MINIMAL vs OPTIMAL MEDICAL CARE
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MINIMAL vs OPTIMAL MEDICAL CARE. M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY. EHS Guidelines - 2003. Minimal Versus Optimal Care. Resources more than science dictate the type of care that can be provided.

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M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

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M mohsen ibrahim md cardiology department cairo university

MINIMAL vs OPTIMAL MEDICAL CARE

M Mohsen Ibrahim, MD

CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY


Minimal versus optimal care

EHS Guidelines - 2003

Minimal Versus Optimal Care

  • Resources more than science dictate the type of care that can be provided.

  • Guidelines have to make a compromise between what is possible (minimal care) and what is ideal (optimal care).

  • No Health Care System Has Unlimited Resources


M mohsen ibrahim md cardiology department cairo university

“Where resources are limited it becomes imperative to direct drug treatment to individuals in the high and very high risk before considering their use in the lower risk patients” (WHO-ISH GUIDELINES)


Assessment of high risk status

Minimal Care

Optimal Care

Age

Family History

Past History of ACVD

Smoking

Body Weight

Blood Sugar

Total Cholesterol /LDL-C

HDL-C

Triglycerides

S Creatinine

ECG

Hs-CRP

ASSESSMENT OF HIGH RISK STATUS

  • Age

  • Family History

  • Past History of ACVD

  • Smoking

  • Body Weight


M mohsen ibrahim md cardiology department cairo university

EHS Guidelines - 2003

Evaluation of Hypertensive Patients

+++: strongly recommended.+: recommended.- : not done

+: done if facilities are available.


M mohsen ibrahim md cardiology department cairo university

EHS Guidelines - 2003

Therapy


M mohsen ibrahim md cardiology department cairo university

EgyptianHTN Physician & Patient Survey*

Ever Stopped Your Antihypertensive Drug Therapy1940 patients

Ibrahim - 1998


M mohsen ibrahim md cardiology department cairo university

EgyptianHTN Physician & Patient Survey*

Reasons of Poor Compliance Doctors Survey

%

Ibrahim - 1998


Methods to reduce the costs of hypeertensive treatment

METHODS TO REDUCE THE COSTS OF HYPEERTENSIVE TREATMENT

  • Improve Effectiveness of Treatment

    - Accurate classification of BP

    - Maximize life style change

    - Balance benefits vs risks of treatment

    - Adherence to treatment regimen

    - Control of other CV risk factors

  • Reduce Costs

    - Start treatment with lower cost medications

    - Limit office visits to clear clinical objective

    - Limit laboratory test to necessary ones


Changes in mean blood pressure over time australian therapeutic trial in mild hypertension

CHANGES IN MEAN BLOOD PRESSURE OVER TIME-Australian Therapeutic Trial in Mild Hypertension*

*1119 subjects given placebo and observed for 3 years Lancet:1980


Blood pressure variability

EGYPTIAN NHP

BLOOD PRESSURE VARIABILITY

54.8%


M mohsen ibrahim md cardiology department cairo university

EHS Guidelines - 2003

Diagnosis of Hypertension

No TOD

TOD / BP > 160/100mmHg

Visit 1

Visit 1

Visit 2

Visit 2

>140/90 mmHg

Visit 3

Visit 4

Visit 3

Visit 5


Risk categorization

EHS Guidelines - 2003

Risk Categorization

  • Hypertensivepatients can be categorized according to their risk profile (adopted from JNC VI):

    • Group A (low risk): no TOD, no other risk factors and no associated cardiovascular disease.

    • Group B (intermediate risk): one or more additional risk factors but not diabetes or TOD.

    • Group C (high risk): diabetes, TOD and/or associated cardiovascular disease.


