Bridging the
Care Gap
2007
Joel Niznick MD FRCPC
www.cvtoolbox.com
© 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
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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
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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
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INTER-HEART: Risk of acute MI associated
with risk factors in the overall population
Risk factor
Odds 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 (3.39-4.42)
3.25 (2.81-3.76)
Current smoking
2.95 (2.72-3.20)
2.87 (2.58-3.19)
Diabetes
3.08 (2.77-3.42)
2.37 (2.07-2.71)
Hypertension
2.48 (2.30-2.68)
1.91 (1.74-2.10)
Abdominal obesity
2.22 (2.03-2.42)
1.62 (1.45-1.80)
Psychosocial
2.51 (2.15-2.93)
2.67 (2.21-3.22)
Vegetable and fruits daily
0.70 (0.64-0.77)
0.70 (0.62-0.79)
Exercise
0.72 (0.65-0.79)
0.86 (0.76-0.97)
Alcohol intake
0.79 (0.73-0.86)
0.91 (0.82-1.02)
All combined
129.2 (90.2-185.0)
129.2 (90.2-185.0)
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Yusuf S. European Society of Cardiology Congress 2004; August 28-September 1, 2004; Munich, Germany.
INTER-HEART: Population-Attributable Risk
(PAR) Acute MI in the overall population
Risk factor
PAR adjusted for age,
sex & smoking 99% CI)
54.1 (49.6-58.6)
PAR adjusted for all
(99% CI)
49.2 (43.8-54.5)
36.4 (33.9-39.0)
12.3 (11.2-13.5)
35.7 (32.5-39.1)
9.9 (8.5-11.5)
Hypertension
Abdominal obesity
Psychosocial
Vegetable and fruits daily
23.4 (21.7-25.1)
33.7 (30.2-37.4)
28.8 (22.6-35.8)
12.9 (10.0-16.6)
17.9 (15.7-20.4)
20.1 (15.3-26.0)
32.5 (25.1-40.8)
13.7 (9.9-18.6)
Exercise
Alcohol intake
All combined
25.5 (20.1-31.8)
13.9 (9.3-20.2)
90.4 (88.1-92.4)
12.2 (5.5-25.1)
6.7 (2.0-20.2)
90.4 (88.1-92.4)
ApoB/ApoA-1 (fifth
quintile compared with
first)
Current smoking
Diabetes
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Yusuf S. European Society of Cardiology Congress 2004; August 28-September 1, 2004; Munich, Germany.
INTERHEART: Summary
1.
2.
3.
Nine simple risk factors are strongly associated with
AMI worldwide.
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.
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.
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Prevention Goals for CVD
Variable
Goal
Smoking
Total Cessation
Total Dietary Fat / Saturated Fat
< 30% calories / < 7% calories
Dietary Cholesterol
< 200 mg/day
Physical Activity
30-45 min. moderate intensity 5X/week
Body Weight by Body Mass index
Initial BMI
25-27.5
> 27.5
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 )
Weight Loss Goal
BMI < 25
10% relative weight loss
Blood ©
Pressure
< 130/80 mmHg …...bridging
(< 120/80 for
LVD)
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the care gap
Diabetes
HbAlc < 7.0 %
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
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Potential Cumulative Impact of
1° Prevention Strategies
Smoking Cessation
2/3
BP reduction 20mm Hg
1/2
LDL reduction 1mmol/L
1/6
Cumulative Prevention
5/6
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Potential Cumulative Impact of
2° Prevention Treatments
RRR
None
Event rate
Event rate
8%
16%
ASA
25%
6%
12%
 -Blockers
25%
4.5%
9.0%
Lipid lowering
30%
3.0%
6.0%
ACEinhibitors
Cardiac Rehab
25%
2.3%
4.6%
25%
1.7%
3.4%
CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF
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78% RRR, WHICH
IS SUBSTANTIAL
Adapted from Yusuf, S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2-3.
