In the last 10 to 15 years, technological advances have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist. Despite its unquestionable benefits, and because of earlier trends of increased utilization, medical imaging has been an area of focus by policymakers at the state and national level, as well as private payers; attempting to control who can perform imaging tests and where, through administrative protocols or state and federal laws as a means of reducing health care costs.

In my newest President’s Page in the Journal of the American College of Cardiology, I take a closer look at the past, present and future of cardiovascular imaging.  In particular I focus on what I consider to be a new imperative for medical imaging in light of the trend towards a more value-driven health care system and the fact that technology will continue to improve, enhancing our ability to diagnose and treat patients earlier. Novel technologies need to show a positive effect in patient care and outcome since ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

The ACC has developed several tools to address over- and under-use of procedures and technologies and is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care. 

Notably, appropriate use criteria (AUC) define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians with their imaging utilization, use of AUC also encourages the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

Further, the College’s “Imaging in FOCUS” (FOCUS) tool, a self-directed, quality improvement software and interactive community was developed to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike Radiology Benefit Managers (RBMs) which have been criticized by health care providers for delaying or denying unnecessary administrative burdens, basing decisions on inconsistent rules and practices and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities, and in some cases, incentives, for improved AUC adherence.

Along the line of appropriate use, this past spring the ACC released a list of “Five things Physicians and Patients Should Question” as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care. Three of the five recommendations were imaging related:

• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
  

As we continue to work towards implementing quality tools and efforts to address over- and under-use of procedures, I am proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.

This post is authored by Keith C. Ferdinand, MD, FACC, chair of the Minority Cardiometabolic Disease Alliance.

Over the last several decades, the U.S. has made substantial progress in overall cardiovascular health and reducing health disparities, but ongoing racial/ethnic, economic, and other social disparities in health are both unacceptable and correctable. Combating diabetes is an example of one such issue.

Diabetes is an urgent public health issue, especially for African Americans, Hispanics, American Indians and Alaskan Natives, and certain other minority populations. National data from 2007-2009 revealed that the prevalence of type 2 diabetes mellitus in non-Hispanic black adults was the greatest at 12.6 percent, with Hispanics closely following at 11.8 percent, followed by Asian Americans at 11.1 percent and non-Hispanic whites at 8.4 percent, respectively. Other groups with high rates of diabetes include American Indians, South Asians and Americans of Middle Eastern descent.

Race and ethnicity are not anthropologic or scientifically based designations, but instead sociocultural constructs of our society. Therefore, disparities in diabetes prevalence observed in racially and ethnically distinct subgroups of the U.S. population may not only be based on attributable, intrinsic factors (e.g., genetics, metabolism), but more prominently extrinsic factors (e.g., diet, environmental exposure, sociocultural issues). These social determinants of health are clearly major considerations in preventing and controlling diabetes and the associated cardiovascular morbidity and mortality and are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. For instance, steps to improve communication for patients who have English as a second language, and positive means to assist with culturally competent communication and care, include utilizing bilingual staff, an on-site professional medical interpreter, a telephonic medical interpreters, or professional interpreters, either on-site, telephonic, video. Using a patient’s bilingual minor relative is not recommended.

The ACC has taken innovative approaches to culturally competent diabetes care and CVD risk reduction. The purpose of CardioSmart.org is to provide comprehensive, thorough, and authoritative informational and educational resources as well as interactive management and compliance tools for heart disease patients and their families. It includes a Diabetes Education Center, with culturally appropriate and literacy level correct language on understanding diabetes. Novel tools include text messaging for adherence reminders and Spanish-language educational materials. In addition, the College’s credo initiative is dedicated to reducing racial/ethnic and other disparities in cardiovascular outcomes, while the new CardioMetabolic Health Alliance includes a focus on diabetes as a way of stemming the outbreak of cardiometabolic disease.

Over the past 30 years, the Journal of the American College of Cardiology (JACC) has become one of the most highly cited and influential journals in the area of cardiovascular medicine and is a key membership benefit of the College. With the first issue published in 1983, JACC has developed an international reputation for excellence and publishes peer-reviewed articles on all aspects of cardiovascular disease, including original clinical studies, experimental investigations with clear clinical relevance, state-of-the art papers, viewpoints, and editorials and essays interpreting and commenting on the research presented.

