ACC staff and leaders tuned in last week for Million Hearts' Public Health Grand Rounds. The presentation focused on effective strategies for improving heart health currently underway in New York City and San Diego.  We discussed sodium intake, trans fat consumption, and smoking. When it comes to the leading preventable cause of death—smoking—only 23 percent of people attempting smoking cessation reach out for help. Million Hearts Executive Director Janet Wright, MD, FACC (and former Senior Vice President of Science and Quality for the ACC) discussed the imperative to promote more ‘smoke free’ laws, cigarette tax increases, access to treatments and mass media campaigns to change untoward behaviors and reduce the incidence of CV disease.

The Commissioner of the New York City Department of Health, Tom Farley, MD, MPH, described the drastic and effective steps his city has taken over the last decade to reduce heart disease mortality. New York City began its prevention oriented approach in 2002 by enacting smoke-free air policies that have since been extended to all outdoor beaches and parks and will include 23 university campuses this year. Cigarette taxes have been hiked up to $6.86 per pack (!), bringing the total cost of a pack of cigarettes to nearly $11, the highest in the nation. Additionally, a powerful mass media campaign continues to build awareness of the effects of smoking and encourages behavior change. Over 10 years, Big Apple ischemic heart disease mortality dropped 33 percent, cerebrovascular disease dropped 16 percent, and New York City greatly outpaces the nation in life-expectancy-at-age-40.

On the left coast, San Diego is a perfect example of a city that has successfully translated federal initiatives into local action. JACC Editor-in-Chief Tony DeMaria, MD, FACC, discussed the “University of Best Practices,” a unique opportunity for competing medical groups to come together to share strategies and data, ultimately improving the health of San Diego residents.

DeMaria also showcased San Diego’s successful “Be There” campaign that has set the audacious goal of establishing a “Heart Attack and Stroke-Free Zone” and has caught the public’s attention. The campaign employs an emotional tug, versus straight facts, and communicates the gravity of heart disease and the importance of controlling risk factors. The hope is that this successful program can be adapted for other communities across the country and around the world.

The initiatives taking place in NYC and San Diego are just two examples of what is happening around the country to save one million hearts. I’ve previously blogged about how smoke free laws improve heart health and the efforts underway in many states. My home state of Mississippi and the State Board of Health are working together to participate in the Million Hearts Campaign, as are several other chapters at the state level. Keep up the good work y’all!

Common Good and the Bipartisan Policy Center teamed up for an eye-opening Forum on Obsolete Law recently. Speakers hailing from across the spectrum weighed in on government’s desperate need for a spring cleaning. After decades of laws piling up—there are a reported 160,000 pages of regulations—the system has become an immobile beast and common sense has been thrown out the window.

Let’s face it, laws are destined to become obsolete, especially in today’s society where human knowledge is growing, globalization is booming, politics are polarized and economic, technological and social change is evolving faster than we can keep up with. Operating on rules that were put in place in the 60’s and 70’s— when health care regulation was primarily formulated—doesn’t make any sense. As Phillip Howard from Common Good put it, “government is run by dead people.”

A common topic of discussion was the need to move away from incentivizing regulators to add more and more policies regardless of how they perform, and instead implement a “look back” element that evaluates the effectiveness of laws and eliminates legal build-up. Sen. Mark Warner (D-VA) believes the British government is on to something with their “one in one out” model, which requires an outdated bill to be removed from the books whenever a new bill is enacted.

Health care was injected throughout the forum to demonstrate how too much regulation can inhibit innovation. The SGR was mentioned as a prime example of Congress kicking the can down the road for the past decade instead of overhauling the flawed formula in order to protect reimbursement rates. The panel also discussed how physicians’ omnipresent fear of being sued coupled with a straight fee-for-service system has resulted in unnecessary testing that contributes to rising health care costs. What option do we have as physicians? We’ve been backed into a corner and will be stuck there until something is done that allows us to practice without fear.

