It pays to reward physicians for patients at risk of stratification, early data index

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At 1 year, high-risk patients in the intervention group had more initiation or intensification of primary prevention than controls.

Payments made directly to doctor’s offices or health centers that take the initiative to stratify their patients’ risks may slightly improve preventive care efforts for Medicare beneficiaries at high risk for cardiovascular events, recent data shows. publications of the Million Hearts Cardiovascular Risk Reduction Model.

“There are 330 organizations of all different types across the country, so I think it’s promising in that it has clearly improved processes of care for things like risk stratification,” lead author G. Greg Peterson, PhD (Mathematica, Washington, DC), said TCTMD.

The incentive model was launched in 2017 by the US Centers for Medicare & Medicaid Services (CMS) with the goal of reducing the rate of myocardial infarction and stroke in high-risk patients. Provider organizations that signed up were assigned to the intervention or usual care, with the intervention group to stratify patients by CVD risk over 10 years and provide prevention management services, including discussion on risk scores, individualized risk reduction plans, as well as annual assessments. risk assessments and monitoring for the person.

While the model is still ongoing and has yet to report its primary outcome, the secondary analysis, posted online in JAMA Cardiology by Peterson and colleagues, shows a statistically significant, although numerically small, improvement in the intervention group with respect to initiation or intensification of statins and antihypertensives within one year of enrollment.

Registered organizations include primary care and cardiology practices, health centers, and inpatient outpatient services. Of 125,436 Medicare beneficiaries included in these organizations, the high-risk patients in the intervention group had an average age of 74 years at the time of enrollment and 91% of them were above the blood pressure threshold. systolic (> 130mm Hg), LDL-cholesterol (> 70mg / dL), or both. In addition, 69% of people in the intervention group were already taking statins, 90% were taking an antihypertensive drug, and the average number of office visits in the past year was 10.

At 1 year, the initiation or intensification of statins or antihypertensive drugs was 37.3% in the intervention group versus 32.4% in the control group (P myocardial infarction or stroke, there were also higher rates of initiation or intensification of statins or antihypertensive drugs in the medium risk patients in the intervention group, who were at risk of 15 % to 30% (27.9% vs. 24.8; P

Besides the difference in drug use, the model also showed an impact on clinical parameters, with mean arterial pressure 1.2% lower in high-risk patients in the intervention group at 1 year compared to witnesses (P = 0.003), as well as an average LDL cholesterol level 2% lower (P = 0.003).

Systematic ‘Spillover’ improvement

“I think the spillover onto the medium risk group is significant,” noted Peterson, adding that this could be the result of more systematic use of risk scores in daily practice among enrollees, a key element that the model is supposed to encourage. The impact on blood pressure and cholesterol is certainly modest to low, however you think of it. But when you spread these impacts over a large population, they can still have a significant effect on the entire population, ”he added.

Million Hearts pays participating organizations $ 10 for each eligible beneficiary that they stratify based on risk. In the first year, the cardiovascular management fee is set at $ 10 per beneficiary per month for each high-risk registrant. In year 2 and later, the cardiovascular management fee is replaced with risk reduction payments phased over performance in 10-year predicted risk reduction for those who were at high risk at enrollment initial (up to a maximum of $ 10 per beneficiary per month). Controllers are also paid to collect and report clinical data, but they are not asked to calculate CVD risk scores or make changes to their usual clinical care.

Peterson said it is too early to know whether the pay-for-performance model will have a significant impact on the primary outcome of the first incidence of MI or stroke over 5 years. The model is expected to continue until 2022. However, although it has so far shown only a modest difference between the intervention and control groups on drug management, preliminary data at 2, 5 years suggest that the difference is holding, he said.

“If the benefits of drugs accumulate over time, the impact on risk of an actual event could increase over time, even if the impact on drugs is only a lasting difference.” , added Peterson.

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