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Main Results and Lessons Learned from the CUTEheart project Mariana F Lobo, Claudia Nisa Leonor Bacelar Nicolau, Elisabete Fernandes
Main Results and Lessons Learned from the CUTEheart project
Mariana F Lobo, Claudia Nisa Leonor Bacelar Nicolau, Elisabete Fernandes
To analyze health technology use in hospital managementof coronary heart disease (CHD) focusing on:
Portugal and US health systems
Health technologies diffusion
Clinical effectiveness of CHD treatment
High‐risk patients
Health impact assessment and HTA
MAIN RESEARCH GOALS
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Public (PT) vs. Private (US)100% public health insurance (PT) vs. 29% (US)74% (PT) vs. 25% (US) beds per capita in public hospitals
Strikingly high health expenditure in US10.4 (PT) vs. 17.9 (U.S.) % of GDP
Health technologies approval systemCentralized in US vs. Variable in PT (drug type, # countries)Fewer new drug launches and longer launch delays in PTCentralized in US vs. Decentralized in PT35 months faster in EU than US
All‐cause of death (age‐sex‐adjusted)1041 (PT) vs. 1075 (US) per million population
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HEALTH SYSTEMS COMPARED – 2010Background
16% UNINSURED
$$
HEALTH COSTS
• Except for hypertension, US > CHD risk factors obesity 71.6% (US) vs. 51.3 % (PT)
• US CHD hospitalizations twice PT435.2 (US) vs. 171.0 (PT) crude hospitalizations
• Large infrastructure differences 60% more diagnostic facilities in US4xmore cardio thoracic wards per capita in US
• US > double CHD‐related death rate but no differences in AMI deaths168.3 (US) vs. 72.8 (PT) age‐sex‐adjusted CHD deaths
HEALTH SYSTEMS COMPAREDCHD epidemiology and patient care
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HEALTH TECHNOLOGIES DIFFUSIONMedical devices & Drugs in CHD Treatment
Med
ical Devices
Drugs
Although, most medical devices were approved soonerin PT, at least five devices considered were adopted first or diffused faster in the US
Most drugs were available sooner in the US, despite often approved earlier in PT
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Characteristic Portugal United States(20% Sample)
No. Hospitals 83 3863
No. Discharges 123,442 7.2 million
Mean [SD] Age 68 [13] 68 [14]
Emergently Admitted, % 96 84
IN‐HOSPITAL AMI MANAGEMENTPORTUGAL versus US – 2000‐2010
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AMI HOSPITALIZATIONSPORTUGAL versus US – 2000‐2010
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Adjusted Analyses
• Females less likely to get revascularization interventions, regardless of country
• Females 20%more likely to die than males after AMI in Portugal
• % of hospitals with lowrevascularization‐volume higher in PT
• Dramatic between‐hospital heterogeneity in survival in Portugal
In‐hospital Procedures use and outcomes, PT and US
2010 Rate Ratio: Portugal/U.S.
Diagnostic Catheterization 0.88
PCI 1.09
Stenting 0.94
CABG 0.19
Off‐Pump 0.38
Revascularization 0.99
In‐hospital Mortality 2.14
Length of Stay 50% >
CLINICAL EFFECTIVENESS OF CHD TREATMENTIn‐hospital AMI management PORTUGAL versus US – 2000‐2010
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CLINICAL EFFECTIVENESS OF CHD TREATMENTHospital AMI readmission in Portugal – June 1st to November 30th 2012
Purpose: To characterize acute myocardial infarction (AMI)
readmissions occurred within 30 days post‐discharge in Portugal
To determine the 30‐day readmission rate
for patients with AMI
To identify risk factorsassociated with AMI 30‐day
readmission
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30‐Day Readmission Rate (%)
94.4%
5.6%
In‐patients (n=3696)
Patient Inclusion Criteria
• Adults (age ≥ 18 years)• Patients admitted with AMI diagnosis
• Patients with at least one hospitalization
• All unplanned admissions• First admission until November 30 2012
• Patients alive after their first hospital stay
CLINICAL EFFECTIVENESS OF CHD TREATMENTHospital AMI readmission in Portugal – June 1st to November 30th 2012
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206 (5.6%) patients were readmitted within 30 days
CharacteristicsCrude Odds Ratios
(95% CI)
DemographicsAge ≥ 65 1.3 (0.9 ‐ 1.7)Male 1.1 (0.7 ‐ 1.4)
Comorbidities
Atherosclerosis 3.3 (2.3 ‐ 4.7)
Hypertension 3.0 (2.1 ‐ 4.3)
Diabetes 1.8 (1.4 ‐ 2.4)
Obesity 1.9 (1.4 ‐ 2.7)
In‐Procedures
Cardiac Catheterization 2.5 (1.8 ‐ 3.4)
PCI 0.8 (0.5 ‐ 1.2)
CABG 2.2 (0.6 ‐ 7.5)
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CLINICAL EFFECTIVENESS OF CHD TREATMENTHospital AMI readmission in Portugal – June 1st to November 30th 2012
These factors are associated with a higher likelihood of 30‐day
readmission.
