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Cost Effectiveness: How Can We Do More With Less?

Cost Effectiveness: How Can We Do More With Less?. Stephen P. Merry, MD, MPH, DTM&H Assistant Professor of Family Medicine Mayo Clinic, Rochester. Disclosures. Financial Disclosures None Off label drug use None. 2. Learning Objectives.

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Cost Effectiveness: How Can We Do More With Less?

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  1. Cost Effectiveness:How Can We Do More With Less? Stephen P. Merry, MD, MPH, DTM&H Assistant Professor of Family Medicine Mayo Clinic, Rochester

  2. Disclosures • Financial Disclosures • None • Off label drug use • None 2

  3. Learning Objectives • Treat chronic diseases in adults and children in resource limited settings in a rational, cost-effective way. • Follow an income and country GNP based protocol for hypertension, type 1 and 2 diabetes, hyperlipidemia, and coronary artery disease diagnosis and care. • Design treatment protocols based on guiding principles of cost-effectiveness.

  4. Medical Missionaries Behaving Badly • Follow US treatment protocols • “We shouldn’t treat them any differently than we’d want to be treated…” • Treating chronic diseases regardless of benefit or cost • Expensive testing • Expensive monitoring • Expensive meds • Frequent rechecks

  5. The Summary Slide Careful consideration of the whole care process from care access to care follow-up including all costs including harms and benefits coupled with compassion Cost effective care

  6. Disclaimer • I’m a clinician • The following is a patient centric view on cost effectiveness analysis • I’m not an economist

  7. Cost-Effective Health Care • Caring for people in resource limited setting • Less tests, technology, meds; just the essentials • Less specialists • Less physician driven – lifestyle/public health primary • Avoid futility • Person centered, coordinated, comprehensive care by an accessible primary care provider

  8. Cost Effective Care • Requires analysis of the “care delivery value chain” • Prevention • Testing/Screening • Staging • Delaying progression of disease • Initiation of therapy • Continuous disease management • Management of deterioration Rhatigan et al. Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Setttings. Harvard Business School working paper, 2009

  9. Cost Effectiveness Analysis • Searches for “best buys” • E.g. smoking cessation vs statins for CVD prevention. • Expresses decisions in cost per benefit (usually cost in US$/DALY gained) • Requires clear knowledge (rather than guesses) of numbers needed to treat for one to benefit WHO and World Economic Forum, “From Burden to ‘Best Buys’”, 2009

  10. What Is A Reasonable Cost? • How much are they willing to pay for the estimated value of the treatment? • What is 1 DALY worth • 3 x the per capita income • The income of the family / # in family?

  11. Case 1:The Hypertensive Guinean Farmer A 55 yo Guinean farmer from 2 hours away sees you for a rash on his feet. His exam reveals a BP 159/99 and is normal other than tinea pedis. He is a non-smoker, mildly obese (BMI 33) man without history of CAD, stroke, DM or symptoms of polyuria. In addition to Clotrimazole for his tinea, you would • Recommend lifestyle changes, BP checks by a VHW, and return if consistently elevated above 160/100. • Do “a” but start HCTZ daily now and ASA 81 mg daily. • Do “b” but check a potassium, creatinine, fasting glucose, U/A, CBC, and ECG • Do “c” and also check his cholesterol level and initiate statin if elevated. • Do “d” and also begin Metformin if diabetic.

  12. What is HTN?JNC 7 and WHO • Normal = systolic <120 mmHg and diastolic <80 • Pre-hypertension: systolic 120-139 or diastolic 80-89 • Hypertension: • Stage 1: systolic 140-159 or diastolic 90-99 • Stage 2: systolic 160 or diastolic 100

  13. Hypertension in Africa Adapted from Edwards R, Unwin N, Mugusi F et al. Hypertension prevalence and care in an urban and rural area of Tanzania 2000. J Hypertens; 18:145-52.

  14. HTN in Guinea N'Gouin-Claih AP, Donzo M, Barry AB, Diallo A, Kabiné O, Barry R, Abdoulaye K, Sylla C, Magassouba FB, Baldé AM Prevalence of hypertension in Guinean rural areas Arch Mal Coeur Vaiss. 2003 Jul-Aug;96(7-8):763-7

  15. Should we treat mild HTN? • > 140/90 even if no risk factors? • NNT for 1 year = 700 to prevent 1 MI or stroke related death (mild HTN). • If cost of Rx = US$50/year, is the Guinean farmer REALLY consenting to US $35,000 to save ?10 years life (WHO suggests max cost should be 3 x per capita GNP or about $1300 for Guinea)? • Paternalism vs. shared decision making.

