Optimizing disease management at a health care system level: The rationale and methods of the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study

Improving Cardiovascular Outcomes in Nova Scotia (ICONS) is a five year project that aims to determine whether the management of patients with an acute coronary syndrome, congestive heart failure or atrial fibrillation can be improved through a multi-lateral health care stakeholder effort using a disease management strategy. It is a large prospective cohort study with two major phases. The first involves passive baseline measurement of process of care and outcomes as these relate to all hospitalized Nova Scotians with a disease of interest as well as high risk persons from the community. The second comprises a series of interventions, developed on the basis of insights gained from the analysis of baseline, that are aimed at optimizing care. Process of care and outcomes during and after these interventions are compared with those measured at baseline. There is no control population. The hypothesis is that a population based disease management approach will lead primarily to an optimization in health care delivery, as reflected by a 25% absolute increase in the utilization of evidence-based marker therapies over the course of the study, and that this will secondarily result in improved health outcomes. Approximately 1000 patients in each of the three disease groups are required to test the primary hypothesis. However, about 10,000 Nova Scotians annually are study eligible and are targeted for enrolment. Outcomes evaluated are all-cause and cardiovascular mortality, major cardiovascular morbidity, hospitalization, revascularization, health care resource use, patient quality of life and satisfaction with their care, and employment and workplace productivity issues.