CVD Prevention: Integrated
Health System Perspective
Ronald D. Scott, MD
KP Southern California ASCVD Co-Lead
Disclosure
 Contracted research with KP and Novartis.
 Ronald D. Scott MD
KP Southern California ASCVD Co-Lead
KP National Integrated Cardiovascular Health
Family Medicine and Diplomate of Clinical Lipidology
 Los Angeles, CA
2
Systemic CVD Prevention:
Overview.
Introduce KP Systemic “Complete Care”. Example of AAA screening
Statins and aspirin – potential for more MI and stroke prevention
Tactics in KP for CVD prevention, from Clinician to System
Fits into “Complete Care” quality promotion.
3
Kaiser Permanente: Largest Non-Profit Health
Care System in the United States
Permanente
Medical
Groups
Kaiser
Permanente
Kaiser
Foundation
Hospitals
National 9.5 million members
Southern California region
 3.8 million members
 67,000 employees
 6,000 physicians
 Hospitals, Medical Offices,
Pharmacies, Labs, etc.
4
Kaiser
Foundation
Health Plan
Features of Integrated Healthcare Systems
Which Support “Complete Care”
•
Closed member populations •
Extensive computerized clinical data systems
•
Vertically integrated healthcare delivery •
Collaborative, team‐based care models
•
Culture of continuous quality improvement
•
Incentives aligned towards prevention Juhn, P et al. The Permanente Journal. 1998; Vol 2 No 2:38-43. McCarthy, D et al.
The Commonwealth Fund; June 2009; Publication 1278; Volume 17:1-27.
KP Robust Health IT Infrastructure Optimizes Systemic “Complete Care”
Complete Care
Tools
Permission to use this graphic granted by Walter Suarez, MD, MPH
Kaiser Permanente, August 2013.
Abdominal Aortic Screening in KPSC
 USPSTF rec for AAA screening was not consistently implemented,
eAutopsy.
 Electronically find members that need Abdominal Aorta imaging.
Prepare + align the system (vascular surgery, radiology, primary
care).
 Best Practice Alert fires triggers nursing staff (primary care,
cardiology, etc) to stage the order for clinician to sign.
Hye et al. J Vasc Surg 2014 Jun;59(6):1535-43.
AAA screening rates KPSC by Area
Sun, Angela, SCPMG Clinical Analysis, October 2014
Statin benefit groups: opportunity to leverage
more CV prevention
1. Clinical ASCVD, start atorvastatin 40-80 mg
2. LDL >= 190, start atorvastatin 40-80 mg
3. DM age 40-75, A-Risk >= 7.5%, start atorvastatin 40 mg.
A-Risk < 7.5%, start atorvastatin 20 mg
4. By A-Risk (ASCVD 10 year risk)
• >= 15%,
start atorvastatin 40 mg
• 7.5-14.9%, discuss atorvastatin 40 mg
• 5.0 to 7.4%, consider atorvastatin 20 mg
• May consider “additional factors”
KPSC Dyslipidemia Tip Sheet, Dec 2014. Adapted from KP and ACC / AHA Guidelines.
Aspirin for Primary Prevention:
Recommendations Tailored to Risk Level
25
A-Risk
20
start asa
15
discuss asa
10
no asa
5
0
m 45-59, w 55-59
KPSC Dyslipidemia Tip Sheet, Dec 2014
m,w 60-69
m,w 70-79
ASCVD relative risk reduction
Modeled statin and aspirin risk reduction,
primary prevention. Archimedes ARCHeS
Dudl, Scott, Chan. AHA poster, Nov 2014
Cumulative Per Capita Cost Savings with
ASA+Statin in Primary Prevention
Discounted Medical Costs $
aspirin 81 mg
$1,638
@ 3 yrs
atorvastatin 40 mg
+ aspirin 81 mg
atorvastatin 20 mg
$6,453
@ 10 yrs
$9,288
@ 20 yrs
Dudl, Scott, Chan. AHA poster, Nov 2014
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Statin Use in Primary Prevention,
Large Treatment Gap
90
80
70
% on statin
60
50%
50
40
30
20
10
0
NHANES pp
7/2013 pp
NHANES rate from Pencina et al. N Engl J Med 2014;370:1422-31.
