HMSP:CUTEheart Comparative Use of TEchnologies for coronary heart disease
Altamiro Costa-Pereira Sharon-Lise Normand JosĂŠ Pereira-Miguel Faculdade de Medicina Universidade do Porto
Harvard Medical School
Faculdade de Medicina
Universidade de Lisboa
HMS – Portugal Program, Annual Retreat, 07-09 December,Lisbon
HMSP:CUTEheart
Motivation - Process of adoption of new health technologies 1
Different health systems have different abilities to adopt new health technologies, depending on: •
Gross domestic product
•
State-based vs. private-based health systems
•
Scientific and professional development level
•
Population epidemiologic profile
HMSP:CUTEheart
Motivation - Process of adoption of new health technologies 2
Different health systems have different abilities to adopt new health technologies: Regardless of the health system , whenever a new technology is determined to be cost-effective compared to previous available care, there may be significant individual and societal benefits to its adoption and access: •
Lives may be saved
•
Disability may be reduced
•
Economic savings can be invested elsewhere
HMSP:CUTEheart
Motivation - Process of adoption of new health technologies 3
Different health systems have different abilities to adopt new health technologies: Regardless of the health system , whenever a new technology is determined to be cost-effective compared to previous available care, there may be significant individual and societal benefits to its adoption and access: The accurate determination of whether technologies are both clinically effective and costeffective is thus of critical importance, and may differ significantly across health systems. •
Disease epidemiology
•
Institutional resources
•
Specialized professional training
•
Clear political planning surveillance and evaluation instruments
HMSP:CUTEheart
Motivation - Process of adoption of new health technologies 4
Different health systems have different abilities to adopt new health technologies: Regardless of the health system , whenever a new technology is determined to be cost-effective compared to previous available care, there may be significant individual and societal benefits to its adoption and access: The accurate determination of whether technologies are both clinically effective and costeffective is thus of critical importance, and may differ significantly across health systems. Despite the increasing rates of scientific and technological development, clear guidelines are currently lacking. These inefficiencies likely have a negative impact on the ability of physicians and health systems to deliver high quality cost-effective care.
HMSP:CUTEheart
Specific Motivation – Health technologies for coronary heart diseases
Why evaluate CHD interventions? •
CHD is highly prevalent in western countries, accounts for a disproportionate share of disease-related morbidity, mortality and cost
•
CHD imparts a high economic burden on health systems
•
There may be heterogeneity across health systems
•
Need for better and detailed studies of comparative effectiveness with focus on CHD
HMSP:CUTEheart
Goal and Aims Overall goal: To compare the use of health technologies between the health systems of
the United States (US) and Portugal, with focus on the treatment of coronary heart disease (CHD)
• Aim 1: To compare the diffusion rates of new technologies for treating CHD, and identify patient, hospital, and environmental determinants of use between the US and Portugal.
• Aim 2: To assess the impact of health technology diffusion on clinical outcomes in high risk patient cohorts.
• Aim 3: To compare clinical effectiveness of the use of procedures to treat CHD as a function of patient, hospital, and health system characteristics.
• Aim 4: To compare cost effectiveness of treating CHD in the US and Portugal. • Aim 5: To develop a framework for designing and implementing health services research between two health care systems.
HMSP:CUTEheart
Expected Impacts
Aim
Impact in Healthcare
Aims Retrospectively assess the 1 to 4 impact of specific health technologies, based on demographic and other external environmental variables.
Simulate the impact of different options regarding the use of different health technologies.
Impact in Policy
Impact in Research
Develop a framework for comparative examination of technology adoption among different health systems.
Characterization of main drivers of difference between the two healthcare systems, i.e., important parameters regarding effectiveness will be evaluated.
Better political decision-making as to the development of integrated IHD policies, such as organizational and clinical standards and guidelines or bestpractices.
Establishment of the basis for a comparative effectiveness assessment program between Portuguese and US researchers.
Defining recommendations for technology adoption policy, monitoring, and evaluation.
