AFib is catching a lot of buzz lately. Two weeks ago, the PINNACLE Registry announced the expansion of its outpatient registry with a new platform focusing on atrial fibrillation that will include the next generation of anticoagulants and will be free for all cardiology practices. The new registry will help providers evaluate and improve adherence to established guidelines and performance measures and will strengthen future research and innovation. PINNACLE, part of NCDR, is the largest cardiovascular outpatient database in the country and currently has 2.1 million patient records representing valid patient encounters from hundreds of outpatient practices nationwide. Of the 2.1 million patients, more than 100,000 have AFib. Stay tuned for more developments as the registry becomes operational in 2012 and delves into collecting data that will improve patient care.

How do you use anticoagulants in your practice when dealing with AFib? Weigh in on the poll and see how others are thinking about new agents as well.

Results from the AFFIRM Trial (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) were released last week. This trial explored how individual rhythm-control agents affect cardiovascular outcomes in patients with atrial fibrillation, looking at individual antiarrhythmic drug therapies compared with rate control with propensity score-matched analyses.  It turns out that rhythm-control agents had no effect on all-cause mortality, but were associated with an increased risk of cardiovascular hospitalizations.

This month’s featured article in the Atrial Fibrillation Community covers the clinical significance of silent stroke. According to the article, “[Recent] studies raise strong evidence that ‘ablation technology and energy source matters’ since non-irrigated multielectrode ablation resulted is a significantly higher silent stroke rate as compared to other ablation techniques. Thus, regarding the mechanism(s) leading to silent stroke it is very likely that most thromboembolic events are due to energy application, i.e. charring at the ablation catheter, rather than due to mobilization of pre-existing left atrial thrombi or air embolization.” So, should we be worried? Even though there is no current evidence that silent stroke impacts cognitive function, future studies are needed that explore the factors leading to their occurrence.

I invite you to visit the AFib Community which is a great resource to stay up-to-date on AFib developments and features articles, hot topics, news, case challenges and much more.

By now the Joint Select Super Committee has received their Congressional recommendations on how to further reduce the federal deficit, and they only have until November 23 to have their deficit reduction plan scored by the Congressional Budget Office (CBO) and introduced to Congress. Congress then has until December 23 to act on the proposal or allow automatic cuts to kick in.

The Committee is supposedly working on a $1.5 trillion deficit reduction goal, but still appears to be unable to come together on key issues like the need for revenues. Republican members of the Committee still refuse to support any tax increases, while Democratic members will not budge on cutting entitlements. Washington insiders are getting a little nervous about the apparent lack of progress and are now betting the Committee will come up with a minimalist solution with just enough savings to temporarily avoid defaulting on the debt.

Yesterday, Rep. Phil Roe, MD (R-TN) and Rep. Allyson Schwartz (D-PA) — who were instrumental in securing the support of more than 115 Members of Congress in a letter to the Joint Select Committee urging them to include full repeal of the SGR (or SGRrrr the un-Sustainable Growth Rate Medicare physician payment formula expressed as a growl) in the deficit reduction package — brought together a bipartisan briefing and panel discussion on the future of the Medicare physician payment system. The speakers at the briefing — Mark McClellan of the Brookings Institution, Joseph Antos of the American Enterprise Institute, and Stuart Guterman of the Commonwealth Fund — described the many problems with the current Medicare payment formula.

In the discussion, McClellan noted the “good ideas” within medical specialties that are improving quality and lowering cost, including the use of registries in cardiology, while Antos noted that cutting providers will negatively impact Medicare beneficiaries. Panelists also agreed on the need to incentivize care coordination.

The ACC is urging Congress and the Super Committee to hear the concerns raised by this panel. In fact, a group of ACC leaders will be hitting Capitol Hill next week and talking to key members of Congress and their staff. We know the focus should be on improving quality and lowering costs, and ACC has the tools and quality initiatives in place to lower the rate of inappropriate care, resulting in cost savings.

