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.

This post is authored by Gary Puckrein, PhD, president and chief executive officer of the National Minority Quality Forum.

Physicians and the medical community have reached a fork in the road: we need to document that quality and reduced costs are related. By doing so, we hope to offer policymakers a new framework in which to measure the value of medicine. The conjectures:

• An avoidable mortality index can be an indicator of unnecessary acute events (disease, hospitalizations, disability and death) in a population. Such an index may have utility in localizing the performance of our health care system, thus enabling the investigation of gaps in outcomes of care. 
• There are signals that avoidable acute events are non-random occurrences. There is a possibility that they manifest at predictable frequencies within clinical and geographic sub-populations, and are sentinels of health care and health status disparities.
• Unnecessary acute events have financial implications. At least one study found that 36% of diabetes-related hospitalizations were avoidable. If that percentage holds true for Medicare beneficiaries, the savings could well be over $10 billion per year.
• By reducing unnecessary acute events, we may be able to establish an association between improved quality and bending the cost curve, thereby offering a counterpoint to those who believe reducing provider reimbursements is a desirable cost savings device.
  

The American College of Cardiology, the National Minority Quality Forum (NMQF), and the American Association of Clinical Endocrinologists have joined forces to put our conjectures to the test and have formed the CardioMetabolic Health Alliance. The objective of the Alliance is to improve cardiometabolic risk factor control in diverse populations, including high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity (waist circumference) and elevated triglycerides; and to provide more effective and coordinated care for people with established cardiometabolic disorders.

In pursuit of its mission, the Alliance will study the possibility that predictable patterns of unnecessary acute cardiac events occur in communities, and that these patterns are measurable and amenable within the context of current treatment modalities. By using the ACC’s PINNACLE Registry and CathPCI Registry, as well as NMQF’s Cardiovascular Disease Index and U.S. Diabetes Index, the Alliance will explore the possible correlation between cardiometabolic disease and unnecessary emergency room visits and hospitalizations; and how these findings can be used to design predictive models and quality improvement interventions targeted for providers and patients at high risk for an acute cardiovascular episode.

Members of the CardioMetabolic Health Alliance and ACC will be meeting at the 2012 Cardiometabolic Health Congress this week in Boston, Ma. Visit the Alliance’s website for more information www.cardiometabolicha.org. Also read more about CardioMetabolic Syndrome in an article in the July/August issue of Cardiology magazine.

This post was authored by Janet Wright, MD, FACC, Executive Director of Million Hearts™, a national, public-private initiative of the U.S. Department of Health and Human Services.

While one in three adults has high blood pressure, only half of them have it under control. This is one critical reason why public and private organizations united in September 2011 in an unprecedented effort to help Americans improve the health of their hearts. Together we created the Million Hearts™ initiative that aims to prevent 1 million heart attacks and strokes by 2017 through clinical and community interventions.

In our first year, thousands of supporters—individuals, medical professionals, public health agencies, health care systems, and private companies—have made specific commitments to achieving our goal. We are delighted by their passion as we work together to reduce high blood pressure, the leading cause of heart attacks and strokes. Today, the Centers for Disease Control and Prevention (CDC) published the latest Vital Signs report as part of its Morbidity and Mortality Weekly Report. It reports that the majority of people with uncontrolled high blood pressure are being treated but they still do not have their hypertension under control. These are missed opportunities to make a difference in their lives and the health of the country.

Working as a team is one way we can better capture these opportunities. In May, the U.S. Preventive Services Task Force recommended team-based care for blood pressure control. The Task Force found that blood pressure control improved when care was provided by a team of health professionals—a physician supported by a pharmacist, nurse, dietitian, social worker, or community health worker—rather than by a physician alone. By taking this approach, some of our partners, including private practitioners, community clinics, and large health care systems, such as the VA and Kaiser Permanente, already have been able to help more than 80% of their patients control their blood pressure. Join us in helping 10 million more hypertensive Americans control their blood pressure by 2017. How can you—and your patients—be the best in blood pressure control?