So what is the solution to the issue of obsolete law? In a room full of lawmakers, CEOs, political scientists and professors, no one had the magic formula for tackling this mess, of course. While the panel had a wide range of suggestions, the resounding theme was the need for spring-cleaning and simplification, restoring a nimble, user- friendly government in these rapidly changing times.

This post was authored by Blair D. Erb, Jr., MD, FACC, founder of Cardiology Consultants of Bozeman in Montana and chair of the ACC’s PINNACLE Network Work Group.

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A recent article in Cardiology magazine that reviews the subject of Maintenance of Licensure as well as a session at the CV Summit I attended gave me pause to consider the future of our profession.

While we have witnessed magnificent strides in the management of cardiovascular disease in the last 30 years thanks to new tools and pharmacotherapy, I fear we have sacrificed some of that which characterizes us as a caring profession as we unleashed this sometimes monster of technology in an unguided fashion.

I am saddened that ICAEL has evolved from a voluntary vehicle for the demonstration of my commitment to quality to yet another mandatory hurdle for payment. Now the carrot of pride has become the stick of punishment.

I am saddened that we have failed so miserably as a profession to regulate ourselves that we now find it necessary to create tests and certifying agencies so we can “prove” to the public that we are good.

I am saddened that we have allowed ourselves to become the political pawns of a dysfunctional government and that we must lobby a Congress that knows nothing of what we do.

I am saddened that new doctors seem to have lost the notion of the “physician.” Bayes’ theorem has disappeared. The Oslerian concept of “listen to the patient and he will give you the diagnosis” has vanished. Now we order tests and round up consultants in hopes that one will give an answer.

I am saddened that the majority of us, who come to work each day and do our best, continue to be dragged down by a few opportunists.

I believe a cynic could be convinced that all the board exams, lab certifications and so forth just represent an ailing profession attempting to heal itself. I believe there is something more fundamental at the root of this issue. There are almost too many to count external pressures threatening our profession. These pressures seem to be resulting in a gradual transition from physician to medical worker. This is what we (the curmudgeons) fear. This is the real challenge before us.

In Hamlet, Shakespeare wrote, “the lady doth protest too much.” Does a wall full of board certifications and diplomas make a good physician? Does a list of five fellowships after the MD in a signature signify quality? By bagging a slew of parchments in the hope that wall coverings will prove our worth, are we not becoming the lady in Hamlet?

I recognize the efforts of the ABIM and others and applaud their attempts at quantifying quality. I would argue however, that these measures are at best artificial. I would also suggest that they are more focused on weeding out the fakers, than supporting those with integrity. When we are asked to help a patient with symptomatic coronary artery disease, we are in fact dealing with the final stages of a lifelong disease. To really work on the prevention of coronary disease, we must focus on youth.  In the same way, our work at ensuring quality in our colleagues must begin with our fledglings. Doing the right thing at the very best of our ability must become central to our professional lives. We must make quality something real and applied in everyday practice. The transition from episodic test taking to the demonstration and application of quality initiatives in our daily lives must happen. Only when this occurs will we have achieved real quality, worth or value -- improved patient care.

The ACC leads the way in creating the tools necessary to do this. Witness the PINNACLE Registry, FOCUS, and our life-long learning portfolio. These are some of the tools that can help to restore the carrot of professionalism and banish the stick of outside regulation. I believe the College is in a position to steer the future of our profession. We will be successful only if we are bold and act with the strength of commitment to this cause.

This post is authored by Ralph G. Brindis, MD, MPH, MACC, Immediate Past President of the American College of Cardiology 

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In medicine there are cases in which most physicians could decide instantaneously which procedure would be best for the individual patient, and there are times when physicians are on the fence and turn to the clinical practice guidelines to help guide their decision. The ACC and AHA have been working together to create these clinical guidelines for over 25 years. The guidelines provide a foundation for summarizing evidence-based cardiovascular care, and where there is evidence lacking provide expert consensus opinion. However, variability still remains raising the question of over- or underuse.