  16. Initial Evaluation of HTN • Labs • Dip U/A; maybe other if history, exam or urinalysis suggests need and can afford. • Creatinine • K+ • (ECG) • (Lipids) • (Fasting blood sugar)

  17. Who to Treat? • WHO & JNC 7 : > 140/90 or >130/80 in renal disease • Depends… • Access to care and follow up • Availability/cost of meds • Co-morbidity • Household finances • Risk-Based treatment with full informed consent

  18. Who to Treat?Isolated Systolic HTN? • Systolic > 160 (Diast < 95). • NNT 5 years to prevent a major CV event • 18 men; 38 women • 19 elderly > 70; 39 < 70 yo • 16 people with prior CV disease • So, have to treat about 20 people for 5 years to prevent one CV event or 100 people for 1 year • NNT/year = 100 • Cost to prevent an event in Africa = US$50/year (cheapest method of treatment!) x 100 = US$5,000 to prevent a fatal MI or stroke Staessen JA. Lancet 2000; 355(9207): 865-72

  19. Wait…Are You Saying Life Isn’t Worth That? • No… • Examine the total costs per benefit. • Where is that money coming from • Children’s nutrition • Wife’s prenatal care

  20. Choose Meds & Methods Wisely Start with Thiazide diuretics - cheap, few side effects • Hydrochlorthiazide 25 mg daily # 300 + 1 banana/day • “See me in 6 months” (or 1 year) – sooner if high risk. • Annual check on co-morbidities, compliance, refills, (dip urine).

  21. Risk Stratification of hypertensive patients Adapted from WHO Guidelines

  22. The Big Idea: • Patients/Families/Countries with more resources should be treated at earlier stages with fewer co-morbidities. • If the Guinean Farmer is paying out of pocket, mild hypertension should not probably be treated.

  23. Etiology of Heart Failure in a Urban Cardiology Practice in Africa(Ghana) Amoah AG. Cardiology 2000; 93(1-2):11-8

  24. How should we treat mild HTN or low risk patients? • Depends… “Shared Decision Making” • Diet • Low salt • High fruits and vegetables • Weight loss • Less alcohol • Exercise

  25. Lifestyle Modifications in the Management of Hypertension Adapted from JNC 7

  26. Patient Education - HTN • HTN requires lifelong treatment • HTN increases the risk of many diseases – stroke, heart attack, etc. • HTN treatment won’t make you feel much better but it’s good for you. • Lifestyle mod is AS IMPORTANT as medicine. • You need to take your medicine daily.

  27. Choose Meds Wisely • Goal • Cheap • Convenient • Effective risk reduction • No side effects

  28. Second Rx:Choose Meds Wisely • All meds ~ same benefit in large studies (ALLHAT). • Start with Thiazide diuretics - cheap, few side effects, superior in CHD prevention • CCB’s work best in Africans

  29. Antihypertensive Medication Response in US African Americans Materson BJ, Reda DJ, Cushman WC, et al. NEJM 1993, 328:914

  30. Choosing Meds Wisely • Amlodipine or Verapamil cheap and effective second line • CCB’s, Alpha-B’s, methyldopa, reserpine, hydralazine - effective without a Thiazide. • B-blockers and ACE’s - made more effective in Africans with a Thiazide. • Choose med based on co-morbidity e.g. • Start with ACE if DM2 • Expect a creatinine rise up to 0.3 mg/dl • Check creatinine and K+ after ~ 2 weeks

  31. The ABCD’s of Choosing HTN Meds Wisely

  32. Case 2: The Togolese Boy With DM1 A 7 year old boy presents with DKA to your rural mission hospital. He is from a village without electricity or running water in his home. His family lives on < $2/day per person. His father comes to you as medical director of the hospital & asks you to d/c his son home to die. You would • Become angry and give dad your “man up” pep talk • Find the funds for home monitoring and insulin admin. • Ask the chaplain to share with father and son our eternal hope in Jesus and d/c him per the father’s wishes • Keep him hospitalized and provide continued monitoring and insulin until stable and think about it later.