Stay up to date with the Joint Select Super Committee Budget activities and view the Budget Countdown page on CardioSource.org/Budget.

The last month has been filled with exciting international opportunities and accomplishments stemming from discussions with colleagues all over the world. Over the last year, the College has seen a 12 percent increase in international members, the highest rate of growth the ACC has ever achieved in a 12 month period. This is huge! Currently, there are 14 International Chapters and 4,869 members who hail from over 100 countries.  Recent collaborations across the globe have promising implications for the upcoming year and there are still several more meetings on the radar for the rest of 2011 and throughout 2012.

Two weeks ago, I joined an eight member ACC delegation and over 18,000 Chinese physicians at the Great Wall International Congress of Cardiology in Beijing, China. Combined, the ACC group presented on an exhaustive list of topics, including coronary revascularization, patient protection and the Affordable Care Act, late breaking trials at ACC.11, the Hospital to Home initiative, disease management models, cardiovascular imaging and CV care among geriatric patients. Moving forward, we are working with the ACC China Chapter and the Chinese Cardiology Society to build registries and collaborate on research and education.  We also just launched the China ACCEL audio education program in Mandarin, and the new JACC in Chinese journal.

At the end of September, I trekked to New Delhi for the India Heart Protection Summit where leaders from across the world convened to tackle the growing trend of cardiovascular disease (CVD) in developing countries. The meeting followed on the heels of the United Nation’s (UN) Summit on Non-Communicable Diseases (NCDs) during which Bill Zoghbi, MD, FACC, and I advocated for the inclusion of CVD in the UN’s Eight Millennium Development Goals. During my visit, I presented “Quality, Efficiency, and Professional Accountability: The Importance of Clinical Registries” and was able to attend the exciting launch of the PINNACLE Network in India. The first 10 PINNACLE participants in the NCDR outpatient registry have begun sending us their data through our partner, FIGMD, who is based in Chicago and Bangalore, India. Quality and outcomes data, both inpatient and outpatient, is extremely limited in India. During a meeting with the Minister of Health, Ghulam Nabi Azad, I shared the possibility of us helping them to improve quality and outcomes with data-supported solutions. I also mentioned the Million Hearts Campaign, as Azad is rolling out the largest NCD campaign in the world.  Stay tuned.

To round out a month of heavy international travel, I just returned from the Canadian Cardiovascular Congress in Vancouver where I participated in a panel discussion on what Americans and Canadians can learn from each other in these challenging times. We discussed the strengths and challenges of current strategies that are employed in order to improve health care in both countries. By learning from each other, I am confident that we will achieve greater heights of success. 

To keep up to date on international developments, visit the International Center on CardioSource.org.

Although a significant amount of data exists in relation to early clinical outcomes after transcatheter aortic valve replacement (TAVR), there are few data on outcomes beyond one year. As such, a new study released today in the Journal of the American College of Cardiology (JACC) provides a much-needed look at the long-term outcomes after TAVR in high-risk patients with severe aortic stenosis.  

In 2007, the UK established a national registry – the United Kingdom Transcatheter Aortic Valve Implantation Registry – to coordinate and monitor the practice and dissemination of all TAVR procedures, regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term. The new study, based on data from this registry from January 2007 through December 2009, found that, overall, midterm to long-term survival after TAVR was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.   

Specifically, survival at 30 days was 92.9 percent, followed by 78.6 percent at one year and 73.7 percent at two years. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction _30 percent), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model. 

A corresponding editorial commentary, suggests that “all our efforts to pursue the development of this technique should aim at improving patient selection both by a dedicated medicosurgical team and by improving procedural performance through careful training and improvement in technology, and also by adequately evaluating randomized studies as well as good-quality registries that represent real life and are a necessary complement to the former.”  

