The California Right Care Initiative (Text Version)

Slide presentation from the AHRQ 2009 conference

On September 16, 2009, Robert Kaplan made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation ( 1.89 KB) (Plugin Software Help).


Slide 1

Slide 1. The California Right Care Initiative

The California Right Care Initiative

Robert M. Kaplan
Wasserman Distinguished Professor
UCLA Schools of Public Health and Medicine
AHRQ Conference

Slide 2

Slide 2. The Translation Problem

The Translation Problem

Slide 3

Slide 3. NIH View of Translational Research

NIH View of Translational Research

Image of a flowchart showing the research process:

Bench research - Phase I - Clinical research - Phase II - Community research and application, and then back to Bench research

  • According to the National Institutes of Health, "in order to improve human health, scientific studies must be translated into practical applications."

Slide 4

Slide 4. Where is this going

Where is this going

  • Cardiovascular disease is common.
  • Risk factors have been known for 50 years
  • Evidence clearly shows that modifying some risk factors reduces events
  • Population level modification of risk factors has been disappointing 
  • Several strategies show promise for risk factor modification in group practices

Slide 5

Slide 5. More than one in three adults have prevalent CVD

More than one in three adults have prevalent CVD

Percentage of population between 20-39:

  • Men: 15.9
  • Women: 7.8

Percentage of population between 40-59:

  • Men: 37.9
  • Women: 38.5

Percentage of population between 60-79:

  • Men: 73.3
  • Women: 72.6

Percentage of population between 80+:

  • Men: 79.3
  • Women: 85.9

Prevalence of CVD in adults age 20 and older by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.

These data include coronary heart disease, heart failure, stroke and hypertension.

Slide 6

Slide 6. There are more than 850,000 CVD deaths per year 1/3rd before age 75, 50% higher than cancer deaths

There are more than 850,000 CVD deaths per year 1/3rd before age 75, 50% higher than cancer deaths

Percentage of Deaths in Thousands < 45:

  • CVD: 26
  • Cancer: 21

Percentage of Deaths in Thousands 45-54:

  • CVD: 48
  • Cancer: 50

Percentage of Deaths in Thousands 55-64:

  • CVD: 81
  • Cancer: 99

Percentage of Deaths in Thousands 65-74:

  • CVD: 125
  • Cancer: 138

Percentage of Deaths in Thousands 75-84:

  • CVD: 258
  • Cancer: 166

Percentage of Deaths in Thousands 85+:

  • CVD: 327
  • Cancer: 83

Percentage of Deaths in Thousands Total:

  • CVD: 864
  • Cancer: 559

CVD deaths vs. cancer deaths by age.
(United States: 2005). Source: NCHS and NHLBI.

Slide 7

Slide 7. 6 Year CHD Mortality by Total Serum Cholesterol 356,222 Men Screened for MRFIT, Aged 35-57 Yrs

6 Year CHD Mortality by Total Serum Cholesterol 356,222 Men Screened for MRFIT, Aged 35-57 Yrs

Chart of Age Adjustment CHD Death Rate/1,000 Men Vs. Serum Cholesterol (mg/dL)

Slide 8

Slide 8. LDL-C Lowering With Statins Reduced CHD Events

LDL-C Lowering With Statins Reduced CHD Events

Chart of Primary Prevention and Secondary Prevention
Events vs. LDL Cholesterol (mg/dL)

Slide 9

Slide 9. Clinical Event Reduction in Clinical Trials

Clinical Event Reduction in Clinical Trials

Chart of Control and Treatment of Clinical Events broken down by percentage.
(Superko, H. R. et al. Circulation 2008;117:560-568))

Slide 10

Slide 10. From Prospective Studies Collaboration: 61 studies, 1 million Adults

From Prospective Studies Collaboration: 61 studies, 1 million Adults

Graph of two charts broken down by age, one is Systolic Blood Pressure, the other is Diastolic Blood Pressure.

Lancet 2002, 360, 1904

Slide 11

Slide 11. BP Lowering Trial Results

BP Lowering Trial Results

Collins & Peto. Textbook of Hypertension 1994 Blackwell Scientific Publications p1159. 

Slide 12

Slide 12. Evidence Based Opinions

Evidence Based Opinions

  • Most people with HTN will need 2 or 3 medications to control BP.
  • Diuretic/ACEI, Diuretic/ARB, CCB/ACEI, CCB/ARB likely good first choices for combination Rx.
  • Diuretic/CCB combination of uncertain effectiveness.
  • Reserpine underused, but probably a good third line agent.

