Transcript MINIMAL vs OPTIMAL MEDICAL CARE

MINIMAL vs OPTIMAL
MEDICAL CARE
M Mohsen Ibrahim, MD
CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY
EHS Guidelines - 2003
Minimal Versus Optimal Care
• Resources more than science dictate the type of
care that can be provided.
• Guidelines have to make a compromise between
what is possible (minimal care) and what is ideal
(optimal care).
• No Health Care System Has Unlimited Resources
“Where resources are limited it becomes
imperative to direct drug treatment to
individuals in the high and very high risk
before considering their use in the lower risk
patients” (WHO-ISH GUIDELINES)
ASSESSMENT OF HIGH RISK
STATUS
Minimal Care
•Age
•Family History
•Past History of ACVD
•Smoking
•Body Weight
Optimal Care
•
•
•
•
•
•
•
•
•
•
•
•
Age
Family History
Past History of ACVD
Smoking
Body Weight
Blood Sugar
Total Cholesterol /LDL-C
HDL-C
Triglycerides
S Creatinine
ECG
Hs-CRP
EHS Guidelines - 2003
Evaluation of Hypertensive Patients
Minimal Care Optimal Care
Detailed History- Physical Exam.
+++
++
Urine dipstick
+
+
Blood Sugar
+
+
ECG
+
+
Blood tests: urea, creatinine,
+
lipid profile, K+
Optic Fundus
+
+++: strongly recommended. +: recommended. - : not done
+: done if facilities are available.
EHS Guidelines - 2003
Therapy
Duration of blood pressure
monitoring before starting drug
therapy
Life style and diet therapy
Threshold Blood Pressure
Low risk group
Intermediate risk group
High risk group
Drug of first choice
Target Blood Pressure
Low & intermediate risk groups
High risk group
Minimal Care
Weeks to months
Optimal Care
Weeks to months
+++
++
160/100
150/90
140/85
Small dose thiazide
160/100
140/90
135/85
Individualize
< 140/90
< 135/85
< 140/90
< 135/85
Egyptian HTN Physician & Patient Survey*
Ever Stopped Your Antihypertensive Drug Therapy
1940 patients
never stopped
21
stopped
79
Ibrahim - 1998
Egyptian HTN Physician & Patient Survey*
Reasons of Poor Compliance
Doctors Survey
%
80
71
70
56
60
51
50
40
40
30
24
20
8
10
5
0
Cost
Ibrahim - 1998
HTN has no
Symp
Drug Side
Effects
Forgetfulness
Friend's
Advice
No Effect on DR's Advice
BP
METHODS TO REDUCE THE COSTS OF
HYPEERTENSIVE TREATMENT
• Improve Effectiveness of Treatment
- Accurate classification of BP
- Maximize life style change
- Balance benefits vs risks of treatment
- Adherence to treatment regimen
- Control of other CV risk factors
• Reduce Costs
- Start treatment with lower cost medications
- Limit office visits to clear clinical objective
- Limit laboratory test to necessary ones
CHANGES IN MEAN BLOOD PRESSURE OVER TIMEAustralian Therapeutic Trial in Mild Hypertension*
200
150
mmHg
100
50
0
First
12
screenin 2 weeks 4 weeks 4 months 8 months
months
g
16
months
20
months
24
months
32
months
36
months
Line 1
SBP(mmHg)
157.4
154.1
152.3
144.6
144.6
146.4
142.9
144.2
144.6
142.2
144.2
102
98
96.9
92.2
92.2
93.6
91
91.6
91.6
90
90.7
Line 3
DBP(mmHg)
*1119 subjects given placebo and observed for 3 years
Lancet:1980
EGYPTIAN NHP
BLOOD PRESSURE VARIABILITY
HTN Patients
1800
1600
1400
1200
1000
800
600
400
200
0
1559
54.8%
999
855
567
All HTN
Untreat HTN
EHS Guidelines - 2003
Diagnosis of Hypertension
No TOD
TOD / BP > 160/100mmHg
Visit 1
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
>140/90 mmHg
Visit 2
Visit 3
EHS Guidelines - 2003
Risk Categorization
•
Hypertensive patients can be categorized according to their risk profile
(adopted from JNC VI):
• Group A (low risk): no TOD, no other risk factors and no
associated cardiovascular disease.
• Group B (intermediate risk): one or more additional risk factors
but not diabetes or TOD.
• Group C (high risk): diabetes, TOD and/or associated
cardiovascular disease.
