With 2010 quickly coming to a close, I'd like to end the year by highlighting the range of topics we've covered on the ACC in Touch Blog. Below are the top 10 most popular blog posts of 2010.

10. Reform-O-Rama: In March I outline the chronology of the health reform law by year. 

9. SHOCKING! Use of Medical Services Dropping: I discuss how use of medical services among U.S. residents appears to be dropping during this ongoing recession. 

8. An Opportunity for ACC Leadership: Blog Co-author and ACC President Ralph Brindis, MD, FACC, discusses the ongoing allegations of stent overuse in Maryland and the opportunity for professional associations like the ACC to lead. 

7. Another Setback for Triple Therapy for ACS: CardioSource Science and Quality Editor-in-Chief Chris Cannon, MD, FACC, discusses the discontinuation of the Phase 3 APPRAISE-2 clinical trial in ACS patients treated with apixaban.

6. Is a New Study on ARBs and Cancer Risk Cause for Alarm?: Jeffrey Anderson, chair-elect of the ACC/American Heart Association Task Force on Practice Guidelines and Vice Chair of the 2010 UA/NSTEMI Focused Update, talks about a July article in Lancet Oncology on the cardiovascular effects of ARBS. 

5. New ACCF/AHA Clinical Alert Addresses Clopidogrel Warning: Brindis discusses the ACCF/AHA clinical alert that was released in June on the clopidogrel black box warning. 

4. The Patient with a Left Ventricular Assist Device: Past ACC President Fred Bove, MD, MACC, discusses former U.S. VP Dick Cheney's decision to have an LVAD implanted. 

3. Does CV Imaging Increase Cancer Risk?: Brindis discusses a study that came out in JACC in July finding that cardiac imaging procedures increased risk of radiation exposure and effective doses for those in the study. 

2. Dabigatran: Good news (and Odd News from FDA): Cannon discusses the approval of dabigatran and hypothesizes why the specific dosages were chosen to be approved. 

And for our most popular blog post of the year ... [drum roll, please] ...

1. Do Interventionalists Need to PARTNER with the FDA on TAVI?: Brindis sums up the findings of the PARTNER trial, presented at TCT 2010, and its implications for the TAVI procedure.

Tomorrow I leave for the holiday break. With the ACC closed until Jan. 3, the blog will be dark during this period. Here's wishing you and yours a wonderful holiday season! We'll see you in 2011!

Let’s face it, nobody really loves change unless it doesn’t mess with your world or you are assured of being a big winner -- no risks, please. In most circumstances, the status quo is comfy. Change is pain. Okay, okay, I could rightfully be diagnosed as either a disruptive innovator or a being who is drinking too much coffee.  

While a majority of physicians and hospitals, and a good number of cardiology practices, are digging in their heels to protect against the looming and threatening-appearing changes afoot in health system reform, others are entrepreneurially moving forward to be positioned as winners in the future. Betting on those kinds of practices and innovators now will be the CMS' Center for Medicare and Medicaid Innovation (CMI) in the grants they will soon be awarding. They are already sponsoring a two dozen accountable care organization (ACO)-like pilot projects for group and solo practice volunteers.

And now, the Robert Wood Johnson Foundation, AHRQ (the HHS Agency for Health Care for Research and Quality), and the ONC (the HHS Office of the National HIT Coordinator) have teamed up in aligning their grant-giving to foster the same thing, but in this case the focus is on improving care and health status at lower costs in entire geographic communities, and in both private and public health care services.

David Blumenthal, Carolyn Clancy, & Risa Lavizzo-Mourey write about these plans as directors of ONC, AHRQ, and the RWJF in a Health Affairs blog this month. They point out that “if you’re looking for a transformation in health care, look first to America’s cities, towns and communities. That’s where it happens, among local men and women who deliver and receive care, and the employers and consumers who pay for it.”

They are together now funding more than half a billion dollars in various regions. They point out that money alone won’t improve quality and reduce costs. Rather, for that to happen, teams of local leaders from a range of perspectives must design and implement tailored changes in the way their region organizes, delivers and pays for health care. Each of the projects is thus different.

• RWJF’s Aligning Forces Program kicked off in 2006, and has engaged consumers and providers to measure the performance of docs and hospitals, reporting it publicly, and improving the quality, cost and equality of care being delivered. The Aligning Forces regions are beginning to explore payment reforms to help sustain and increase local improvements in quality.
• ONC’s Beacon Communities has joined the regional improvement effort with a large three-year grant, helping select regions use health IT as a community foundation on which to improve health and health care by being on the cutting edge of electronic health record adoption and IT-supported care coordination, quality improvement, payment reform and population health initiatives.
• Aid To Communities From AHRQ funds tools to build and sustain local collaborative leadership, engage the public and increase performance measurement, and create incentives for quality and improve preventive services. AHRQ’s Chartered Value Exchange project (CVE), in particular, is helping 24 select regions systematically improve the quality and value of health care provided locally.

