Do our patients know the signs of a heart attack and what to do if someone goes into cardiac arrest? When every minute counts, are we meeting the standards for door to balloon (D2B) times? These are the questions the ACC’s North Carolina Chapter has focused on over the past decade in collaboration with hospital systems throughout the state.

The Regional Approach to Cardiovascular Emergencies (RACE) project was developed in 2003 as a statewide system for providing rapid artery reperfusion for patients with ST-elevation myocardial infarction (STEMI). The RACE system is the largest state-wide STEMI system in the U.S. and incorporates the quality improvement efforts of over 100 hospitals, 700 emergency systems, and thousands of health care professionals working in a coordinated effort in order to improve timely reperfusion.

A recent study published in Circulation authored by NC Chapter Governor James Jollis, MD, FACC, who has been a champion on this issue, and colleagues looked at expanding regional coordination to the entire state of North Carolina. In doing so, rapid diagnosis and treatment of STEMI has become an established standard of care independent of health care setting or geographic location, and has resulted in improvements in timely coronary artery reperfusion.

Without a doubt, teamwork and grassroots efforts were needed to accomplish this streamlined effort. However, patient education and involvement is also a big component of helping to save lives.

The ACC, the NC Chapter and CardioSmart recently headed to Charlotte, NC, home of the NASCAR Hall of Fame, to participate in the Coca-Cola 600. As recently updated CPR guidelines recommend compression-only CPR, representatives from the RACE program were on-site to give CPR demos teaching race car fans about the 5 C’s (check, call, compress, continue, connect) and how to save a life. Cardiac arrest is a prominent issue in North Carolina and will affect an estimated 8,000 North Carolinians this year, of which only 1 in 4 will receive bystander CPR and only 1 percent will have an AED used on them.

In addition to the CPR demos, blood pressure screenings and fact sheets on CPR and heart health were given to thousands of race car fans. Dr. Jollis and Philip Iuliano, MD, FACC, also took the stage during the track walk alongside NASCAR racers and discussed tips for avoiding heart disease, keeping active and living a healthy lifestyle. CardioSmart’s partnership with Coca-Cola has given the College numerous opportunities to increase awareness of heart health and get out into the community.

I am encouraged by state-wide efforts such as the North Carolina RACE program that focus on coordinating and improving treatment times. It goes to show that by working together through quality improvement programs and initiatives we really can make a difference.

Innovation is the topic du jour among lawmakers and others lately. Recently the co-chairs of the House Medical Technology Caucus, Rep. Erik Paulsen (R-MN) and Rep. Anna Eshoo (D-CA), held a briefing on Treating Cardiovascular Disease: Advancements in Medical Technology Innovation. A panel of experts shared examples of many ways in which cardiovascular technology innovation is changing the industry and the way health care is delivered.

Mayo Clinic was featured for being on the cutting edge of education and research, spending $421 million in these areas in 2011 alone. Mayo’s 2020 vision, “Mayo Everywhere,” involves engaging technology to impact patient care globally.  For example, instead of bringing patients to Rochester, MN for treatment, Mayo is focused on delivering affordable health care to their patients wherever they live using home monitoring and other technological approaches that foster mobility and independence.

Industry representatives were also on hand to describe the latest innovations stemming from extensive cardiovascular research and development. The Edwards Lifesciences’ SAPIEN Transcatheter Heart Valve, which recently received FDA approval, was an obvious example (read more about transcatheter valve therapy here). The MitraClip, a Mitral Valve Repair System that EVEREST II deemed safe for patients with moderate to severe mitral regurgitation, was touted as another impactful innovation that is currently in FDA review.

Meanwhile, it was noted that while the U.S. has been a strong force in medical technology, China, Brazil, India and other countries are surpassing us in the innovation arena due to the structure of current U.S. policies.  Rep. Eshoo, a long-time champion for technology and innovation, stressed the need for the U.S. to regain its status as the leader in medical advancement and set the gold standard for the world. She echoed the need for transforming the FDA and other agencies into innovation drivers, versus hindrances, and encouraged her congressional colleagues to visit technology companies in order to gain a first-hand perspective of the impact they have on the medical system.

This focus on innovation provides a great opportunity for the College to showcase our leadership and expertise when it comes to cardiovascular advances both in the past and moving forward.  Our work on TAVR is the most recent example. Hopefully this will be the new paradigm moving forward working with the FDA, CMS and our fellow specialty societies.

In addition innovative programs like Hospital to Home and D2B are already contributing to major gains in reducing cardiovascular hospital readmissions and D2B times, respectively. Other programs like PINNACLE, FOCUS and SMARTCare are well on their way.

We have a lot to be proud of. We’ll be showcasing a lot of this innovation and exploring what cardiovascular care might look like in a number of sessions and activities at ACC.12 for those of you headed to Chicago this month. Definitely plan to check out the Heart of Innovation Featured Learning Destination during the Expo, which is specifically designed to showcase the continuum of advances in cardiovascular innovation and provide a unique glimpse of what the future can be. It’s truly amazing.

