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CityAge: The Data Effect Vancouver
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Using BC and Canadian Data to Improve Health and Healthcare
What are the best ways to improve health outcomes and system sustainability?
Dr. Bruce Carleton University of Bri<sh Columbia
Child & Family Research Ins<tute BC Children’s Hospital
BC Data and Diabetes
Diabetes Control
• Major test used to monitor control is hemoglobin A1C – measures glucose control over 4 months by analyzing the amount of glucose on the red blood cell
• CDA recommends tes<ng every 3 months; Test at 6-‐month intervals when glycemic targets are consistently achieved
• No evidence to suggest tes<ng more oPen than every 4 months is necessary
Annual cost of A1C tests performed in BC 2005-‐2011
Annual number of A1C tests performed in VCHA
Annual cost of A1C tests performed in VCHA
Annual number of A1C tests performed in FHA
Annual cost of A1C tests performed in FHA
One-‐third of all A1C tests are repeated within 3 months
BC Data and Asthma
3 million Canadians live with asthma
Asthma is the #1 chronic condi<on in children
6 out of 10 people living with asthma do not have it under control
250 people die each year in Canada from asthma (and most are preventable)
Improving Asthma Management
The Opportunity: Bri<sh Columbia’s Data
Medical Service Plan
PharmaNet
Discharge Abstracts Database
Vital Sta<s<cs
Inhaled Short-‐ac<n
g Bron
chod
ilator
Use
(Salbu
tamol Equ
ivalen
ts)
> 500 µg/day
> 250 & ≤ 500 µg/day
>0 & ≤ 250 µg/day
0 µg/day
> 4 inhalers / year
2 -‐ 4 inhalers / year
1 -‐ 2 inhalers / year
≤ 1 inhaler / year
Inhaled Corticosteroid Use (Beclomethasone Equivalents)
Asthma Regimen Op<mality Classifica<on (Pa<ent Ages 5-‐11 Years)
Green = Op<mal regimen, n=6,155 (67%) Yellow = Unclassified regimen, n=2,162 (23%) Red = Subop<mal regimen, n=913 (10%)
Suboptimal regimen use
Optimal regimen use
Emergency Department Visits
Suboptimal regimen use
Optimal regimen use
Hospital Admissions
Family Prac<<oner Visits
60 – 80
90 – 100
100 – 120
120 – 130
> 130
Per 100 pa<ents Children 0 -18 years/ Asthma related visits/ 2009
Emergency Department Visits
1 -‐ 5 5 -‐ 10 10 -‐ 15 15 -‐ 20 20 -‐ 25
Per 100 pa<ents
Children 0 -‐18 years/ Asthma related visits/ 2009
Hospital Admissions
0 – 0.4
0.4 – 0.8
0.8 – 1.2
1.2 – 1.6
1.6 -‐ 2
Per 100 pa<ents
Children 0 -‐18 years/ Asthma related visits/ 2009
Costs per Pa<ent (by region)
*ED Costs are based on BCCH Data, Physician Visits Costs from MSP All Costs based on 2009 Data/Dollars
ED Service Use
Urban vs. Rural
Bubble Size: Estimated number of physicians in the area
0
200
400
600
800
1000
1200
ED visits Hospital admissions
471.98
47.59
1,067.23
180.28 Cos
t per
pat
ient
Health Services
Pts with optimal regimens
Pts with suboptimal regimens
Cost per pa*ent according to op*mality of asthma drug regimens (2009)
The costs of ED services was 2.3X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen The costs of hospital admission was 4X higher for patients with a suboptimal regimen when compared to those treated with an optimal regimen
Daily vs. Intermikent (Seasonal) Use of Inhaled An<-‐inflammatory Asthma Drugs
�
1. Intermikent users of ICS are 28% more likely to have hospital admissions than regular users.
2. Intermikent users of ICS are 19% more likely to have ED visits than regular users.
BC Data and Prostate Cancer
Prostate Cancer is the most commonly-‐diagnosed cancer among Canadian men
23,600 Canadian men will be diagnosed with prostate cancer this year
In 2013, 3,900 Canadians will die from Prostate Cancer
Using BC Data to Develop a New Approach to Prevent Prostate Cancer
Metastasis
Prostate Cancer Mortality
• Most of the <me, prostate cancer is a chronic disease with low mortality
• Unfortunately, when the disease became metasta<c, it has a high mortality rate
• There is evidence to suggest that blocking a specific type of calcium channel can prevent metastases
The opportunity: Bri<sh Columbia’s Data
BC Cancer Registry
BC Cancer Agency
Pharmacy Data
PharmaNet Medical Services Plan
Relevance
If blockade of specific calcium channels decreases metastases, then men who take these drugs for heart disease should have lower rates of prostate cancer metastases than men who do not. If an associa9on is found between this par9cular class of calcium channel blocker use and survival or metastases, then calcium channel blockers could poten9ally be prescribed to either prevent prostate cancer metastases or prolong survival.