If your practice, hospital, or community isn’t involved in one of these efforts, or isn't preparing for a CMI innovation grant, sitting around griping about change isn’t going to position you well in the future. The ACC is using NCDR and PINNACLE, FOCUS (imaging AUC), and other programs in CV care to give any of you who really are ready for needed change to be a the forefront on those communities and groups ready to get involved in creating a better future.

The WSJ Health Blog featured an interesting discussion yesterday about using mediation to settle health care malpractice lawsuits rather than going to trial. In a study of 31 malpractice cases from non-profit hospitals in New York City, 16 were settled through mediation, five were settled afterward and 10 were not settled. Of those who agreed to go to mediation, the patients bringing the complaint, the hospitals representatives, insurers and lawyers reported being satisfied with the process. At Kaiser Permanente where I am employed, we use mediation with great success and general happiness by all parties. The study notes that no physicians accused of malpractice participated in the mediations, with their lawyers citing full work schedules as a reason for not attending the mediation.

There’s plenty of talk these days about how we can reduce the costs associated with defensive medicine. In fact, as Jack pointed out, cardiology has one of the higher rates of malpractice across the board (49.4% ever sued; 29.8% sued two or more times; 3.3% sued in the last 12 months; 110 claims/100 doctors). While the ACC strongly believes that defensive medicine can be reduced with tort reform (see some specific suggestions here), I’d be interested to hear your thoughts on using mediation as a method. Would you ever participate in mediation for a malpractice suit?

The Virginia federal court reviewing the legality of the Affordable Care Act has made a tough blow to the individual mandate provision of the law, while leaving the remaining provisions intact. In the full opinion released this week, U.S. District Court Judge Henry Hudson determined that the individual mandate and associated provisions could be declared unconstitutional — severing the “problematic portions [of the law] while leaving the remainder intact.” The basis of his decision was whether the federal government can regulate and tax people's decision to participate or not participate in interstate commerce (interstate commerce being the justification for the individual mandate provision). He concluded that the law “embraces far more than health care reform. It is laden with provisions and riders patently extraneous to health care — over 400 in all.” The law is under review by courts in several states. Michigan has previously decided in favor of the law.

The full text of the ruling is available from Kaiser Health News.

The Senate and the House have approved a bill (H.R. 4994) that will avert the 25% cut in the sustainable growth rate (SGRrrr) that would have taken effect Jan. 1, 2011. While it averts the 25% cut, it provides no update in physician reimbursement levels for 2011. The bill offsets the cost it will incur (about $19 billion) by tightening tax credits designed to make insurance more affordable that were part of the health care reform law (the Affordable Care Act).  The bill now goes to the White House for President Obama's signature.

While we are certainly pleased that Congress has passed a 12-month fix, this solution is far from good enough. We will continue to collaborate with the rest of the medical community to work with Congress on a permanent alternative to the SGR that rewards physicians based on the quality of care they deliver, rather than quantity. How innovative.

Thanks to all who took the time to contact their lawmakers on this critical issue. Good things can happen for patients when Congress works to solve problems as opposed to using Medicare as a political football.

Accountable Care Organizations (ACOs) are as yet ill-defined integrated networks of doctors, hospitals, and payers proposed in the Affordable Care Act that will be eligible for large additional payment incentives for care of patients across defined geographies. A central feature of ACOs may be “patient centered medical homes” (PCMHs) that will eligible for additional capitated payment for coordinating care. A growing controversy within these discussions is whether PCMHs will be “gatekeepers,” that determine who will be able to see a specialist, or whether there will be both primary and specialty versions of PCMHs with some degree of patient choice of physician depending on the acuity of the diagnoses and chronic diseases requiring care.

A group of primary care associations—the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association—has released their Joint Principles for Accountable Care Organizations (.pdf).

The 21 principles describe important aspects to consider when building the administrative structure of ACOs, as well as how payment should be facilitated. The four organizations developed the principles through an extensive collaborative process to reflect those attributes they believe are essential for the effective implementation of the ACO model within the health care system. The principles state that primary care should be the foundation of any ACO and that the recognized patient and/or family-centered medical home is the model that all ACOs should adopt for building their primary care base.

The groups said in a joint statement that they sent their principles to CMS “to encourage their use as the agency outlines ACO demonstration projects, as well as to guide related ACO activities offered through the newly established CMS Center for Medicare and Medicaid Innovation.” The ACC agrees that primary care should be the typical basis for the PCMH, but disagree that a universal mandate to that effect will be harmful to seriously ill patients.

What do you think? Should specialties be allowed to participate in the medical home? Answer in the comments section below or in the Cardiology Discussions forum on CardioSource.

Larry Dean, president of SCAI, and I just sent out an e-mail to our memberships regarding a series of articles that have appeared in the mainstream press about overuse of stents and the opportunity this offers for professional associations like the ACC & SCAI to take a proactive approach to quality issues. Please see the full text below, and leave your comments at the end of the article.