JACC expanded its umbrella in 2008 with the launch of JACC Cardiovascular Imaging and JACC Cardiovascular Interventions, and in February 2013 JACC: Heart Failure will be added to the JACC family of journals to address the clear need for a publication outlet in this growing subspecialty field. Christopher O’Connor, MD, FACC, will serve as the Editor-in-Chief (EIC) of this new journal.  The launch of JACC: Heart Failure is a tremendous step for the JACC team, and I know we are all looking forward to a great future for this sister journal. 

After nearly 12 years, during which JACC’s prestige, readership and impact factor have experienced spectacular gains, Anthony N. DeMaria, MD, MACC will be stepping down as EIC of JACC. I want to thank Dr. DeMaria for his passion, dedication and hard work in achieving these milestones. Although he will not be easily replaced, the Publication Committee is in the process of searching for a new EIC, and the deadline to apply is quickly approaching. For those who wish to be considered, please submit a letter with your vision for JACC along with your qualifications by this Friday, Nov. 23. Address the letter to the ACC Publications Committee, headed by Noel Bairey-Merz MD, FACC, and send it to Elizabeth Wilson via e-mail ewilson[at]acc.org. Qualifications to apply include: current academic appointment in cardiovascular medicine; broad and in-depth knowledge of the field of cardiovascular medicine, its leadership and current trends and advances; substantial experience in writing, editing and reviewing scientific articles; and more. For more information about the position and its requirements, you can also email Elizabeth Wilson, ewilson[at]acc.org.

The search committee will review all applications in early December and develop a short list of potential candidates to be invited for an in-person interview and in depth presentation scheduled in January or February 2013.  The team anticipates announcing the new EIC at ACC.13.  While some preparatory work would begin almost immediately, the new EIC and his/her editorial team will not begin receiving manuscripts until January 1, 2014; a 6-month overlap with the current editorial team is also planned.

The College has also added JACC Journals to its Facebook page family, joining the American College of Cardiology and CardioSmart pages. The page is updated regularly by JACC Executive Editor Glenn Collins and JACC Associate Editor Chris Cannon, MD, FACC, with the latest headlines from all of the JACC journals. Be sure to “like” the page and share it with colleagues.

My best wishes for a Happy Thanksgiving to all of you!

This post is authored by Renee Sullivan, MD, member of the ACC’s Sports and Exercise Cardiology Section.

I recently presented a case study at the ACC’s Sports Cardiology Summit about a 20 year old athlete with syncope and rhythm disturbance. The patient was previously healthy, exercised and ran competitively his entire life, however, over the last six months he had experienced palpitations and syncope immediately after he would end a four mile run. Although this would not happen with every run, he eventually decided to seek care since he was passing out more frequently.

From what I could tell, the cause of the syncope was not clear and could have been related to neurocardiogenic syncope as it happened right after the run was complete and never happened during the run; but it was also possible that an arrhythmia was to blame.

We decided to issue a holter monitor which the patient would wear while running, and we immediately observed ventricular tachycardia. The patient refused admission but came to the office the next day to undergo an exercise treadmill test.  At 28 minutes, we again noted the patient had ventricular tachycardia but he did not pass out. 

An aggressive EP study was then performed on the patient, but ventricular tachycardia was not inducible. Further, his echocardiogram, cardiac MRI, and CT coronary angiogram were all normal. 

The patient was started on a beta blocker to suppress ventricular tachycardia. He chose to continue participating in sports despite the ventricular tachycardia and did not want an implantable cardioverter-defibrillator. Luckily, the patient is healthy, currently participates in extreme sports and rarely has palpitations.

A number of observations can be learned from this case. When evaluating an athlete, or any patient, it is important to reproduce the physical activity that causes the symptoms to the best of our ability. However, often times the symptoms may not happen in a test situation, and the athlete must be playing the exact sport in order for the symptoms to occur.  This may be due to stress or catecholamines. 

In addition, we are often faced with patients who do not want to be restricted from playing sports and prolong seeking medical advice, which can be detrimental to their health. It’s critical that young athletes understand the warning signs and know when to seek help.

There is a lot to learn from one another within the sports and exercise community, and I hope that by sharing this case, others can learn from our observations. I invite you to leave your own case studies or observations in the comment section below.

For more information about the ACC’s Sports and Exercise Cardiology Council and Section, click here.  

This post was authored by William R. Lewis, MD, FACC, chair of the ACC’s shared decision making workgroup and a member of the patient centered care steering committee.

In the current health care system, patients have traditionally played relatively passive roles in their own health care. They have little knowledge of their disease(s) and treatment options, leaving them not only ill-prepared to communicate their needs and wishes to their health care team, but to implement health plans when necessary. They have primarily relied on their physician for the majority of their medical information and have essentially left medical decision making up to their doctor.