  33. DM1 – The Present Reality • Costs exceed household financial resources • Life expectancy in low income country < 1 year • If annual treatment costs are > 2/3 the country’s per capita income, treatment is not reasonable (without relief type aid). • International attn focused on providing specifically for DM1 costs (c.f. http://www.un-ngls.org/IMG/pdf_MDGs_and_Diabetes_Factsheet.pdf)

  34. IMS-Health (IV) Geneva Health Forum

  35. Case 2b:The 70 year old Togolese Diabetic A 70 yo man presents with polyuria to your rural mission hospital. He is from a village without electricity or running water. His family lives on < $2/day. You find no percussed suprapubic fullness over his bladder and a random glucose is 354. His exam is otherwise normal. You would • Advise weight loss, exercise, and 1 aspirin per day • “a” and add Metformin 2000 mg daily • Check a creatinine and do “b” if < 1.5 • Do “c” and check his cholesterol and add a statin to control his LDL < 100 • Do “d” and also add an ACE in case and recommend home glucose monitoring

  36. Risk Reduction of Various Interventions - 1993 Increased cardiovascular risk in type 2 diabetes Calculated effects of different interventions on coronary and total deaths in 1000 normal and 1000 men with type 2 diabetes aged 35 to 57 years without a history of myocardial infarction. Yudkin, JS, BMJ 1993; 306:1313

  37. Conclusion Errors… • The residual risk of “MRFIT” is due to high sugars • Lowering sugar will eliminate the risk • We should focus on frequently testing glucose and treating hyperglycemia

  38. Value of Intensive Glycemic Control3867 Type 2 DM followed 10 years Conclusion: Tight control of DM2 doesn’t affect mortality (or help much). UKPDS 33, Lancet 1998

  39. ADVANCE:The End of Tight Control? • 215 centers, 20 countries; U. of Sydney, AU • 11,140 pts DM2 randomized to “tight” A1C 6.5% or standard A1C to 7.3%; f/u 5 years • Age > 55, Vascular disease or risk • No difference in CV death, nonfatal MI, stroke. • Less macroalbuminuria (9.4% vs 10.9%) • More hypoglycemia (2.7% vs 1.5%) The ADVANCE Collaborative Group. INTENSIVE BLOOD GLUCOSE CONTROL AND VASCULAR OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES. N Engl J Med 358(24):2560, June 12, 2008

  40. ACCORD:The End of Tight Control? • No significant different in MI or stroke • Intensive treatment caused • Increased all-cause mortality 5% vs 4% (P=NS) • More Hypoglycemia 16.2% vs 5.1% • More Weight gain > 10 kg 27.8% vs 14.1% The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group . The EFFECTS OF INTENSIVE GLUCOSE LOWERING IN TYPE 2 DIABETES. N Engl J Med 358(24):2545, June 12, 2008

  41. The Big Point • Summary of 50 years of type 2 diabetes research: • Glycemic control has little to do with morbidity and mortality • Obesity, inactivity, and other bad behaviors mitigate risk • Correcting the real problems reduce risk.

  42. Rational CV Risk Reduction Method: • Smoking Cessation • Med Diet, weight loss, exercise • ASA • BP normalization • Statin (not lipid lowering) • Glycemic control of minor benefit – use for symptoms unless well resourced. • Self testing wasteful unless on insulin

  43. World Health Organization/ Health Action International (VII) – Cost of Meds Expressed in Days of Wages Geneva Health Forum

  44. Cost Effective Care of DM2 in LIC • One medication decreases mortality = Metformin • Order of highest to lowest priority • Reduce cardiac risk (see prior slide) • Treat to reduce symptoms not A1C • Retinal monitoring if affordable/treatment available • Microalbuminuria -> ACE if affordable • Lower fasting glucose as income allows

  45. Case 3: The Pregnant Pakistani Woman A healthy 30 yo G2P1 with an uncomplicated last pregnancy delivered by trained TBA in her home presents for prenatal care to your rural hospital at 12 weeks GA. You would • Recommend monthly visits increasing to every 2 weeks at term with hospital delivery to be safest • Recommend she simply again deliver at home with the TBA • Recommend care at the maternity in town • Recommend TT2, iron/folate, insecticide treated bednet use, IPTp, a prenatal visit in each trimester with a midwife or physician and delivery with the midwife.

  46. Why Be Involved Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

  47. per 100,000 live births

  48. 69

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