The Appropriate Use Criteria (AUC) are decision support quality improvement tools that are intended to help clinicians select the right patients for the right diagnostic tests, and provide a practical standard upon which to assess and better understand variability. However, as with any system, there is room for improvement and in the case of the AUC, there are times when what’s best for an individual patient isn’t always deemed appropriate and what is deemed appropriate isn’t always best for the individual patient.

As the field of medicine rapidly changes, it remains a challenge to stay current with the new and evolving science. Over the years the ACC has seen a need for true “living documents” that respond rapidly to the changing evidence created from random clinical trials or even from the College’s National Cardiovascular Data Registry (NCDR). Fortunately under Alice Jacobs’, MD, FACC, Chair of the ACCF/AHA Task Force direction, clinical guidelines have become more timely through focused updates and are more congruent between related guidelines to minimize the risk of discordant recommendations between guidelines simply due to the timing of the updated cycle.  The 2012 AUC coronary revascularization update reflects such changing science learned from the SYNTAX trial in addition to assessing other clinical scenarios not originally evaluated in the first 2009 AUC document.

Many concerns and questions still remain about AUC – relationships with clinical outcomes in their application, negative unintended consequences, and so forth. Several interesting editorials have recently been published including, “The Privilege of Self-Regulation – the Role of Appropriate Use Criteria” and “Percutaneous Coronary Intervention Use in the United States: Defining Measures of Appropriateness.” These papers offer food for thought as we move forward implementing new science and technologies.

Important ongoing studies are also now assessing the application of AUC with looking at midterm CV clinical outcomes while closely assessing for the potential for negative unintended consequences. Professional societies such as the ACC need not only to educate our members as to the value of AUC implementation in their practice but perhaps even more importantly need to aggressively educate our patients, the media, and payers and purchasers as to the proper use and caution for misuse of AUC assessments.

The AUC task force is continuously faced with new challenges, but the cardiovascular community is privileged to be able to measure ourselves against one another as we strive for the best outcomes for our patients.

I invite you to share your thoughts about AUC and the way they are evolving with new science in the comments section below.

A study published earlier this week in The Lancet shows that treating heart attack patients with an infusion of their own heart-derived cells helps damaged hearts re-grow healthy muscle. The study results are from the Cedars-Sinai Heart Institute clinical trial CADECEUS and is the first-of-its-kind stem cell procedure.

As it has shown that cardiosphere-derived cells (CDCs) reduce scarring after myocardial infarction, increase viable myocardium, and boost cardiac function in preclinical models, the authors aimed to assess safety of such an approach in patients with left ventricular dysfunction after myocardial infarction.

The study involved 25 patients who had suffered a myocardial infarction that left them with damaged heart muscle. Eight patients received standard care, and the remaining 17 received the stem cell treatment. The results showed that one year later, scar size was reduced from 24 percent to 12 percent of the heart in patients with cells. Patients also experienced sizable increase in healthy heart muscle following the experimental stem cell treatments. Patients in the control group who did not receive stem cells did not experience a reduction in their heart scars.

Eduardo Marban, MD, PhD, director of the Cedars-Sinai Heart Institute who invented the procedures and technology involved in the study noted, “While the primary goal of our study was to verify safety, we also looked for evidence that the treatment might dissolve scar and regrow lost heart muscle... this has never been accomplished before, despite a decade of cell therapy trials for patients with heart attacks.”

While the grim concerns about the alarming contributions of health care costs to the national deficit seem to dominate the conversation, who could deny that this is an unprecedented and exciting time for the cv community! Science is moving fast. The ACC wants more medical research and NIH funding to pursue innovative, life-saving therapies. Although funding of stem cell research is often a topic of controversy, we need to publicly educate how life-saving therapies like these are exactly what innovators in medicine and science strive to achieve.

Let’s not forget that this type of innovation requires funding and support, and it’s not looking good for those of us in the U.S. folks. President Obama’s Fiscal Year 2013 Budget Proposal freezes funding for NIH, and many in Congress advocate for significantly slashing funding for innovation and research.  Nonetheless, innovators like Marban are paving the wave of the future. Let’s have at it!

