Transcript - Society for Heart Attack Prevention and Eradication

Framing the Public Policy Debate
on Screening for CVD:
Forming a Foundation
with Clinical & Cost Effective-Based Medicine
Leslee J. Shaw
Associate Professor
Director, Outcomes Research
Cardiovascular Research Institute
Presenter Disclosure Information
Disclosure Information...
The following relationships exist related to this presentation:
Leslee J. Shaw, PhD
No relationships to disclose
U.S. Preventive Services Task Force:
Screening for CHD
(Release Date: February 2004)



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Recommendation: TF recommends against routine screening with rest or Ex
ECG, or EBT for detection of severe coronary stenosis or predicting CHD
events in low risk asymptomatic adults.
Rationale: TF found insufficient evidence for or against routine screening.
…Absence of evidence that detection improves outcomes, TF concluded that
potential harms exceed benefits.
…evidence is inadequate to determine how testing changes treatment!
• False + tests are common among asymptomatic adults, especially women,
& lead to unnecessary diagnostic testing, over-treatment, and labeling.
• False + results, cause psychological distress & anxiety, often lead to
invasive tests, such as angio or treatment with unnecessary meds.
• Test sensitivity is limited, screening could result in False - results. False results can mislead those with CHD and result in delayed rx.
Source: http://www.ahrq.gov/clinic/uspstf/uspsacad.htm, Access date: March 2, 2004.
Common arguments have been employed for all screening tests: false -/+
costs, anxiety, labeling, …
What is the real potential
value to society for CVD
screening?
Source: Belch JJF, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management. Arch Int Med
2003;163:884-892.
Technology Hierarchy
Current State of Health Care System

~50% of health care costs
are for end-stage or hospital
care.
• Avg yrly health expenditure
for end stage care is ~4.6 fold
higher than non-end stage
care.

Shifting care to OP sector
reduces cost.
• Although prescription drug
costs are rising, only 3.3% of
change is due to increased
utilization.
$412 Billion
Medicare pays 31%
Hospital
$286 Billion
Medicare pays 21%
MD / Clinical Services
$122 Billion
Medicare pays 2%
Drug
$92 Billion
Medicare pays 10%
Nursing Home
$60 Billion
Medicare pays 0%
Dental
$39 Billion
Medicare pays 12%
Other Professionals
$37 Billion
Medicare pays 0%
Other Personal Health
$32 Billion
Medicare pays 29%
Home Health
$31 Billion
Medicare pays 4%
Other Nondurables
Medicare Spending
Other Payers
$19 Billion
Medicare pays 25%
Medical Durables
0
50
100
150
200
250
300
350
400
Personal Health Spending (Billions of Dollars)
Source: CMS, Office of the Actuary, National Health Statistics Group.
Access date: March 2, 2004.
CV Imaging Costs
Cost Effective Screening

Cost effective screening may be
defined as …
 Cost
 Life Years Saved
Decreased
Cost
Increased
Cost
Decreased Effectiveness
Improved Effectiveness
Need to determine whether
cost savings are worth
decreased effectiveness
Cost effective
Not cost effective
Need to determine whether
increased effectiveness worth
increased cost
Ankle Brachial Index
$61
Ex ECG
$67
Carotid Ultrasound
$71
EBT / CT Coronary Ca
$87
Rest Echo
$91
Other CT
$283
SPECT
$296
MR
$873
IVUS
$712
PET
$1,272
Rt / Lt Heart Cath
$1,810
Comparative Costs
Cholesterol panel
$13
CRP
$13
Outpatient Office Visit
$39
Advanced lipid analysis
$247
Source: Mark DB, Shaw LJ, Lauer MS, O’Malley P, Heidenreich P. 34th Bethesda Conference: Task force #5 – Is atherosclerotic
imaging cost effective? J Am Coll Cardiol 2003;41:1906-17., Shaw LJ, Raggi P, Berman DS et al. Cost effectiveness of screening for
CVD with measures of coronary calcium. Prog Cardiov Dis 2003;46:171-84.
Shifting the Paradigm to Screening

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Early detection leads to:
• …improved life expectancy.
• …less costly, less invasive care, less hospitalizations with shorter lengths
of stay
• …improved societal productivity
Cost – Benefit Ratio is:
DM
• Does a more productive,
asymptomatic individual
Stroke
reduce costs of care in
relation to symptomatic
IHD
presentation?
• Despite improvements in
0
0.5
1
1.5
CVD mortality, is there still
a detection gap?
Gains in Life Expectancy After Eliminating Condition
2
Source: Pasternak RC, Abrams J, Greenland P, Smaha LA, Wilson PW, Houston-Miller N. 34th Bethesda Conference: Task force
#1--Identification of coronary heart disease risk: is there a detection gap? J Am Coll Cardiol 2003 Jun 4; 41(11): 1863-74.
High Risk Cost Effectiveness

Selecting higher risk cohorts results in a
more effective test.
• Risk reduction w/ Rx is greater in
higher risk populations.
 Clinical effectiveness drives cost
effectiveness
• Focus on Intermediate Risk
Individuals
Improved Resource Allocation
• Requires Selective Screening with
optimal clinical effectiveness (i.e.,
added value)
 Accurate detection of high risk
 Exclusion of treatment in low
risk
• Low cost test that can be widely
utilized
12.0
Delta Disability-Adjusted Life Years

2.0% / yr risk
10.0
8.0
1.0% / yr risk
6.0
4.0
2.0
<0.6% / yr risk
0.0
$-
$100,000 $200,000 $300,000 $400,000 $500,000 $600,000
Cost Effectiveness Analysis
Source: Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium combined with Framingham score for risk prediction in
asymptomatic individuals. JAMA 2004;291:210-215., Budoff MJ, Blumenthal RS, Carr JJ, et al. Assessment of Coronary Artery
Calcification by Electron Beam and Multidetector Computed Tomography. Circulation 2004. Shaw LJ, Raggi P, Schisterman E, et al.
Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiol 2003;228:826-33.,