Outcomes Research Task Force

1
Outcomes Research Task Force
2
Outcomes Research Task Force (ORTF)

• An overview of the Task Forces objectives and
  methods has been published in Campbell NR, Can J
  Cardiol 200622556-558

3
Outcomes Research Task Force (ORTF)

• Collaborative effort with the Public Health
  Agency of Canada, Statistics Canada, Canadian
  Institute for Health Research, Heart and Stroke
  Foundation of Canada, Canadian Stroke Network,
  provinces and other organizations to develop a
  national surveillance system for hypertension
  using
• Physical Measures Surveys
• Intercontinental Medical Statistics (IMS) Health
  Data
• National Questionnaires (CCHS, NPHS)
• National Hospitalization and Mortality Data
• Provincial Administrative Databases

4
Canadian Hypertension Education Program
Outcomes Research Task Force Finlay McAlister
(Chair), Oliver Baclic (Vice-chair)
Michel Joffres Helen Johansen Janusz
Kaczorowski Nadia Khan Patty Lindsay Lisa Lix Wei
Luo Colleen Maxwell Robert Nolan Jay Onysko Raj
Padwal
Gillian Bartlet Asako Bienek Rollin Brant Norm
Campbell Guanmin Chen Denis Drouin Bill
Ghali Steven Grover Femida Gwadry-Sridhar Brenda
Hemmelgarn Michael Hill
Stephen Phillips Hude Quan Chris Robinson Mark
Smith Larry Svenson Greg Taylor Karen Tu Lianne
Vardy Robin Walker Andrew Wielgosz Kelly Zarkne
5
Canadian Community Health Survey (CCHS)National
Population Health Survey (NPHS)

• Large national questionnaires/surveys
• Results are representative of the Canadian
  population
• The surveys do not measure blood pressure
• CCHS Cross sectional design
• NPHS Cross sectional and longitudinal design

Neutel CI, Can J Cardiol 200723561-65, Onysko
J, Hypertension 200648853-60
6
NPHS (1994-2002) More Lifestyle Changes After
Hypertension Diagnosis Are Needed
Small decreases in smoking and physical
inactivity along with increases in BMI were
observed of newly diagnosed patients in the
longitudinal National Population Health Survey
(NPHS). This trend was largely seen in patients
who were taking antihypertensive medication. A is
the survey cycle prior to diagnosis and B is the
survey cycle following hypertension diagnosis.
Can J Cardiol, 2008. 24 3 199-204.
7
Population Analysis Hypertensive Canadians and
Pharmacotherapy
54.9 of aware hypertensive patients 20-39 years
of age were not taking antihypertensive
medications while 17.3 of patients 40-59 and
4.6 of patients gt60 years of age were not on
pharmacotherapy. Daily smokers aware of having
hypertension within all age strata were less
likely to be taking antihypertensive drug
therapy.
Can J Cardiol, 2008. 24 6 485-490.
8
Hypertensive Patients Not Receiving
Pharmacotherapy, CVD Risks
Young aware hypertensives are far less likely to
receive pharmacotherapy as demonstrated by the
large gap in the graph. There is no trend to
increase the use of antihypertensive
pharmacotherapy with increasing number of
cardiovascular risk factors.
Can J Cardiol, 2008. 24 6 485-490.
9
Physician visits, age, and gender in Aware
Hypertensive Patients not taking antihypertensive
drugs
Young and middle aged aware hypertensive men who
have no recent physician visits are unlikely to
be treated with antihypertensive drugs In all
age groups, men were least likely to seek
consultation. As age increased, both genders
were more likely to be taking anti-hypertensive
medications
Can J Cardiol, 2008. 24 6 485-490.
10

Sociodemographic Analysis of Canadians Not
Monitoring Blood Pressure (Data, 2000-2001)
Blood Pressure monitoring is a tool used to
diagnose, treat and control hypertension.
Awareness and screening are of critical
importance. Target Canadian Population Found to
be LEAST likely to monitor BP - Younger - No
regular Doctor or Physician - Male -Recent
Immigrants/visible minorities - Spoke no English
or French Reason Roughly half of
respondents stated they did not think it was
necessary. Because of this misconception, public
education through HCP is imperative.
Journal of Clinical Hypertension, 2007. 9 12
944-951.
11
THE CHALLENGE IN CANADA 1985-1992
12
Control of Hypertension

• Low Korea 0.9
• High Barbados 38 (1996)
• Developed countries 5-31
• Canada 16
• USA 31
• 40 in Cuban sub sample
• 37 in 2004

13
Changes in Management of Hypertension in Canada
OntHHS 1992
HSFO 2006 Ontario
The data on proportion of not aware and aware
but not treated are estimated based on the CCHS
data CMAJ 2008
14
Control of Hypertension