Aim 5 To develop a framework for designing and implementing health services research between two health care systems
HMSP:CUTEheart
Team Members – Faculty of Medicine, University of Porto (FMUP) Name
Background
Role
Costa Pereira A, PhD, MD
Health Service Research
PI (Porto team and overall project)
Teixeira-Pinto A, PhD (Sydney) Biostatistics
Consultant
Freitas A, PhD
Computer Sciences
Consultant
Rocha-Gonçalves F, PhD, MD
Health Economy
Consultant
Azevedo LF, MD
Health Services Research
Health researcher
Almeida F, MD
Cardiology
PhD student
Melica B, MD
Cardiology
PhD student
Soares AJ, PhD
Health Psychology
Researcher
Lobo M, MSc
Applied Mathematics
Data management, Data analysis
Open position: post-doc fellow, Research fellow (MSc)
HMSP:CUTEheart
Team Members – Harvard Medical School (HMS)
Name
Background
Role
Normand S-L, PhD
Biostatistics
PI (Harvard team)
Resnic F PhD, MD
Interventional Cardiologist
Consultant
HMSP:CUTEheart
Team Members – Faculty of Medicine, University of Lisbon (FMUL)
Name
Background
Role
Pereira Miguel J, PhD, MD
Public Health
PI (Lisbon team)
Rocha E A PhD, MD
Cardiology
Consultant
Pereirinha A, PhD, MD
Cardiology
Consultant
Open position: post-doc fellow
HMSP:CUTEheart
Research Collaboration
Why a collaborative effort? •
At broad level, the study of health technology utilization, cost-effectiveness of different treatment modalities, and their impact on clinical outcomes across geographically, culturally, medically and economically distinct communities requires local expertise at each site. Framing appropriate hypothesis and analyses requires a deep knowledge of underlying local disease epidemiology and the determinants of how clinical decisions are made.
•
At a practical level, international comparative research demands researchers who are familiar with clinical practice, with data coding practice, and with the limitations of local databases.
•
Share and combine different expertise.
HMSP:CUTEheart
Research Collaboration Responsibilities FMUL Aims 1 to 4
HMS
FMUP
Study coordination Overseeing the statistical aspects of the study Managing the US and Portuguese datasets Development of statistical methods (diffusion Health economics, etc) Clinical expertise Epidemiological study design
Aim 5
Type of research Basic Database management Development of statistical model and research: • Diffusion models • Propensity scores • Cost effectiveness evaluation strategy
Translational Establishing a more rigorous approach to outcomes measurements Establish the impact of Health Technology diffusion on clinical outcomes in cardiovascular patients Define the cost-effectiveness of expense health technology in real life cardiovascular patients Also address to one of the main sources of expense in healthcare
To develop a framework for designing and implementing health services research between two health care systems
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts Geographic site
California
Massachusetts
Portugal
Total population
36.408.700
6.374.700
10.617.575
11
14
18
White
43
80
-
Black
6
6
-
Hispanic
37
7
-
Other
14
6
-
Male
50
52
49
Female
50
48
51
Male
78,5
78
75,5
Female
83,4
83
82,3
Male
239,4
213,4
252,8
Female
155,9
137,0
123,2
% Aged >65 Race (%)
Sex (%)
Life Expectancy (years)
No. Heart disease deaths/100.000
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
•
Data sources
Data type Inpatient discharge data Hospital characteristics
Cost information
Portugal Administração Central do Sistema de Saúde (ACSS)
US Healthcare Quality and Research
Annual reports of the Health Ministry
American Hospital Association files
Official Diagnostic Related Group (DRG) tables Infarmed’s prices, prescription database for drugs, hospitals published reports on their analytical accounting for specific items, government for reimbursement for costs on exams.
