Slide 2 Continuing Medical Implementation ...bridging the care
gap Bridging the Care Gap 2007 Joel Niznick MD FRCPC
www.cvtoolbox.com Slide 3 Continuing Medical Implementation
...bridging the care gap Care Gap Slide 4 Continuing Medical
Implementation ...bridging the care gap Care Gap Failure to,
translate, transfer and utilize medical knowledge effectively Usual
Care best care Population outcomes do not match results of clinical
trials Patient, physicians & payers do not reap the benefits of
validated medical knowledge Slide 5 Continuing Medical
Implementation ...bridging the care gap Care Gap The difference
between what we know and what we do The difference between
achievable and actual outcomes The failure to systematize knowledge
and apply it consistently Slide 6 Continuing Medical Implementation
...bridging the care gap Knowledge Translation Definition:
Knowledge translation is the effective and timely incorporation of
evidence-based information into the practices of health
professionals in such a way as to effect optimal health care
outcomes and maximize the potential of the health system. Adapted
from the Canadian Institutes for Health Research definition, 2001
Slide 7 Continuing Medical Implementation ...bridging the care gap
INTER-HEART: Risk of acute MI associated with risk factors in the
overall population Yusuf S. European Society of Cardiology Congress
2004; August 28-September 1, 2004; Munich, Germany. Risk factorOdds
ratio adjusted for age, sex, and smoking (99% CI) Odds ratio
adjusted for all (99% CI) ApoB/ApoA-1 (fifth quintile compared with
first) 3.87 (3.39-4.42)3.25 (2.81-3.76) Current smoking2.95
(2.72-3.20)2.87 (2.58-3.19) Diabetes3.08 (2.77-3.42)2.37
(2.07-2.71) Hypertension2.48 (2.30-2.68)1.91 (1.74-2.10) Abdominal
obesity2.22 (2.03-2.42)1.62 (1.45-1.80) Psychosocial2.51
(2.15-2.93)2.67 (2.21-3.22) Vegetable and fruits daily0.70
(0.64-0.77)0.70 (0.62-0.79) Exercise0.72 (0.65-0.79)0.86
(0.76-0.97) Alcohol intake0.79 (0.73-0.86)0.91 (0.82-1.02) All
combined129.2 (90.2-185.0) Slide 8 Continuing Medical
Implementation ...bridging the care gap INTER-HEART:
Population-Attributable Risk (PAR) Acute MI in the overall
population Risk factorPAR adjusted for age, sex & smoking 99%
CI) PAR adjusted for all (99% CI) ApoB/ApoA-1 (fifth quintile
compared with first) 54.1 (49.6-58.6)49.2 (43.8-54.5) Current
smoking36.4 (33.9-39.0)35.7 (32.5-39.1) Diabetes12.3 (11.2-13.5)9.9
(8.5-11.5) Hypertension23.4 (21.7-25.1)17.9 (15.7-20.4) Abdominal
obesity33.7 (30.2-37.4)20.1 (15.3-26.0) Psychosocial28.8
(22.6-35.8)32.5 (25.1-40.8) Vegetable and fruits daily12.9
(10.0-16.6)13.7 (9.9-18.6) Exercise25.5 (20.1-31.8)12.2 (5.5-25.1)
Alcohol intake13.9 (9.3-20.2)6.7 (2.0-20.2) All combined90.4
(88.1-92.4) Yusuf S. European Society of Cardiology Congress 2004;
August 28-September 1, 2004; Munich, Germany. Slide 9 Continuing
Medical Implementation ...bridging the care gap INTERHEART: Summary
1.Nine simple risk factors are strongly associated with AMI
worldwide. 2.These risk factors are even more important in the
young, and their effects are consistent in men and women, across
all ethnic groups and all regions. 3.Abnormal Apo-B/ApoA-1 ratio
and smoking are the most important risk factors and account for
>2/3 of the PAR. All 9 risk factors account for >90% of the
PAR globally and in most regions. IMPLICATIONS: Implementing
preventive strategies based on our current knowledge would avert
the majority of premature CHD worldwide. Slide 10 Continuing
Medical Implementation ...bridging the care gap Prevention Goals
for CVD VariableGoal SmokingTotal Cessation Total Dietary Fat /
Saturated Fat< 30% calories / < 7% calories Dietary
Cholesterol< 200 mg/day Physical Activity30-45 min. moderate
intensity 5X/week Body Weight by Body Mass indexInitial BMI Weight
Loss Goal 25-27.5 BMI < 25 > 27.5 10% relative weight loss