• Low Korea 0.9
• High Barbados 38 (1996)
• Developed countries 5-31
• Canada 16
• USA 31
• 40 in Cuban sub sample
• 37 in 2004

15
Changes in Hypertension Management in Canada
ONT
CHHS
NPHS - CCHS
16
Changes in Diagnosis of Hypertension in Canada

• Post 1999 compared
• to pre 1999
• Marked increase in the rate of diagnosis of
  hypertension
• Closing of the gender gap

1999
NPHS, CCHS
Onysko J, Hypertension 200648853-60
17
Changes in Treatment of Hypertension in Canada

• Post 1999 compared
• to pre 1999
• Doubling of the rate of treatment of hypertension
  
• Closing of the gender gap

NPHS, CCHS
Onysko J, Hypertension 200648853-60
18
Changes in proportion of aware hypertensive
Canadians not treated with antihypertensive drugs

• Post 1999 compared
• to pre 1999
• Marked decrease in proportion of aware
  hypertensives that are untreated
• Closing of the gender gap

NPHS, CCHS
Onysko J, Hypertension 200648853-60
19
Changes in proportion of aware hypertensive
Canadians not treated with antihypertensive drugs

Onysko J, Hypertension 200648853-60
NPHS, CCHS
20
Increased use of two or more antihypertensive
drugs in Canadians diagnosed with hypertension
within the last two years
After 1999, an increase in use of
antihypertensive therapy is seen after diagnosis
and in the use of concurrent antihypertensive
therapy within 2 years of diagnosis
Neutel CI, Can J Cardiol 200723561-65
NPHS longitudinal survey
21
Increased use of two or more antihypertensive
drugs in Canadians diagnosed with Hypertension
within the last two years


Neutel CI, Can J Cardiol 200723561-65
NPHS longitudinal survey
22
Increased use of two or more antihypertensive
drugs in Canadians diagnosed with Hypertension
within the last two years


Neutel CI, Can J Cardiol 200723561-65
NPHS longitudinal survey
23
Increased persistence with antihypertensive
therapy after initial diagnosis
After 1999, there has been an improvement in 2
year persistence with antihypertensive drug
therapy
Neutel CI, Can J Cardiol 200723561-65
NPHS longitudinal survey
24
Treatment of Hypertension Canada versus USA

• USA 2004
• Awareness 66.5 (33.5 unaware)
• Treatment 53.7
• 81 of aware hypertensive Americans are on drug
  therapy
• Control 33.1
• Canada 2003
• 85 of aware hypertensive Canadians are on drug
  therapy
• Control unknown

25
Linked Provincial Administrative Data

• An opportunity to track the diagnosis, management
  and outcomes of all hypertensive Canadians
• The characteristics for using administrative data
  to diagnose hypertension has been defined in
  Ontario (Tu, K. Open Medicine 2007 2007118-26)
• Ongoing validation studies are being conducted in
  British Columbia, Alberta, Quebec and Nova Scotia
• Ongoing negotiations are occurring to access
  provincial data
• Initial data on diagnosis and treatment of
  hypertension in elderly Ontarians has been
  examined

26
Linked Provincial Administrative Data Changes in
Antihypertensive Therapy in Elderly Ontarians,
1994-2002

• Linked data bases in Ontario and use of IMS
  prescription data
• Age over 65 years
• New antihypertensive therapy
• Exclusion of other indications for blood pressure
  lowering therapy
• Almost 200,000 newly treated patients
• Did not use validated algorithm

Campbell NR, Hypertension 20064722-28, Tu K,
Hypertension 2005451113-18
27
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians


Campbell NR, Hypertension 20064722-28
28
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians with
Thiazide-like Diuretics


Campbell NR, Hypertension 20064722-28
29
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians with Beta
Blockers


Campbell NR, Hypertension 20064722-28, Tu K, J
Hum Hypertens 200721271-75
30
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians with ACE-I


Campbell NR, Hypertension 20064722-28
31
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians with CCBs


Campbell NR, Hypertension 20064722-28
32
Changes in Initiation of Antihypertensive
Prescriptions in Elderly Ontarians with ARBs


Campbell NR, Hypertension 20064722-28
33
Changes in Initial Prescription Rates for
Antihypertensive Therapies in Elderly Ontarians
Prior to and Following the CHEP Program


Campbell NR, Hypertension 20064722-28
34
Increases in Use of 2 or more Drugs to Treat
Hypertension and Reduced Discontinuation of
Treatment in Elderly Hypertensivesfrom Ontario
July 1994 - March 2002
Increase in use of 2 or more drugs (21 to 40)
Decreased discontinuation of antihypertensive
drugs

plt0.0001

Tu K, Hypertension 2005451113-1118
35
Use of Commercial Drug Prescriptions Data

• Data from about two-thirds of Canadian Pharmacies
  adjusted to reflect all Canadian prescriptions
• No patient information in the database
• A sample of physicians track the indication for
  drug prescriptions (e.g. hypertension) and the
  major diagnosis for the patient visit
• IMS Health Compuscript data is used by CHEP