Shared decision-making is one concept that is garnering closer attention for its ability to potentially improve outcomes, while at the same time facilitate patient involvement in their own health care decisions. The purpose behind shared decision-making is not to persuade but to improve patient knowledge and to provide information about the disease and clarify the risks and benefits of treatment or screening options and their associated outcomes. An article published in the Annals of Internal Medicine found that “patients who ask questions, elicit treatment options, express opinions, and state preferences about treatments during office visits with physicians have measurably better health outcomes than patients who do not.”

Key to shared decision-making is the ability of patients to become acquainted with the options available, the risks of each option and the outcomes anticipated from treatment with each option. Cardiovascular disease is particularly well-suited for the devel¬opment of shared decision-making tools that enable doctors to provide patients with an understanding of their options. Guidelines and evidence-based therapies form a solid foundation from which evidence can be distilled and shared with patients. In addition, there are many validated risk models of outcomes that can be used to inform patients of the outcomes of previously treated patients.

Cardiovascular care also involves many treatments for which small differ¬ences in outcomes exist, allowing opportunities for patients’ values and perspectives to play larger roles in the decision making process. For example, while bare metal stents result in more frequent repeat procedures than drug eluting stents, they require fewer blood thinners. As a result, patients concerned about bleeding or bruising, or who can’t afford medications, may select a bare metal stent, even if a drug eluting stent might minimize the likelihood of repeat coronary blockage.

Challenges of implementing shared decision making include lack of physician time to fully inform patients on all aspects of their treatment options including incorporating their values into the equation. Even if they did, the information retained during a single physician visit is limited, especially when there is additional stress involved.

In addition, patients need to know that the information they are reading is unbiased and complete. The solution to these problems is for a trusted organization, like the ACC, to build a website which can act as an extension of the physician’s office. With a tool like this, patients could gain the knowledge needed to make a quality decision and use tools to incorporate their values into the decision and develop questions for their doctor. The next physician visit then becomes a high quality meeting.

Other challenges involve aligning the goals of insurance companies with those of patients. Additionally, physicians are often judged on “quality measures” which, if contradictory to a patient’s values, might jeopardize a physician’s standing on a particular measure. For instance, if a patient chooses to take a lower dose of a cholesterol-lowering drug to avoid symptoms of muscle pain, their physician may be penalized for failing to achieve that lower cholesterol level.

The ACC is currently piloting several projects, one of which is focused on the use of ACC’s Appropriate Use Criteria for Coronary Revascularization. The goal is to use the results of these pilots to ensure that future shared decision-making models best meet the needs of patients and their families.

Additionally, CardioSmart.org is an excellent source of medical information and is trusted by patients and their cardiologists. The ultimate goal will be to develop shared decision making tools and make them interactive on CardioSmart.

If implemented correctly, shared decision making tools have the ability to drastically improve outcomes and will strengthen the provider/patient relationship.

To read more about the ACC’s plans for shared decision making, visit CardioSource.org.

This post was authored by Bo Walpole Jr. MD, MBA, FACC, chair of ACCPAC.

It’s that time of year again, where we’re on the edge of our seats wondering what next year will bring for physician payment. On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) released the 2013 final Medicare Physician Fee Schedule, which sets payment rates and related policies for next year. While 2010 was a particularly uprooting year, one that we haven’t quite recovered from yet, each year brings its own challenges.  

So what’s in store for next year? In addition to the 26.5 percent cut stemming from the flawed Sustainable Growth Rate (SGR) and across the board cuts of 2 percent associated with sequestration provisions of the Budget Control Act of 2011, we face an overall -2 percent impact on cardiovascular medicine.

Next year, PCI is also in the line of fire. We’ll see physician work RVU reductions of roughly 20 percent to the family of PCI codes and roughly 27 percent to the family of EP/ablation codes. Another concern is CMS’ decision to expand a multiple procedure payment reduction (MPPR) to cardiovascular services, resulting in 25 percent reductions in certain cases. Unfortunately, CMS decided to move in this direction despite the ACC, other stakeholders and 60 members of Congress voicing strong objection earlier this year. (See congressional sign-on letter.)