LDL cholesterol (primary goal) 1.6 2.2 mmol/L (60-85 mg/dL ) HDL
cholesterol (secondary goal)1.0 mmol/L ( > 40 mg/dL )
Triglyceride (secondary goal)1.7 mmol/L ( < 150 mg/dL ) Blood
Pressure< 130/80 mmHg (< 120/80 for LVD) DiabetesHbAlc <
7.0 % Slide 11 Continuing Medical Implementation ...bridging the
care gap Primary Prevention Dietary modification 30% fat
7%saturated fat 200mg/day cholesterol. Weight loss 5-10% TBW
Physical activity 30 min 5X/wk Smoking cessation Slide 12
Continuing Medical Implementation ...bridging the care gap
Potential Cumulative Impact of 1 Prevention Strategies Smoking
Cessation2/3 BP reduction 20mm Hg1/2 LDL reduction 1mmol/L1/6
Cumulative Prevention5/6 Slide 13 Continuing Medical Implementation
...bridging the care gap Potential Cumulative Impact of 2
Prevention Treatments RRREvent rate None8%16% ASA25%6%12% -Blockers
25%4.5%9.0% Lipid lowering30%3.0%6.0% ACE- inhibitors 25%2.3%4.6%
Cardiac Rehab25%1.7%3.4% Adapted from Yusuf, S. Two decades of
progress in preventing vascular disease. Lancet 2002; 360: 2-3.
CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF 78% RRR, WHICH IS
SUBSTANTIAL Slide 14 Continuing Medical Implementation ...bridging
the care gap CVD 2 Prevention Cocktail CAD, CVA,TIA, PVD, AAA, Type
2 DM Same Disease/Same Rx: ASA Lipid Targets TC < 4.5 LDL <
2.0 (1.8) HDL > 1.2;TC/HDL < 4 TG < 1.7 ACE inhibitor HOPE
Trial EUROPA Trial -blocker for post- MI, HPT or CAD Slide 15
Continuing Medical Implementation ...bridging the care gap Top 10
Evidence Based Advances in CV Disease ASA/Plavix-CAD/ACS UF/LMW
Heparin ACS Thrombolytic/PCI-STEMI -blocker post-MI ACE-i/ARB
CHF/LV dysfunction Post MI Vascular disease/DM Anticoagulation in
atrial fibrillation Lipid Lowering 2 - CAD, CVD, PVD, DM 1 - Risk
Factors HTN (hypertension): LDD/-blocker/ACE-i/ ARB/long-acting CCB
Isolated Systolic HTN > 60: LDD/long-acting DHP- CCB/ARB (avoid
-blocker or alpha- blocker as initial Rx) -blocker -CHF Slide 16
Continuing Medical Implementation ...bridging the care gap Top 10
Failures to Implement Evidence Based Advances in CV Disease
ASA/Plavix-CAD/ACS UF/LMW Heparin ACS Thrombolytic/PCI-STEMI
-blocker post-MI ACE-i/ARB CHF/LV dysfunction Post MI Vascular
disease/DM Anticoagulation in atrial fibrillation Lipid Lowering 2
- CAD, CVD, PVD, DM 1 - Risk Factors HTN (hypertension):
LDD/-blocker/ACE-i/ ARB/long-acting CCB Isolated Systolic HTN >
60: LDD/long-acting DHP- CCB/ARB (avoid -blocker or alpha- blocker
as initial Rx) -blocker -CHF Slide 17 Continuing Medical
Implementation ...bridging the care gap Goals in Cardiovascular
Prevention Identify all patients who could benefit Stratify
according to all risk factors Initiate therapy in all where
cost/benefit favorable Achieve appropriate targets or % reductions
Provide long term follow-up to ensure adherence Achieve
mortality/morbidity benefits attained in clinical trials Target
every patient for optimal risk stratification and reduction Slide
18 Continuing Medical Implementation ...bridging the care gap Where
can we have the greatest impact in cardiovascular disease? Stroke
prevention Hypertension control Anticoagulation in atrial
fibrillation CAD Secondary prevention cocktail Medical management
for symptoms Appropriate revascularization CHF Patient education
Medical management for prognosis and symptoms Admission and
readmission prevention programs Slide 19 Continuing Medical
Implementation ...bridging the care gap Ways to influence practice
Consensus guidelines Didactic CME Workshop CME Practice pattern
review Specific recommendations by local experts Usual channels of
communication Reminder strategies Evidence based application tools
Slide 20 Continuing Medical Implementation ...bridging the care gap
Guideline Implementation Bring together national experts Develop
guideline,consensus statement or recommendation Publication