36
Changes in Total Antihypertensive Prescriptions
in Ontario 1998-2004 (IMS)


Campbell NR, Hypertension 20064722-28
37
Changes in Diuretic Prescriptions in Ontario (IMS)


Campbell NR, Hypertension 20064722-28
38
Changes in Rates of Antihypertensive
Prescriptions in Ontario Prior to and Following
the Initiation of the CHEP Program


Campbell NR, Hypertension 20064722-28
39
Antihypertensive Drugs within 2 years of
Diagnosis of Hypertension in Elderly Diabetic
Ontarians 1995-2001

• Linked Ontario data bases
• Age over 65 years
• 27,822 patients with diabetes newly started on
  antihypertensive therapy

McAlister FA, Diabetes Care 200629836-82
40
Changes in Blood Pressure Treatment of Elderly
Hypertensive Diabetic Ontarians 1995-2001

• 46 increase in new prescriptions for treatment
  of hypertension
• Initial use of ACEI increased from 54 to 76

McAlister FA, Diabetes Care 200629836-82
41
Changes in Blood Pressure Treatment of Elderly
Hypertensive Diabetic Ontarians 1995-2001
Population-adjusted rates of initial
antihypertensive prescriptions per 1,000 elderly
Ontario residents with diabetes and newly treated
for hypertension

McAlister FA, Diabetes Care 200629836-82
42
Increasing use of 2 or more Antihypertensive
Drugs within 2 years of Diagnosis of Hypertension
in Elderly Diabetic Ontarians


McAlister FA, Diabetes Care 200629836-82
43
Increasing Continuation of Antihypertensive Drugs
within 2 years of Diagnosis of Hypertension in
Elderly Diabetic Ontarians


McAlister FA, Diabetes Care 200629836-82
44
Antihypertensive Drugs within 2 years of
Diagnosis of Hypertension in Elderly Diabetic
Ontarians 1995-2001

• Increasing use of antihypertensive drugs
• Increasing use of ACEI as initial therapy
• Increasing use of two or more drugs for treatment
  within 2 years of starting therapy
• Increasing continuation of therapy

McAlister FA, Diabetes Care 200629836-82
45
Percent Increase in Antihypertensive
Prescriptions in Canada (IMS)
1999


Campbell NR, J Hypertension 2003 211591-97
46
Antihypertensive Prescription Rates Prior to and
Following the Introduction of the CHEP Program in
1999 (IMS)


Campbell NR, J Hypertension 2003 211591-97
47
Proportional Changes in Antihypertensive
Prescriptions and Changes in Stroke Death in
Canada


Percent increase in total antihypertensive
prescriptions
Stroke mortality rate
48
Crude Stroke Deaths in Canada


Campbell NR, Can J Cardiol. 200622425-27
49
Crude CHF Deaths in Canada


Campbell NR, Can J Cardiol. 200622425-27
50
Crude AMI Deaths in Canada


Campbell NR, Can J Cardiol. 200622425-27
51
CHEP now has the Ability to Identify Management
Gaps

• Almost 50 of women over age 60 are on drug
  therapy
• A low proportion of younger hypertensives are on
  drug therapy this has not changed since CHEP
  started
• More than 10 of uncomplicated elderly
  hypertensives are started on B-Blocker therapy

52
CHEP Outcomes Research Task Force

• There has been significant progress towards
  developing a hypertension surveillance program
• Substantial data from independent sources
  indicate increased treatment of hypertension
  including increased initiation of therapy,
  increased use of concurrent therapy and greater
  continuation of therapy

53
CHEP Outcomes Research Task Force

• Emerging data supports a reduction in
  hypertension associated CVD in Canada
• Greater changes have occurred after the
  initiation of CHEP in 1999
• The data is observational and cause and effect
  relationship can not be made

54
ORTF 2007

• Public Health Agency of Canada leadership
  personnel and funding support for hypertension
  surveillance
• Collaboration with Statistics Canada, Heart and
  Stroke Foundation of Canada, IMS Canada and
  provincial governments to obtain data and
  expertise
• PHAC developing an extensive questionnaire for
  patients with hypertension

55
ORTF 2007

• Canadian Institute for Health Research and Heart
  and Stroke Foundation grants to examine
  validation of diagnosis algorithm in British
  Columbia, Ontario and Alberta urban and rural
  areas
• Financial support from RxD Pharma (Merck Frosst,
  Pfizer, Sanofi Aventis-Bristol Myers Squibb,
  Servier)
• New outcomes publications