1. A Coordinated Approach to Cardiovascular Care Sharon Levine MD Associate Executive Director The Permanente Medical Group Kaiser Permanente Bay Area Council June 9, 2008 Delivering Health and Economic Value to Patients and Purchasers

2. 2 The Impact of Cardiovascular Disease In 2008 Americans will suffer: –1.2 million heart attacks –800,000 strokes –1.5 million new cases of diabetes –6 million hospitalizations for CVD,1.3 million angioplasties and 500,000 bypass surgeries An American dies from CVD every 35 seconds. Heart disease and stroke are leading causes of disability among working adults. The cost of heart disease and stroke in the United States is estimated at $450 billion in 2008. It includes direct medical costs and lost productivity from death and disability. Improved care decreased CVD mortality 25% from 1994 to 2004.

3. 3 Translating Evidence Into Benefit EvidenceBenefits Abundant Body of Evidence A 13 point reduction in blood pressure can lower deaths due to CVD by 25%. 4 generic meds can reduce CV event risk by 50%. 7 interventions during the ED/Hospital can reduce mortality. Managing transition of HF patients from hospital to home can reduce readmissions and prevent catastrophic declines.

4. 4 Translating Evidence Into Benefit: The Quality Chasm The “Chasm” Quality Chasm In US only 55% of indicated care is provided Diabetes patients received 45% of indicated care. Hyperlipidemia patients received 49% of indicated care. CAD patients received 68% of indicated care. HTN patients received 65% of indicated care. Source: Rand EvidenceBenefits

5. 5 What’s the Problem? I’m doing everything as I was trained to do -- I can’t work faster!  Accountability for panel/population  Transparency  Use of EMR, registries, internet  Team care (including pt)  Moving care out of Dr. office The Traditional Model Of Care  One patient at a time  Only know about patients who appear in your office  No use of IT  Limited use of “extenders” New Model Elements

6. 6 Turning Evidence Into Health Benefit EvidenceBenefits Success Factors: Integrated delivery system; organized medical group Process redesign Use of advanced information technology Aligned incentives (Pre-payment; salaried physicians) Clinical Leadership Patient Engagement

7. 7 Our Systematic Approach …and accountability across the Continuum of Cardiovascular Disease and from “cradle to grave”. Primary Prevention Secondary Prevention Acute Care Chronic Care

8. 8 Primary Prevention Secondary Prevention Acute Care Chronic Care Investing in Primary Prevention Delivering the Benefits: Modify Lifestyle Increase HTN control Smoking Cessation Decrease LDL Cholesterol levels

9. 9 Increase Hypertension Control What we did: leadership priority Clinical Champions –Academic “detailing” “Revealing Reports” –Where the opportunity is “Data that Drives” –Tools to pinpoint gaps in blood pressure testing, treatment or documentation Process Redesign –“Check, Treat, Repeat” –Treatment intensification to target –Medical Assistant BP Checks Primary Prevention

10. 10 ActionDescriptionOutcome Check Was BP taken and recorded? Documentation Was BP high? (Determines denominator for measure 3) Treat Was treatment intensified ? Upward titration of dose and/or medication type Repeat Was there another BP taken within 4 weeks? Follow up care Was the f/u BP lower than the initial BP? Better Control of BP Was the f/u BP in control? Controlling BP Increase Hypertension Control Primary Prevention Making the process clearer and easier…

11. 11 Increase Hypertension Control KP at HEDIS 90%tile Primary Prevention Trends in Hypertension Control Rates 2001-2006 …led to significant gain. 20012005

12. 12 We are in the Top 5 Secondary Prevention

13. 13 Adult Smoking Prevalence 2002 vs. 2005 Decrease Smoking Primary Prevention …Reducing smoking rates over time.

14. 14 Primary Prevention Secondary Prevention Acute Care Chronic Care Crossing the Chasm – Secondary Prevention Delivering the Benefits: Heart protective meds: Aspirin, Statin, ACE-I, and Beta-blocker Lifestyle changes: Tobacco Cessation, Physical Activity, Healthy Eating and Weight Management Risk factor control: Blood Pressure, Cholesterol and Blood Sugar

15. 15 PHASE Population Secondary Prevention Approximately 300,000 members or 11% of membership. Composition of population is displayed below:

16. 16 Poor control N=59,633 (49%) Good Adherence, Tx Int. N=27,157 (46%) Poor Adherence N=14,568 (24%) Good adherence, NO Tx Int. N=17,908 (30%) DM Population N=143,858 Good control N=86,609 (51%) Diabetes Potential Targets for DM Intervention Secondary Prevention Revealing report on adherence…