Diffusion Dissemination Implementation Slide 21 Continuing Medical
Implementation ...bridging the care gap Knowledge Evolution DATA
Knowledge Translation INFORMATION Knowledge Utilization ACTION DATA
Knowledge Translation INFORMATION Knowledge Utilization ACTION
Slide 22 Continuing Medical Implementation ...bridging the care gap
Opportunities to Improve Care for Patients With Cardiovascular
Disease Despite overwhelming clinical trial evidence, expert
opinion, national guidelines, and a vast array of educational
conferences, evidence-based, life-saving therapies continue to be
underutilized New approaches to improving the use of proven,
guideline-recommended, life-saving therapies are clearly needed
Fonarow GC. Rev Cardiovasc Med. 2002;3:S2-S10. Slide 23 Continuing
Medical Implementation ...bridging the care gap Clinical Research
to Clinical Practice-Lost in Translation. Claude Lenfant, M.D. NEJM
349(9) 868-874 August 28 2003 both health providers and members of
the public, are not applying what we know. we are not reaping the
full public health benefits of our investment in research. there is
plenty of evidence that "old" research outcomes have been lost in
translation as well. Slide 24 Continuing Medical Implementation
...bridging the care gap The case for knowledge translation:
shortening the journey from evidence to effect. BMJ 2003;327:33-35
(5 July 03) Davis et al A large gulf remains between what we know
and what we practice. Such variation is common not only
internationally but within countries. Large gaps also exist between
best evidence and practice in the implementation of guidelines.
Slide 25 Continuing Medical Implementation ...bridging the care gap
Why most interventions to improve physician prescribing do not seem
to work. Majumdar and Soumerai CMAJ 169(1) July 8 2003
Interventions that rely solely on passive information transfer are
ineffective Active knowledge translation strategies are usually
effective, although the effects are modest. Interventions that
incorporate 2 or more distinct strategies (i.e., that are
multifaceted) are more likely to work Slide 26 Continuing Medical
Implementation ...bridging the care gap The Canadian Cardiovascular
Society and Knowledge Translation: Turning Best Evidence into Best
Practice Tremblay et al Can J Cardiol 2004;20(12):1195-1198.
Estimates of the size of the care gap indicate that 30% to 40% of
patients fail to receive treatments of proven effectiveness, 20% to
25% of patients may receive care that is not needed or is
potentially harmful Slide 27 Continuing Medical Implementation
...bridging the care gap Patient Health Management Patients First:
Closing the Health Care Gap in Canada starts with a premise no one
can disagree with: Things can be better in our health care system,
in every way. Dr. Montague then goes on to show how patients,
practitioners and policy-makers can make incremental improvements
that will make things better. At the centre of his vision is the
patient, and he provides a blueprint that will deliver optimal
health care results without necessarily engendering a greater
burden on available resources. Slide 28 Continuing Medical
Implementation ...bridging the care gap Analyzing the Care Gap
Evidence Gap Guideline Gap Diffusion Gap Dissemination Gap
Implementation Gap Adherence Gap Outcome Gap Rising Health Care
Costs Slide 29 Continuing Medical Implementation ...bridging the
care gap Barriers to Implementing Risk Factor Management in
Patients With CHD Physician is focused on acute problems Time
constraints and lack of incentives, including reimbursement Lack of
training, including inadequate knowledge of benefits and lack of
prescription experience Lack of resources and facilities Lack of
specialistgeneralist communication; passing on responsibility
Adapted from Pearson TA et al. J Am Coll Cardiol.
