the ankle-brachial index as a screening method for atherosclerosis john michael frullo, sana yaklur,...
TRANSCRIPT
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The Ankle-Brachial Index as a Screening Method for
Atherosclerosis
John Michael Frullo, Sana Yaklur, Lara Pferdehirt, Kathryn Wallace,
Sam Vallagomesa, Veronica Gough, Stephen Phillips, Paul Greenfield
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Atherosclerosis in Today’s World
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The Atherosclerosis Issue
• Plaque buildup on walls of arteries
• Causes blockage
• Can lead to heart attack or stroke
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Scope and Statistics
• 400,000+ die annually from coronary heart disease related to atherosclerosis
• 50% of men and 64% of women who die of heart disease are not diagnosed
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• Atherosclerosis Coronary Heart Disease
• Often undetected
• Diagnosis is expensive and invasive
• Prevention is possible through early detection
• Currently no standard method
Problem Statement
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Mission Statement
Identify individuals at risk
Choose a method to classify people into risk groups
Minimize cost to society
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Key Results
• Screen an intermediate and high risk population for atherosclerosis
• Using the Ankle-Brachial Index
• Extend ≈800,000 lives in the first year
• Save $27.7 billion in the first year
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Target Design Criteria
Design Criteria Desired Measure
Cost ≤ $30
Sensitivity 85%
Specificity 50%
Accessibility Suburban/Urban Clinic
Administration General Practitioner
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Assumptions
• Numerical data related to CHD is also applicable for atherosclerosis• Costs from healthcarebluebook.com • Most hospitals equipped to:
otake blood pressureodraw bloodoconduct blood analysis
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3 Screening Methods
Low Density Lipoprotein (LDL) Cholesterol Testing
High-Sensitivity C-Reactive Protein (hs-CRP)
Ankle-Brachial Index (ABI)
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Low Density Lipoprotein (LDL) Cholesterol Testing
• LDL, risk of cardiovascular diseases
• Cost: $50• Sensitivity and
specificity: 88%
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High-Sensitivity C-Reactive Protein
• CRP biomarker showing inflation
• Cost: $80• Sensitivity: 93%• Specificity: 65%
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Ankle-Brachial Index
• Blood pressure measurements at arm and ankle
• Cost: $20• Sensitivity: 85%• Specificity: 45%• Simple
implementation
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PUGH SCORING MATRIX Ankle-Brachial Index hs-CRP Cholesterol Testing
(LDL)
Evaluation Criteria Weight Raking Weighted
Score Ranking Weighted Score Ranking Weighted
Score
Cost 40% 5 2.00 2 0.80 3 1.20
Sensitivity 20% 2 0.40 4 0.80 3 0.60
Specificity 15% 3 0.45 4 0.60 5 0.75
Accessibility 15% 3 0.45 3 0.45 3 0.45
Administration 10% 4 0.40 3 0.30 4 0.40
Total Weighted Score
100% 3.70 2.95 3.40
Rank - 1 3 2
Chosen - IMPLEMENT NO NO
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Ankle-Brachial Index
• Administration• Possible Results:
o ≥ 0.9: good cardiovascular healtho < 0.9: indication of arterial problems
Posterior Tibial Artery Blood Pressure
Brachial Artery Blood Pressure
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Population• Selection Process:
o Ages when risk increaseso Risk factors derived from Framinghamo Targeting intermediate/high risk group
• Risk Factors:1. Family history of Coronary Heart Disease2. Obesity3. Physical Activity4. Smoking
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Men: 45-65 yearsWomen: 55-65 years
U.S. Population
≥ 2 risk factors
Ankle-Brachial Index
HIGH RISK GROUPLOW RISK GROUP
≥ 0.9 < 0.9
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LOW RISK GROUP HIGH RISK GROUP
• Maintain a healthy lifestyle (especially in the risk factor categories)
• Rescreen in two years
• Consult doctor for:• diagnosis
(angiography)• treatment
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Cost-Benefit Analysis
• 11.1 million people screened• Add 2.6 years of life• Save $27.7 billion in the first year
Cost: $24.4 billion
Benefit: $52.1 billion
Benefit to Cost Ratio = 2.14 : 1
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Limitations of Ankle-Brachial Index
• Disadvantageo Relatively low specificity value (45%)
Test Positive Test Negative
Actual Positive True Positive False Negative(Sensitivity)
Actual Negative False Positive(Specificity) True Negative
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Advantages of Ankle-Brachial Index
• Cost: $20• Sensitivity: 85%• Accessibility
o Most Hospitals and Clinics• Administration
o Requires 2 hours of trainingoMost medical professionals
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Conclusion
• Atherosclerosis & CHD ultimately fatal, but preventable
• Screening is the best solution• We recommend screening using the
Ankle-Brachial Indexo Intermediate and high risk population
• Save $27.7 billion, Benefit to Cost (2.14:1)
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Reference Slide1. What is Atherosclerosis? (n.d.). National Heart, Lung and Blood Institute.
Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/2. . What Is Coronary Heart Disease? (n.d.). National Heart, Lung, and Blood Institute.
Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/cad/3. Castellon, X., & Bogdanova, V. (2013). Screening for subclinical atherosclerosis by
noninvasive methods in asymptomatic patients with risk factors. Clinical Interventions in Aging, 2013(8), 573 – 580.
4. Carotid Angiogram: How to prepare for your procedure . (n.d.). University of Washington Medical Center. Retrieved from
https://healthonline.washington.edu/document/health_online/pdf/Carotid_Angiogam_7_08.pdf5. What is Cholesterol? (2012, September 19). National Heart, Lung, and Blood
Institute. Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/hbc/ 6. Miller, W. G., Myers, G. L., Sakurabayashi, I., Bachmann, L. M., Caudill, S. P.,
Dziekonski, A., … Remaley, A. T. (2010). Seven Direct Methods for Measuring HDL and LDL Cholesterol Compared with Ultracentrifugation Reference Measurement Procedures. Clinical Chemistry, 56(6), 977–986. doi:10.1373/clinchem.2009.142810
7. Low Density Lipoprotein Cholesterol (Direct). (2013).Healthcare Blue Book. Retrieved from http://healthcarebluebook.com/page_Results.aspx?id=1072&dataset=lab&g=Lo w-Density%
20Lipoprotein%20Cholesterol%20(Direct 8. Rifai, Nader, and Paul M. Ridker. “High-Sensitivity C-Reactive Protein: A Novel and
Promising Marker of Coronary Heart Disease.” Clinical Chemistry 47, no. 3 (March 1, 2001): 403–411. http://www.clinchem.org/content/47/3/403.
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Reference Slide(2)9. High Sensitivity C-Reactive Protein Testing for Cardiovascular Disease. (2013, April
9). Blue Cross Blue Shield of Tennessee. Retrieved from http://www.bcbst.com/learn/treatment-options/crp.shtm 10. Diercks, D. B., Kirk, J. D., Naser, S., Turnipseed, S., & Amsterdam, E. A. (2011).
Value of high-sensitivity C-reactive protein in low risk chest pain observation unit patients. International Journal of Emergency Medicine, 4, 37. doi:10.1186/1865-1380-4-37. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141386/ 11. Ankle-brachial index. (2006).Harvard Medical School Family Health Guide.
Retrieved from http://www.health.harvard.edu/fhg/updates/ankle-brachial-index.shtml12. Crimmel, B.L. Co-pays and Coinsurance Percentages for Employer-Sponsored Health
Insurance in the Private Sector, by Firm Size Classification, 2002–2005. Statistical Brief #189. November 2007. Agency for Healthcare Research and Quality, Rockville, MD. 13. Thoshiaki Shinozaki, , T. H., & Eiji Yano. (1998). Ankle–Arm Index as an Indicator
of Atherosclerosis: Its Application as a Screening Method. Journal of Clinical Epidemiology, 51(12), 1263–1269. doi:http://dx.doi.org/10.1016/S08954356(98)00122-X
14. Coronary Heart Disease (10-year risk) Framingham Heart Study. (n.d.). RetrievedSeptember 17, 2013, from http://www.framinghamheartstudy.org/risk/coronary.html
15. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). (2002, September). National Heart, Lung, and Blood Institute. Retrieved from
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Reference Slide(3)16. Naghavi, M., Falk, E., Hecht, H. S., Jamieson, M. J., Kaul, S., Berman, D., … Shah,
P. K. (2006). From Vulnerable Plaque to Vulnerable Patient—Part III: Executive Summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report.The American Journal of Cardiology, 98(2, Supplement 1), 2– 15.doi:10.1016/j.amjcard.2006.03.002
17. Lalkhen, A. G., & McCluskey, A. (2008). Clinical tests: sensitivity and specificity.Continuing Education in Anaesthesia, Critical Care & Pain, 8(6), 221
223. doi:10.1093/bjaceaccp/mkn041 18. Mohler III, E., Treat-Jacobson, D., Reilly, M., Cunningham, K., Miani, M., Criqui,
M., … Hirsch, A. (2004). Utility and barriers to performance of the ankle brachial index in primary care practice. Vascular Medicine, 9(243), 253 – 260. doi:10.1191/1358863x04vm559oa. Retrieved from http://vmj.sagepub.com/content/9/4/253.long.
