   for   heart   disease   should   have  lower  rates  of  prostate  cancer  metastases  than  men  who  do  not.      If  an  associa9on  is  found  between  this  par9cular  class  of  calcium  channel   blocker   use   and   survival   or   metastases,   then   calcium  channel  blockers  could  poten9ally  be  prescribed  to  either  prevent  prostate  cancer  metastases  or  prolong  survival.  

 

BC  and  Canadian  Data  and  Hepa<<s  C  

Standard  HCV  Drug  Therapy  

•   Recommended  treatment:    

•    PEG-­‐IFN-­‐α  +  Ribavirin  (48-­‐week  course)  

Significant Variability in Response

40-50% clear virus

50-60% do not clear virus

Significant ancestry related differences in response rates (European > African response rates)

Treatment often poorly tolerated because of ADRs

New  drugs  available  and  on  pipeline      Direct  Ac*ng  An*virals  

 

•   High  Rates  of  ADRs  •   Boceprevir/telaprevir  decreased  hemoglobin  (9-­‐52%)  

•   Telaprevir/boceprevir  neutropenia  and  thrombocytopenia    

•   Telaprevir-­‐induced  skin  reac<ons  (56%;    1%  severe)  •   Psychiatric  symptoms  from  boceprevir  

 

New Therapeutic Options for HCV Drug Therapy

Telaprevir  (2012:  4  safety  warnings)   Bocepravir  (2012-­‐13:  5  safety  warnings)  

PEG-­‐IFN-­‐RBV  

PEG-­‐IFN-­‐RBV    +    

Prot.  Inhib.  

Pa*ent  

Can we determine the  op*mal  HCV  treatment  prior  to therapy?

+  $20,000-­‐40,000  

IL28B    Genotype  

&  Clinical    Factors  

“An  individual  with  a  CC  genotype  could  be  spared  the  expense  and  adverse  events,  and  would  achieve  similarly  excellent  results  with  PEG-­‐IFN/RBV  alone”  -­‐  Jenson  &  Pol,  Liver  Intl,  2012  

PEG-­‐IFN+RBV  

PEG-­‐IFN+RBV    +    

Prot.  Inhib.  

Safe  &  Effec*ve  

Adverse  Drug    Reac*on  

70-­‐86%  SVR  

80-­‐90%  SVR  

IL28B    C/C  

Safe  &  Effec*ve  

Adverse  Drug  Reac*on  

+  $20-­‐40k  

No  Effect  

No  Effect  

1.  Triple  therapy    offers  modest  

improvement  for    IL28B  C/C patients but $$, ADRs

PEG-­‐IFN+RBV  

PEG-­‐IFN+RBV    +    

Prot.  Inhib.  

Safe  &  Effec*ve  

Adverse  Drug    Reac*on  

70-­‐86%  SVR  

80-­‐90%  SVR  

IL28B    C/C  

Safe  &  Effec*ve  

Adverse  Drug  Reac*on  

+  $20-­‐40k  

No  Effect  

Safe  &  Effec*ve  

25-­‐40%  SVR  

60-­‐75%  SVR  

No  Effect  

Safe  &  Effec*ve  

No  Effect  

Adverse  Drug    Reac*on  

No  Effect  

Adverse  Drug  Reac*on  

IL28B    T/T  

2. Triple therapy significantly

improves SVR in IL28B T/T patients with  $$,  ADRs  

The  opportunity:      Build  the  Dataset  in  Canada  

Ac<ve  Surveillance  with  CPNDS  across  

Canada  

Chronic  Hepa**s  C  treatment  goal:    Biomarker  and  Stepwise  Approach  

PegIFN  +  RBV  

Pa<ents  with  predictors    

of  good  response:  

 IL  28  C/C  

 IFN  4  

 Clinical  factors  

 

Pa<ents  at  higher  risk  to  develop  toxicity  to  DAA  

PegIFN  +  RBV  +  DAA  

Pa<ents  with  NO  predictors  of  good  response  

 

Pa<ents  without    an  increased  risk  to  develop  toxicity  to  DAA  

 

Pa<ents  with  failure  or  relapse    to  PegIFN/RBV  

DAA  combina<on  (IFN  Free)  

Future  treatment???  

 

Pa<ents  at  higher  risk  to  develop  toxicity  to  Peg-­‐RBV  

SVR  

Op<mizing  Cost:    Each  Pa<ents  receives  the  appropriate  medica<on  

Op<mizing  Safety:    Clearly  iden<fied  risk-­‐benefit  profile  for  each  drug  

HCV  Treatment  Algorithm  

Patient with HCV genotype 1 No previous HCV treatment

Genetic testing for IL28B/IFNL4 gene

region variants

ITPA genetic testing for RBV-induced anemia

risk

Treat with dual therapy: PegIFN/RBV

Treat with dual therapy + early erythropoietin

+ enhanced monitoring for anemia

ITPA genetic testing for RBV-induced

anemia risk

Treat with triple therapy:

PegIFN/RBV + telaprevir or boceprevir

Treat with triple therapy + Reduce RBV dose by 50%

(to 600mg/day) + enhanced monitoring for

anemia

Predicted good responder to dual therapy

Predicted poor responder to dual therapy

Low Risk Low Risk

Low Risk Low Risk High Risk High Risk

Hepa<<s  C  Treatment  

•   The  right  treatment  for  every  pa<ent,  avoiding  unnecessary  risk  and  providing  the  best  possible  care.  

•   Op<mize  healthcare  expenses  for  Hepa<<s  C  treatment  

This  is  Beau<ful,  Bri<sh  Columbia    

•   BC  has  the  BEST  health  data  in  North  America  •   Rich  informa<on  on  collec<ve  health  experiences  •   Can  help  us  find  solu<ons  to  health  and  health  system  problems  

•   Not  just  about  research,  but  USE  of  findings  to  increase  system  efficiencies  and  improve  care  of  pa<ents  

•   Preserve  health  benefits  for  Bri<sh  Columbians  in  the  next  and  future  genera<ons