In a recent issue of Nature magazine, an article entitled “The Toxic Truth About Sugar” (subscription required), authored by three academics, one of whom is Claire Brindis, PhD, wife of ACC Past President Ralph Brindis, MD, MPH, MACC, is causing quite a stir.

Brindis and her co-authors highlight the growing body of evidence about the adverse effects of ubiquitous added sweeteners in the U.S. and global diet, particularly high fructose additives, which contribute immensely to non-communicable diseases, including diabetes and obesity. The United Nations recently declared that we must combat non-communicable diseases (NCDs), which represent a global threat killing over 35 million a year, and far exceeding the toll from communicable diseases now. (Read a previous blog post here). These problems now affect every country that has adopted the western diet of low-cost, highly processed food -- which is most of the world. The UN targets tobacco, alcohol, and diet as the three priority areas -- and diet issues are dominated by the metabolic syndrome-fostering impacts of added sweeteners to foods.

Brindis and her co-authors noted that tobacco and alcohol controls and social costs are typically mediated by government regulation and taxation, but that sugar addiction and its related toxicity escape this kind of regulation. The U.S. still leads the world in the average calories per day from added sweeteners in the diet (over 600 per day), but the rest of the world is catching up. These authors suggest -- despite the political hurdles anticipated -- that regulation and taxation of added sweeteners could have an enormous impact on reducing NCDs (including heart disease!), as well as health care and productivity loss costs. A courageous position!

Of course, you might imagine how much threatening opposition mail the authors have also been barraged with.  Nonetheless, my hat is off to the ‘other’ Dr. Brindis. The food industry is not going to give in easily here, even though this week we also saw that the transfat labeling requirements on foods (in combination with the restaurant transfat bans in some cities) have had a real impact in reducing consumption.

This post was authored by Marjorie King, MD, FACC, MAACVPR, past president and chair of the Professional Liaison Committee of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).

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Updated clinical practice guidelines for secondary prevention of coronary artery disease and treatment following PCI and CABG published in 2011 provided a class IA level of recommendation for referral to cardiac rehabilitation (CR)/secondary prevention programs.  This was based on recent evidence that participation in cardiac rehabilitation for patients with angina or following PCI, CABG, or myocardial infarction improves five-year mortality by 25-46%, with a clear dose response effect, in addition to multiple studies demonstrating improvement in function, modifiable risk factors, and quality of life. Despite this, cardiac rehabilitation programs remain underutilized, especially among older patients, women, and minorities. 

Under-appreciation of the benefits of cardiac rehabilitation by healthcare professionals is only one of the issues, but is easily corrected as referral to CR is incorporated into performance measure sets and guidelines, based on accumulating evidence.  Like other important, but easily forgotten, treatments, such as recommending aspirin use, referral to CR needs to become systematized into the thought processes, algorithms and systems we use to care for patients. This is beginning to happen as hospitals are incorporating referral to CR in discharge order sets and instruction sheets.  Unfortunately, several studies have shown that although this increases the referral rate, actual enrollment rates remain low (<35% of eligible patients).   This discrepancy can be attributed to multiple factors – including healthcare practitioners at acute care hospitals, physicians, practitioners and office staff in outpatient settings, and insurance company policy makers, as well as to patient barriers such as financial issues, belief systems, and motivation.

Fortunately, some of the provider-based barriers to CR participation are reversible with simple measures incorporated into daily practice.  Even brief endorsement of cardiac rehabilitation by a physician has been shown to improve participation, so adding CR referral to your mental algorithm that already includes aspirin, stains, beta blockers, ACEI, is a simple step to take. A brief script about the importance of cardiac rehabilitation that can be used by a medical practitioner during discharge planning is included in the AACVPR/ACCF/AHA referral to CR measure.