As TAVR moves forward in the U.S., we need to look closely at these results from abroad and learn from them. You can be sure that as the American College of Cardiology and the Society for Thoracic Surgeons move forward with their joint TVT Registry, the lessons learned from the UK experience will be critical as we attempt to harmonize data elements from around the world. In a recent JACC President’s Page I marveled out how the process and the need for measuring things has occupied a central role in human history, and how nowhere in the medical field is measurement more important than when new therapeutic strategies are developed. Data from registries like the one in the UK and the one being developed by us and STS in the U.S. are essential to the appropriate use of transformational technologies like TAVR.

This post is authored by Immediate Past-President Ralph Brindis, MD, MACC. 

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Health Affairs, along with co-sponsors the ABIM Foundation, the California HealthCare Foundation and the Foundation for Informed Medical Decision Making, hosted an event on Oct. 19 focused on discussions around Medicare savings ideas for the federal budget “Super Committee.”  Implantation of ICDs was one of the hot-topic areas in a session on Medicare coverage policy, with speakers highlighting overuse of the procedure among physicians as a major contributor to Medicare costs. Suggestions were made to require prior authorization as a means of reducing Medicare costs.  

It is important to note that the science surrounding ICD implantation is constantly evolving but guidelines and Medicare coverage policy take more time. That being said, it is true that recent studies have indicated a wide variation in ICD implantation. A study published earlier this year in the Journal of the American Medical Association (JAMA) found that ICD implantations were not in accordance with practice guidelines in 22.5% of patients, most commonly because of newly diagnosed heart failure (62%) or an MI within 40 days (37%). The risks of in-hospital death and complications were significantly lower when the ICD implant was consistent with practice guidelines (0.18% and 2.4%, respectively) than when it was not (0.57% and 3.2%, respectively). 

While these statistics are sobering, the ACC and the Heart Rhythm Society (HRS) already have programs and processes in place to turn the tide, so to speak, and ensure providers are appropriately using this procedure on the right patients. For one, the Centers for Medicare and Medicaid Services, has mandated that every U.S. hospital that implants ICDs for the purpose of primary prevention of sudden cardiac death participate in the ACC and HRS ICD Registry. Over the last year we have made great strides in enhancing this registry to allow for the connection of longitudinal Medicare administrative data of ICD patient outcomes -- such as mortality and repeat hospitalizations -- with our in-patient hospital registry data. This longitudinal follow-up assessment will extend our knowledge base substantially. In addition, the electrophysiology community is not only closely examining practice patterns but working more closely with staff responsible for entering ICD Registry data to ensure that the data quality is at the highest level. The ACC and HRS are also encouraging the practice of shared decision making, particularly in the elderly, for the use of ICD implants for prevention of sudden cardiac death. Recent studies actually show substantial underuse of ICD therapy for prevention of sudden cardiac death (SCD).  

Unlike prior authorization, which may reduce costs but not necessarily ensure appropriate patient care and/or change provider behavior, registry use can do all three by ensuring greater adherence to practice guidelines, providing insight into practice patterns and also extending overall physician knowledge and evidence base. At the end of the day, ICDs are effective in stopping life-threatening arrhythmias and enhancing survival and overall quality of care. We believe that we are moving in the right direction to ensure cost-savings in the Medicare system and welcome the discussion on how to do this even better.

This post is authored by Immediate Past-President Ralph Brindis, MD, MACC.

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Today, the Journal of the American Medical Association (JAMA) released a study, co-authored by Harlan M. Krumholz, MD, SM, FACC, on the significant downward trend in hospitalization for Medicare beneficiaries with heart failure (HF). Since 2008, HF hospitalizations decreased by an impressive 30 percent. There has also been a 30 percent reduction in morbidity and mortality from cardiovascular disease in the last decade and acute myocardial infarction rates were down by 23 percent from 2002 to 2007. These results highlight how far we have come in cardiovascular treatment and care and open the door for future innovation.