State inpatient data sets
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
•
Data sources Patient demographic data Patie nt identi ficati on
Hospi tal admi ssion data
Hospi tal outco mes
Patient identification
Portuguese data
US data
(partial)
Race code
Non-existent
Birth date
Patient’s age
Zip code of the patient’s residence
Admission date
Diagnosis determined to be responsible for the admission
Non-existent
Secondary procedures which carry operative or other risk
Hospital where the patient was transferred from
Discharged disposition
Days in ICU
Days in Hospital
Sex
Procedure performed for definitive treatment
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
• •
Data sources Cohorts inclusion criteria: Diagnosis and Procedures Diagnosis
ICD-9-CM code
Coronary artery disease
414
Unstable angina
411
Acute myocardial infarction
410
ICD-9-CM - International Classification of Diseases, 9th Revision, Cinical Modification
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
• •
Data sources Cohorts inclusion criteria: Diagnosis and Procedures Diagnosis
ICD-9-CM code
In-patient technology
ICD-9-CM and CPT codes
Coronary artery disease
414
PCI
Unstable angina
411
ICD-9-CM: 36.01-36.07, 00.66 CPT: 92980-92984
Acute myocardial infarction
410
ICD-9-CM - International Classification of Diseases, 9th Revision, Cinical Modification
Bare metal stent
ICD-9-CM: 36.06
Drug eluting stent
ICD-9-CM: 36.07 CPT: 92980
Brachytherapy
ICD-9-CM: 92.27 CPT: 77781-77784
CPT - Current procedural terminolofy
CABG
ICD-9-CM: 36.10-36.19, 39.61
PCI - percutaneous coronary intervention On-pump CABG ICD-9-CM: 39.61 CABG - coronary artery bypass graft
HMSP:CUTEheart
Study cohorts, Data sources and Clinical outcomes •
Geographical areas: – Initially proposed areas: Portugal, Massachusetts and California – Actual funded areas: Portugal, Massachusetts
• • •
Data sources Cohorts inclusion criteria: Diagnosis and Procedures Clinical outcomes: – – – – –
All cause in-hospital mortality Number of days hospitalized for the index event Repeat revascularization In-hospital complications (e.g., bleeding, infection, renal failure) Readmission to the hospital within one year
HMSP:CUTEheart
Preliminary Results - Summary table
Portuguese inpatient discharge episodes (2000-2010)
Procedure
PCI
Primary or secondary diagnosis of CHD
All other primary or secondary diagnosis
N=543 446
N=10 042 672
n
‰
n
‰
Other PCI technologies
80 960
149,0
2 428
0,2
Bare Metal Stent
51 757
95,2
1 835
0,2
Drug-eluting Stent
15 522
28,6
261
0,0
27
0,0
6 150
0,6
6 933
12,8
30
0,0
20 044
36,9
100
0,0
431 819
794,6
10 010 290
996,8
Brachytherapy CA off-pump CABG BG on-pump CABG No treatment
N - Number of episodes within a diagnostic group of patients n - Number of episodes within a diagnostic group of patients for a specific procedure CHD - Coronary heart disease
PCI - percutaneous coronary intervention CABG - coronary artery bypass graft No treatment - absence of procedures of type PCI and CABG
HMSP:CUTEheart
Preliminary Results - Episode yearly frequencies
Portuguese inpatient discharge episodes having a primary or secondary coronary heart disease diagnosis 70000 60000 50000 No treatment Brachytherapy on-pump coronary artery bypass graft off-pump coronary artery bypass graft Drug-eluting stent Bare metal stent Other percutaneous coronary interventions
40000 30000 20000 10000
Year
.0 10 20
.0 09 20
.0 08 20
.0 07 20
.0 06 20
.0 20
05
.0 04 20
.0 03 20
.0 02 20
.0 01 20
00
.0
0 20
No of episodes
HMSP:CUTEheart
Preliminary Results - Episode yearly frequencies
Portuguese inpatient discharge episodes having a primary or secondary coronary heart disease diagnosis 25000
20000
15000
10000
5000
Year
.0 10 20
.0 09 20
.0 08 20
.0 07 20
.0 06 20
.0 20
05
.0 04 20
.0 03 20
.0 02 20
.0 01 20
00
.0
0 20
No of Episodes
on-pump coronary artery bypass graft off-pump coronary artery bypass graft Drug-eluting stent Bare metal stent Other percutaneous coronary interventions
HMSP:CUTEheart
Preliminary Results - Episode yearly frequencies per geographic site
Portuguese inpatient discharge episodes having a primary or secondary coronary heart disease diagnosis Bare metal stent per geographic site
Drug-eluting stent per geographic site
4000 3500 3000
North Center Lisbon Alentejo Algarve
North Center Lisbon Alentejo Algarve
2500 No of episodes 2000 1500 1000 500 0 2000.02002.02004.02006.02008.02010.0 Year
Year
HMSP:CUTEheart
Preliminary Results - Episode yearly frequencies per hospital group
Portuguese inpatient discharge episodes having a primary or secondary coronary heart disease diagnosis Bare metal stent per hospital economical group
Drug-eluting stent per hospital economical group
4000
1600
3500
1400
3000
1200 Group I Group II Group III Group IV
2500 No of episode 2000
No of episode
800
1500
600
1000
400
500
200
0 2000.0
2002.0 Year
2004.0
2006.0
Grupo I Grupo II Grupo III Group IV
1000
0 2000.0
2002.0 Year
2004.0
2006.0
HMSP:CUTEheart