1. Make control a priority. Measure yourself via PINNACLE or submit the ABCS-related Cardiovascular Prevention Measures Group in CMS’ Physician Quality Reporting System. Recognize and reward those in your practice or system who are leading the way.
2. Use EHRs to identify patients who aren’t being treated or are not yet under control.
3. Enlist every member of your team.  Pharmacists, nurses, nurse practitioners, physician’s assistants, clerical office staff, and others all play key roles in helping patients control blood pressure.
4. Ask your patients to self-monitor, and make sure they know their goal numbers. Use an elevated reading as a signal to acquire and assess the blood pressure pattern over the next month, enabling prompt, sound, and safe treatment decisions.
5. Make adherence as easy as possible for patients. Prescribe once-a-day regimens, combination pills, and 90-day supplies when appropriate. Ask patients about difficulties taking medicines, and encourage them to use pillboxes, a simple and proven tool to improve adherence.

Visit millionhearts.hhs.gov for resources from Million Hearts™. Check out ACC blood pressure tools for patients and providers, as well as read more on the CDC report, on CardioSource.org.

A new post on the New York Times Blog provides an interesting glimpse at the challenges we face as health care providers when it comes to involving patients in their own care decisions – a key tenet of patient-centered care.

“For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment,” writes Pauline Chen, MD, for the Times. “Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train … But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.”

Chen cites a new article published in the latest issue of Health Affairs that explores the patient perspective. The article, which highlights the results of six focus-group sessions with 48 people in the San Francisco area, indicates that while the majority of people have a strong desire to engage in shared decision making, there are several obstacles that inhibit the ability to move from concept to reality. Key among these obstacles is the perception of physicians as authoritarian and fears of being categorized as a “difficult” patient. “This fear of retribution seemed related to both potential immediate and delayed effects,” the article notes. “A challenge to authority might modify treatment decisions as well as negatively influence the nature of the physician-patient relationship.”

Other findings from the focus groups, include the large amount of time spent by patients in conducting their own research regarding their disease state and/or treatment options, as well as the desire by patients to bring family, friends or other care providers with them to help compensate for any “social challenges” and time pressures “inherent in clinical consultations.”

Interestingly, these findings underscore the need for implementation of many of the elements identified as essential in the College’s recent health policy statement on patient-centered care. For example, focused education and training around patient–clinician communication incorporated as part of medical school and continuing education curricula could help providers learn how to best avoid the authoritarian perception. The health policy statement also calls for the development of easy-to-use decision aids that provide information about diseases, as well as risks and benefits of treatment or screening options. These have been shown to improve knowledge, reduce decisional conflict due to feeling uninformed or unclear about personal values, increase active participation in decision-making, and reduce indecision.

There is no denying that shared decision making poses challenges on both the physician and patient fronts. Chen is absolutely correct when she notes that “care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.” However, there is also no denying the benefits to patients and to the health care system as a whole if we are successful. Cardiovascular disease is particularly well-suited as a testing ground for the concept, given the number of treatment options that exist for which small or no differences in outcomes exist. This allows for patients’ values and perspectives to play larger roles in the decision making process.

At the end of the day, the College is fully committed to patient-centered care. Our task is to learn from studies like the one in Health Affairs and continue to chart a course that ensures the needs of each patient and his/her family are met in the most appropriate, high quality and cost-effective fashion possible.  After all, a patient shouldn’t be afraid to speak up at the doctor’s office!

This post was authored by Dick Kovacs, MD, FACC, former chair of the ACC Board of Governors and chair of the Best Practices and Quality Improvement Subcommittee, part of the College’s Clinical Quality Committee.

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The ACC, the American Heart Association, and the American Medical Association–Physician Consortium for Performance Improvement have released updated performance measures for adults with heart failure (HF) in order to provide further guidance to clinicians on the provision of optimal patient care.

Heart failure is a condition that occurs when the heart can no longer pump enough blood to meet the needs of the body. Because heart failure is often chronic, heart failure patients must work closely with their cardiovascular care team to not only slow the progression of the disease but also control symptoms and improve quality of life.

The newly released performance measures include care provided in both the outpatient and inpatient setting, emphasizing the need to measure care quality over time and across providers, while also focusing on functional outcomes.

The release of these performance measures are a timely reminder about the varied ACC resources to help manage heart failure patients, chief among them the new Heart Failure Practice Solutions “toolkit,” which provides easy access to nine tools (one for patients and eight for clinicians). This toolkit is intended to help cardiovascular professionals and others brush up on guideline recommendations for HF care; understand what to report for HF performance measures; prescribe appropriate drug therapies for HF patients; provide quality education and self-management strategies to patients; and assess performance improvement.

