Rational Allocation of Cardiovascular Care A DELICATE BALANCE: Resource allocation in cardiovascular care Eric A. Cohen MD, FRCPC Schulich Heart Centre, Sunnybrook Health Sciences Centre Toronto, ON ACC Rockies Banff AB, March 2013
Rational Allocation of Cardiovascular Care Disclosures • Relevant to this presentation, ERIC COHEN has received financial support within the past three years for consulting and/or CME from: • sanofi-aventis • Eli Lilly • AstraZeneca • Novartis • Sepracor / Sunovion • Medtronic • Boston Scientific • Abbott Vascular October, 2012
Rational Allocation of Cardiovascular Care Additional disclosures • Advisory • Ministry of Health & Long-Term Care (Ontario) • Cardiac Care Network • Health Quality Ontario • Health Canada • Administrative • Schulich Heart Program, Sunnybrook Health Sciences Centre
Rational Allocation of Cardiovascular Care Outline • Dilemmas • Insights • A conceptual proposal for change
Rational Allocation of Cardiovascular Care Dilemma #1 • You’re an interventional cardiologist about to stent the mid -RCA of a non- diabetic 72 year old woman • The lesion is a bit long (20-25 mm) but the vessel is large (3.5 mm) • Her brother had PCI and a lot of difficulty with restenosis • A bare metal stent in your lab costs $300 and a drug eluting stent $900 • What type of stent are you going to implant?
Rational Allocation of Cardiovascular Care Dilemma #2 • You are the (physician) cardiac program director in a large hospital with a structural heart program. • Your team has been doing 40 TAVI procedures per year using donated funds, but the waiting list is growing and several patients have died while waiting, including 2 last week. • The CEO (also a physician) has made it clear there are no funds from outside the cardiac program to increase TAVI volume, but has suggested that you as program director could impose a reduction on the use of drug-eluting stents and use the savings to fund additional TAVI cases. • The patient currently #7 on the TAVI wait list – as well as the woman in dilemma #1 – are both anxiously awaiting your decision.
Rational Allocation of Cardiovascular Care Dilemma #3 • You’re a pharmacist with responsibility for publicly funded drug reimbursement in a hypothetical province. • You’ve received funding requests for several new anti -platelet / anti- coagulant drugs that appear to show clinical benefit and in some cases reasonable cost-effectiveness. • The current drug budget is at its limit. • Under new rules to enhance accountability in the public sector, your own salary is subject to performance bonus or penalty, according to whether the drug budget is under- or over-spent. • Drug companies, cardiologists, and the woman in dilemma #1 all await your decision
Rational Allocation of Cardiovascular Care Dilemma #4 • You’re the Minister of Health (of the same hypothetical province). • Your own riding has no invasive cardiac centre; there is pressure from the community and from local cardiologists to establish a new cath facility. • You understand the benefits of prompt access to cath, but you’ve also heard concerns about the relatively low volume of procedures that will be done. • You are frustrated because despite convening (and paying for) a so-called “expert consensus panel” there seems to be no consensus. • Your constituents, the local cardiologists, and – you guessed it - the woman in dilemma #1 - all await your decision.
Rational Allocation of Cardiovascular Care What is unique about resource allocation in the cardiovascular domain? Magnitude (clinical and economic) 1. Potential lethality 2. Non-linear relationship between treatment and outcome 3. Abundance of technology 4.
Rational Allocation of Cardiovascular Care Insight #1: These are complex decisions Clinical evidence • Multiple inputs, each with a Politics and Economic degree of uncertainty timing analysis Allocation • No clear rules on weighting the various inputs Decision • In this context, can Ethics & Affordability allocation decisions ever be values truly “rational”? Guidelines, Appropriate use criteria
Rational Allocation of Cardiovascular Care Insight #2: Being smart is not enough • His job is all about resource allocation decisions • “Infinite” budget but finite salary cap • He’s very smart (Harvard Law 1981) • He was successful – on the balance sheet . . . . . • But that wasn’t enough
Rational Allocation of Cardiovascular Care Insight #3: Allocation happens anyway Example: ST elevation MI • One of the most common . . . • One of the most clearly defined . . . Conditions of all time • One of the most studied . . .
