CAD program cuts hospitalizations by 34%
CAD program cuts hospitalizations by 34%
Overall costs drop by 25%
An innovative coronary artery disease management program that assesses patients with a digital monitor instead of an exercise stress test and then connects them with an interactive database is working well at a large California managed care practice.
Patients at the 40,000-member Bakersfield Family Medical Group of Bakersfield, CA, who participated in the On-line Health Management System for Coronary Artery Disease (ohms/cad) had significantly fewer heart attacks, hospitalizations, emergency department visits, and revascularizations than patients who received "usual care," says Richard Levin, MD, FACP, FACC, professor of medicine and director of the laboratory for cardiovascular research at New York University School of Medicine. Levin invented the digital monitoring technology used in the program and was a founder of Laurence Harbor, NJ-based qmed Inc., the company that developed it.
"The data for these patients are one of the first confirmations that a systematic approach to coronary disease management can achieve positive outcomes and enhance patient management and satisfaction," Levin says.
Levin and colleagues followed 1,546 CAD patients for 18 months and found the ohms/cad program reduced the total of all events by 25%. Heart attacks were reduced by 30%, hospitalizations by 34%, catheterizations by 20%, and angioplasties by 20%. Overall costs associated with coronary artery disease were reduced by 25%. Ischemia was reduced by 79%, in contrast with the fact that 84% of the patients in the "usual care" group showed a worsening of ischemia. The program improved the use of aspirin and normalized blood pressure levels in 72% of patients and low-density lipoproteins in 79% of patients.
"Coronary artery disease patients in the United States do not receive maximal medical therapy," Levin says. "Only a fraction of patients who need to be put on aspirin, ACE inhibitors, beta-blockers and lipid-lowering agents receive them, and when they are utilized, they’re given the lowest possible doses. It’s been documented that these patients should have low cholesterol, and only a small number do. We have consensus guidelines for these patients, but the levels are not being achieved."
To try to solve that problem, Levin and colleagues at qmed developed ohms/cad to optimize medical therapy, reduce unnecessary invasive procedures and provide constant surveillance of CAD patients to help primary care physicians manage them effectively. "We needed a mechanism to change the system," Levin says. "There is a belief on the part of many physicians that preventive measures are not particularly effective. Then there is patient resistance where in the absence of symptoms, they don’t take their medications. What we have done is shown that by combining surveillance with efforts to ablate ischemia, we can achieve success in the reduction of coronary events."
Better than an exercise stress test
The first step in the ohms/cad program is to put the patient on a monitor, called Monitor One STRx, which digitally records electrocardiographic output while the patient participates in normal activities for 24 hours. Levin says that length of time, plus the fact that patients are doing normal activities, makes the monitor better able to indicate CAD than the exercise stress test. The monitor also measures the severity of the disease a limitation of the stress test so the physician can see right away whether the patient can be medically managed, needs a cardiology consultation, or needs a surgical intervention.
Patient information age, gender, blood pressure, medications, CAD medical history, aspirin use, smoking history, comorbidities, and exercise profile is also stored in the monitor. After the 24-hour period, the data are transferred by modem to a database at the ohms center in New Jersey. Based on the information it receives, the database automatically compiles a full summary report, formulates an individualized patient care plan, and classifies the patient as high- or low-risk. If the data indicate that the patient is negative for ischemic activity, it faxes the report and care plan back to the physician’s office within 30 minutes, says Teri Kraf, RN, MHA, director of disease management for qmed. If the data indicate that the patient is positive for ischemic activity, an academic cardiologist reviews the information and sends the physician a detailed recommendation within 24 hours.
"It’s not a cookbook plan," Kraf says. "It’s different for each patient. For example, if the patient has a history of hypertension, is already on a beta-blocker, and his blood pressure is still high, the plan might recommend increasing his meds from 25 mg to 50 mg. The physicians are more apt to read it if it’s individualized."
The ohms center also sends faxed reminders to physicians when it’s time to get the patient back in the office for a follow-up visit, and provides educational programs for physicians and patients. Monthly reports on physician utilization of the system and patient outcomes such as blood pressure, ischemia, and use of aspirin are sent to the managed care organization. More detailed outcomes reports based on claim reviews and compared with a control group receiving "usual care" are done twice a year. More than 80% of the physicians use ohms/cad regularly. "The system was designed for primary care physicians," Levin says. "Cardiologists are certainly involved, but the technology belongs to the PCPs. They have ownership and the reinforcement of seeing proof in black and white that their modifications work."
The constant monitoring is key, Levin says. "The field is moving from episodic, chest-pain induced acute care to one in which there is constant surveillance. Where you used to have a patient who had a myocardial infarction in 1970, was chest-pain free and now has pain, and you used that event as a reason to provide care, now the patient will be constantly monitored. It helps the physician avoid invasive procedures, and it helps the patient know his medications are indeed for a useful purpose."
[For more information on ohms/cad, contact: Richard Levin, MD, FACP, FACC, professor of medicine, New York University School of Medicine, 550 1st Ave., New York, NY 10016. Telephone: (212) 263-6554. Teri Kraf, RN, MHA, director of disease management for qmed, Inc., 100 Metro Park South, Laurence Harbor, NJ 08878. (800) 237-2039.]
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