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The American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) are deeply disturbed by findings in a new U.S. Senate Finance Committee report concerning the ongoing investigation into alleged inappropriate use of percutaneous coronary intervention (PCI) and overutilization of stents at St. Joseph Medical Center, in Towson, MD. While the ACC and SCAI cannot comment on the merits of ongoing investigations, the use of inappropriate or unnecessary procedures is intolerable and a violation of both organizations strict codes of ethics (.pdf) as well as the Hippocratic Oath.

Over the last several months the Maryland Chapter of the ACC and SCAI, working closely with the national ACC, have been proactively addressing the issues raised by these allegations. ACC and SCAI representatives have met with state policymakers and have, at the request of Maryland officials, drafted comprehensive legislation that would require accreditation for all state hospitals performing PCIs.

Meanwhile, the overarching issue of quality and appropriate use of medical procedures is not just confined to the state of Maryland and the use of stents. In fact the Senate Finance report has generated national media coverage in the New York Times, Wall Street Journal and other papers. The investigations and subsequent media coverage provide an opportunity for professional societies like the ACC and SCAI to take the lead locally, regionally and nationally to ensure patients receive the right care at the right time.

Collectively, these developments underscore the need for internal peer-review that is clear, rigorous and objective. A standardized internal process must be followed by independent external oversight performed by an external body, such as the Accreditation for Cardiovascular Excellence (ACE) program. ACE has an independent governing board, allowing for removal of any perceived or real conflicts of interest in oversight of hospital and physician quality performance. ACE accreditation criteria also calls for use of registries like the National Cardiovascular Data Registry (NCDR) and adherence to appropriate use criteria -- both of which are already widely accepted and respected by professional and regulatory communities nationwide.

In addition, quality tools produced by both the ACC and SCAI can provide states, payers and purchasers of care with critical, transparent metrics with which to evaluate quality of care, especially as the health care community adopts a National Quality Strategy and shifts from a fee-for-service reimbursement model to one more focused on outcomes-based care and commensurate reimbursement.

The ACC and SCAI have the knowledge base and expertise as cardiovascular leaders to advise and implement such programs. The efforts under way in Maryland to address quality and appropriate care have far-reaching implications. Addressing them proactively will allow the field of cardiology to remain ahead of the curve and avoid future allegations like those outlined by the Senate Finance Committee. Working together we can ensure our patients receive high quality and effective cardiovascular care delivery driven by physician oversight and leadership.

The New York Times this weekend featured a detailed article on the ongoing investigation into alleged inappropriate use of percutaneous coronary intervention (PCI) and substantial overutilization of stents at St. Joseph Medical Center, in Towson, MD. 

The issue of quality and appropriateness of medical care is not limited to use of stents in the state of Maryland (In fact, the Times article mentions similar cases in Texas and Louisiana), nor is it confined to the field of cardiology. That being said, this current issue provides an opportunity to illustrate how professionals societies, like the ACC, can take a leadership role in ensuring quality care through use of peer-review, accreditation and data management. 

We happen to have over two-thirds of the US angioplasty/stent clinical data in the United States. Applying the currently recognized best evidence for appropriate use to these procedures, our data shows that nearly 70 percent of stents are placed appropriately as life-saving care for persons having heart attacks. Of the 30 percent placed in patients electively, as in the NYT story, we believe about 12 percent may be inappropriate. That's 4 percent of overall stent use, which while not a crisis of mass overuse, is nonetheless unacceptable. The point is: we now have means to give doctors and hospitals continuous data feedback on how their performance compares with best evidence and with their peers. Why don't we use it!

Not only is Congress busy working on a longer-term fix to the SGR, we also have advocacy work ahead of us pressing for adjustments to the 2010 Medicare Physician Fee Schedule. The 2010 fee schedule included some payment cuts in excess of 10 percent that were phased in over 4 years.  Unfortunately, CMS did not phase-in many newly-bundled codes that have had a direct impact on cardiology, such as SPECT codes that were cut 28 percent.

Rep. Charlie Gonzalez (D-Texas), ACC’s legislator of the year, has sponsored legislation (H.R. 6459) that will help correct inconsistencies in CMS' application of this phase-in in a budget-neutral way. We’re asking all ACC members to take a moment to call or e-mail your representatives in Congress to co-sponsor Rep. Gonzalez’ bill. In the Senate, the ask is for your senators to introduce a companion bill.

Here are some talking points to help that appeared in a recent ACC action alert:

• When you are connected to your lawmakers' offices, introduce yourself as a cardiovascular specialist and constituent and ask to speak to the health legislative assistant.
• Explain to the health legislative assistant that this issue is separate from the SGR, and how the cuts have impacted your patients and your practice.

Congress is likely to only be in session for a short time before they adjourn -- this is our last opportunity to get some much-needed relief! In these remaining days in the session, the ACC is putting everything it has into making one last effort to help private practice cardiology.

You can visit CardioSource to be connected by phone or to send an e-mail to your representatives. Also, make sure to ask your colleagues to contact their representatives as well. You can share this blog by clicking on the button below that says “Add this.” Congress needs to hear from us loud and clear on this!