Transcript A Canadian View on Effective Use of VADs

Value Based Care and the Role of INTERMACS in our
Evolving Health Care Environment
A Canadian View on Effective Use of VADS
Anique Ducharme MD, MSc,
Montreal Heart Institute, Montreal (Qc), Canada
AND
LJ Lambert, G Sas, N Dragieva, LJ Boothroyd, M Carrier, R Cecere,
E Charbonneau, MD, C Sanscartier, AMA, JE Morin, MD, P Bogaty, MD
Institut national d’excellence en santé et en services sociaux, (INESSS),
Montréal, Québec, Canada;
Disclosures
• Research grant: St-Jude Medical, Sorin inc.
• Adboard: Pfizer
• Speaker bureau
– Abbot Vascular
– Thoratec
– Pfizer
– Servier
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USA versus Canada
USA
Canada
About Canada
What’s relevant for this audience?
• Land area: 3,855,100 sq mi (2nd largest in the world)
• Population : 35,158,300,
– Smaller than California (38,041,430)
– Quebec (8, 155 300)
• Canadian Health care system = socialized
– Universal access
– HF patients: lost leader
• Hospital admission: $ $ $ $
• No DRG-diagnosis reimbursement
• Devices therapy (ICD-CRT-MCS): more $
– No possibility for the hospital to “Gain Back” some of the lost”
VAD survival (“DT”) compared to
Optimal Medical Therapy (IM 3)
Park SJ. AHA Scientific Sessions, November 2010.
So we had to open up the bank somehow
to offer this therapy to a growing number of patients.
• The publicly funded cardiology evaluation unit
from INESSS conducted a review
of the evidence,
And recommended to the Québec Ministry of
Health that use of long-term left ventricular assist
devices (LVAD) should be carefully monitored but
not limited to bridge-to-transplant patients.
March 2012
A Canadian View on Effective Use
of VADS: First the data
• In 2013, many Canadian centers joined CANAMACS
–Data non available yet
• INESSS:
–Retrospective review of hospital data sources of all
LVAD-implanted patients (3 centers)  2010-12.
–Variables, definitions & time points as INTERMACS
–Major clinical outcomes (death, transplant, recovery)
and adverse events were determined during 1-year
follow up.
Patient characteristics at implant:
Québec vs INTERMACS
Québec
(2010-2012)
N=53
%
INTERMACS*
(2010-2011)
N=3,573
%
≤ 39
13
12
40 - 59
53
41
60 - 79
34
46
80+
0
0.6
77
78†
Mean body mass index, kg/m2
25.7
27.0‡
Mean body surface area, m2
1.9
2.07†
Age group, years
Male
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to September 30, 2013
†Kirklin et al. J Heart Lung Transplant 2012; 31:117-26.
‡Teuteberg et al. JACC Heart Failure 2013;1;5:369-78.
Initial LVAD implant strategy:
Québec vs INTERMACS
60
N=53 Québec (2010-2012)
N=3,573 INTERMACS (2010-2011)*
51
Québec
INTERMACS
50
Percent (%)
40
37
36
30
30
25
20
11
10
8
0.4
0
BTT
BTC
DT
Rescue therapy
0
0.7
Bridge to
recovery
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to Sept 30, 2013
INTERMACS clinical profile at time of LVAD implant:
Quebec vs INTERMACS
60
N=53 Québec (2010-2012)
N=3,573 INTERMACS (2010-2011)*
Québec
INTERMACS
50
43
40 40
Percent (%)
40
30
27
20
15
13
13
10
4
3
0
1
2
3
4
2
0
0
5
6
1
0
7
*Quarterly Statistical Report 2013; 3rd Quarter; Implant and event dates: June 23, 2006 to Sept 30, 2013
Clinical results at 1 year after LVAD implant:
Québec vs INTERMACS
Québec
(2010-2012)
N=53
%
INTERMACS *
(2006-2012)
N=6,609
%
Alive on LVAD support
57
57
Died on LVAD support
17
18
Transplanted after LVAD and alive
19
Transplanted after LVAD and died
6
LVAD explanted / recovery
2
*Quarterly Statistical Report 2012; 4rd Quarter; Implant and event dates: June 23, 2006 to December 31, 2012
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Adverse events during the first year after implant:
Quebec vs INTERMACS
Adverse events
Québec (2010-12) INTERMACS (2006-12)*
N=53 , % RVAD/inotropeN=6,796, %
Device malfunction
13
Bleeding
42
Infection
43
Cardiac arrhythmia
47
Right heart failure
LLE & high CVP post-op (4)
25
17
Neurological dysfunction
excluding delirium:
> 1 week post-op
or 2/4 criteria;
– CVP> 18
– CI < 2.3
– Ascites/edema
–↑ CVP by Echo
14
38
40
TIA or CVA or 26
Seizure or
Encephalopathy 14
or Confusion
28
18,5
16
Renal dysfunction
26
12
Hepatic dysfunction
9
5
Respiratory failure
19
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*Quarterly Statistical Report 2012; 4th Quarter; Implant and event dates: June 23, 2006 to December 31, 2012
Total/average cost of hospital stay for LVAD
implantation according to costing component
(2013 $CAN)
Costing component
Total cost
Average per
patient cost
In-hospital drug cost
$246,618
$5,075
LVAD implantation cost
$300,889
$6,269
Hospital stay cost
$2,557,486
$53,282
LVAD acquisition cost
$5,365,534
$111,782
Total
$ 8,470 527
Excluding:
$ 176 408
160,652.46 USD
physicians fees,
VAD program structure & staff
Devices-related rehospitalization
A Canadian View on Effective Use of VADS
Conclusion
• Our implant rate is very low
– « US benchmark »: 30/100 000 population
– Quebec: 0.67/100 000
• In comparison with INTERMACS patients, Québec LVAD
patients are younger but sicker and less likely to be DT.
• Despite low volumes, clinical results in Québec hospitals
are similar to those reported for INTERMACS.
– More adverse events reported with independent data
abstraction compared to self reporting ?
• The cost of initial VAD implant in Canada is cheap.
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As for DT…
• We owe to our patients not to miss the boat
– Our volumes will increase, but will remain << USA
• Key for a successfull DT program lies in patients
selection.
• Will future policies affect our capacity to offer DT
to the Canadian patients?
– Some costs are not expected to drop (hospital,…)
– The politicians are getter older also…
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USA vs Canada: The Reality ?
USA
Canada