BC and Canadian Data and Hepa<<s C
Standard HCV Drug Therapy
• Recommended treatment:
• PEG-‐IFN-‐α + Ribavirin (48-‐week course)
Significant Variability in Response
40-50% clear virus
50-60% do not clear virus
Significant ancestry related differences in response rates (European > African response rates)
Treatment often poorly tolerated because of ADRs
New drugs available and on pipeline Direct Ac*ng An*virals
• High Rates of ADRs • Boceprevir/telaprevir decreased hemoglobin (9-‐52%)
• Telaprevir/boceprevir neutropenia and thrombocytopenia
• Telaprevir-‐induced skin reac<ons (56%; 1% severe) • Psychiatric symptoms from boceprevir
New Therapeutic Options for HCV Drug Therapy
Telaprevir (2012: 4 safety warnings) Bocepravir (2012-‐13: 5 safety warnings)
PEG-‐IFN-‐RBV
PEG-‐IFN-‐RBV +
Prot. Inhib.
Pa*ent
Can we determine the op*mal HCV treatment prior to therapy?
+ $20,000-‐40,000
IL28B Genotype
& Clinical Factors
“An individual with a CC genotype could be spared the expense and adverse events, and would achieve similarly excellent results with PEG-‐IFN/RBV alone” -‐ Jenson & Pol, Liver Intl, 2012
PEG-‐IFN+RBV
PEG-‐IFN+RBV +
Prot. Inhib.
Safe & Effec*ve
Adverse Drug Reac*on
70-‐86% SVR
80-‐90% SVR
IL28B C/C
Safe & Effec*ve
Adverse Drug Reac*on
+ $20-‐40k
No Effect
No Effect
1. Triple therapy offers modest
improvement for IL28B C/C patients but $$, ADRs
PEG-‐IFN+RBV
PEG-‐IFN+RBV +
Prot. Inhib.
Safe & Effec*ve
Adverse Drug Reac*on
70-‐86% SVR
80-‐90% SVR
IL28B C/C
Safe & Effec*ve
Adverse Drug Reac*on
+ $20-‐40k
No Effect
Safe & Effec*ve
25-‐40% SVR
60-‐75% SVR
No Effect
Safe & Effec*ve
No Effect
Adverse Drug Reac*on
No Effect
Adverse Drug Reac*on
IL28B T/T
2. Triple therapy significantly
improves SVR in IL28B T/T patients with $$, ADRs
The opportunity: Build the Dataset in Canada
Ac<ve Surveillance with CPNDS across
Canada
Chronic Hepa**s C treatment goal: Biomarker and Stepwise Approach
PegIFN + RBV
Pa<ents with predictors
of good response:
IL 28 C/C
IFN 4
Clinical factors
Pa<ents at higher risk to develop toxicity to DAA
PegIFN + RBV + DAA
Pa<ents with NO predictors of good response
Pa<ents without an increased risk to develop toxicity to DAA
Pa<ents with failure or relapse to PegIFN/RBV
DAA combina<on (IFN Free)
Future treatment???
Pa<ents at higher risk to develop toxicity to Peg-‐RBV
SVR
Op<mizing Cost: Each Pa<ents receives the appropriate medica<on
Op<mizing Safety: Clearly iden<fied risk-‐benefit profile for each drug
HCV Treatment Algorithm
Patient with HCV genotype 1 No previous HCV treatment
Genetic testing for IL28B/IFNL4 gene
region variants
ITPA genetic testing for RBV-induced anemia
risk
Treat with dual therapy: PegIFN/RBV
Treat with dual therapy + early erythropoietin
+ enhanced monitoring for anemia
ITPA genetic testing for RBV-induced
anemia risk
Treat with triple therapy:
PegIFN/RBV + telaprevir or boceprevir
Treat with triple therapy + Reduce RBV dose by 50%
(to 600mg/day) + enhanced monitoring for
anemia
Predicted good responder to dual therapy
Predicted poor responder to dual therapy
Low Risk Low Risk
Low Risk Low Risk High Risk High Risk
Hepa<<s C Treatment
• The right treatment for every pa<ent, avoiding unnecessary risk and providing the best possible care.
• Op<mize healthcare expenses for Hepa<<s C treatment
This is Beau<ful, Bri<sh Columbia
• BC has the BEST health data in North America • Rich informa<on on collec<ve health experiences • Can help us find solu<ons to health and health system problems
• Not just about research, but USE of findings to increase system efficiencies and improve care of pa<ents
• Preserve health benefits for Bri<sh Columbians in the next and future genera<ons