Hospital case study May 2015
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Transcript of Hospital case study May 2015
Anatomy of a SuccessfulPrevention Practice
A Case Study for Providers
Prevention is common sense...but is it profitable?
“The doctor of the futurewill give no medicines, butwill interest his patients inthe care of the humanframe, in diet, and in thecauses and prevention ofdisease.”
Thomas Edison, 1847-1931
“Today’s risky behaviors becometomorrow’s risk factors, and today’srisk factors become tomorrow’scardiovascular events.”
Dr. K. Srinath ReddyPresident of the
World Heart Federation
Strategic Goals• Simplify Your Practice• Streamline and Standardize care with Best Science
• Improve Patient Outcomes• Pay for Performance metrics achieved
• Enhance Revenue Generation• Patient Retention and Ancillary Services
• Reclaim Leadership Role for Primary Care Providers• Become a Center of Excellence
Clinic/Practice Model
• Private medical practice in a major suburban environment
• 15-year database of clinical results
• 800+ patients
Clinic/Practice Strategy: Prevention
• Identify risk and disease – arteriology focus
• Lipid status• Oxidative stress evaluation• Inflammation status• Metabolic factors• Genetics• Nutritional factors• RAAS system
Clinic/Practice Program
• RISK STRATIFICATION ALGORITHM
• EVALUATION ALGORITHM
• TREATMENT ALGORITHM
• OPTIMAL GOALS ESTABLISHED
• EDUCATIONAL SUPPORT SYSTEM
Advanced Technologies
ENDOTHELIAL FUNCTION TESTING
PLAQUE DETECTION
CAROTID INTIMA MEDIA THICKNESS TESTING (CIMT)
ANKLE-BRACHIAL INDEX
Advanced Biomarker Testing
ADVANCED LIPIDS
INFLAMMATION ASSESSMENT
INSULIN RESISTANCE
MYOCARDIAL FUNCTION
Clinic/Practice Algorithm FlowInitialPre-
Screen (online or
paper)
Initial Intake Visit
&Blood Draw
Testing
Plan Delivery
Visit
Continual Follow-up
Visits
Monitor Testing
Practice DemographicsDisease
Management Practice
Prevention Clinic
Wellness Center
After 25+ years, the M.D.’s patients are aging with him...
• Patients 100 years or older: 2• Patients 90 years or older: 51• Patients age 85 to 89 years: 74• Patients age 80 to 85 years: 195`
Practice DemographicsDisease
Management Practice
Prevention Clinic
Wellness Center
Revenue by payer type:
Medicare: 47.6%BCBS: 28.4%Commercial: 22.1%Misc.: 1.8%
Practice Mortality Statistics2001 - 2011
• Total Deaths: 163
• CAD/CVA: 30 (18.4%)
• All Others: 133 (81.6%)
• CVD Rate at <65: 17%
• CVD Rate at >80: 16%
• CVD Deaths > 80: 50%
Personalized Prevention Plans
• Medication changes• Weight loss goals• Exercise goals• Dietary plans• Diagnostic plans• Follow-up visits with
– FNP– Dietician– Wellness Center staff– Disease Management
Practice– Diabetes Store Classes
Used the available evidence, the data, to predict and prevent the onset of disease
Leading Causes of Death...and Heart Disease, Stroke, and Diabetes
1990 - 2010
Diet is #1
Weight is #3
Inactivity is #6
ObesityCDC's Behavioral Risk Factor Surveillance System (BRFSS) available at http://www.cdc.gov/obesity/data/trends.html
Diabetes
Diabetes Epidemic Predicted by CDC
• Currently 8.3% of U.S. adults (26 million people)suffer from diabetes.
• By 2050, 33% (more than 100 million people) will havea form of diabetes.
• 5,000 new cases every day over the next 40 years
• 80% of diabetics die of heart attack (60%) or stroke(20%)
Heart Disease
Arterial Biology
“A man is as old as his arteries.”