Other rates KPSC.
7/2014 >=15%
Facilitates System Tactics and Team Care
Sophisticated Decision Support Generates Actionable Lists Daily.
area
KPSC
May “drilldown” from KPSC, to Medical Center area, to medical
team of 10 clinicians, to individual provider, to member.
Scott R. http://cardiometabolic.cardiosource.org/. November 14, 2014. Pharmacy Analytic Services (PAS)
Revised with primary prevention statin and
aspirin benefit groups.
• Inclusion allows systemic tactics and team care to these
additional members.
• This should facilitate more CV Prevention across many
more members.
• KPSC pp aspirin metric planned to start 2016.
• Proxy for NCQA pp aspirin metric.
Scott R. http://cardiometabolic.cardiosource.org/. November 14, 2014. Pharmacy Analytic Services (PAS)
“Summary Sheet” with prompts
available for providers at point of care
Scott R. http://cardiometabolic.cardiosource.org/. November 14, 2014.
Artery Graphic Tool
 Tear-off pads to hand members graphic with bullets on back and
exam room posters widely disseminated. Providers trained to use.
 Helps overcome literacy barriers, facilitates recall. Used to
promote statin and aspirin use.
Houts et al. Education and Counseling, 35: 83-88 (1998)
Promote Med Adherence
 Members who understand the risk of disease and benefits of
medicine report fewer side effects, are more tolerant of the costs, and
are more adherent to the medicine.
 Sig printed and placed on bottle: “take 1 tab orally daily to reduce
heart attack and stroke risk”.
 Use “golden opportunities” – like when in hospital with new MI, or
informing of new diagnosis of Diabetes.
• More receptive to behavior change.
 Pillbox “gift” with new prescription. Build trust and collaboration.
Chi et al. Am J Manag Care. 2014. Cheetham et al. Journ of Managed Care
Pharmacy, April 2013. Harrison et al. Am J Man Care, April 2013.
Statin + aspirin start smartphrase
Mr Jones,
Your 10 year risk of heart attack or stroke is elevated
at 16.5%. Two medicines taken together can reduce your risk
about 50%. I recommend taking atorvastatin (Lipitor) and
aspirin 81 mg (baby or low dose) daily to reduce your risk.
• With 3 keystrokes (period, y, r) Can use “dot phrase” to pull
sentences into emails or letters to members when
communicating results (or other times).
Personal Action Plan on kp.org
customized for members with data from health record
Your risk of heart attack or stroke is about 16.5% (high).
Discuss with your provider statin and aspirin to lower your risk.
Impact of KP.org Use on Quality of Care
Among KPSC members, use of KP.org was associated with
statistically significant improvement in 9 HEDIS measures evaluated.
Selected Measures/Pre-Post Matched-Control Study
100
90
80
70
60
50
HbA1c
Screening
HbA1c <9%
LDL-C
Screening
Post: Non-Users
Zhou YY. Health Affairs 2010;29:1370-1375
LDL-C
<100 mg/dL
Post: Users
BP <140/90
BP <130/80
Mobilizing Team Care
“Inreach” – visit checklists
 Medical assistants follow lists to close “care gaps” while
interacting with members.
 Monitored with feedback, pay for performance.
KPSC Regional Outreach
 Automated letters, phone calls, emails to get patients to
take action. Examples for lipids: go to pharmacy to get or
refill statin, or go to lab (Lipid Panel overdue), or schedule
appointment with provider.
Automated Outreach Improves Statin NonAdherence: A Randomized Controlled Trial
 Primary Non Adherence :
Automated call/letter
outreach to patients who fail
to fill their 1st statin
prescription within 1-2 weeks
after electronic order.
• Increase fill OR 2.2.
