When the Art of Medicine Gets in the Way

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When the Art of Medicine Gets in the Way

• Evidence
• Guidelines
• Reality
• Solutions

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MD Primer Inc

• An academic research and physician education
  organization

Clinical Trials Research
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Physician Education
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Management Oriented Registries
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Care gap is not a knowledge gap
Chart Review Canadian primary care
of Patients
100
n5,185 275 MDs
92.7
89.8
80
60
45.7
44.9
40
20
0
LDLlt2.5 mmol/L
Total Cholesterol/HDL lt4.0
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Vascular Protection (VP) Registry
4,639 patients 287 MDs enrolling December 9, 2001
June 15, 2004

Newfoundland 10 MDs n108
New Brunswick 10 MDs n144
British Columbia27 MDs n578
Saskatchewan 16 MDs n227
Quebec 40 MDs n594
P.E.I
Manitoba13 MDs n505
Alberta7 MDs n66
Ontario 69 MDs N1244
Nova Scotia8 MDs n173
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Ontario Guidelines
Disease modifying therapy for Stable Ischemic
Heart Disease

• Recommendations
• Beta-blockers
• Anti-platelet therapy (ASA 80-325 mg)
• ACE inhibitor therapy (Ramipril 10 mg)
• Lipid modifying therapy (LDLlt2.5)

Ontario Program for Optimal Therapeutics,
Guidelines for Stable Ischemic Heart Disease in
Primary Care, pages 11-17 (June 2000)
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Letter to Enrolling MD
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Feedback to Enrolling MD
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Reasons Why Patients Are NOT Receiving Treatment
ACE Inhibitor (Ramipril)
(n747) I have now prescribed this
drug Allergy/Intolerant/Hypotension Renal
insufficiency/artery stenosis Other safety
concerns Non-compliant On Angiotensin Receptor
Blocker Patient not high risk enough Normal LV
systolic function
31.0 27.8 3.0 4.8 6.4 6.7 13.8 11
55
Including evidence or guidelines dont support
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Increase in use of specific products (2003)
45.9
41.1
34.6
39.3
38.7
31.6
33.9
31.2
?19.5 plt0.0001
?14.1 plt0.0001
?6.2 plt0.0001
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CHRC ACS Registries

Newfoundland
New Brunswick
British Columbia
Saskatchewan
Quebec
P.E.I
Manitoba
Alberta
Ontario
Nova Scotia
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Very High Risk
High Risk
Intermediate Risk
Low Risk
30-day Death/MI gt15
gt8-15
lt3
3-8

• Prolonged, recurrent pains
• ST ? gt 2 mm, multiple leads, especially with pain
• Transient ST ? gt 1 mm
• ST ? lt 2mm with ? CK-MB or troponin
• Hemodynamic instability e.g., hypotension, CHF
• Refractory ischemia with ECG ST shift

Rest pain duration gt20 min ST ? lt 2 mm, deep T ?
(e.g., gt5 mm), T ? gt2 mm, especially in ?5
leads Isolated ? CK-MB or troponin
Rest pain New onset / crescendo low threshold
angina ECG non-specific abnormalities or
normal Biochemical markers borderline elevation
or normal Increased baseline risk e.g., diabetes,
prior MI or revascularization
No rest pain New onset / crescendo angina of
moderate severity ECG non-specific abnormalities
or normal Biochemical markers normal
ASA Enoxaparin Eptifibatide or
Tirofiban Immediate referral for earlycardiac
catheterization ? revascularization Clopidogrel
after anatomy known and PCI candidate
ASA EnoxaparinClopidogrel Immediate referral for
earlycardiac catheterization ? revascularization
ASA Enoxaparin ? Clopidogrel Ischemia-guided risk
stratification
ASA Discharge home from Emergency
Department Early stress test as an outpatient
Adapted from Fitchett, Goodman, Gupta Langer
Can J Cardiol 2002181179-90
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Cardiac Catheterization
During index hospitalization
of patients
of patients
100
100
Time to Cath in Days (25th, 75th iles)
Time to Cath in Days (25th, 75th iles)
3 (2, 5)
5 (3, 7)
4 (2, 6)
3 (2, 6)
5 (2, 7)
5 (3, 8)
80
80
68.4
63.7
60
60
50.6
46
40
40
39.6
32.4
20
20
n690
n1523
n1539
n681
n686
n1547
0
0
Low
Intermediate
High
Low
Intermediate
High
GRACE Risk Score
15
In-Hospital Revascularization
of patients
20
16.6
15
15
13.5
10
5
4.4
3.6
3.3
0
Low (?103) n1,535
Intermediate (104-134) n1,524
High (?135) n1,550
GRACE Risk Score
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Management Oriented registries at CHRCCare Gap
and the Model for Improved Care

• Link guidelines and risk based management with
  actual patient care (physician education)
• Monitor outcome and provide feedback to improve
  care
• Ensure dynamic (over a period of time) and
  interactive environment (allowing for changes)
• Use data for future research direction and
  guidelines development

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The Concept Behind CHRC Management Oriented
Registry

• Adult behaviour change providing reasonable
  opportunity
• Knowledge and motivation alone are not sufficient
  to sustain a behaviour change
• Work environment must provide opportunities to
  practice the new behaviour and provide continuing
  reinforcement and feedback
• Physicians already highly motivated to provide
  high-quality care
• Do not need incentives to do the right thing
• Need new tools that will make it easier to do the
  right thing

Adapted from Elson Connelly Arch Fam Med
19954698-705
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Risk Management Approach
Evidence-Based Medicine Recommendations
High
Inter.
Low
ASA (Aspirin)
?
?
?
Clopidogrel Medical treatment
?
?
Clopidogrel Post-stent
?
?
?
?
Heparin Enoxaparin
?
GP IIb/IIIa Inhibitor Medical treatment
?
GP IIb/IIIa Inhibitor PCI
?
?
?
Enoxaparin superior to unfractionated
heparin Eptifibatide or tirofiban Eptifibatid
e or abciximab
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Risk Management Approach
Evidence-Based Medicine Recommendations
High
Inter.
Low
?-blocker
?
?
?
ACE inhibitor
?
?
?
?
?
?
Statin
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Cardiac cath referral Initial 24 hours
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Cardiac cath referral In-hospital
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If CAD is proven In setting of LV dysfunction
(EFlt40) and/or congestive heart failure (CHF)
captopril, enalapril, lisinopril, ramipril, or
trandolapril in setting of CAD without LV
dysfunction and/or CHF ramipril In setting of
acute coronary syndromes (ACS) atorvastatin in
setting of post-ACS pravastatin or simvastatin
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Treatment/ management
If not given, why? (Use coding system)
þ
o
þ
o
þ
o
oo
o
o
X
þ
o
oo
o
o
X
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Correlation of Composite Adherence Score to
In-hospital Mortality
In-hospital Mortality
of Patients
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n32,981 1,085 hospitals
15
10
5
0
Low Quarter
2nd Quarter
3rd Quarter
High Quarter
Hospital Composite Adherence Score Quartiles
Petersen et al
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Performance Matters!Relationship between Process
and Outcome
In-hospital Mortality
of Patients
8
6
4
2
0
lt65
65-75
75-80
gt80
Hospital Composite Adherence Quartiles
Roe et al
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CHRC Management Oriented Registries
Provide guidelines
Collect Data
Review Results and provide feedback
Monitor Progress (improvements in adherence)
Improve Patient Outcomes