© Continuing Medical Implementation ® …...bridging the care gap Bridging the Care Gap 2007 Joel Niznick MD FRCPC

© Continuing Medical Implementation ® …...bridging the care gap Care Gap

© Continuing Medical Implementation ® …...bridging the care gap Care Gap Failure to, translate, transfer and utilize medical knowledge effectively Usual Care ≠ best care Population outcomes do not match results of clinical trials Patient, physicians & payers do not reap the benefits of validated medical knowledge

© Continuing Medical Implementation ® …...bridging the care gap Care Gap The difference between what we know and what we do The difference between achievable and actual outcomes The failure to systematize knowledge and apply it consistently

© Continuing Medical Implementation ® …...bridging the care gap Knowledge Translation Definition: “Knowledge translation is the effective and timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health system.” –Adapted from the Canadian Institutes for Health Research definition, 2001

© Continuing Medical Implementation ® …...bridging the care gap INTER-HEART: Risk of acute MI associated with risk factors in the overall population Yusuf S. European Society of Cardiology Congress 2004; August 28-September 1, 2004; Munich, Germany. Risk factorOdds ratio adjusted for age, sex, and smoking (99% CI) Odds ratio adjusted for all (99% CI) ApoB/ApoA-1 (fifth quintile compared with first) 3.87 ( )3.25 ( ) Current smoking2.95 ( )2.87 ( ) Diabetes3.08 ( )2.37 ( ) Hypertension2.48 ( )1.91 ( ) Abdominal obesity2.22 ( )1.62 ( ) Psychosocial2.51 ( )2.67 ( ) Vegetable and fruits daily0.70 ( )0.70 ( ) Exercise0.72 ( )0.86 ( ) Alcohol intake0.79 ( )0.91 ( ) All combined129.2 ( )

© Continuing Medical Implementation ® …...bridging the care gap INTER-HEART: Population-Attributable Risk (PAR) Acute MI in the overall population Risk factorPAR adjusted for age, sex & smoking 99% CI) PAR adjusted for all (99% CI) ApoB/ApoA-1 (fifth quintile compared with first) 54.1 ( )49.2 ( ) Current smoking36.4 ( )35.7 ( ) Diabetes12.3 ( )9.9 ( ) Hypertension23.4 ( )17.9 ( ) Abdominal obesity33.7 ( )20.1 ( ) Psychosocial28.8 ( )32.5 ( ) Vegetable and fruits daily12.9 ( )13.7 ( ) Exercise25.5 ( )12.2 ( ) Alcohol intake13.9 ( )6.7 ( ) All combined90.4 ( ) Yusuf S. European Society of Cardiology Congress 2004; August 28-September 1, 2004; Munich, Germany.

© Continuing Medical Implementation ® …...bridging the care gap INTERHEART: Summary 1.Nine simple risk factors are strongly associated with AMI worldwide. 2.These risk factors are even more important in the young, and their effects are consistent in men and women, across all ethnic groups and all regions. 3.Abnormal Apo-B/ApoA-1 ratio and smoking are the most important risk factors and account for >2/3 of the PAR. All 9 risk factors account for >90% of the PAR globally and in most regions. IMPLICATIONS: Implementing preventive strategies based on our current knowledge would avert the majority of premature CHD worldwide.

© Continuing Medical Implementation ® …...bridging the care gap Prevention Goals for CVD VariableGoal SmokingTotal Cessation Total Dietary Fat / Saturated Fat< 30% calories / < 7% calories Dietary Cholesterol< 200 mg/day Physical Activity30-45 min. moderate intensity 5X/week Body Weight by Body Mass indexInitial BMI Weight Loss Goal BMI < 25 > % relative weight loss LDL cholesterol (primary goal) 1.6 – 2.2 mmol/L (60-85 mg/dL ) HDL cholesterol (secondary goal)1.0 mmol/L ( > 40 mg/dL ) Triglyceride (secondary goal)1.7 mmol/L ( < 150 mg/dL ) Blood Pressure< 130/80 mmHg (< 120/80 for LVD) DiabetesHbAlc < 7.0 %

© Continuing Medical Implementation ® …...bridging the care gap Primary Prevention Dietary modification –  30% fat –  7%saturated fat –  200mg/day cholesterol. Weight loss –5-10% TBW Physical activity –30 min 5X/wk Smoking cessation

© Continuing Medical Implementation ® …...bridging the care gap Potential Cumulative Impact of 1° Prevention Strategies Smoking Cessation2/3 BP reduction 20mm Hg1/2 LDL reduction 1mmol/L1/6 Cumulative Prevention5/6

© Continuing Medical Implementation ® …...bridging the care gap Potential Cumulative Impact of 2° Prevention Treatments RRREvent rate None8%16% ASA25%6%12%  -Blockers 25%4.5%9.0% Lipid lowering30%3.0%6.0% ACE- inhibitors 25%2.3%4.6% Cardiac Rehab25%1.7%3.4% Adapted from Yusuf, S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2-3. CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF 78% RRR, WHICH IS SUBSTANTIAL

