An Alternative to Overuse How evidence-based decision making can impact outcomes in stable coronary artery disease.

Transcription

1 An Alternative to Overuse How evidence-based decision making can impact outcomes in stable coronary artery disease. Optum

2 The numbers speak for themselves: The United States spends one and a half times more per capita on an adjusted basis on health care than any other developed country yet these costs do not necessarily translate into improved health outcomes.1 Today s health care stakeholders are charged with lowering these costs while improving quality and managing the growth of chronic conditions. Part of managing costs involves reducing overuse, which thrives in a complex, fragmented and rapidly changing health care system. The treatment of coronary artery disease serves as an example of both the need to reduce waste and the existence of effective treatment alternatives. The most common type of heart disease, coronary artery disease, costs the United States $108.9 billion a year when health care services, medications and lost productivity are factored in, according to the American Heart Association. 2 Providers manage coronary artery disease through a combination of medications, procedures, surgeries and recommended lifestyle changes. Among the interventions available for this condition is percutaneous coronary intervention (PCI), which involves opening a blocked vessel in the heart. Over the past two decades, PCI has become a common first-line procedure for Americans suffering from coronary artery disease. 3 However, the procedure is overused, performed 600,000 times a year in the United States with a collective price tag of more than $12 billion, according to estimates published in the Journal of the American Medical Association (JAMA). 4 Decision support that encourages appropriate alternatives can reduce overuse. The Existence of Alternatives PCI is potentially life saving for individuals who present with a heart attack or unstable angina (a condition in which the heart doesn t get enough blood flow and oxygen). In these high-risk situations, PCI is the appropriate treatment. However, for lower-risk individuals, such as those with chronic stable angina (or chest discomfort due to chronic poor blood flow through the blood vessels in the heart), PCI may not be appropriate. In the case of these individuals, the goals of treatment are to prevent heart attacks and death, and control symptoms that could limit typical daily activities. 5 According to the American College of Cardiology and American Heart Association Task Force s evidence-based guidelines, most individuals with chronic stable angina can reduce their risk for cardiac events through optimal medical therapy (OMT). This includes a combination of lifestyle modification (e.g., smoking cessation, blood pressure control, weight management, control of other coexisting conditions) and medication management. Symptoms can generally be controlled with medications such as betablockers, calcium channel blockers, nitroglycerin and long-acting nitrates. 6 For these low-risk individuals, PCI does not improve mortality when employed as part of the initial management strategy. The 2007 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, published in the New England Journal of Medicine, compared OMT to OMT combined with PCI. The study involved 2,287 patients screened in the United States and Canada. The group of participants that had the combined treatment did not see statistically significant differences in the rate of death or heart attack over 4.6 years 7. Although one-third of the OMT-only patients required PCI for control of angina symptoms, the study demonstrated that in the long run, PCI is not needed in two-thirds of these low-risk individuals. For these low-risk individuals, PCI does not improve mortality when employed as part of the initial management strategy. Optum Page 2

3 A meta-analysis published in the February 2012 issue of the Archives of Internal Medicine re-examined comparative outcomes in stable coronary artery disease, with consideration for improvements in PCI and OMT. Researchers found that not only is there still no greater health benefits if PCI is used as a first-line procedure with OMT as compared to OMT alone, but improvements to OMT medications and recommendations have actually increased the number of individuals who are angina-free and now elicit improvements for those individuals in the short term as well. Perhaps most important, 70 percent of individuals initially treated with OMT remained on OMT alone and did not require further revascularization procedures (see tables 1 and 2). 8 Table 1. Outcomes at 4.6 Years, 2012 Meta-Analysis Invasive Procedure (PCI) plus OMT w/ Dual Anti-platelet Rx Noninvasive Medical Management (OMT) Number of intial procedures Subsequent PCI or coronary artery bypass graft procedures Total number procedures Death from any cause and nonfatal heart attack 19% 18.5% Hospitalization for acute coronary syndrome 12.4% 11.8% Source: Boden WE, O Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356: Table 2. Outcomes at 4.3 Years Initial PCI Initial OMT Number of intial procedures Subsequent unplanned revascularization (per 100 patients) Total revascularization procedures Persistent angina 29% 33% Death from any cause 8.9% 9.1% Non-fatal heart attack 8.9% 8.1% Source: Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: Meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172: Optum Page 3