Slide 13

Slide 13. The Payoff is Potentially Large: Benefits of Lowering BP

The Payoff is Potentially Large: Benefits of Lowering BP

Average Percent Reduction

  • Stroke incidence 35-40%
  • Myocardial infarction 20-25%
  • Heart Failure 50%

Slide 14

Slide 14. Mortality and AHA Get with the Guidelines Awards

Mortality and AHA Get with the Guidelines Awards

Award Hospital Effect
30-day Mortality Rate (%)

Heart Failure Mortality

  • Adjusted for case mix: -.2
  • Above plus hospital characteristics: -.1
  • Above plus Surgical and Pneumonia Measures: -.1
  • Above Plus HF and AMI measures: -.1

Acute MI Mortality

  • Adjusted for case mix: -.3
  • Above plus hospital characteristics: -.2
  • Above plus Surgical and Pneumonia Measures: -.2
  • Above Plus HF and AMI measures: -.1

Heidenreich, AHJ (In Press)

Slide 15

Slide 15. But, BP Control Rates Remain Disappointing

But, BP Control Rates Remain Disappointing

Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74

National Health and Nutrition Examination Survey

 II
1976-80
III
(phase 1)
1988-91
III
(phase 2)
1991-94
IV
1999-2000
Awareness51%73%68%70%
Treatment31%55%54%59%
Control10%29%27%34%

Slide 16

Slide 16. Extent of Awareness, Treatment and Control of High Blood Pressure by Age (NHANES: 2005-2006)

Extent of Awareness, Treatment and Control of High Blood Pressure by Age (NHANES: 2005-2006).

Awareness

  • Percentage of Population with Hypertension between the ages of 20-39: 53.8%
  • Percentage of Population with Hypertension between the ages of 40-59: 79.9%
  • Percentage of Population with Hypertension between the ages of 60+: 82.4%

Treatment

  • Percentage of Population with Hypertension between the ages of 20-39: 33.1%
  • Percentage of Population with Hypertension between the ages of 40-59: 67.2%
  • Percentage of Population with Hypertension between the ages of 60+: 77.2%

Controlled

  • Percentage of Population with Hypertension between the ages of 20-39: 27.9%
  • Percentage of Population with Hypertension between the ages of 40-59: 48.8%
  • Percentage of Population with Hypertension between the ages of 60+: 45.9%

Source: NCHS and NHLBI.

Slide 17

Slide 17. Why Focus on Lipids and Blood Pressure Even for People with Diabetes?

Why Focus on Lipids and Blood Pressure Even for People with Diabetes? (Ray: Lancet 2009, 373,1765)

Chart of Intensive treatment vs. standard treatment

Slide 18

Slide 18. California Problem

California Problem

Slide 19

Slide 19. The LA-San Diego Contrast

The LA-San Diego Contrast

Question: Is health care in West LA as unusual as the people who live there?

Image of Los Angeles
Image of San Diego

Slide 20

Slide 20. Figure of Total 2005 Medicare expenditures in Los Angeles and San Diego HSAs

Figure of Total 2005 Medicare expenditures in Los Angeles and San Diego HSAs

Slide 21

Slide 21. Total Medicare Reimbursements per enrollee (Part A + Part B)

Total Medicare Reimbursements per enrollee (Part A + Part B)

Figure of LA vs. SD
Los Angeles is between 8,000 and 14,000
San Diego is between 7,000 and 8,500

Slide 22

Slide 22. Hospital Admissions During Last 6 Months of Life

Hospital Admissions During Last 6 Months of Life

Figure of LA vs. SD
Los Angeles is between 1,400 and 1,900
San Diego is between 1,100 and 1,300

Slide 23

Slide 23. California Pay for Performance: Clinical Performance Variation

California Pay for Performance:Clinical Performance Variation: Composite Clinical Score (from Williams 2008)

  • Inland Empire:: 65
  • Los Angeles: 67
  • Central Cost: 69
  • Central Valley: 70
  • San Diego: 71
  • Orange County: 74
  • Bay Area: 76
  • Sacramento/North: 77
  • Statewide: 70

Slide 24

Slide 24. California Pay for Performance: A Tale of Two Regions

California Pay for Performance:A Tale of Two Regions (From Williams 2008)

Inland Empire

  • All Groups: 66
  • Top Performing Groups: 85

Bay Area

  • All Groups: 79
  • Top Performing Groups: 85

Slide 25

Slide 25. Berwick's Rules for Dissemination

Berwick's Rules for Dissemination

Seven 'rules' for translating research into practice; require an implementer to

  1. Find sound innovations
  2. Find and support innovators
  3. Invest in early adopters
  4. Make early adopter activity observable
  5. Trust and enable reinvention
  6. Create slack for change
  7. Lead by example

Berwick, JAMA.2003;289:1969-1975.

Slide 26

Slide 26. History of RCI

History of RCI

  • In 2007, Governor Schwarzenegger's health reform proposal called for healthcare quality improvement. In response, NCQA and the California Department of Managed Health Care (DMHC) collaborated in launching a statewide effort known as the Right Care Initiative (RCI) to improve the quality of care delivered to commercial HMO members in California.