Additionally, the final rule lays out details for the Physician Quality Reporting System (PQRS) and e-prescribing, and Value-Based Payment. In each of these cases, there are definitely incentives for successful participation, however, we are now entering the phase where many of these programs are transitioning to penalties for non-participation. It’s important that we all stay on top of the varying deadlines for these programs and weigh the costs and benefits associated with not participating. The College has resources for members in the Physician Payment Resource Center in the Advocacy section of CardioSource.org and includes frequent reminders about deadlines in the weekly ACC Advocate newsletter.

These are challenging times across the health care spectrum, with sequestration, the fiscal cliff and the debt ceiling looming over the country, and we must continue to work together to ensure the voice of cardiology is heard loud and clear on the Hill. The good news is that 104 out of 122 ACCPAC-supported candidates won their elections last week. That’s an astounding 90 percent success rate and means, at the very least, that we have potential allies on both sides of the political spectrum as we work to encourage health policies that allow us to provide quality, cost-effective care to our patients!

Now is the time to foster partnerships with these lawmakers through legislator practice visits and other grassroots events. We can provide them with first-hand perspectives of how their decisions impact health care for patients with cardiovascular disease; facilitate the delivery of high-quality, cost-effective cardiovascular services; and fund cardiovascular research and prevention.

I also urge you to check out the agenda and register for the Cardiovascular Summit that will take place Jan. 10 – 12 in Las Vegas. The Summit will bring together health policy leaders, payers and other stakeholders who will delve into the impact of the elections, health reform implementation, evolving payment models, coding and documentation and more. There is no better time to be involved in these conversations!

***************

Stay tuned to The ACC Advocate, CardioSource.org and the Nov./Dec. issue of Cardiology magazine for more information on the implications of the 2013 Medicare Physician Fee Schedule on cardiology. You can also hit the ground running in 2013 by preparing for coding changes now.  The ACCF/AMA CPT Reference Guide for Cardiovascular Coding is your one-stop resource for understanding significant new code revisions; efficiently and accurately reporting cardiovascular services and procedures; brushing up on CPT guidelines; and guidance on general intent and use of radiological and cardiovascular diagnostic and therapeutic procedures and services. In addition, a special webinar on Nov. 28 from 3-5 p.m. ET will explore major coding changes for 2013. Learn directly from those who presented the codes and sat at the table during the CPT and RUC processes. Register now.

This post is authored by JoAnne Foody, MD, FACC, editor of CardioSmart.org

November is American Diabetes Month, a month of awareness of the growing diabetes epidemic that kills more Americans each year than AIDS and breast cancer combined. According to the Centers for Disease Control and Prevention, one in three Americans will have diabetes by 2050. There are several health complications associated with diabetes, including heart disease and stroke, hypertension, blindness and eye problems, and more. Further, adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes.

The good news is that our patients living with, or at risk of, diabetes can manage the disease by following these steps:

• Eat healthy foods, and spread carbohydrate intake throughout the day
• If you take diabetes medicine, take it exactly as prescribed 
• Check and record your blood sugar as often as recommended 
• Try to do moderate activity for at least 2½ hours a week 
• Limit alcohol intake 
• Do not smoke
  

The ACC’s patient-focused initiative CardioSmart offers a number of tools to help with these steps. Targeted fact sheets on topics ranging from diabetes and exercise, to meal planning, to better understanding tests are available for patients. In addition, the CardioSmart Med Reminder mobile app can help manage and track medications. If your patient is looking to quit smoking, the “QUIT” CardioSmartTXT program offers regular text messages to help kick the habit for good. Plus, coming soon, a newly designed CardioSmart.org website will offer an activity tracker to help log exercise and weight loss, and will reward those who do so.

In addition, the recently launched CardioMetabolic Health Alliance, of which the ACC is a founding partner, is making strides to improve cardiometabolic risk factor control in diverse populations. Given that diabetes is one of the key risk factors for cardiometabolic disease, the Alliance is focused on providing tools and information to both providers and patients on how to prevent and/or control the disease. Among the tools: ACC's Type 2 Diabetes and Cardiovascular Disease Self-Assessment Program, which is designed to help clinicians expand their knowledge of the connection between diabetes and cardiovascular disease. This includes providing information about the cardiovascular effects of various therapeutic options and management strategies for diabetes and the breadth of therapeutic options with evidence-based cardiovascular benefits. Other helpful tools include the Blood Sugar Basics Program and the U.S. Diabetes Index, powered by the National Minority Quality Forum. Click here to learn more about the Alliance.

The College offers a number of ways to help us better manage and prevent diabetes in our patients. Together we can help the estimated 25.8 million people affected in the U.S.