4 Overuse of PCI Despite evidence that it may not be appropriate, PCI continues to be used when it may not be the best therapeutic option. In fact, in cases of chronic stable coronary artery disease, PCI is frequently an unnecessary and potentially problematic procedure. A 2011 study published in JAMA examined data for 500,000 PCIs from the National Cardiovascular Data Registry. 9 Among the 30 percent of PCIs that were performed in a non-acute setting for stable coronary artery disease, 50 percent of them could be classified as appropriate. But another 38 percent were categorized as uncertain, meaning there was insufficient clinical evidence to determine whether the procedure was appropriate. Perhaps more startling, the remaining 12 percent of PCIs in non-acute situations were classified as inappropriate. The overwhelming majority of these individuals had few or no symptoms, were not undergoing OMT and had low-risk findings on noninvasive tests, according to the study. 10,11 Inconsistent Counseling The overuse of procedures such as PCI before the alternate consideration of other proven therapy is a major contributor to excessive health care spending. To curb costs, individuals with coronary artery disease and their providers must select more noninvasive treatment alternatives when appropriate. Unfortunately, a lack of health literacy as well as inconsistent counseling from physicians stand in the way of the selection of treatment alternatives. When faced with a health care decision that offers at least one alternative choice that could potentially result in improved health results over time, individuals make a less-than-optimal selection 46 percent of the time, according to an analysis of UnitedHealthcare s 2010 book of business claims data. As the number of treatment options grows, it is more important than ever for individuals to discuss available treatments and considerations with their providers. A survey published in the Journal of Medical Ethics indicates that of 8,000 patients admitted to a hospital internal medicine service, nearly all of those individuals wanted to discuss treatment options with their physicians. Yet, at the same time, two-thirds of the individuals preferred that their physician make the ultimate choice about their care. 12 Other studies have shown that when there is shared decision-making between the physician and patients, patients are better equipped to make choices that are focused on their preferences and clinical needs. Of course, this requires the care provider to convey objective and trusted health information, supported by evidence-based medicine. 13 The overuse of procedures such as PCI before the alternate consideration of other proven therapy is a major contributor to excessive health care spending. Optum Page 4

5 The Need For Decision Support Treatment decision support programs can help your employees become an active part of the care equation and provide a foundation for informed decisions that are rooted in both quality and cost. Decision support targets conditions that share four criteria: 1. Highly prevalent 2. Costly drivers of health care expenses 3. Conditions where there is documented, widespread variation in treatment 4. Conditions where past outcomes have been suboptimal These conditions coronary artery disease, back pain, and prostate cancer, to name a few typically require preference-sensitive care, or treatments that involve significant trade-offs that could impact a patient s quality or length of life. Individuals facing these conditions often must make a decision from at least two valid treatment options yet it may be unclear which one is ideal. The decision may come down to individual preferences and values. Decision support can empower your employees to answer certain questions about their treatment options on their own. Such programs provide evidence-based information about the diagnosis, common treatment options and alternative solutions; explain considerations unique to the individual; and prepare employees to choose the best provider and health care facility for treatment or specialty care. A More Informed, Less Costly Process For individuals with coronary artery disease, PCI remains a potentially life-saving procedure. It is particularly effective in situations where it is proven to boost the odds of survival and alleviate symptoms that OMT can t adequately manage. Yet for low-risk individuals, alternative treatments could help improve health outcomes and reduce unnecessary costs and resource allocation. This is likely true of other chronic conditions. By adding decision support to the treatment process, you can deliver value to your employees and combat overuse of inappropriate treatments or providers. This, in turn, can reduce health care costs and encourage more appropriate resource consumption. Optum Page 5

6 References: 1. Organization for Economic Cooperation health data Centers for Disease Control and Prevention. Heart Disease Facts Boden WE, O Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356: Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. JAMA 2011; 306: Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP- ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with chronic stable angina). J Am Coll Cardiol 2001;38: Ibid. 7. Boden WE, O Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356: Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: Meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172: Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. JAMA 2011; 306: Ibid. 11. Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA. Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention. JAMA 2011; 305: Chung GS, Lawrence RE, Curlin FA, Arora V, Meltzer DO. Predictors of hospitalised patients preferences for physician-directed medical decision-making. J Med Ethics 2012; 38: Shannon Brownlee, John E. Wennberg, Michael J. Barry, et al. Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Project Report Highlighting Minnesota. A Report of the Dartmouth Atlas Project; Technology Drive, Eden Prairie, MN All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer Optum, Inc. All Rights Reserved