M mohsen ibrahim md cardiology department cairo university

EHS Guidelines - 2003

Drug Initiation

BP Monitoring

Risk Category

BP Threshold

A

6-12 month

160/100 mmHg

140/90-150/90 mmHg

B

3-6 month

140/85-135/85 mmHg

1-3 month

C


Drug costs to prevent one mi stroke or death uncomplicated mild to moderate hypertension

IMPROVE COST EFFECTIVENESS

DRUG COSTS TO PREVENT ONE MI, STROKE OR DEATH(UNCOMPLICATED MILD TO MODERATE HYPERTENSION)

Source: Pearce et al. Am J Hypertens , 1998


Evaluation of therapeutic intervensions

Evaluation of Therapeutic Intervensions

  • Clinical Effectiveness

  • Safety

  • Cost


Comparing a new therapy and a standard therapy

Comparing a New Therapy and a Standard Therapy

Clinical Effectiveness

--------------------------------------------------------------

Net CostNew>Std New=Std New<Std

-----------------------------------------------------------------------------------New>StdCEA needed Standard Rx. cost- saving Use Standard Rx

New=Std New Rx. Better Toss-up Standard Rx. better

New<StdUse New Rx. New Rx. cost-saving CEA needed

----------------------------------------------------------------------------------------------------------

CEA: Cost-effectiveness analysis

Modified After Mark and Hlatky . 2002


Cost effectiveness analysis

Cost - Effectiveness Analysis

C/new – C/usual care

CE = --------------------------------

HB/new – HB/usual care

-----------------------------------------------------------------------

CE: cost-effectiveness; C: costs; HB: health benefits


Assessment of health benefits

Assessment of Health Benefits

  • Sensible units :

    -mmHg blood pressure change

    -No of myocardial infarctions prevented

    -Minutes of exercise increased

  • Number of added life-years (LYs)

  • Primary therapeutic goal is to prolong life expectancy

  • Quality- adjusted life-year (QALY)

  • One year of life in excellent health = 1.0 QALY


Cost assessment

COST ASSESSMENT

  • Costs of Intervention :

    -Drugs

    -Lab tests

    -Physician

  • Costs of Morbidity after an Event :

    - Direct costs (health care costs)

    - Indirect costs (loss of productivity)


M mohsen ibrahim md cardiology department cairo university

MINIMAL vs OPTIMAL MEDICAL CARE

M Mohsen Ibrahim, MD

CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY


M mohsen ibrahim md cardiology department cairo university

NUMBERS-NEEDED-TO TREAT TO PREVENT CV EVENTS OR DEATH IN PATIENTS WITH MILD-TO- MODERATE HYPERTENSION


Cost effectiveness of treatment for hypertension

COST-EFFECTIVENESS OF TREATMENT FOR HYPERTENSION

>69 YEARS

<45 YEARS

Approximate net cost per life-year gained in US dollars Source: Johannesson M,1995


Prevention priorities primary prevention

PREVENTION PRIORITIESPRIMARY PREVENTION

  • Population Approach

    2% reduction of mean population BP (about 3 mmHg in DBP)

Prevent every year by 2020 in Asia Pacific Region :

-1.2 million deaths from stroke ( about 15% of all deaths from stroke)

-0.6 million deaths from CHD (6% of all deaths from CHD)

Reducing Salt Content of Manufactured Food


Prevention priorities primary prevention1

PREVENTION PRIORITIESPRIMARY PREVENTION

  • Individual Approach

  • Population Approach


Cost effectiveness

Cost-Effectiveness


Cost effectiveness1

Cost-Effectiveness

  • <$50.000 per LY is economically acceptable

  • >$100.00 per LY is economically unacceptable


Cost effectiveness in hypertension

Cost-Effectiveness in Hypertension

  • Costs of drugs and other medical expenses required to prevent one MI, stroke or death

  • Medications account for 50% to 90% of the direct costs of hypertension treatment

  • NNT: number of patients needed to treat for 5 years to prevent one event

  • Cost-effectiveness of drug therapy = average whole sale price of drug for 5 years of treatment X (5-y NNT)


Cost effectiveness2

Cost-Effectiveness


Cost effectiveness3

Cost-Effectiveness

  • Event Rate = No of events/P-Yof observation

  • Risk Difference = Control – Treatment event rate

  • Cost –Effectiveness of Drug (Cost to Prevent an Event) = AWP(5y trt) X 5y NNT

    -AWP : average whole sale prices

    -5y NNT : No of patients treated for 5 years to prevent one event


Cost effectiveness4

Cost-Effectiveness

  • Cost of QALY gained:

    - < $40.000 – highly cost-effective

    - = $60.000 – reasonable cost-effective

    - > $100.000 – not cost-effective

  • If society is willing to pay $60.000 to gain a QALY treatment should be started if the 5-year-risk of CHD exceeded

    -For men -For women

    35 y 2.4% 2.0%

    50 y 4.6% 3.5%

    70 y 10.4% 10.4%


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