Download 2007 Performance Improvement Project Proposal: Improving

2008 Performance Improvement
Project:
Improving the documented use
of aspirin in MSHO/MSC/MSC+
seniors with diabetes or ischemic
heart disease
Developed by Jackson Thatcher MD FACC FSCAI
Presented by Theresa Zeman NP
2008 Performance Improvement Project
Scope, Evidence & Disclosures
The scope of this project is limited to
seniors age 65-84 covered under the
senior Medicaid plans: Minnesota Senior
Health Options (MSHO), Minnesota Senior
Care (MSC) or
Minnesota Senior
Care Plus (MSC+)
The scientific statements in this PowerPoint
are drawn from the Project Executive
Summary and References and ACC-AHA
Cardiovascular Disease Guidelines
Why Diabetics and Patients with
Vascular disease?
 Diabetics
have a comparable risk of MI
to that of matched non-diabetics
with prior MI
 All
diabetics and patients with vascular
disease have an evidence-based
guideline supported Class I indication
for aspirin
Why Aspirin?
 Aspirin
is fundamental to the care of
patients with cardiovascular disease
Why Aspirin?
 There
are very few patients with an
absolute contraindication to aspirin
Approximately 98% of
patients may have a trial
of aspirin therapy when
indicated
Why Aspirin?
 Aspirin
is the only essential drug used
in vascular disease and diabetes that is
not well documented by claims data
 Claims
data indicate senior Medicaid
patients and their providers fail to use
the OTC aspirin benefit provided by
their plan
Why Aspirin?
 Poor
utilization of the senior Medicaid
OTC aspirin benefit leaves aspirin use
grossly under documented
 Many
of these undocumented seniors
are probably taking aspirin, but could
utilize their OTC benefit to obtain their
aspirin at little or no cost
Why Aspirin?
 Utilizing
the senior OTC aspirin benefit
would provide data documenting the
quality of care in eligible patients
Platelets and Thrombosis

Platelets are small cell-like particles in the
blood that help patch leaks and promote
blood-clotting

In diseased arteries platelet thrombi
(clumps) can completely block the
narrowed vessel resulting in stroke or
heart attack
Platelets and Thrombosis
Cholesterol rich
Plaque
Platelet Clump
(White Thrombus)
usually at a site of
plaque fibrous cap
rupture
Thin fibrous cap
prone to rupture
So what happens if this occurs?

Plaque rupture results in platelet activation

Activated platelets release chemical signals
that allow other platelets to attach
So what happens if this occurs?

Platelets release additional chemicals that
constrict blood vessels slowing blood flow
and allowing more platelets to accumulate

Activated platelets start the clotting cascade
and red clot forms
So what happens if this occurs?

Platelet thrombi (clumps) break loose from
the white clot and embolize (clog) small
branches downstream causing
microvascular occlusion which results in
rest angina (chest pain at rest) and
eventual injury to heart muscle

The entire vessel may close resulting in a
full-blown heart attack
Plaque Rupture
Factors promoting plaque rupture
(wall stress, inflammation, thin cap
and large lipid core)
Platelet thrombus
(white clot)
Platelet embolus
Developing
thrombin and blood
cell clot (red clot)
Fibrous plaque
Semi liquid lipid
core under thin
cap
Extruded lipid
after cap rupture
Angiogram of
Acute Myocardial Infarction
Acutely occluded right
coronary artery
Angiogram of
Acute Myocardial Infarction
Partial flow restored
Angiogram of
Acute Myocardial Infarction
After stenting restored
full blood flow stopping
further damage
to heart muscle
Angiogram of
Acute Myocardial Infarction
Heart pumping after
normal blood flow
restored
So How Does Aspirin Reduces the
Risk of Heart Attacks and Strokes?