Thomas Sydenham, 1624-1689Father of English Medicine
CIMT FINDS DISEASE
Belcaro, G., et. al. (2001). “Carotid and femoral ultrasound morphology screening and cardiovascular events in low risk subjects: a 10-year follow-up study (the CAFES-CAVEstudy).” Atherosclerosis 156: 379-387.
The Utility and Promise of
Correlates with ASCVD Risk Factor levels Directly related to risk of Vascular
Events Correlates with ASCVD elsewhere
Reflects Pathophysiology of Entire Arterial Vasculature
Rate of Change is Measurable Reflective of Atherosclerotic Process
Progression Regression
Modifiable with Treatment Reflects Cardiovascular Risk
CarotidIntimaMedia ThicknessUltrasound(CIMT)
Cholesterol: Truth or Myth?
“If my cholesterol is normal I won’t have a heart attack.”
Truth: More than half of all heart attacksoccur in people with normal cholesterol. Thereare tests to find those at risk.
Cholesterol: Truth or Myth?
“If I take a statin drug and lower my LDLcholesterol, I wont have a heart attack.”
Truth: Statin drugs only prevent about 1 out 3heart attacks – the other two will still occurunless action is taken.
Cholesterol: Truth or Myth?
“Everyone in my family dies of a heart attack, so Iknow it’s inevitable.”
Truth: Family history is predictive, not destiny.There are several genetic tests now availableto uncover some of the causes.
Cholesterol: Truth or Myth?
“My doctor told me my HDL cholesterol is so high I’ll never have a heart attack.”
Truth: We now know that not all HDL isprotective – and there are tests to help decidethis.
Standard Lipid Levels in Heart Attack
• Get With The Guidelines Database*
• 136,905 hospitalized with CAD• 70% ACS• 30% Chest pain and known CAD• 83% LDL < 130 mg/dl• 50% LDL < 100 mg/dl• 18% LDL < 70 mg/dl
• At most, 25% of premature heart disease was attributable to elevated LDL
*Sachdeva A, et al. Am Heart J. 2009;157:111-7.
• Get With The Guidelines Database*
• 136,905 hospitalized with CAD• 70% ACS• 30% Chest pain and known
CAD• 45% HDL > 40 mg/dl*Sachdeva A, et al. Am Heart J. 2009;157:111-7.
Standard Lipid Levels in Heart Attack
Standard Lipid Levels in Heart Attack• Get With The Guidelines
Database*• 136,905 hospitalized with CAD
• 70% ACS• 30% Chest pain and known CAD• 70% Trigs < 150 mg/dl
*Sachdeva A, et al. Am Heart J. 2009;157:111-7.
Russell Ross’s response to injury hypothesis
1976
Injury
CholesterolApproximately
50% of individuals who experience heart attack or
stroke have normal lipids
Response
Inflammation
Vascular InflammationMyeloperoxidase (MPO)Inflammation outside the vessel wall – in the bloodstream – dueto the WBC response to arterial damage or vulnerable plaqueLp-PLA2 (The PLAC® Test)Inflammation inside the vessel wall due to cholesterolaccumulation
Endothelial Damage
Urinary MicroalbuminEndothelial damage in the kidneys that may indicate riskof endothelial damage in other parts of the body andrisk for cardiovascular disease
General InflammationhsCRPAn acute phase – or short-term – protein produced by theliver in response to body damage or infection. Also,associated with the presence of cardiovascular disease.