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
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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
© Continuing Medical Implementation ®
• 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 DHPCCB/ARB
– (avoid ß-blocker or alphablocker as initial Rx)
• ß-blocker -CHF
…...bridging the care gap
Top 10 Failures to Implement Evidence
Based Advances in CV Disease
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•
•
•
•
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
© Continuing Medical Implementation ®
• 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 DHPCCB/ARB
– (avoid ß-blocker or alphablocker as initial Rx)
• ß-blocker -CHF
…...bridging the care gap
Goals in Cardiovascular
Prevention
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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
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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
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Consensus guidelines
Didactic CME
Workshop CME
Practice pattern review
Specific recommendations by local experts
Usual channels of communication
Reminder strategies
Evidence based application tools
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Guideline Implementation
• Bring together national
experts
• Develop
guideline,consensus
statement or
recommendation
• Publication
• Diffusion
• Dissemination
• Implementation
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Knowledge Evolution
DATA
Knowledge Translation
INFORMATION
Knowledge Utilization
ACTION
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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.
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Clinical Research to Clinical Practice-Lost in
Translation. Claude Lenfant, M.D.
NEJM 349(9) 868-874 August 28 2003
• …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.
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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.
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Why most interventions to improve physician
prescribing do not seem to work.
Majumdar and Soumerai CMAJ 169(1) July 8 2003
• 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
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The Canadian Cardiovascular Society and
Knowledge Translation:
Turning Best Evidence into Best Practice
Tremblay et al Can J Cardiol
2004;20(12):1195-1198.
• 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
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Patient Health Management
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• 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.
…...bridging the care gap
Analyzing the Care Gap
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Evidence Gap
Guideline Gap
Diffusion Gap
Dissemination Gap
Implementation Gap
Adherence Gap
Outcome Gap
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• Rising Health Care
Costs
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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
© Continuing
Medical Implementation
® Coll Cardiol. 1996;27:1039-1047.
…...bridging the care gap
Adapted
from Pearson
TA et al. J Am
Why the Gap?
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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
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Why the Gap?
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Uncertainty
Inertia
Jurisdiction
Effectiveness
Resources
Continuity
Adherence
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Adherence Gap
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Cost of medications
Complacency-patient and physician
Side effects
Lack of understanding
Media impact/fears
Infrequent monitoring
Lack of feedback
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Evidence Based
Implementation Tools
CME
CMI
A New
Paradigm
Continuing Medical
Implementation®
CMI
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www.cvtoolbox.com
© Continuing Medical Implementation ®
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www.cvtoolbox.com
© Continuing Medical Implementation ®
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www.cvtoolbox.com
© Continuing Medical Implementation ®
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Three Pronged Approach
• Condensed
evidence review
and guideline
distillation
• Patient information
products
• Implementation
tools
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Post MI Discharge Summary
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Guide for Comprehensive
Cardiovascular Risk Reduction
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Dyslipidemia Package
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Lipid Optimization Tool
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Hypertension Package
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HOP To ITT
Hypertension Calendar
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Diet Information Sheets
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Diet Information Sheets
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Optimal Management of Atrial
Fibrillation
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Guide for HF Management
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Multiple Modalities of
Distribution
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Targeted mailings
Hard copy/photocopy
Reprint/re-order
Digital copy
Web site
CME programs
Implementation
networks
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Multifaceted Product
• Education
– Patient
– Physician
– House-staff
– Nurses
• Implementation Tools
• CPD
• CME
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The Physician Patient Interface is
Not a Virtual World
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Implementation Network
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How can we amplify the impact
of preventative strategies?
Interventions-Revascularization-DevicesProcedures
4º
Specialist/Cardiologist-Invasive Dx/TxMonitoring/Rehab/Reinforcement
2º & 3º
Risk Stratification-Rx Optimization/
Adherence-FD & Specialist
1º & 2º
Recognition-Screening-Initial
Therapy- Family MD
Community Based
Awareness/Understanding
Primary Care Physician
Prevention Awareness Programs/PHN
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Network of Networks
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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
• www.cvtoolbox.com may be a useful
vehicle in this regard
© Continuing Medical Implementation ®
…...bridging the care gap