Heart Failure—the Next Frontier

1. Heart Failure—the Next Frontier Carol Zaher, MD, MBA, MPH Medical Director Health Net June 21, 2018

2. Disclosure • I do not have relevant financial relationships with commercial interests.

3. Objectives • Summarize the clinical and economic burden and importance of heart failure to the health care system • Provide an overview of current evidence-based guideline recommendations for treatment of heart failure • Substantiate the rationale for why inclusion of a heart failure prevention and management program aligns with the Right Care Initiative mission

4. Overview • Types of HF • Heart failure statistics • US • CA • Burden of disease • Disease management efforts • Treatment options • EB Guidelines • Role for RCI?

5. Heart Failure Basics Types What’s the difference? • HFrEF • HFpEF • HFiEF • Underlying pathology • Outcomes similar • Treatment?

6. HF Stats

7. HF Statistics* • ARIC study of the NHLBI: 1.0 million new HF cases annually • 6.5 million American adults ≥20 years of age had HF between 2011 and 2014 compared with 5.7 million between 2009 and 2012. • Prevalence of HF will increase 46% from 2012 to 2030, resulting in >8 million people ≥18 y0 • Increasing incidence and improved survival contribute to increasing prevalence • African Americans had the highest risk of developing HF, followed by Hispanic, White, and Chinese Americans (4.6, 3.5, 2.4, and 1.0 per 1000 person-years, respectively). • 30-day, 1-year, and 5-year case fatality rates after hospitalization for HF were 10.4%, 22%, and 42.3%, respectively • Most common risk factors for HF: CAD, HTN, DM, obesity, smoking *Heart Disease and Stroke Statistics— 2018 Update A Report From the American Heart Association March 20, 2018 Circulation. 2018;137:e67–e492. DOI: 10.1161/CIR.0000000000000558

8. Burden of Disease-US • Discharges for HF decreased from 2004 to 2014, with principal diagnosis discharges of 1,042,000 and 900,000, respectively • In 2014, there were 2,371,000 physician office visits with a primary diagnosis of HF and 459,000 ED visits** • *CDC; 2010 National Ambulatory Medical Care Survey and 2010 National Hospital Ambulatory Medical Care Survey. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.Accessed July 17, 2013. • **NAMCS, NHLBI unpublished tabulation • Age-adjusted 28-day and 1-year mortality after hospitalization was 10.4% and 29.5%, respectively. • In one study, 43% HF pts are hospitalized at least 4 times. More than one half of all hospitalizations were related to non-cardiovascular causes*** • ***J Am Coll Cardiol. 2009;54:1695–1702. doi: 10.1016/j. jacc.2009.08.019.

9. Cost of HF- US • Total estimated cost for HF ~$30.7 billion in 2012(2010$)* • 68% direct medical costs • Hospital costs represent majority • By 2030, HF total cost will increase to almost $70 billion *American Heart Association. Circ Heart Fail. 2013;6:606–619. doi: 10.1161/HHF.0b013e318291329a

10. HF Prevalence CA Age > 65 yrs* *Conroy SM, Darsie B, Ilango S, Bates JH (2016). Burden of Cardiovascular Disease in California. Sacramento, California: Chronic Disease Control Branch, California Department of Public Health.

11. HF Burden in California* *Conroy SM, Darsie B, Ilango S, Bates JH (2016). Burden of Cardiovascular Disease in California. Sacramento, California: Chronic Disease Control Branch, California Department of Public Health.

12. HF Mortality CA* *Conroy SM, Darsie B, Ilango S, Bates JH (2016). Burden of Cardiovascular Disease in California. Sacramento, California: Chronic Disease Control Branch, California Department of Public Health.

13. Evolution of Disease Management for HF

14. Attempts at Disease Management for HF Early efforts • HEDIS measures • LV EF measurement • Use of ACEI • Creation of DM /Case Management programs to integrate care • Initial focus on post DC • Later on high risk HF pts • Emergence of care in an Observation Unit-CMS developed new coding for such outpatient care • Heart failure clinics/specialists • Guideline, Care Maps, and Best Practice development • Remote care • Home scales • Telemedicine • Team approach: pharmacists, MD, NP, social services, etc.

15. Get With the Guidelines • American Heart Association collaborative quality improvement program • Goal is to improved adherence to evidence based care in pts hospitalized for heart failure • Voluntary observational program • Registry data • Patient Management ToolTM • Decision support • Real-time benchmarking

16. Get With the Guidelines-Heart Failure

17. HF as Part of the Right Care Initiative? • HF imposes a steep economic and clinical burden on the health care system and patient QOL • Multiple treatments available for HF make optimal management more complex

18. HF as Part of RCI ! • Primary prevention of HF can be augmented by greater adherence to the AHA’s Life Simple 7 goals: non-smoking, optimal body mass index, physical activity, diet, and control of cholesterol, blood pressure, and glucose.* • Current RCI efforts toward reducing heart attacks, stroke and improving diabetic care/outcomes • HFs top underlying pathologies are MI, HTN, and diabetes • RCI efforts to reduce incidence of MI, treat HTN and treat DM aligns with methods to prevent HF. *Heart Disease and Stroke Statistics— 2018 Update A Report From the American Heart Association March 20, 2018 Circulation. 2018;137:e67–e492. DOI: 10.1161/CIR.0000000000000558 Folsom et al. Am J Med 2015;128:970-6

19. Thank You! • Carol Zaher, MD, MBA, MPH • carol.a.zaher@healthnet.com