Oxidation/LifestyleOxidized LDLLDL cholesterol – or “bad” cholesterol – may become damaged dueto oxidation and identifies increased risk of metabolic syndromeF2-IsoprostanesFormed in your body due to red meat intake, smoking or lack ofexercise and place you at risk for cardiovascular disease
Endothelial health is key
Risk of Disease
Presence of Disease
Disease Activity
Endothelial Damage
Cholesterol Accumulation
Plaque activity/rupture/event
Biomarkers to Better Define Patients at Risk
Long-TermRisk
Mid-Term Risk
Near-Term Risk
Life Long Decade(s) YearsStandard
Lipid Panel
Advanced Lipid
Testing
InflammatoryMarkers
Inflammation TestingOxidation
Disease initiation/Plaque growth
Plaque maturation/Vulnerable plaque Acute coronary syndrome
LOW RISK
RISK OF DISEASE
MODERATERISK
PRESENCEOF DISEASE
HIGHRISK
DISEASE ACTIVITY
Why Monitor Inflammation?Studies continue to show the value of assessing the degree of inflammation in a patient
Younger Patient Older Patient
Plaque formation
Healthy Vulnerable plaque
Adverse events (MI, stroke, death)
hsCRP is a more reliable predictor ofcardiovascular events in women thanLDL-C
Women’s Health Study
28,345 women (8 yrs.; 15,745 were not on HRT)
hsCRP and LDL-C measured at baseline
Ridker PM et al. Comparison of C-reactive protein and low-density lipoproteincholesterol levels in the prediction of first cardiovascular events. N Engl J Med.2002; 347: 1557-1565.
The Two Sides of Vulnerable Plaque
Outside the vessel wallMPO can be used to tell us ifcirculating white blood cells are beingactivated in response to fissures,erosions or warming plaque increasingthe risk of vulnerable plaque rupture
Inside the vessel wallLp-PLA2 can be used to tell us if there is active inflammation within the vessel wall that could contribute to vulnerable plaque formation
MPO & CRP have combined utility in predicting cardiovascular mortality risk in patients with angiographic
evidence of CAD
Patients with either a high MPO or high CRP elevated had 5.3-foldhigher mortality risk
Patients with high levels of both MPO and CRP had a 4.3-fold risk vs. patients with only one elevated
marker
MPO CRPLow and Low
High or High
High and High
Log-rank test: p<0.001 for trend
Modified from Heslop CL et al. Myeloperoxidase and C-reactive protein have combined utility for long-term prediction ofcardiovascular mortality after coronary angiography. J Am Coll Cardiol . 2010; 55:1102-1109.
The Two Sides of Vulnerable Plaque
Outside the vessel wallMPO can be used to tell us if circulating white blood cells are being activated in response to fissures, erosions or warming plaque increasing the risk of vulnerable plaque rupture
Inside the vessel wallLp-PLA2 can be used to tell us if there is active inflammation within the vessel wall that could contribute to vulnerable plaque formation
High Lp-PLA2 and Low MPO
Interpretation: Active artery wall,but a stable collagen cap
Management of Lp-PLA2 Levels
Assess LDL-C• Initiate/titrate statin therapy, if
medically necessaryUtilize 10-yr. ACC/AHA CV risk calculator
Lp-PLA2
≤200 >200
Monitor every 6 mo.
Assess diet/lifestyleAssess blood pressureAssess insulin sensitivityAssess dental health
Assess presence of CAD w/ imaging (CIMT/CACS)If clinically appropriate, consider dual platelet inhibition
Assess risk for pre-diabetes/diabetesIf pre-diabetic/ diabetic, consider insulin sensitizing therapy
Assess CoQ10 levelsIf low, consider supplementation for its cardioprotective benefits
With the aforementioned ruled out, consider Hashimoto’s thyroiditis or serious liver issues which may result in the overproduction of Lp-PLA2.
The Two Sides of Vulnerable Plaque
Outside the vessel wallMPO can be used to tell us if circulating white blood cells are being activated in response to fissures, erosions or warming plaque increasing the risk of vulnerable plaque rupture
Inside the vessel wallLp-PLA2 can be used to tell us if there is active inflammation within the vessel wall that could contribute to vulnerable plaque formation
Low Lp-PLA2 and High MPO
Interpretation: Less active artery wall, but an unstable collagen cap
Management of MPO LevelsAssess LDL-C• Initiate/titrate statin therapy, if
medically necessaryUtilize 10-yr. ACC/AHA CV risk calculator
MPO
<470 470-539 or ≥539
Monitor every 6 mo.