Partnering with local peer advocates, such as Mended Hearts and WomenHeart can help break down patients’ reluctance to enroll in cardiac rehabilitation and may support their participation.  Mended Hearts visitors are strong advocates of CR and are now trained to work with patients after PCI, as well as CABG or valve surgery. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recently developed printable PDF fact sheets for patients about CR and CardioSmart also has patient fact sheets available in both English and Spanish and videos about CR that can be used in office or hospital settings.  Finally, AACVPR has a Program Directory which can help locate programs close to patients’ homes.

Cardiac rehabilitation core components include not only individualized, medically supervised exercise, education about modifiable risk factors, psychosocial support, but also stress communication with healthcare providers about progress and barriers to meeting goals. Cardiac rehabilitation programs extend practitioners secondary prevention efforts beyond those provided during hospital and office visits. It’s unfortunate that cardiac rehabilitation referral may be inadvertently omitted, depriving patients of this effective therapy. However, just adding a few simple steps to your office or hospital practice to facilitate enrollment in CR may make a big difference to your patients’ health and quality of life.

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Please note that statements or opinions expressed herein reflect the views of the contributor, and do not reflect the official views of the ACCF, unless otherwise noted.

For more information about Cardiac Rehabilitation visit CardioSource.

Last week I had the pleasure of testifying on behalf of the ACC at the House Ways and Means Subcommittee on Health during a special hearing to explore how private sector payers are rewarding physicians who deliver high quality and efficient care. I was joined by other panelists: Lewis G. Sandy, MD, senior vice president, Clinical Advancement, UnitedHealth Group; David Share, MD, MPH, vice president, Value Partnerships, Blue Cross Blue Shield Michigan; John L. Bender, MD president and CEO, Miramont Family Medicine; and Len Nichols, PhD, director, Center for Health Policy Research and Ethics and editor-in-chief of the ACC’s online Community on Payment Innovations.

During my testimony I discussed several of the quality improvement collaborations underway in cardiology and what lessons can be applied across the health care system to simultaneously reduce unnecessary readmissions, complications, testing, and ineffective spending. My testimony also focused on the power of data as exemplified by our experience with the NCDR and the importance of decision support tools in helping care providers actually use evidence-based guidelines and appropriate use criteria to “get science to the point of care” to ensure not only the right therapy and/or test, but also engage patients in the decision making process. I also focused on the ways the ACC is currently working to “put the data to work” through programs like Hospital to Home, Imaging in FOCUS and PINNACLE. I also expressed the need for payment reforms linked to these tools.

A big part of my testimony was also the “SMARTCare” projects currently underway in Wisconsin and Florida that combine data collection, decision support and quality improvement initiatives into a focused project that documents clinical quality, resource use and cost variation in the treatment of stable ischemic heart disease. The projects are driven by the ACC’s state chapters and the ACC in collaboration with integrated health care systems, payers and multi-stakeholder collaborative groups.

The ACC was absolutely a vital part of this conversation. The development of innovative new programs and payment models that reward physicians who deliver high quality and efficient care has been a College priority over the last several years in light of health care reform and the need to curb out-of-control health care costs. I also told the Subcommittee that one of the key points to keep in mind about new systems is the time it takes to implement -- so the faster they are established the faster we can move forward with implementing these new payment reforms!

I invite you to share your “big ideas" on how to reward providers for quality care and cost savings in the comment section below.

Read the complete testimony and learn more about the hearing here.

This post is written by Kathy Jenkins, MD, FACC, Chair of the Adult Congenital and Pediatric Cardiology Council

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Congenital Heart Defects Awareness Week is Feb. 7-14. According to the Center for Disease Control and Prevention (CDC), “congenital heart defects affect nearly 1 percent of infants born in the U.S.” As medical care and treatments have advanced, infants with congenital heart defects are living longer and healthier lives and over the past 10 years we have seen a 25 percent reduction of congenital heart disease (CHD) morbidity and mortality. It is estimated that approximately two million people of all ages are living with congenital heart defects in the U.S.

There is still a lot that can be done to help those who are living with congenital heart defects and the physicians who treat them. Since its inception in 2005, the College’s Adult Congenital and Pediatric Cardiology (ACPC) Section has been working to bring quality care to children and adults with CHD through education, quality and advocacy efforts.