© Continuing Medical Implementation ® …...bridging the care gap CVD 2° Prevention Cocktail CAD, CVA,TIA, PVD, AAA, Type 2 DM Same Disease/Same Rx: –ASA –Lipid Targets TC < 4.5 LDL < 2.0 (1.8) HDL > 1.2;TC/HDL < 4 TG < 1.7 – ACE inhibitor HOPE Trial EUROPA Trial –ß-blocker for post- MI, HPT or CAD

© Continuing Medical Implementation ® …...bridging the care gap Top 10 Evidence Based Advances in CV Disease ASA/Plavix-CAD/ACS UF/LMW Heparin ACS Thrombolytic/PCI-STEMI ß-blocker post-MI ACE-i/ARB –CHF/LV dysfunction –Post MI –Vascular disease/DM Anticoagulation in atrial fibrillation Lipid Lowering –2 ° - CAD, CVD, PVD, DM –1 ° - Risk Factors HTN (hypertension): – LDD/ß-blocker/ACE-i/ ARB/long-acting CCB Isolated Systolic HTN > 60: –LDD/long-acting DHP- CCB/ARB –(avoid ß-blocker or alpha- blocker as initial Rx) ß-blocker -CHF

© Continuing Medical Implementation ® …...bridging the care gap Top 10 Failures to Implement Evidence Based Advances in CV Disease ASA/Plavix-CAD/ACS UF/LMW Heparin ACS Thrombolytic/PCI-STEMI ß-blocker post-MI ACE-i/ARB –CHF/LV dysfunction –Post MI –Vascular disease/DM Anticoagulation in atrial fibrillation Lipid Lowering –2 ° - CAD, CVD, PVD, DM –1 ° - Risk Factors HTN (hypertension): – LDD/ß-blocker/ACE-i/ ARB/long-acting CCB Isolated Systolic HTN > 60: –LDD/long-acting DHP- CCB/ARB –(avoid ß-blocker or alpha- blocker as initial Rx) ß-blocker -CHF

© Continuing Medical Implementation ® …...bridging the care gap Goals in Cardiovascular Prevention Identify all patients who could benefit Stratify according to all risk factors Initiate therapy in all where cost/benefit favorable Achieve appropriate targets or % reductions Provide long term follow-up to ensure adherence Achieve mortality/morbidity benefits attained in clinical trials Target every patient for optimal risk stratification and reduction

© Continuing Medical Implementation ® …...bridging the care gap Where can we have the greatest impact in cardiovascular disease? Stroke prevention –Hypertension control –Anticoagulation in atrial fibrillation CAD –Secondary prevention cocktail –Medical management for symptoms –Appropriate revascularization CHF –Patient education –Medical management for prognosis and symptoms –Admission and readmission prevention programs

© Continuing Medical Implementation ® …...bridging the care gap Ways to influence practice Consensus guidelines Didactic CME Workshop CME Practice pattern review Specific recommendations by local experts Usual channels of communication Reminder strategies Evidence based application tools

© Continuing Medical Implementation ® …...bridging the care gap Guideline Implementation Bring together national experts Develop guideline,consensus statement or recommendation Publication Diffusion Dissemination Implementation

© Continuing Medical Implementation ® …...bridging the care gap Knowledge Evolution DATA Knowledge Translation INFORMATION Knowledge Utilization ACTION DATA Knowledge Translation INFORMATION Knowledge Utilization ACTION

© Continuing Medical Implementation ® …...bridging the care gap Opportunities to Improve Care for Patients With Cardiovascular Disease Despite overwhelming clinical trial evidence, expert opinion, national guidelines, and a vast array of educational conferences, evidence-based, life-saving therapies continue to be underutilized New approaches to improving the use of proven, guideline-recommended, life-saving therapies are clearly needed Fonarow GC. Rev Cardiovasc Med. 2002;3:S2-S10.

© Continuing Medical Implementation ® …...bridging the care gap Clinical Research to Clinical Practice-Lost in Translation. Claude Lenfant, M.D. NEJM 349(9) August …both health providers and members of the public, are not applying what we know. …we are not reaping the full public health benefits of our investment in research. …there is plenty of evidence that "old" research outcomes have been lost in translation as well.

© Continuing Medical Implementation ® …...bridging the care gap The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003;327:33-35 (5 July 03) Davis et al A large gulf remains between what we know and what we practice. Such variation is common not only internationally but within countries. Large gaps also exist between best evidence and practice in the implementation of guidelines.

© Continuing Medical Implementation ® …...bridging the care gap Why most interventions to improve physician prescribing do not seem to work. Majumdar and Soumerai CMAJ 169(1) July Interventions that rely solely on passive information transfer are ineffective Active knowledge translation strategies are usually effective, although the effects are modest. Interventions that incorporate 2 or more distinct strategies (i.e., that are multifaceted) are more likely to work

© Continuing Medical Implementation ® …...bridging the care gap The Canadian Cardiovascular Society and Knowledge Translation: Turning Best Evidence into Best Practice Tremblay et al Can J Cardiol 2004;20(12): Estimates of the size of the care gap indicate that 30% to 40% of patients fail to receive treatments of proven effectiveness, 20% to 25% of patients may receive care that is not needed or is potentially harmful

© Continuing Medical Implementation ® …...bridging the care gap Patient Health Management Patients First: Closing the Health Care Gap in Canada starts with a premise no one can disagree with: Things can be better in our health care system, in every way. Dr. Montague then goes on to show how patients, practitioners and policy-makers can make incremental improvements that will make things better. At the centre of his vision is the patient, and he provides a blueprint that will deliver optimal health care results without necessarily engendering a greater burden on available resources.