1996;27:1039-1047. Slide 30 Continuing Medical Implementation
...bridging the care gap Why the Gap? Lack of information-knowledge
gap Information overload-guideline overload Jurisdiction: Whose job
is it? Too busy to read recommendations Patient overload/Physician
shortage Issue overload/Patient priorities Lack of tools or
resources Confusion - competing marketing strategies Medico-legal
implications Slide 31 Continuing Medical Implementation ...bridging
the care gap Why the Gap? Uncertainty Inertia Jurisdiction
Effectiveness Resources Continuity Adherence Slide 32 Continuing
Medical Implementation ...bridging the care gap Adherence Gap Cost
of medications Complacency-patient and physician Side effects Lack
of understanding Media impact/fears Infrequent monitoring Lack of
feedback Slide 33 Continuing Medical Implementation ...bridging the
care gap Evidence Based Implementation Tools CME CMI CME CMI A New
Paradigm Continuing Medical Implementation CMI A New Paradigm
Continuing Medical Implementation Slide 34 Continuing Medical
Implementation ...bridging the care gap www.cvtoolbox.com Slide 35
Continuing Medical Implementation ...bridging the care gap
www.cvtoolbox.com Slide 36 Continuing Medical Implementation
...bridging the care gap www.cvtoolbox.com Slide 37 Continuing
Medical Implementation ...bridging the care gap Three Pronged
Approach Condensed evidence review and guideline distillation
Patient information products Implementation tools Slide 38
Continuing Medical Implementation ...bridging the care gap Post MI
Discharge Summary Slide 39 Continuing Medical Implementation
...bridging the care gap Guide for Comprehensive Cardiovascular
Risk Reduction Slide 40 Continuing Medical Implementation
...bridging the care gap Dyslipidemia Package Slide 41 Continuing
Medical Implementation ...bridging the care gap Lipid Optimization
Tool Slide 42 Continuing Medical Implementation ...bridging the
care gap Hypertension Package Slide 43 Continuing Medical
Implementation ...bridging the care gap HOP To ITT Hypertension
Calendar Slide 44 Continuing Medical Implementation ...bridging the
care gap Diet Information Sheets Slide 45 Continuing Medical
Implementation ...bridging the care gap Diet Information Sheets
Slide 46 Continuing Medical Implementation ...bridging the care gap
Optimal Management of Atrial Fibrillation Slide 47 Continuing
Medical Implementation ...bridging the care gap Guide for HF
Management Slide 48 Continuing Medical Implementation ...bridging
the care gap Multiple Modalities of Distribution Targeted mailings
Hard copy/photocopy Reprint/re-order Digital copy Web site CME
programs Implementation networks Slide 49 Continuing Medical
Implementation ...bridging the care gap Multifaceted Product
Education Patient Physician House-staff Nurses Implementation Tools
CPD CME Slide 50 Continuing Medical Implementation ...bridging the
care gap The Physician Patient Interface is Not a Virtual World
Slide 51 Continuing Medical Implementation ...bridging the care gap
Slide 52 Implementation Network Slide 53 Continuing Medical
Implementation ...bridging the care gap
Recognition-Screening-Initial Therapy- Family MD Community Based
Awareness/Understanding How can we amplify the impact of
preventative strategies? Risk Stratification-Rx Optimization/
Adherence-FD & Specialist Specialist/Cardiologist-Invasive
Dx/Tx- Monitoring/Rehab/Reinforcement
Interventions-Revascularization-Devices- Procedures 4 2 & 3 1
& 2 Primary Care Physician Prevention Awareness Programs/PHN
Slide 54 Continuing Medical Implementation ...bridging the care gap
Network of Networks Slide 55 Continuing Medical Implementation
...bridging the care gap Summary Cardiovascular diseases pose a
huge clinical and economic burden Metabolic precursors including
obesity, dyslipidemia, metabolic syndrome, IFG, DM are epidemic
Inactivity, smoking, hypertension, CHF & AFIB add to the global
burden Prevention is sub-optimal/proven therapies are
underutilized-there remains a huge Care Gap Slide 56 Continuing
Medical Implementation ...bridging the care gap Summary
Comprehensive primary & secondary prevention strategies are
required Multiple interventions are required to Bridge the Care Gap
Educational resources and management tools are necessary at point
of care www.cvtoolbox.com may be a useful vehicle in this
regardwww.cvtoolbox.com