Spanish 3.0
 Secondary Non Adherence :
Automated refill reminder
calls to patients overdue by 2
– 6 weeks for refills
Based on AHA graphic on CV Med Adherence
Derose et al, JAMA Intern Med 173:1, Jan 14, 2013
More Med Adherence Tactics
 Lists of members that do not respond to automated outreach
forwarded to local areas for follow up emails or live calls to members.
 Outpatient pharmacists at discuss CV med adherence when
members come into KP pharmacy for other reasons.
 Members using KP Mail-Order Pharmacy with free shipping achieved
better cholesterol control, higher medication adherence, and lower
rates of ER visits.
 Medication adherence promotion is incorporated in member selfmanagement materials and health education classes.
Spence et al, J Manag Care Pharm 2014;20:1036-45. Schmittdiel et al, JGIM 2011; 26 (12)
1396-1402. Schmittdiel et al, Am J Manag Care. 2013;19(11):882-887.
Team Care example
PCP
Care
Manager
Support
Coordinator
Team Care Example
 Care Manager:
• Clinical Pharmacist or specially trained RN that partners with about 10 PCPs.
• Uses telephone and email to adjust meds of DM with A1C > 9, and others.
 Support Coordinator
• Checks on and calls / reminds patient to pickup medicine, go to lab, etc.
• Trained to identify and work barriers with members to get them on meds and to
lab.
 Panel Management meetings
• Performance reports and actionable lists of patients to review.
• Interface with PCPs, opportunity for Academic Detailing.
• Example: those with DM that need statin starts. PCP approves a list, staff do
logistics of starting the members on statins and communicating with members.
Scott section of Cohen et al. Journal of Clinical Lipidology Nov-Dec 2013
KPSC HEDIS
Year
Cardiovascular Lipid Control <100mg/dL Medicare
2008
75.7%
2009
75.9%
2010
79.2%
2011
80.2%
2012
83.7%
0%
20%
40%
Rate
60%
80%
100%
“Disparities were seen . . . except the West, where Kaiser
health plans achieved substantially better control overall.”
Ayanian et al. NEJM Dec 11, 2014;371_2288-97
Declining Incidence of MI: KPNC 1999-2008
Yeh et al. NEJM June 10, 2010
MS
Obesity
Osteoporosis
Pneumonia
Rare Diseases
Sepsis
HIV
Hypertension
HF
Hepatitis C
Geriatrics
CKD
COPD
Depression
Diabetes
Cancer
ASCVD
Asthma
Asthma
Complete Care
Decreasing Rhabdomyolysis with
KPSC Outpatient Safety Net (SureNet)
* Lawrence Pt Safety Award 2012.
* American Society of Health-System
Pharmacists (ASHP) Award for Excellence
in Medication-Use Safety Finalist 2013.
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2004 – Sept 2012 KPSC
Metric
Increase
Lipid control (CVC and DM)
34.5%
Blood pressure control
43.5%
HbA1C < 9.0
13.5%
Smoking cessation
17.0%
Breast cancer screening
11.1%
Colon cancer screening
35.8%
AAA screening 2011-2013
28.2%
Kanter et al. Jt Comm J Qual Patient Saf 2013;39:484-94.
Medicare Quality Ratings
 National Committee for Quality Assurance (NCQA) Ranks KPSC
Medicare Health plan # 1 out of 405 plans nationally.
• Second year in a row KPSC is ranked # 1.
• Other KP regions are also in the top 4% of the national rankings
for consumer satisfaction, prevention services, and clinical
treatment outcomes.
 Medicare 5 Star rating for KP California, 4th straight year.
• Financial incentive from CMS. Open enrollment year round.
• Only 11 of 400 rated plans nationally received 5 stars.
Systemic CVD Prevention:
Summary / Take Home
Introduce KP Systemic “Complete Care”. Example of AAA screening
Statins and aspirin – potential for more MI and stroke prevention
Tactics in KP for CVD prevention, from Clinician to System
Fits into KP “Complete Care” quality promotion.
Consider system tactics to improve CV prevention.
36
CVD Prevention: Integrated
Health System Perspective
Ronald Scott, MD
KPSC ASCVD Co-Lead
37