© Continuing Medical Implementation ® …...bridging the care gap Analyzing the Care Gap Evidence Gap Guideline Gap Diffusion Gap Dissemination Gap Implementation Gap Adherence Gap Outcome Gap Rising Health Care Costs

© Continuing Medical Implementation ® …...bridging the care gap Barriers to Implementing Risk Factor Management in Patients With CHD Physician is focused on acute problems Time constraints and lack of incentives, including reimbursement Lack of training, including inadequate knowledge of benefits and lack of prescription experience Lack of resources and facilities Lack of specialist–generalist communication; passing on responsibility Adapted from Pearson TA et al. J Am Coll Cardiol. 1996;27:

© Continuing Medical Implementation ® …...bridging the care gap Why the Gap? Lack of information-knowledge gap Information overload-guideline overload Jurisdiction: Whose job is it? Too busy to read recommendations Patient overload/Physician shortage Issue overload/Patient priorities Lack of tools or resources Confusion - competing marketing strategies Medico-legal implications

© Continuing Medical Implementation ® …...bridging the care gap Why the Gap? Uncertainty Inertia Jurisdiction Effectiveness Resources Continuity Adherence

© Continuing Medical Implementation ® …...bridging the care gap Adherence Gap Cost of medications Complacency-patient and physician Side effects Lack of understanding Media impact/fears Infrequent monitoring Lack of feedback

© Continuing Medical Implementation ® …...bridging the care gap Evidence Based Implementation Tools CME CMI CME CMI A New Paradigm Continuing Medical Implementation® CMI A New Paradigm Continuing Medical Implementation®

© Continuing Medical Implementation ® …...bridging the care gap

© Continuing Medical Implementation ® …...bridging the care gap

© Continuing Medical Implementation ® …...bridging the care gap

© Continuing Medical Implementation ® …...bridging the care gap Three Pronged Approach Condensed evidence review and guideline distillation Patient information products Implementation tools

© Continuing Medical Implementation ® …...bridging the care gap Post MI Discharge Summary

© Continuing Medical Implementation ® …...bridging the care gap Guide for Comprehensive Cardiovascular Risk Reduction

© Continuing Medical Implementation ® …...bridging the care gap Dyslipidemia Package

© Continuing Medical Implementation ® …...bridging the care gap Lipid Optimization Tool

© Continuing Medical Implementation ® …...bridging the care gap Hypertension Package

© Continuing Medical Implementation ® …...bridging the care gap HOP To ITT Hypertension Calendar

© Continuing Medical Implementation ® …...bridging the care gap Diet Information Sheets

© Continuing Medical Implementation ® …...bridging the care gap Diet Information Sheets

© Continuing Medical Implementation ® …...bridging the care gap Optimal Management of Atrial Fibrillation

© Continuing Medical Implementation ® …...bridging the care gap Guide for HF Management

© Continuing Medical Implementation ® …...bridging the care gap Multiple Modalities of Distribution Targeted mailings Hard copy/photocopy Reprint/re-order Digital copy Web site CME programs Implementation networks

© Continuing Medical Implementation ® …...bridging the care gap Multifaceted Product Education –Patient –Physician –House-staff –Nurses Implementation Tools CPD CME

© Continuing Medical Implementation ® …...bridging the care gap The Physician Patient Interface is Not a Virtual World

© Continuing Medical Implementation ® …...bridging the care gap

Implementation Network

© Continuing Medical Implementation ® …...bridging the care gap Recognition-Screening-Initial Therapy- Family MD Community Based Awareness/Understanding How can we amplify the impact of preventative strategies? Risk Stratification-Rx Optimization/ Adherence-FD & Specialist Specialist/Cardiologist-Invasive Dx/Tx- Monitoring/Rehab/Reinforcement Interventions-Revascularization-Devices- Procedures 4º 2º & 3º 1º & 2º Primary Care Physician Prevention Awareness Programs/PHN

© Continuing Medical Implementation ® …...bridging the care gap Network of Networks

© Continuing Medical Implementation ® …...bridging the care gap Summary Cardiovascular diseases pose a huge clinical and economic burden Metabolic precursors including obesity, dyslipidemia, metabolic syndrome, IFG, DM are epidemic Inactivity, smoking, hypertension, CHF & AFIB add to the global burden Prevention is sub-optimal/proven therapies are underutilized-there remains a huge Care Gap

© Continuing Medical Implementation ® …...bridging the care gap Summary Comprehensive primary & secondary prevention strategies are required Multiple interventions are required to Bridge the Care Gap Educational resources and management tools are necessary at point of care may be a useful vehicle in this regardwww.cvtoolbox.com