The ACPC section has identified several tools for CHD patients as they transition between a pediatric cardiologist and an adult congenital cardiologist, including the Adult Congenital Heart Association’s Personal Health Passport and other tools like Follow My Heart, an electronic based personal health record (PHR). These types of tools are important as CHD patients transition into an adult congenital clinical setting. A CHD patient’s ability to access electrocardiograms and echocardiogram, heart catheterization, and operative reports and other important medical information will help his or her various healthcare providers understand the patient’s unique health care needs.

On the quality side, the College’s continued efforts with NCDR’s IMPACT Registry™ (IMproving Pediatric and Adult Congenital Treatment) is an enormous step in measuring outcomes and care for CHD patients undergoing a diagnostic or treatment cath. Additionally, the ACPC Section has other quality effort underway to develop quality metrics in CHD which may ultimately be used in local or national Quality Improvement initiatives.

On March 1, the ACPC Section will join the Adult Congenital Heart Association and Mended Little Hearts for National Congenital Heart Lobby Day. Together we will lobby Congress for continued funding for the Congenital Heart Futures Act, (included in the ACA and passed into law in 2012). The law established a population-based surveillance registry (through the CDC's existing National Center on Birth Defects and Disabilities). This registry will allow for increased research to better understand congenital heart disease incidence, prevalence and disease burden, as well as a CHD public health impact assessment.  Congenital Heart advocates will also promote the recently established Congenital Heart Caucus chaired by Representative Bilirakis.

A welcome reception for National Congenital Heart Lobby Day will be held February 29 at Heart House. The reception is generously sponsored by the Texas Chapter of the ACC. Thank you also to ACC’s Iowa, Georgia, and Louisiana Chapters who have provided funding to benefit this advocacy effort for ACC members, as well as congenital heart disease patients and family members.

To join us or for more information about the National Congenital Heart Lobby Day click here.  For more information about the College’s ACPC Section visit www.cardiosource.org/ACPC.

This past month at the Leadership Forum in Las Vegas I had the pleasure of presenting the Chapter Award for Education to the Colorado Chapter for its unprecedented efforts aimed at increasing member’s professionalism, awareness of key issues and satisfaction of work.

On the professionalism side, the chapter focused a number of educational activities designed to foster relationships between cardiovascular professionals and patients. The chapter hosted monthly “Walk With A Doc” programs that provided education and exercise to an average of 40 patients per walk. Most recently, the Colorado Chapter launched a state-wide initiative to improve patient outcomes from atrial fibrillation (Afib). The program involves educating caregivers and patients about Afib and the proper treatment to reduce reoccurrences.

Several other programs focused on increasing chapter member knowledge on key issues ranging from malpractice reforms to preventive cardiology. Back by popular demand, a 2nd annual all-day CME meeting focusing on preventative cardiology, "How To Prevent A Stroke,” while a separate program conducted in partnership with the state malpractice insurance company focused on initiating a malpractice reform for cerebral palsy patients. The chapter also held a large variety of scientific and networking events on topics of nuclear cardiology, pharmacology, atrial fibrillation, and more.

The Chapter also developed several unique programs just for its Fellows in Training. One such program worked with a local University’s training program to encourage FITs to become active with the ACC, while several other FIT-focused educational events provided opportunities for the next generation of cardiovascular professionals to learn from local lawyers, stockbrokers, and business managers on topics critical to running a practice and increasing work satisfaction. Looking ahead, the Colorado Chapter is planning to host a national boot camp for ACC FITs on medical liability reform that will address how best to communicate with patients, families, and staff to alleviate potential sources of malpractice.

All of these reasons and more are why BOG Chair-Elect Dipti Itchhaporia and I presented Thomas Haffey, DO, FACC, governor of the Colorado Chapter with the award for Education. We are well aware that all of these programs require time, effort and dedication from the chapter leaders and its members. Kudos to Colorado for showing us how to successfully bring additional educational programming to its members!

What types of educational programming would you like to see in your local area?