Over 5.8 million Americans suffered from HF in 2006 alone, making it the number one cause of hospitalization and rehospitalization for aging adults. Additionally, we are all too familiar with the excessive amount of resources that HF eats up, pushing cost of care limits during a time when Medicare spending has run rampant.  Given these circumstances, HF is an area that greatly benefits from these and future reductions.  

However, the recent JAMA findings also point to areas that need improvement in the way of HF. The rate of hospitalization for black men declined at a lower rate than the national average and a substantial variation by state remains.  Additionally, the one-year mortality rate was only reduced slightly over the ten-year period, remaining high at 29.6 percent. This sobering statistic reminds us of how much more work needs to be done in applying our evidence-based medicine to this vulnerable cohort of patients and of the research that is still needed to alter the fairly dismal prognosis of this lethal disease.

These findings follow on the heels of an August paper in Circulation that unveiled stunning improvements in door-to-balloon (D2B) times.  The study found that D2B times were reduced by over 30 percent, from 96 minutes in 2005 to 64 minutes in 2010. The percent of patients treated within 90 minutes increased from 44 percent to 91 percent over those same years. Even more remarkably, the percent of patients treated within 75 minutes increased from 27 percent to 70 percent.

The importance of programs focused on increasing quality and decreasing health care costs is confirmed by these studies. The ACC remains dedicated to appropriate use criteria, guidelines and initiatives such as Hospital to Home (H2H) and the D2B Alliance and is leading the way to further reductions in hospitalizations and rehospitalizations across the country.  

We should all be proud to be a part of this win for our patients and the institution of cardiology!

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For some time now, the lack of continuous care for congenital heart disease (CHD) patients who are transitioning from the pediatric to adult care settings has been a concern for adult cardiology practices.  Although many CHD patients require specialized care, many more still end up in adult cardiology clinics. I experienced two scenarios when seeing CHD patients in my nonurban practice; a basic layman’s history is provided or several storage boxes of records are presented that must be reviewed and summarized.  One is inadequate; the other is cumbersome and subject to errors of oversight.  A complete, organized patient history is difficult to come by and ultimately can threaten the quality of care as these cases continue to increase in volume. Enhancing collaboration between a coordinated care team, to include congenital heart specialists, and CHD patients would open the doors to consistent and efficient treatment.

I have come up with the acronym DOORRS to sum up the essential information patients should easily be able to provide their cardiologist upon an initial visit. 

D  Initial Diagnosis 

O  Operations Chronologically with institution and surgeon 

O  All Operative Notes 

R  Most Recent diagnostic studies and results 

R  Recommended follow up 

S  Special considerations or previous complicating factors unique to this patient 

I have received positive and encouraging feedback from colleagues and the College on this issue, which affects us all but to which there is no easy solution.  I know the ACC’s Adult Congenital and Pediatric Cardiology (ACPC) Section is on top of this issue and is dedicated to collaborating with patient advocacy groups, such as the Adult Congenital Heart Association, on promoting professional and patient resources for CHD patient care.  For the College’s part, several ACC chapters have supported past National Congenital Heart Lobby Day activities, which have focused primarily on advocating for national CHD surveillance tools.  

The Congenital Heart Futures Act (included in the ACA) authorizes establishing a population-based surveillance registry (through the CDC's existing National Center on Birth Defects and Disabilities). However, the funding for this expansion has not been appropriated.  

To compound the issues related to care of the CHD patients, limited outcomes data regarding CHD treatment is available. The NCDR’s IMPACT Registry™ (IMproving Pediatric and Adult Congenital Treatment) has been established to assess the prevalence, demographics, management and outcomes of pediatric and adult patients with CHDs who are undergoing diagnostic catheterizations and catheter-based interventions. The collection and analysis of this data facilitates performance measurement, benchmarking and quality improvement initiatives.  The IMPACT Registry, which has collected over 3,000 patient records so far, will provide significant contributions to the knowledge base and outcomes associated with CHD. While this is exciting and a big step forward, gaps in data collection and outcomes reporting remain in other CHD care settings, most notably the ambulatory setting.  