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Picture Reference
• http://www.foxnews.com/health/2013/05/30/high-doses-common-painkillers-increase-heart-attack-risks/ [Heart Clutch]
• http://familydoctor.org/content/familydoctor/en/diseases-conditions/atherosclerosis/_jcr_content/par/image.img.png [Athero]
• http://www.wakemed.org/images/heartcenter/H2H_Spring2011_anckle.jpg [ABI]• [Slide 2 - Hook] http
://lebanonfamilyhealth.org/wp-content/uploads/2013/01/lfhs_website_header_images.jpg
• [Slide 2 - Hook] http://www.thebestsuccesscoach.com/wp-content/uploads/2013/02/shutterstock_124099558-200x300.jpg
• [Pop. Infographic] http://www.thebestsuccesscoach.com/wp-content/uploads/2013/02/shutterstock_124099558-200x300.jpg
• http://www.scientificamerican.com/article.cfm?id=next-generation-blood-test • http://www.examiner.com/article/pacquiao-says-he-is-now-open-to-do-random-bl
ood-tests-with-14-day-cutoff-for-mayweather-fight
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SCORING MATRIX
Ankle-Brachial
IndexCIMT
Coronary Calcium
Scorehs-CRP ECG LDL Test
Cost + 0 - + - +
Sensitivity 0 0 + + - 0
Specificity - 0 - 0 + +
Accessibility + 0 0 + 0 +
Administration + 0 - - - +
Sum of +, 0, -+: 30: 1-: 1
+: 00: 5-: 0
+: 10: 1 -: 3
+: 30: 1-: 1
+: 10: 1-: 3
+: 40: 1-: 0
Rank 2 4 5 2 5 1
Pass? YES NO NO YES NO YES
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5 0-24
4 25-49
3 50-74
2 75-99
1 ≥ 100
5 96-100
4 91-95
3 86-90
2 81-85
1 76-80
5 80-100
4 60-79
3 40-59
2 20-39
1 0-19
5 At home
4 Suburban/Rural Clinic
3 Most Urban Hospitals
2 Specialized Hospitals
1 No available in the U.S.
5 Anybody (at home)
4 Technician/Nurse/Blood Tests: any lab
3 Family Practitioner/Blood Tests: labs with more diverse options
2 Cardiologist
1 Specialized Cardiologist
Table 1: Cost Scale (in USD) Table 2: Sensitivity Scale (%) Table 3: Specificity Scale (%)
Table 4: User-Defined Scale Accessibility Table 5: User-Defined Scale Administration
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Cost Benefit Analysis
Population Numbers (people)
Test Positive Test Negative
Actual Positive TP: 800,000 FN: 140,000
Actual Negative FP: 5.6 mill TN: 4.56 mill
6.4 million
11.1 million
60.3 million
Flier
ABI
Angiography
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Cost Benefit Analysis• Benefit = $52.1 billion– Lives saved * Life-years/person * Monetary
value/ Life-year– 800,000 people * 2.6 years/person * $25,000/yr
• Cost = $24.4 billion– Costs of: fliers + screening + angiography +
patient time + doctor time– $661 mill + $222 mill + $9.18 bill + $445 mill +
$13.9 bill• Benefit to Cost Ratio = 2.14 : 1