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HMSP:CUTEheart Comparative Use of TEchnologies for coronary heart disease

5os Seminários de Investigação em Serviços de Saúde Altamiro Costa-Pereira Sharon-Lise Normand José Pereira-Miguel Faculdade de Medicina Universidade do Porto

June 14th, 2013

Harvard Medical School

Faculdade de Medicina

Universidade de Lisboa


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

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

Massachusetts

Portugal

6.374.700

10.617.575

14

18

White

80

-

Black

6

-

Hispanic

7

-

Other

6

-

Male

52

49

Female

48

51

Male

78

75,5

Female

83

82,3

Male

213,4

252,8

Female

137,0

123,2

Total population % 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) - DRG grouped Inpatient discharge database

US Center for Health Information and Analysis - Inpatient hospital discharge database

Portuguese Society of Caridiology - Portuguese National Registry for Interventional Cardiology (only some hospitals)

Massachusetts Data Analise Center (Mass-DAC) - Percutaneous Coronary Intervention study - Cardiac Surgery Project

Annual reports of the Health Ministry

Center for Health Information and Analysis - Massachusetts All-Payer Claims Database 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.xx (excl. 410.x2)

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 codes

Coronary artery disease

414

PCI

Angioplasty

36.01-36.07, 00.66

Unstable angina

411

Bare metal stent

36.06

Acute myocardial infarction

410.xx (excl. 410.x2)

Drug eluting stent

36.07

Brachytherapy

92.27

Off-pump CABG

36.10-36.19, 39.61 & ~(39.61)

ICD-9-CM - International Classification of Diseases, 9th Revision, Cinical Modification

CABG

PCI - percutaneous coronary intervention CABG - coronary artery bypass graft 36.10-36.19, 39.61 & On-pump CABG

39.61


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 Comparative Use of TEchnologies for coronary heart disease


Preliminary Results – Primary Diagnosis of CHD

Portugal

USA Primary Diagnosis of CHD 60

60

50 Percentage

50 30 20 10

30

Co di

20

2010

2010

2009

2008

2007

2006

2005

2004

2003

2010

2009

2008

2006

2005

2007

e

010

007

006

005

004

003

002

001

AMI/410.xx no 410.x2

50 PCI-CAGB Discharges/ Discharges with Primary

008

2009

2008

2007

2006

2005

0

000

Unstable angina/411.xx

60no 410.x2 AMI/410.xx

Fiscal Year

Year

PCI-CAGB Discharges/ Discharges with Coronary artery Diagnosis for CHD Fiscal Year disease/414.xx

2004

AMI/410.xx no 410.x2

20

Unstable angina/411.xx Fiscal Coronary artery disease/414.xx

2003

2000

30

2002

40

2001

30 Unstable 20 angina/411.xx 10 Coronary artery disease/414.xx 0

2002

Percentage

2001

2000

2010.0

2009.0

2008.0

2006.0

50

AM

0

Fiscal Year

50 2003 Percentage 2004

Un an

Primary Diagnosis of CHD 40

60

2002

2005.0

2004.0

2003.0

2002.0

2001.0

2000.0

Primary Diagnosis of CHD60

2007.0

0

10

40

10 of CHD Primary Diagnosis

009

Percentage

40

2001

2000

HMSP:CUTEheart


Percen

60 50 Percentage

HMSP:CUTEheart

40

30 20 10

Preliminary Results 20– Revascularization 0procedures and CHD discharges 30

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

10

Fiscal Year

0

Portugal2000 2001

USA

associated with PCI or CAGB 2002 2003 2004 2005 2006 2007 2008 Discharges 2009 2010

Fiscal Year

Revacularization discharges and CHD discharges 50,000 Revacularization discharges 40,000 and CHD discharges 30,000

2002.0

50,000 40,000

30,000 2004.020,000 2006.0

2008.0

Number of discharges

30,000.00 25,000.00 20,000.00 15,000.00 10,000.00 5,000.00 0.00 2000.0

Number of discharges

Number of discharges

Discharges associated with PCI or CAGB

20,000 10,000 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009 Fiscal Year

Fiscal Year10,000

-

PCI or CAGB 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009

All Primary CHD discharges

Fiscal Year PCI or CAGB

All Primary CHD discharges

3|Page


HMSP:CUTEheart

Preliminary Results – Treatment patterns over time

Portugal

USA patterns over time Treatment patterns over Treatment time 100.00

100.00 100 90

80.00

80.00 70.00

60

60.00

Percentage

70 50 40

70.00 Percentage

80 Percentage

90.00

90.00

50.00

60.00 50.00 40.00

40.00

30.00

20

30.00

20.00

10

20.00

10.00

30

0 2000.0

2002.0

10.00 2006.0 0.00 Fiscal Year

2004.0

0.00

2008.0

2010.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2008 2010 Fiscal Year

2000 2001 2002 2003 2004 2005 2006 2007 2008 2008 2010 Fiscal Year

All PCI/All CHD

All CAGB/All CHD

DES/All PCI

BMS/All PCI

All PCI/All CHD

On Pump CAGB/All CAGB All CAGB/All CHD

DES/All PCI

BMS/All PCI

On Pump CAGB/All CAGB

Off Pump CAGB/All CAGB

Off Pump CAGB/All CAGB


5os seminários de investigação em serviços de saúde