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
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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