Aspirin irreversibly binds to cyclooxygenase (COX-1) on the platelet

Aspirin blocked COX-1 cannot catalyze
the formation of thromboxane A-1, which
stimulates platelet activation
How Aspirin Reduces the Risk of
Heart Attacks and Strokes

Aspirin treated platelets are much less
likely to activate and clump together

Since there are over 80 separate
pathways that initiate platelet activation
aspirin therapy is not 100% effective in
stopping platelet activation and clumping
How Drugs Reduce the Risk of
Heart Attacks and Strokes

Some other agents that reduce platelet
clumping include:
(Plavix®)
 Didpyridamole (Persantine®, and combined
with aspirin in Aggrenox®)
 Intravenous glycoprotein receptor inhibitors
such as abciximab (ReoPro®) or eptifibitide
(Integrilin®)
 Clopidogrel
How Drugs Reduce the Risk of
Heart Attacks and Strokes

Some other agents that reduce platelet
clumping include:
 Omega-3
fatty acids (Fish Oil)
 Some calcium channel blockers
 Beta-blockers
 Nitrates
 Fibrin split products - created when
streptokinase is used as a thrombolytic
(‘clot busting’ drug)
How Many Seniors are at Risk?
 Risk
increases in lower income
populations
 Substantial
numbers of seniors
have lower income
How Many Seniors are at Risk?
 A healthy
lifestyle: principally reduced
smoking and blood pressure treatment
delays the onset of vascular disease
until later in life
 But
vascular disease remains a leading
cause of morbidity and mortality even
in seniors who were considered
healthy through middle age
How Many Seniors are at Risk?

Hypertension, obesity, dyslipidemia and
type 2 diabetes (metabolic syndrome)
pose potent increasing risk factors in
the elderly

20% of seniors are currently diabetic
 This number may approach 40% as
the obesity epidemic peaks in seniors

Seniors who live long enough will likely
develop vascular disease
What is the Current Data for Use?
 Patients
with prior MI or diabetic
patients have a 20% risk of
new/recurrent cardiovascular events
within 3 years
 Patients
with diabetes and prior MI
have a risk of over 45%
What is the Current Data for Use?
 Aspirin
use lowers that risk
by about 25%
 35%
reduction nonfatal MI
 25% reduction nonfatal stroke
 15% reduction in vascular and other
cause of death
What is the Current Data for Use?

For every 1000 indicated individuals treated
with low dose aspirin, 10-20 fewer vascular
events are expected each year
What is the Risk of Treatment?

Aspirin causes serious bleeding including
hemorrhagic stroke in 1-2% of patients
treated with low dose aspirin
What is the Risk of Treatment?

Statistically, unless vascular disease or
diabetes is present low dose aspirin therapy
provides no benefit in men prior to age 50
and no benefit in women prior to age 60
What is the Risk of Treatment?

Seniors with vascular disease or diabetes
have unequivocal benefit unless excess risk
is identified
So I have
Good News and Bad News,
Which news do you want first?
Lecturer’s prerogative
First the Bad News
The Bad News
Medicine can be expensive
OK then,
so what’s
The Good News?
The Good News
At least we can afford
aspirin
Relative Generic Costs per Year

Aspirin
$5.00
X

Lisinopril
$30.00
6X

Carvedilol (Target/Sam’s)
$48.00
10X

Lovastatin (Target/Sam’s)
$48.00
10X

Metoprolol (QD formulation)
$75.00
15X

Simvastatin
$200.00
40X

Atorvastatin (not generic)
$1300.00
260X

Clopidogrel (not generic)
$1900.00
380X
What are the Current Criteria for Use?
What is Anticipated in the Future?

Aspirin, along with beta-blocker, converting
enzyme inhibitor and a statin are AHA-ACC
Guideline Indicated (Class 1) in vascular
disease and diabetes unless contraindicated

Studies in diabetics like the ACCORD trial
examining the results of optimal glucose control
on top of hypertension control, lipid treatment,
beta blocker, and aspirin therapy may reduce
cardiovascular events by over 50%
results anticipated by 2011
Where Does All This Lead?

A recent early report from ACCORD
indicates that the most aggressive glucose
lowering arm: HgBA1c < 6.5 was
associated with more deaths than
standard care: HgBA1c < 7.4

Because of this the treatment arm was
softened to aim for an HgbAIc < 7.0
Where Does All This Lead?

While aggressive glucose lowering may
not have been tolerated by some,
researchers expect both arms will do
better than ‘average’ care which still tends
to be suboptimal.