Rational Allocation of Cardiovascular Care Insight #3: Allocation happens anyway Clinical evidence Politics and Economic timing analysis Allocation Decision Ethics & Affordability values Guidelines, Appropriate use criteria
Rational Allocation of Cardiovascular Care Explicit values and preferences Values and preferences. This recommendation places relatively greater weight on the absolute reduction of stroke risk with OACs compared with ASA and less weight on the absolute increased risk for major hemorrhage with OACs compared with ASA.
Rational Allocation of Cardiovascular Care Insight #4: Cost- effective ≠ affordable Pharmaco-economic evaluation of new oral anticoagulants: CHADS 2 < 2 • Dabigatran 110 mg BID: Inremental cost per QALY gained = $86,831 • Apixaban 5 mg BID Incremental cost per QALY gained = $34,572 • Dabigatran 150 mg BID Incremental cost per QALY gained = $20,845
Rational Allocation of Cardiovascular Care Insight #5: It helps to be a bit skeptical . . .
Rational Allocation of Cardiovascular Care • Two ethical arguments for avoiding waste • that patients should not be deprived of useful medical services so long as money is being wasted on useless interventions • and that useless tests and treatments cause harm through false-positive results and complications • Thus, wasteful, non-beneficial medicine imposes opportunity costs for patients in need and also conflicts with the medical maxim of "First, do no harm."
Rational Allocation of Cardiovascular Care • Don’t screen asymptomatic patients with stress tests or imaging • Don’t do stress tests or imaging as routine f/u • Don’t do routine stress or imaging for pre-op evaluation • Don’t do routine f/u echo for mild valve disease • Don’t stent non -culprit lesions in patients with STEMI
Rational Allocation of Cardiovascular Care
Rational Allocation of Cardiovascular Care DES – a potentially wasteful technology? 2,715 physicians
Rational Allocation of Cardiovascular Care
Rational Allocation of Cardiovascular Care Variation and high rate of DES use in low-risk patients – what motivates physicians? • Belief that benefits extend beyond trial enrolment criteria • Influence of prior adverse experience • Allure of technology for it’s own sake • Influence of industry marketing • Pressure from patients • Most importantly, few interventional cardiologists or their patients face financial incentives at the point of care encouraging a choice of stent that maximizes economic value. In a “price - free” environment, the natural inclination is to select the more expensive option. 8
Rational Allocation of Cardiovascular Care • State-of-the-art management methods, research on comparative effectiveness, and incentives for providers to apply this know-how can make care cheaper and better. • It has become common wisdom that 30% of health care spending, or $800 billion a year, is wasted on ineffective measures. • But cutting this 30% is a distant hope. Useless care, critics note, is easy to spot after the fact; it's much more difficult to recognize at the moment of clinical decision.
Rational Allocation of Cardiovascular Care
Rational Allocation of Cardiovascular Care Insight #6: Cutting wasteful spending won’t be enough • Berwick & Hackbarth. Eliminating waste in US health care. JAMA 2012;307:1513 • A significant proportion of health spending is wasteful . . . as much as 30% in US • Despite best efforts at waste avoidance, there will likely be beneficial therapies too expensive to afford
Rational Allocation of Cardiovascular Care Insight #7: Payers are allowed to say no Clinical evidence Politics and Economic timing analysis Allocation Decision Ethics & Affordability values Guidelines, Appropriate use criteria
Rational Allocation of Cardiovascular Care Federal Common Drug Review – Ticagrelor December 2011 Recommendation: The Canadian Drug Expert Committee (CDEC) recommends that ticagrelor not be listed at the submitted price. Reasons for the Recommendation: 1. The pre-specified subgroup analysis . . . in a North American population. 2. . . . the cost-effectiveness of ticagrelor could not be properly assessed. 3. The daily cost of ticagrelor ($2.96) is greater than clopidogrel ($2.58). Of Note: Based on a review of the clinical evidence, the Committee felt that a reduced price would increase the likelihood of a recommendation to “list” or “list with criteria”.
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