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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. The Translation Problem. NIH View of Translational Research.

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The California Right Care Initiative

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  1. The California Right Care Initiative Robert M. Kaplan Wasserman Distinguished Professor UCLA Schools of Public Health and Medicine AHRQ Conference

  2. The Translation Problem

  3. NIH View of Translational Research According to the National Institutes of Health, “in order to improve human health, scientific studies must be translated into practical applications.” Phase I Phase II Community research and application Bench research Clinical research

  4. 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

  5. Prevalence of CVD in adults age 20 and older by age and sex More than one in three adults have prevalent CVD 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.

  6. CVD deaths vs. cancer deaths by age. There are more than 850,000 CVD deaths per year 1/3rd before age 75, 50% higher than cancer deaths CVD deaths vs. cancer deaths by age. (United States: 2005). Source: NCHS and NHLBI.

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

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

  9. Clinical Event Reduction in Clinical Trials Clinical Event Reduction in Clinical Trials (Superko, H. R. et al. Circulation 2008;117:560-568))

  10. From Prospective Studies Collaboration:61 studies, 1 million Adults Lancet 2002, 360, 1904

  11. BP Lowering TrialResults Collins & Peto. Textbook of Hypertension 1994 Blackwell Scientific Publications p1159.

  12. 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.

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

  14. Mortality and AHA Get with the Guidelines Awards Heidenreich, AHJ (In Press)

  15. But, BP Control Rates Remain Disappointing

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

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

  18. California Problem

  19. Question: Is health care in West LA as unusual as the people who live there? The LA-San Diego Contrast Los Angeles San Diego

  20. Figure 1. Total 2005 Medicare expenditures in Los Angeles and San Diego

  21. Total Reimbursements(Part A + Part B)

  22. Hospital Admissions During Last 6 Months of Life

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

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

  25. Berwick's Rules for Dissemination Berwick, JAMA. 2003;289:1969-1975. 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

  26. 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.

  27. 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

  28. 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

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

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

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

  32. 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).

  33. 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

  34. 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

  35. 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

  36. Disseminate Best Practices Implement and Evaluate Intervention Identify Evidence-Based Practices Get Stakeholders & Other Experts Together Focus Attention on the Problem Steps from A to B

  37. Right Care Proposed Strategies • Greater use of electronic technologies • Greater of pharmacist managed care • Departure from reactive, appointment based care

  38. 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

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