in the absence of chest pain
Assess diet/lifestyleAssess blood pressureAssess insulin sensitivityAssess dental health
Assess presence of CAD w/ imaging (CIMT/CACS)• If clinically
appropriate, consider dual platelet inhibition
Assess risk for pre-diabetes/diabetes
• If pre-diabetic/ diabetic, consider insulin sensitizing therapy
Assess CoQ10 levels
• If low, consider supplementation for its cardioprotective benefits
With the aforementioned ruled out, consider the presence of inflammatory conditions (RA, systemic lupus erythematosus, Crohn’s disease, or vasculitis) or the presence of bone marrow dyscrasias. Also, assess extreme exercise levels.
Inflammation TestingTest Identifies
Risk of DiseaseF2-Isoprostanes Oxidation
Oxidized LDL Metabolic Syndrome Risk
Presence of DiseasehsCRP General InflammationMicroalbumin Endothelial Dysfunction
Disease ActivityLp-PLA2 (The PLAC® Test) Vulnerable Plaque Risk
(Active Necrotic Core)
Myeloperoxidase Vulnerable Plaque Risk(Luminal aspect of artery)
Insulin Resistance• More than 70% of Coronary Artery Disease/Acute Coronary Syndrome
sufferers are insulin resistant (Diabetes Care 2008; 31:1955-1959/Lancet 2007; 370:667-675)
• Every 18mg/dl above 140mg/dl at 2-hour plasma glucose increases cardiovascular and all-cause death rates by 26% over 6-7 years (Diabetes Care 2009; 32:1721-1726)
• Hgb A1C cut points were designed for microvascular complication prediction, NOT Cardiovascular Disease...(Diabetes Care 2009; 32:1721-1726/NEJM 2010; 362:800-811)
– A1C >5.5% AND <6.5% IS A RISK FACTOR FOR CVD:– 5.5 TO <6% 1.23 x HAZARD RATIO– 6 TO < 6.5% 1.95 x HAZARD RATIO
• 2 HOUR PLASMA GLUCOSE BETA CELL FUNCTION100-119mg/dl DECLINE STARTS120-139mg/dl 40-50% LOSS140-200mg/dl >50% LOSS
Diagnosis of Insulin Resistance
• Metabolic Syndrome is 90% IR specific; 10%false positive
• 50% with IR do not have Metabolic Syndrome;50% sensitivity
• Fasting Plasma Glucose > 100 mg/dl• 1 hour post glucose load > 125 mg/dl• 2 hour post glucose load > 120 mg/dl• Hgb A1C > 6.5%--definite; > 5.7% suspiciousDiabetes Care 2004; 27:978-983
Diagnosis• Metabolic Syndrome• Presence of 3 of 5 following risk factors:
Risk Factor MEN WOMEN
Waist Circumference >40” >35”
HDL Cholesterol <40mg/dl <50mg/dl
Triglycerides >150mg/dl >150mg/dl
Blood Pressure >130 systolic OR >85 diastolic
Fasting Plasma Glucose 100mg/dl 100mg/dl
Oral Glucose Tolerance TestFindings through January 2012
Normal Results 141 22.8%Insulin Resistant 441 71.3%Diabetes 36 5.8%Total Patients Tested 618
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“Changing ingrained behavior isdifficult. When sciencechallenges existing paradigms,we need effective strategiesto overcome lingering, stronglyheld beliefs.”
Frederick Masoudi, MD 2011
Implementation Barriers to Prevention
• I’m already swamped with acute care and complex chronic disease problems!
• I’m already managing their diabetes/cholesterol/blood pressure/etc.
• I’m following the guidelines already.• Insurance reimbursements aren’t adequate.• How do I keep up with the rapidly changing science?