A number of hot trials have been coming out of AHA’s meeting in Los Angeles over the past few days, including several with positive results that underscore the future of cardiology and stem cell therapy.

Results from the POSEIDON trial indicate that transendocardial injection of allogeneic and autologous mesenchymal stem cells (MSCs) without a placebo control were both associated with low rates of treatment-emergent serious adverse events, including immunologic reactions in patients with left ventricular (LV) dysfunction due to ischemic cardiomyopathy. In addition, results from the ALCADIA trial suggest that transplantation of autologous cardiac-derived stem cells (CSCs) with controlled release of basic fibroblast growth factor (bFGF) is both safe and effective in treating injured human hearts with reconstruction of the post-ischemic environment. While the SCIPIO trial results suggest that infusion of autologous CSCs harvested from the left atrial appendage at the time of coronary bypass surgery in patients with ischemic heart failure is safe and beneficial in both ventricular function and myocardial viability. These effects are sustained at 2 years and improve over time (read the full CardioSource article here). Whether these exciting new observations are sustained in a larger cohort of patients remains to be determined in future studies. 

These innovative advances in stem cell therapy offer opportunities to cure, not just treat, patients with cardiovascular disease, and show how far we’ve come over the past decade since the first application of stem cell transplantation occurred in 2000 involving heart failure therapy. Phase I and Phase II trials have since indicated that it is both feasible and safe for physicians to isolate stem cells and to transplant them. Results however on improvement in ventricular function, viability and outcome have been mixed. Researchers are going back to the bench to gain more insight into the basic and molecular mechanisms of stem cells to improve the potential clinical effectiveness of this approach and also concurrently looking at the best methods of stem cell types and delivery. Among the methods being tested are direct epicardial injection, intravenous infusion and endocardial delivery. However, no single method has emerged as a major winner or standard.

One thing is certain, we will continue to see this hot topic emerge in future meetings (including ACC.13 in San Francisco) and publications as the science rapidly evolves and as we look for novel and more definite cures for heart failure in our patients.

Visit CardioSouce.org for additional AHA 2012 meeting coverage. Also, be sure to follow @ACCinTouch on twitter for the most up-to-date news coverage.

All eyes have been on the east coast this week as Tropical Storm Sandy made its way up the eastern seaboard late Monday evening. Effects of the storm have been seen across several states with more than 8.1 million homes and businesses reported to be without power, and there have been devastating stories of houses being demolished and even several deaths. However, New York and New Jersey were hit the worst, and President Obama issued federal emergency decrees for "major disasters" in both states.

According to ABC News, New York University Langone Medical Center evacuated over 200 patients, including its PICU and NICU patients, due to a power outage and failure of its backup generators. The story of babies being transported down flights of stairs with flashlights is a touching one, and it shows how the medical community with the help of emergency personnel came together to help these patients. As Fred Rogers (a.k.a. Mr. Rogers) once said, “when I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’” The medical community has the ability to save lives daily, but it is times like these when true heroes are born.

In another area of New York, Smadar Kort, MD, FACC, governor of the ACC’s Downstate New York Chapter tells us, “we were lucky here at Stony Brook University Medical Center. We lost power for only half an hour, at which point power was supplied by generators. Other hospitals in Suffolk County of Long Island lost power and therefore had to transfer patients, mainly to our facility. We had canceled all elective procedures and outpatient care so all our efforts were concentrated on caring for the patients in the hospital, some of them transferred from other hospitals, and many of them stayed longer than anticipated simply because they had no safe place to go to. In preparation for the storm, we discharged anyone who could have been safely discharged and created space for transfers from other hospitals. We still don't have power in the vicinity of the hospital, and the police had been very instrumental in directing traffic in the area. Talking to my colleagues in other institutions, many of them were required to help evacuate patients to ensure their safety, so I am happy and grateful that here we were able to do what we are trained for and like to do, which is taking care of patients.”

We also saw the effects of social media and technology come into play during the storm as government officials and agencies, including the Federal Emergency Management Agency, urged people to let their friends and family know they were safe via social media or text message, rather than phone call. Social media also helped disseminate tips and information about how to prepare for a storm, and what to do during a storm, and Google even created an interactive map that allowed people to track the storm and pointed people to the nearest shelter. However, we also saw the vulnerability of social media and how false information can quickly go viral. It underscores the need to be mindful of sources and to be aware of what you put out on social media channels.

Now that the storm has passed, I hope all of my ACC colleagues on the east coast are safe and quickly recover from the damage from the storm.