The California Right Care Initiative

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The California Right Care Initiative

• Robert M. Kaplan
• Wasserman Distinguished Professor
• UCLA Schools of Public Health and Medicine
• AHRQ Conference

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The Translation Problem
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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.

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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

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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.
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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.
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6 Year CHD Mortality by Total Serum Cholesterol
356,222 Men Screened for MRFIT, Aged 35-57 Yrs
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LDL-C Lowering With Statins Reduced CHD Events
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Clinical Event Reduction in Clinical Trials
Clinical Event Reduction in Clinical Trials
(Superko, H. R. et al. Circulation
2008117560-568))
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From Prospective Studies Collaboration61
studies, 1 million Adults
Lancet 2002, 360, 1904
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BP Lowering TrialResults
Collins Peto. Textbook of Hypertension 1994
Blackwell Scientific Publications p1159.
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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.

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The Payoff is Potentially Large Benefits of
Lowering BP
Average Percent Reduction
Stroke incidence 35-40
Myocardial Infarction 20-25
Heart Failure 50
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Mortality and AHA Get with the Guidelines Awards
Heidenreich, AHJ (In Press)
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But, BP Control Rates Remain Disappointing
Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74
National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey
II 1976-80 III (phase 1) 1988-91 III (phase 2) 1991-94 IV 1999-2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
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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.
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Why Focus on Lipids and Blood Pressure Even for
People with Diabetes? (Ray Lancet 2009, 373,1765)
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California Problem
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Question Is health care in West LA as unusual as
the people who live there?

• The LA-San Diego Contrast

San Diego
Los Angeles
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Figure 1. Total 2005 Medicare expenditures in Los
Angeles and San Diego
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Total Reimbursements(Part A Part B)
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Hospital Admissions During Last 6 Months of Life
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California Pay for PerformanceClinical
Performance Variation Composite Clinical Score
(from Williams 2008)
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California Pay for PerformanceA Tale of Two
Regions (From Williams 2008)
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Berwick's Rules for Dissemination

• 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

Berwick, JAMA. 20032891969-1975.
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History of RCI

• In 2007, Governor Schwarzeneggers 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.

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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

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Californias HEDIS Scores

• Californias 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

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California Right Care InitiativePercent of
Plans Meeting HEDIS LDL Standard 2009
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California Right Care InitiativePercent of
Plans Meeting HEDIS Blood Pressure Standard 2009
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Emerging web-based GIS social networking tools
will also facilitate multi-stakeholder QI efforts
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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).

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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

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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

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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

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Steps from A to B
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Right Care Proposed Strategies

• Greater use of electronic technologies
• Greater of pharmacist managed care
• Departure from reactive, appointment based care

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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