Red-Flag Assessment• Obstructive Sleep Apnea• Sleep Deprivation, any cause• Metabolic Syndrome• Psoriasis• Sjogren’s Syndrome• Systemic Lupus• Migraine• Periodontal Disease• Hypothyroidism• Hyperuricemia/Gout• Polycystic Ovarian Syndrome• Miscarriages• Gestational Diabetes, history• Preeclampsia• Kidney Stones• Elevated GGT
• Erectile Dysfunction• First Responder work types• TV viewing time > 2 hours daily• Short Height (April 2015 NEJM
article)• Caffeine in slow metabolizers• Chronic Kidney Disease• Ear Lobe Creases under 40yo• Xanthelasma• Trigeminal Neuralgia• Second Hand Smoke• Hispanic/Latino ethnicity• Spouse Caregivers of Cancer Patient• Low Vitamin D• Sitting (6 hours a day = smoking 1
ppd)
Lowering My Risk• American Heart Association “Simple 7’s”• Less than 1% of us do all seven
Lowering My Risk1. Never smoked, or quit more than a year ago.2. Having a body mass index of less than 25 kg/m2.3. Exercising at a moderate level for at least 150
minutes, or at an intense level for 75 minutes perweek.
4. Meeting four to five of the key components of ahealthy diet in line with current AHA guidelines.
5. Having a total cholesterol of less than 200 mg/dL.6. Blood pressure below 120/80 mm Hg.7. Fasting blood glucose below 100 mg/dL.
Diabetes PreventionLose 7% of weight
150 min aerobic activity weekly• ~30mins 5 days a week• High-intensity interval training• Discuss with your doctor
Muscle resistance training 3 days/week
Metformin therapy? Discuss with your doctor
Treatment Options Beyond Statins
• Insulin Resistance Therapies• Metformin, Pioglitazone, Acarbose• Inflammation• Search for Causes, Statin adjustment, Omega 3, Insulin
Resistance• RAAS blockade—HOPE Trial• Cholesterol Absorption Blockade
Treatment Options Beyond Statins
• Apo E Dietary Implications
• Apo E2: Low Carb, Higher Fat (35%), alcohol allowed
• Apo E3: Neutral effect of carb/fat/alcohol
• Apo E4: Low Fat (20%), More Carbs, No alcohol
• Vitamin D Repletion
• Exercise Prescription
• High Intensity-Interval Training (HIIT)
• Obstructive Sleep Apnea
Treatment OptionsBeyond Statins
• Niacin—lp(a), LDL particle size, HDL particle size, Apo B, Triglycerides, Inflammation
• HATS
• Arbiter 2
• Arbiter 6-HALTS
• AIM-HIGH
• HPS2-THRIVE
Diabetes Projections for One Company
• 35,000 employees (15,000 under 45; 20,000 over 45)
• 2975 known diabetics, 1115 diabetics not yet diagnosed
• 4090 total diabetics -- 294 new diabetics every year• 80% will have a stroke or heart attack at least once
in their lives...• ...and they are already costing their employers 20
cents of every dollar of healthcare spend JUST for their diabetes
ACS Hidden & Long-Term Costs are Significant
• About 47% of patients with ACS in the US areyounger than the eligibility age for Medicare
• Enhanced focus on ACS prevention should yieldgreater-than-expected savings
• Economic benefit of avoiding ACS should beincentive for employers to expand coverage ofprevention efforts
Dr. Robert L. Page (University of Colorado School of Pharmacy, Aurora) 11/5/2012 American Heart Association (AHA) 2012 Scientific Sessions.
ACS Hidden & Long-Term Costs are Significant
• 37,340 employees of service companies with ACS claims; 95% were younger than 65
• Direct out of pocket first year cost to patient ~$8,170
• Short term (~2mos.) disability cost: $2,263 to pt.; $7,943 to employer
• Long term (~398 days) disability cost: $20,609 to pt.; $52, 473 to employer
Dr. Robert L. Page (University of Colorado School of Pharmacy, Aurora) 11/5/2012 American Heart Association (AHA) 2012 Scientific Sessions.
The Ancient Science of Prevention
“Superior doctors prevent the disease.Mediocre doctors treat the disease before itis evident. Inferior doctors treat the full-blown disease.”
Huang Dee Nai-Chang, from the first known Chinese medical text, ca. 2600 B.C.
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