Slide 27

Slide 27. RCI Goals

RCI Goals

  • To improve clinical outcomes through enhancing the practice of evidence-based medicine and management in a collaborative, expert-based, public-private, multi-year effort. Targets
    • Diabetes, heart disease, HAIs

Slide 28

Slide 28. California's HEDIS Scores

California's HEDIS Scores

  • California's HEDIS rankings are surprisingly low relative to the best plans in the nation. No California health plan other than Kaiser Permanente ranks among the top ten plans in the nation or above the 90th percentile for heart and diabetes performance measures

Slide 29

Slide 29. California Right Care Initiative: Percent of Plans Meeting HEDIS LDL

California Right Care Initiative: Percent of Plans Meeting HEDIS LDL Standard 2009

Cardiovascular LDL-C Level <100
CaliforniaNational Top 10
Kaiser - CA (Northern CA)

66.04

Humana Health LA

78.68

Blue Cross of California

65.74

PersonalCare Insurance of IL

75.89

CIGNA HealthCare of CA

64.48

PacifiCare of Texas

73.58

Health Net of California

62.84

Network Health Plan

72.85

Blue Shield of California

62.58

Gundersen Lutheran Health Plan, Inc.

72.48

Kaiser - CA (Southern CA)

62.53

CIGNA HealthCare of MA

71.78

Aetna California

61.16

Humana Health Plan of TX

71.7

Western Health Advantage

59.87

Capital Health Plan

71.29

PacifiCare of California

56.84

Group Health Coop of South Central WI

70.59

Ventura County Health Care Plan

NR

CIGNA HealthCare of NH

70.56

California Average

60.63

National Mean

56.61

 

 

National 90th

66.18

Slide 30

Slide 30. California Right Care Initiative: Percent of Plans Meeting HEDIS Blood Pressure Standard

California Right Care Initiative: Percent of Plans Meeting HEDIS Blood Pressure Standard 2009

Controlling High Blood Pressure
CaliforniaNational Top 10
Kaiser - CA (Southern CA)

73.97

PersonalCare

79.73

Kaiser - CA (Northern CA)

73.31

CIGNA Mid-Atlantic

75.67

CIGNA HealthCare of CA

64.23

HealthAmerica

75.23

Health Net of California

62.23

Kaiser - CA (Southern CA)

73.97

Aetna California

61.06

Kaiser - CA (Northern CA)

73.31

Western Health Advantage

60.83

Aetna Ohio

72.42

Blue Cross of California

60.04

Security Health Plan of WI

71.78

Blue Shield of California

58.60

Anthem BCBS - CT

71.75

PacifiCare of California

53.81

MVP Health Plan, Inc

71.23

Ventura County Health Care Plan

NR

ConnectiCare

70.80

California Average

63.40

National Mean

59.66

 

 

National 90th

68.13

Slide 31

Slide 31. Emerging web-based GIS and social networking tools will also facilitate multi-stakeholder QI efforts

Emerging web-based GIS & social networking tools will also facilitate multi-stakeholder QI efforts

Slide 32

Slide 32. Reasons to Support MTM

Reasons to Support MTM

  • Cochrane review ( 2000) The Cochrane group found pharmacist-based interventions encouraging
  • Increasing evidence form controlled studies that the Ashville principles can be used to control CHD risk factors. The effect on health outcomes awaits evaluation (Carter et al 2008).

Slide 33

Slide 33. Evidence of Effectiveness for CDSMP

Evidence of Effectiveness for CDSMP

  • 2008 (CDC) review of published studies (Gordon and Galloway 2008).
    • Four studies reported lower ER visits, 
    • Three studies demonstrated reduced hospitalizations
    • Four studies reported reduced number of days in the hospital,
    • Two studies reporting statistically significant reductions in outpatient visits.
    • Significant reduction in health care costs

Slide 34

Slide 34. What is ALL?

What is ALL?

  • ALL stands for
    • Aspirin 81 mg, 
    • Lisinopril 20 mg, &
    • Lipid lowering with simvastatin 40 mg/day
    • ALL is a Polypill (but delivered in 3 pills)
  • Suggested that the clinical and cost effectiveness of increasing ALL use in
    • CAD and
    • diabetic (55+) populations

Slide 35

Slide 35. Evaluation of ALL (Polypill) TIPPS Trial 50 Centers in India

Evaluation of ALL (Polypill) TIPPS Trial 50 Centers in India (ACC 2009)

  • Double-blind study, enrolled 2053 patients aged 45 to 80 years without cardiovascular disease but with one risk factor, type 2 diabetes, high blood pressure, smoker within past five years, increased waist-to-hip ratio, or abnormal lipids
    • Pill well tolerated, but
      • Lower than expected reductions in
        • LDL
        • SBP
        • Compliance lower than expected
        • No health outcome data available at this time

Slide 36

Slide 36. Steps from A to B

Steps from A to B

Disseminate Best Practices
Implement and Evaluate Intervention
Identify Evidence-Based Practices
Get Stakeholders & Other Experts Together
Focus Attention on the Problem
 

Slide 37

Slide 37. Right Care Proposed Strategies

Right Care Proposed Strategies

  • Greater use of electronic technologies. Greater of pharmacist managed care Departure from reactive, appointment based care

Slide 38

Slide 38. RCI Collaborators

RCI Collaborators

  • Government - California Department of Managed Health Care
  • Health Plans-Medical Directors - Kaiser, Blue Shield, United, Aetna..
  • Academic - UC Berkeley, UCLA, UCSD, USC
  • Research Organizations - RAND, VA, Lumetra
  • Medical Groups - California Association of Physician Groups
Current as of December 2009
Internet Citation: The California Right Care Initiative (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/kaplan/index.html