I look forward to hearing your thoughts on ensuring congenital heart disease patients receive appropriate care as they age and move out of the pediatric setting.  What have you done in your practice to increase efficiency for adult CHD patients? What resources and educational tools would be helpful to your care of adult CHD patients?  

Make sure to check out the Nov./Dec. issue of Cardiology Magazine for an article on ACHD.

A great man died this past week. Dr. J. Willis Hurst passed away on Oct. 1 at 90-years-old.  Dr. Hurst was chair of Medicine at Emory University for 30 years and a teacher of Emory students for 61 years. His accolades are many, his obituary is expansive, and his eulogies extolled his greatness. I would like to add to these accolades on a personal level. As I do this, I know that thousands, if not tens of thousands, could do the same. Dr. Hurst touched many lives, including those of ACC governors past and present, as well as several ACC presidents.

For me, his mentorship and friendship extended over many years. I met Dr. Hurst when he was visiting professor at the University of Mississippi Medical Center. I had the privilege of introducing him at grand rounds and then being with him at a social event. During that event, he mentioned he would have an intern from Mississippi the upcoming year. Since I was the only one applying, I felt that I had received a summons to be a Grady Hospital intern. It was a great year (in retrospect), with many morning reports before the Chief. During that year, however, I received another summons, this time from the US Navy – the last "doctor draft" got me. 

Years later, while practicing internal medicine at Ochsner Clinic, I felt the need for something different. Despite the several elapsed years since my internship and suspecting he would not remember me, I nevertheless called Dr. Hurst for advice. He responded to my call and issued another summons that forever changed my life. The next year I found myself chief resident and cardiology fellow at Emory. During Emory training, I learned immensely from Dr. Hurst, as well as from Drs. Logue, King, Douglas, Lutz, and many other outstanding staff. Dr. Hurst was a brilliant clinician and lecturer and certainly imparted much medical knowledge. However, what I most took away from him was his edict that caring for the patient always comes first. I recall vividly the day he made the lame to walk. A friend from his hometown was unable to walk and was admitted to the great cardiologist with this definitely non-heart problem. After a few moments alone with her, the door opened and they walked arm in arm down the hallway. The house staff was waiting in the hallway and he winked at us as they passed. She had major emotional problems and Dr. Hurst started her cure by listening and by advising. 

In the guest book of the Atlanta funeral home, many, and in fact most, comment on the personal touch that this great man had for them and the influence he had on their lives. One shared the memory that when she was a pediatric patient and Dr. Hurst was her doctor, he left Atlanta for Washington to take care of another patient, President Johnson.  She tearfully wondered to her parents why Dr. Hurst would leave her since she was his favorite patient.  During ACC.10 in Atlanta, I visited Dr. Hurst in his retirement apartment. His advice to me: "work as long as you can."  He was still excited, then at nearly 90 years of age, to be receiving former students and to be teaching present Emory students. These students were still coming on a regular basis to his apartment to hear his lectures and to touch the hem of his garment. 

These days we are all faced with ever increasing demands on our time, but the passing of Dr. Hurst is a reminder of the impact one person can have on our careers and on our lives.  Most everyone can probably think back on their lives and identify one person who served as a mentor. I encourage everyone to take an example from Dr. Hurst; spend quality time with your young colleagues, return that phone call from a former resident, take a moment to talk to that potential intern. To quote ACC President-Elect William Zoghbi: “[Mentorship]  is very special. It  brings about strong bonds between individuals and will help shape our future leaders.” 

Hail to the Chief!

Just ahead of the Oct. 14 deadline for Congressional recommendations to the Super Committee regarding Medicare cuts, the sustainable growth rate (SGR) battle has really heated up. Last week, after 10 years of Congress “kicking the can down the road” by implementing a series of short-term fixes costing $300 billion, Rep. Allyson Schwartz (D-PA) took initiative, sending a letter to the Joint Select Committee on Deficit Reduction. In just a few short days, Rep. Schwartz’s appeal gained traction and has been signed by 113 Members of Congress. The letter calls on bipartisan Congressional action to permanently repeal the SGR and replace it with “a payment system that promotes efficiency, quality and value and ensures access to medical services for Medicare beneficiaries.”