The Hospital to Home (H2H) Initiative led by the ACC and the Institute for Healthcare Improvement is another important resource for hospitals and cardiovascular care providers interested in improving heart failure patient transitions from hospital to “home.” Implementation of the H2H principles may help institutions avoid federal penalties associated with high readmissions rates. The H2H initiative challenges communities to better understand and tackle readmission problems through use of recommended tools and improvement strategies in three core concept areas: Early Follow-up, Post Discharge Medication Management, and Patient Recognition of Signs and Symptoms.

Beyond heart failure, the College has identified several other areas where the quality of care could be improved using recommended guidelines, appropriate use criteria and/or performance measures. I, working along with other ACC leaders and staff, am currently working to identify best practices for both atrial fibrillation and coronary revascularization. Similar to the Heart Failure toolkit, tools for each will range from web-based forms and check lists to pocket guidelines. It is our hope these tools will introduce real-time, easy-to-use solutions that cross the spectrum of quality, advocacy, and education and bring about real change.

For more details on the new Heart Failure Performance Measures as well as ACC resources, click here.

A recent article in Health Affairs examined the supply and distribution of the cardiology workforce across the country given “a sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease.”  The paper was co-authored by Harlan Krumholz, MD, FACC, a member of the ACC Board of Trustees and professor of medicine and epidemiology and public health at Yale University School of Medicine.

The results showed that there has been a modest increase in the cardiology workforce over the past 12 years, whereas the primary care physician and entire physician workforce shortages are more pronounced. But there’s also a big disparity in the geographic distribution of cardiologists across the country, specifically in rural and socioeconomically disadvantaged areas.

As the U.S. “baby boomer” population becomes older, it is clear we will need to rely on team-based practice models to deal with the cardiovascular demands on the U.S. health care system that are certain to increase. A team-based model will enable delivery system and quality of care improvements as it offers solutions to the workforce shortage, and will expanded physician productivity, and improve job satisfaction by reducing workloads and preventing burnout.

According to the CDC, since 1950, age-adjusted death rates from cardiovascular disease have declined 60 percent, representing one of the most important public health achievements of the 20th century. Despite this huge reduction in morbidity and mortality, just imagine what we can accomplish when we work together in a team-based setting using NCDR^® and PINNACLE Registry^® data to systematically improve patient outcomes, and simultaneously improve efficiency and value.

We still have a long way to go in fighting the leading cause of death in the U.S., so let’s get to it!

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.

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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.

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?”

EP blogger John Mandrola, MD, FACC, (aka Dr. John M) wrote recently about a study looking at outcomes for atrial fibrillation patients who received the majority of care from a nurse rather than a cardiologist. The study looked at whether patients who were counseled by a nurse on their first visit, and nurse and a cardiologist on their second visit, and all remaining visits by the nurse have different outcomes than those who receive usual care. The nurses put together treatment plans guided by software programs intended to increase adherence to practice guidelines. The hypothesis of the study was that the larger amount of patient education done by the nurses would improve outcomes.

This is exactly what the researchers found. Of the 712 patients participating in the study, the abstract of which was presented at ACC.11, significantly fewer patients in the nurse-counseling group experienced heart-related deaths (1.1% vs. 3.9%) and there were fewer heart-related hospitalizations (13.5% vs. 19.1%) for those patients.

Mandrola says the study “offers an optimistic view of health care delivery reform” and I couldn’t agree more. Patient education is a huge component of successful care for cardiovascular patients, and it is very difficult to adequately complete in the short time that you have during an office visit. (As Mandrola notes: “…thoroughly explaining AF takes nearly the same time it takes me to isolate the pulmonary veins – a lot longer than the 10 minutes allotted for a typical office visit.”)

Innovative care models are necessary to improve the quality of care we offer patients. Since we’re unlikely to get more time for an office visit anytime soon, this means exploring how we can effectively provide care through other members of the cardiovascular team or by using educational software that is customizable for each patient’s unique health situation. Additionally, the impending cardiology workforce shortage will place additional demands on a workforce already stretched thin, and we’ll need to rely on other health care providers to fill the gap.

What do you think of this study? Do you think increased counseling by cardiovascular care associates can help improve care?