MCOs don’t need to wait until 2011
to prepare to compare their results in their
‘average’ diabetics to the ACCORD
populations and see where they stand
Where Does All This Lead?
If we plan now we could have
a real jump on a
DHS Senior performance
improvement project for 2011!
Changing Lanes
Moving from what we need to do,
To what may make it difficult to accomplish
Despite our best effort, tools, and successes to date
Why is ASA Treatment
Documentation so Poor?

As an OTC product aspirin is not routinely
administered via written prescription
Why is ASA Treatment
Documentation so Poor?

Although DHS provides an OTC aspirin
benefit for Medicaid patients,
CMS does not cover OTC
products for Part D-Medicare patients
Why is Aspirin Treatment
Documentation so Poor?

While providers may prescribe aspirin for
eligible patients they are:
Why is Aspirin Treatment
Documentation so Poor?
 Largely
unaware of the benefit and
 Unlikely to remember to use it
 Common reason for non-use:
Majority of patients seen by providers
don’t need or cannot make use of an
aspirin prescription - it’s just not something
a busy provider will automatically think of
Providers ≠ Physicians




Providers include:
Physicians
 MDs
 DOs
Mid Level Providers (MLPs)
 Physician Assistants
 Nurse Practitioners
Advanced Practice Nurses
Workable solutions for this problem
must include all care providers
So how do we make
a measurable improvement?

Educating all Minnesota providers to write
OTC aspirin prescriptions for all eligible
patients will prove a difficult task

Getting all eligible patients to submit this
prescription may also prove difficult
They may already have aspirin at home
 They may forget to bring the prescription
since it is not required to obtain the
medication and aspirin is inexpensive

So how do we make
a measurable improvement?

Clinicians will often provide what a patient
requests
 Such
as an aspirin prescription
So how do we make
a measurable improvement?

Care Coordinators can help by ensuring all
eligible patients are aware of the benefit

Patients must understand their use of the
aspirin prescription benefit will also
document their receipt of Best Care

Assisting the clinician with the
name/fax+phone number of the patient’s
preferred pharmacy might expedite the
process
So how do we make
a measurable improvement?

While the preferred contact with the
provider is an office visit, situations will
arise in which patient transport or provider
availability limit access within a reasonable
timeframe

This may result in a phone contact
whether from the patient or the coordinator
in order to obtain the prescription
So how do we make
a measurable improvement?

Assisting the clinician’s office staff by
providing 2 patient identifiers, such as
name and birthdate as well the fax +
phone number of the patient’s preferred
pharmacy may expedite and reduce the
hassle of another office call
So how do we make
a measurable improvement?

In process improvement an average
solution that is very well executed will
always beat a better solution that is not
well disseminated or multiple conflicting
solutions
So how do we make
a measurable improvement?
 Work
hard
 Never give up
 If the first plan fails consider
alternative solutions
Why We Fight…
to improve healthcare
Why We Fight
is the national leader
in reducing cardiovascular death
 Minnesota
without peer
Why We Fight
 This
success is shared by our
hardworking & healthy general
population
 It
includes public health success
in reducing smoking rates and
second-hand smoke
Why We Fight
 It
also includes our progressive
employers who realize the benefits of
insuring for a healthy workforce
 And
our managed care organizations
who have stressed preventive
services and healthy lifestyles
to reduce the costs of
disease management
Why We Fight
 Along
with our tireless providers:
physicians, mid-levels, and nurses
who have embraced evidence-based
medicine and stressed broad
application of guideline indicated
therapies across diverse patient
populations
Why We Fight
 Our
hospitals that have focused on
coordinated, fast and efficient care
with a passion to reduce
medical error
Why We Fight
 And
finally,
our informed and educated patients
who ask the right questions and are
fully vested in seeing they receive
optimal healthcare
Why We Fight
 But
our work isn’t finished until we
fully address one of the greatest
discriminations against the
poor of our state -
Why We Fight
 But
our work isn’t finished until we
fully address one of the greatest
discriminations against the
poor of our state -
poor healthcare
Promoting the use of the OTC
aspirin benefit in covered Medicaid
seniors
Is a big step in the continuing
effort to provide superior
healthcare to all Minnesotans
Good Luck with your project
Improving the documented use of
aspirin in MSHO/MSC/MSC+
seniors with diabetes or ischemic
heart disease
Questions