EHS Guidelines - 2003
Drug Initiation
Risk
Category
A
B
C
BP Monitoring
BP Threshold
6-12 month
160/100 mmHg
3-6 month
140/90-150/90
mmHg
1-3 month
140/85-135/85
mmHg
IMPROVE COST EFFECTIVENESS
DRUG COSTS TO PREVENT ONE MI, STROKE OR DEATH
(UNCOMPLICATED MILD TO MODERATE HYPERTENSION)
Drug Class Treatment
Middle-aged
Elderly
Diuretic
HCTZ
$4731
$1595
B-Blocker
Atenolol
$105,092
$35,438
ACE-I
Enalapril
$156,520
$52,780
Alphablocker
Calcium
blocker
Doxazosin
$151,188
$50,982
Nifedipine
GITS
$346,236
$116,754
Source: Pearce et al. Am J Hypertens , 1998
Evaluation of Therapeutic
Intervensions
• Clinical Effectiveness
• Safety
• Cost
Comparing a New Therapy and a
Standard Therapy
Clinical Effectiveness
-------------------------------------------------------------Net Cost
New>Std
New=Std
New<Std
----------------------------------------------------------------------------------New>Std
CEA needed
Standard Rx. cost- saving Use Standard Rx
New=Std
New<Std
New Rx. Better
Toss-up
Standard Rx. better
Use New Rx.
New Rx. cost-saving
CEA needed
---------------------------------------------------------------------------------------------------------CEA: Cost-effectiveness analysis
Modified After Mark and Hlatky . 2002
Cost - Effectiveness
Analysis
C/new – C/usual care
CE = -------------------------------HB/new – HB/usual care
----------------------------------------------------------------------CE: cost-effectiveness; C: costs; HB: health benefits
Assessment of Health Benefits
Sensible units :
-mmHg blood pressure change
-No of myocardial infarctions prevented
-Minutes of exercise increased
Number of added life-years (LYs)
Primary therapeutic goal is to prolong life expectancy
Quality- adjusted life-year (QALY)
One year of life in excellent health = 1.0 QALY
COST ASSESSMENT
• Costs of Intervention :
-Drugs
-Lab tests
-Physician
• Costs of Morbidity after an Event :
- Direct costs (health care costs)
- Indirect costs (loss of productivity)
MINIMAL vs OPTIMAL
MEDICAL CARE
M Mohsen Ibrahim, MD
CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY
NUMBERS-NEEDED-TO TREAT TO PREVENT CV
EVENTS OR DEATH IN PATIENTS WITH MILD-TOMODERATE HYPERTENSION
Event
Risk Ratio
5-Year NNT
Treated/Control
Middle-aged
Fatal or nonfatal CHD
Fatal or nonfatal stroke
Nonfatal event or death
0.91
0.56
0.82
390
135
86
0.82
0.65
0.84
70
45
29
Elderly
Fatal or nonfatal CHD
Fatal or nonfatal stroke
Nonfatal event or death
Pearce et al. 1998
COST-EFFECTIVENESS OF
TREATMENT FOR HYPERTENSION
DBP
(mmHg)
>69 YEARS
<45 YEARS
Men
Women
Men
Women
>104
$73,700
$125,000
_
_
100-104
$106,500
$232,500
$500
_
95-99
$130,700
$317,200
$2300
$1200
90-94
$158,600
$419,800
$4200
$3500
Approximate net cost per life-year gained in US dollars
Source: Johannesson M,1995
PREVENTION PRIORITIES
PRIMARY PREVENTION
• Population Approach
2% reduction of mean population BP
(about 3 mmHg in DBP)
Prevent every year by 2020 in Asia Pacific Region :
-1.2 million deaths from stroke ( about 15% of all deaths from
stroke)
-0.6 million deaths from CHD (6% of all deaths from CHD)
Reducing Salt Content of Manufactured Food
PREVENTION PRIORITIES
PRIMARY PREVENTION
•Individual Approach
•Population Approach
Cost-Effectiveness
Therapeutic Modality
Cost-Effectiveness Range
(dollars/year of life saved)
Antihypertensive therapy
$4,000 to 93,0000
Renal dialysis
$20,000 to 79,000
CABG (LM/3VD)
$2,3000 to 27,000
Exercise to prevent CHD
Cost-saving to $38,000
Aspirin to prevent CHD
Cost-saving to $5,000
Smoking cessation to
prevent CHD
Cost-saving to $13,000
Cost-Effectiveness
• <$50.000 per LY is economically
acceptable
• >$100.00 per LY is economically
unacceptable
Cost-Effectiveness in
Hypertension
• Costs of drugs and other medical expenses required to
prevent one MI, stroke or death
• Medications account for 50% to 90% of the direct costs
of hypertension treatment
• NNT: number of patients needed to treat for 5 years to
prevent one event
• Cost-effectiveness of drug therapy = average whole sale
price of drug for 5 years of treatment X (5-y NNT)
Cost-Effectiveness
Cost-Effectiveness
• Event Rate = No of events/P-Yof observation
• Risk Difference = Control – Treatment event
rate
• Cost –Effectiveness of Drug (Cost to Prevent
an Event) = AWP(5y trt) X 5y NNT
-AWP : average whole sale prices
-5y NNT : No of patients treated for 5
years to prevent one event
Cost-Effectiveness
• Cost of QALY gained:
- < $40.000 – highly cost-effective
- = $60.000 – reasonable cost-effective
- > $100.000 – not cost-effective
• If society is willing to pay $60.000 to gain a
QALY treatment should be started if the 5-yearrisk of CHD exceeded
35 y
50 y
70 y
-For men
2.4%
4.6%
10.4%
-For women
2.0%
3.5%
10.4%