HIGH RISK PATIENTSReview of Systematic Reviews of Randomized Controlled Trials
N=45 Diabetes
N=18 Kidney Disease
N=11 Old Age 70+
N=8 Women
N=5 Mixed comorbidities
N=87 Specific to high‐riskpatients
N=759 Meta‐analyses related to CHD treatment
Aim: To summarize the evidence from randomized controlled trials examining CHD treatment in high risk patients
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0
2
4
6
8
10
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Num
ber o
f reviews pe
r year Revascularization Medical Therapy
REVIEW Included Studies Follow‐up
Mortality MI Repeat revascularization Stroke Potential sources
of biasFavors Favors Favors Favors
Tu et a 2014
FREEDOM, CARDia, VA
CARDS, ARTS I & ARTS II,
ERACI II & III, SYNTAX,
PRECOMBAT
Min 30 days max 5
yearsCABG n.s. CABG Not
reported
ARTS II and ERACI III not RCTs Mixing pre‐specified with
post‐hoc diabetic subgroup analysis
Fanari et al 2014
SYNTAX, FREEDOM, CARDia
Min 1y max 5 y
1y n.s.; 5y CABG
1y n.s.; 5y CABG Not reported DES
Incomplete search; Mixing
pre‐specified with post‐hoc diabetic subgroup analysis
HIGH RISK PATIENTSInconsistencies identified in the evidence about revascularization strategies
CABG versus PCI 13 Meta‐analyses IdentifiedExample of reviews comparing CABG with drug‐eluting stents
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HIGH RISK PATIENTSReassessment of primary trials about revascularization strategies
CABG versus PCI
2 to 3 years 4 to 5 years Longest follow‐up
13 RCTs included (4372 patients)
Only 6 RCTs with pre‐specified subgroup analysis (46%) for diabetics
Results overall favoring CABG at 5 years only;
Identified only in trials with a pre‐specified subgroup comparison;
Meta‐regression model with dummy for pre‐specification (0=post‐hoc; 1=pre‐specified) not significant but funnel plotsuggests that larger studies with lower variance favor CABG.
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assessesproperties, effects, and/or impacts (social, economic, organizational and ethical) of a health intervention or health technology
ofhealth technology (Diagnostic and treatment methods, medical equipment, pharmaceuticals, rehabilitation & prevention methods, but also organisationaland support systems used to deliver healthcare)
to inform a policy decision making
assesseshealth impacts of policies, plans and projects in diverse economic sectors using quantitative, qualitative and participatory techniques
ofpolicies, plans and projects in diverse economic sectors using quantitative, qualitative and participatory techniques, taking equity issues into account (effects on vulnerable or disadvantaged groups)
toproduce recommendations for decision‐makers and stakeholders, to maximize/minimize the proposal's positive/negative health effects
HTA HIA
HEA
LTH TECHNOLO
GY ASSESSM
ENT
HEA
LTH IM
PACT
ASSESSM
ENT
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Health Technology Assessment & Health Impact AssessmentComplementary approaches
Making HIA m
ore qu
antitative
and ad
ding
value
to HTA Screening through policies to select targets
for assessment: focus policies related with cardiovascular disease that linked hospital
and primary care
Propose a conceptual quantitative path of analysis to study the association between a
public policy and health impacts while taking equity into account
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Health Technology Assessment & Health Impact AssessmentComplementary approaches
Clusters of policies maybe ranked by differentcombinationsof priorities
The registration of different health indicatorsis not uniform throughoutthe regions which maylead to regional inequities
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Health Technology Assessment & Health Impact AssessmentComplementary approaches
Thank you for your attention
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LESSONS LEARNED
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FUTURE RESEARCHProof of Concept for a Visualization Platform for Evidence Synthesis
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CLINICAL EFFECTIVENESS OF CHD TREATMENT
• PT> double AMI‐related death rate (hospital administrative data) & no statistically significant differences in AMI deaths (vital statistics). (Factors that may explain the differences)
- Population risk profilesHigher STEMI burden in PT- Health technology diffusion ratesLonger delays in adoption of new health technologies in PT, despite an expedite approval system (large infrastructure differences, differences in incidence)- Practice patternsLower procedure utilization rates in PTPT > US between‐hospital variability in survival after controlling for procedure use- Deaths outside the hospital
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