17. 17 All PHASE Rx meds (composite metric) improved 30.3% Secondary Prevention Members on PHASE Medications Improvement from Q4 2004-Q2 2007 PHASE Results

18. 18 Results BP Control <139/89 (for DM and CKD 129/79) improved 29.6% (1) HbA1c Control represented on this graph is A1C 9.0 are also measured (2) Lipid Control measure represents the percentage of PHASE patients with most recent test of LDL < 100 mg/dl in last 12 months. (3) Blood Pressure Control is defined as BP <= 129/79 for patients with Diabetes and CKD and BP <= 139/89 for all other PHASE patients. Multiple Risk Factor Management - A1c control (<8.0) has improved along with tight measures of LDL and Blood Pressure 2004-2007 Secondary Prevention HbA1c <8.0 improved 10.6% LDL <100 improved 31.0%

19. 19 Impact of 2007 Improvements: Additional 9,600 patients at LDL target –300 heart attacks/strokes prevented Additional 2,000 patients on statins –170 heart attacks/strokes prevented Additional 1,600 patients on ACEI –70 heart attacks/strokes prevented Additional 4,700 People with Diabetes at A1c <9 –188 adverse outcomes prevented Additional 13,447 People with Diabetes have BP < 129/ 79 –1200 CV events prevented Secondary Prevention

20. 20 Primary Prevention Secondary Prevention Acute Care Chronic Care Crossing the Chasm – Acute Care Delivering the Benefits: 7 Joint Commission Core Measures Provide revascularization to appropriate patients

21. 21 Reducing variation and improving quality Reducing variation and improving quality over time at all NCAL Med Centers Acute Care Inpatient Quality Performance: All Core Measures, Rolling Year

22. 22 Heart attack mortality is declining Acute Care

23. 23 Cardiac Procedures 2001 – 2007 Volume Trends, KPNC Acute Care

24. 24 Coronary Procedures – Less PCIs, CABG, CATH Acute Care National 50 th Percentile RateKaiser Permanente Rate Procedures/ Thousand Males aged 45-64

25. 25 Primary Prevention Secondary Prevention Acute Care Chronic Care Crossing the Chasm – Chronic Care Delivering the Benefits: Stratification by patient status Integration across conditions Panel management to offload algorithm-driven care Member engagement: Self-management skills

26. 26 Level 3 – Intensive or Case Management – Heart Failure patients who are at high risk due to complicated and/or unstable condition, poor functional status and/or psychosocial problems. High intensity management of the patient’s care is required. Level 2 – Assisted Care or Care Management – Heart Failure patients with moderate symptoms, sub-optimal medication management, poor self-care skills. Also include patients who are unable to achieve or maintain self-care skills despite appropriate education and support from the APC team. Level 1 – Self Care Support – Heart Failure patients supported by routine APC team care. Members have mild symptoms & appropriate medication management. Members who may benefit from basic self-care education. Prevention - The foundation of basic care for all levels. Self Care Support 35,000 pts Assisted Care or Care Management 5,000 pts Case Mngmt 2,000 pts Prevention is part of every member’s care Intensive or 42,000 HF pts Chronic Care Chronic Conditions Management Program for Heart Failure in NCAL Heart Failure

27. 27 Trends in HF Mortality CHF Outcome Data Chronic Care

28. 28 100.6 98.2 175.5 162.2 144.4 137.6 109.6 366.7 377.1 579.4 561.6 500.4 506.4 390 212.6 217.8 244.3 236.7 243.1 240.9 238.2 0 100 200 300 400 500 600 700 1999Q4 2000Q4 2001Q4 2002Q4 2003Q42004Q42005Q1 Rate/1000 HF Registry Day Rate ED Visits Discharge -44.0% Utilization Due to Heart Failure is Decreasing for Registry Members Heart Failure Chronic Care -13.0% -36.7%

29. 29 Total and ST Elevated MIs are declining Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates for Kaiser Permanente, 1998 - 2007 Full Spectrum of Care

30. 30 Strokes are declining Stroke and Intracerebral Hemorrhage – Hospitalization Rates in Kaiser Permanente – 1998 - 2007 Full Spectrum of Care

31. 31 Heart disease mortality declining 30% less chance of dying due to HD if you are a Kaiser Permanente Member Full Spectrum of Care

32. 32 Summary Using our integrated system, advanced IT systems, process redesign financial alignment and patient engagement, we’ve made it easier to “do the right thing” across the spectrum of cardiovascular disease, so that cardiovascular disease is no longer the number one cause of death for KP members