Unfortunately, today’s Medicare Payment Advisory Commission (MedPAC) recommendation on the flawed SGR issue is not a viable solution. MedPAC’s proposal targets specialists who, after five years of flat payments, would face extreme cuts of 5.9 percent per year for the first three years followed by seven years of reimbursement rates freezes. Instead of addressing the shortage of primary care physicians, the Commission’s solution is to simply freeze their rates for 10 years.  

This decision is unacceptable and fails to carve out a comprehensive payment reform plan, enhance Medicare beneficiary access, or promote quality or resource stewardship. ACC believes that physicians should be paid for quality and care coordination, not their specialty designation. Additionally, the notion that doctors can make more by increasing volume ignores the significant marginal costs associated with seeing each additional patient.   

MedPAC has voted to increase physician payment by 1-2 percent for each of the last five years, despite the SGR issue.  They have abandoned their focus on what are the most appropriate payments to maintain access and to attempt to fix a Congressional mistake. 

While the ACC has long advocated for Congress to permanently repeal the SGR, we strongly oppose the MedPAC recommendation.  Joining forces with 42 other medical societies, ACC sent a letter to the Commission earlier this week stressing the consequences of penalizing specialists across the board regardless of quality of care. This approach is detrimental to the institution of cardiology and threatens the advances that we have made and are determined to make in the future. 

Visit the Budget Countdown page for related information on the issues of SGR, medical liability reform, and imaging cuts. I also urge you to take part in the ACC’s new Payment Innovations Community, in partnership with the American Journal of Managed Care. While there, don’t miss the New England Journal of Medicine article that looks at the question: “How Much Savings Can We Wring From Medicare?”

The College’s goals are three-fold:

1. Permanently repeal the sustainable growth rate (SGR) formula as part of any deficit reduction plan
2. Include medical liability reforms in any deficit reduction plan
3. Protect medical imaging from any further cuts

When it comes to the SGR, time constraints and the diminishing pool of spending offsets makes the Super Committee the only viable vehicle for addressing the flawed formulas this year. For every year that Congress postpones fixing the SGR, the cost grows. The American Medical Association (AMA) estimates that by 2016 the cost of permanent repeal would be $600 billion – a significant increase from the roughly $50 billion it would have cost in 2005. If we’re talking about reducing costs, then the SGR should be on the table.

Protecting medical imaging from additional cuts is also crucial. Imaging has been the focus of numerous drastic cuts over the past five years and continues to remain a target by Congress and regulators for potential payment reductions. Additional payment cuts and restrictions on imaging services cannot be absorbed by physician practices without impacting quality and access to high quality care. We cannot stress this enough to our members of Congress.

While at the end of the day we might not like all of the recommendations made by the Super Committee, now is our chance to stand together and at the very least educate members of Congress about the long-term ramifications if our requests are ignored. For those who think this is futile, I’ll leave you with an email that a fellow ACC governor just forwarded; he had received it from his congressman's legislative director. The governor had met with the congressional staff during the Legislative Conference. He received the email as he was about to respond to an ACC alert asking for help in generating support for a sign-on letter to repeal the SGR in the House. The email he received said: “Since we were just talking about the SGR, I wanted to let you know that my boss agreed to sign on to the letter below to the Super committee asking that they include a permanent solution to the SGR.” In the letter, the congressman stated the following important facts: "We are presented with an important choice: continue to distort the picture of our nation’s fiscal status with another short-term solution or restore fiscal transparency to the Medicare program by eliminating the $300 billion debt that has accumulated as a result of the SGR". 

Now that’s what I call Advocacy in action. OK, y'all, let’s hit the phones!