I am in San Francisco today and speaking about the state of cardiovascular medicine at the CRF's TCT 2011 conference. Here is a snapshot of what I will be discussing:

Dynamic Changes in Health Care Resource Allocation

The trend in U.S. health care is simple: spending is drastically rising. U.S. health care expenditures total more than $2.5 trillion. In the past few decades, hospital, physician and prescription drug expenditures have also been steady to rise. Medicare spending for cancer and heart disease varies greatly – with heart disease still almost double cancer spending even though new hope to someday become take second place in morbidity, mortality and spending. Heart disease spending Medicare alone is projected at about $220 billion in 2011 and will rise to well over $300 billion or more by 2020. Health care spending in the U.S. is more than double that of other developed nations – and health care is the primary driver of future federal spending and the accumulating deficit. With more than 35 million U.S. citizens and 15 million non-citizens uninsured, 50 million on Medicare and 40 million on Medicaid, it is clear that the spending incurred by the American health system is a heavy burden to the nation unless the profession moves in to reduce unnecessary spending.

Impact of Changing Demographics of Physician Practice

Baseline demand of physicians is sharply outpacing the baseline supply as medical school enrollment and choice to practice a medical specialty decline. Practices are changing as more than 38 percent surveyed by the ACC in 2010 are either already integrated or considering hospital integration and 14 percent are merged or considering a merger with another practice. Well over 50 percent of CV private practices have sold to hospitals or other employment venue and the trend continues.  It is clear that this is a time of change for CV medicine and health care at large. Practice transformation will be affected by the bullish forces promoting integration, payment reforms, delivery system reform that requires team practice and advanced health information technologies, more informed patients who will engage in shared decision making, public reporting on quality and efficiency, and pressures to use clinical data and feedback to systematically improve quality and value, and to reduce variation and disparities.

Socioeconomic Trends and Imperatives

Stunning technology and infrastructure, a superbly trained workforce, excellent academic institutions, leading innovation – these are hallmarks of the U.S. health care system which currently covers more than 84 percent of Americans with private or public health insurance. Unfortunately, that also means that 16 percent of Americans are uninsured, and the nation is saddled with skyrocketing costs, great variation in quality of care and lack of needed care coordination. Clearly our non-system is in great need of mending. While the embattled Affordable Care Act offers new opportunities to promote access, insurance reform, and prevention, while also adding new funding to stimulate innovation, research,  public health and work force development, it’s fate is uncertain. In this chaotic environment, CV medicine  faces major uncertainties in terms of the impacts of system reform and deficit reduction on the future attractiveness and viability of CV physician practice,  the availability of primary care, and the affects of delivery system reforms and funding changes on patient care.  

While uncertainties abound, the future of health care and CV medicine can be positive influenced by the use of registry data and quality improvement programs which more consistently deliver best evidence at the point of care. ACC’s NCDR® and PINNACLE registries; Hospital to Home, Door-to-Balloon,  and Imaging in FOCUS initiatives, and other quality improvement programs will greatly improve outcomes and  reduce unnecessary spending if they can diffused more widely and include primary care. The ACC is poised to help the nation solve the problems of uneven quality, poor care coordination, and skyrocketing costs in health care through these and other efforts and partnerships.

 

To emulate management guru Peter Drucker, “The best way to predict the future is to create it.” Let’s get on with it. 

For more information on ACC’s quality initiatives, visit http://www.cardiosource.org/qualityprograms.

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!

By Harlan Krumholz, MD, SM, FACC

 

Krumholz is the lead author of the paper discussed below and a member of the ACC Board of Trustees.

 

It is with great pride and some awe that I report on the findings of a new paper published today in Circulation on door-to-balloon (D2B) times. In a comprehensive assessment of patients of all ages and across virtually all institutions providing primary percutaneous coronary intervention (PCI), we report that median D2B times have declined from 96 minutes in 2005 to 64 minutes in 2010. This is over a 30% reduction. The percent of patients treated within 90 minutes increased from 44% to 91% over those same years. Even more remarkably, the percent of patients treated within 75 minutes increased from 27% to 70%. The story of this success began with the identification of a quality problem with consequence. The benefit of primary PCI depends on its timely application, and in 2002, only one-third of patients received PCI in less than 90 minutes. NIH-funded research helped characterize the problem, while qualitative and quantitative studies revealed the secrets of top performers. Then, the ACC, with the American Heart Association and many other stellar partners, sought to translate that research into action with cardiology leadership throughout the country. The D2B Alliance was launched by the ACC in November 2006. Meanwhile, the Centers for Medicare and Medicaid Services were beginning to publicly report D2B times and, a year later, the AHA launched Mission: Lifeline, with its focus on systems of care. 

 

All this focus on D2B came together to change medical performance. I doubt that any voluntary effort to improve care has ever progressed with such speed and effect. This success reflects directly on the cardiologists, emergency medicine physicians, other clinicians, nurses, technicians, transporters, administrators and so many others who declared that patient care would improve and took the steps necessary to improve the timeliness of care for patients. I particularly cite the interventional cardiologists who embraced this effort even as they knew it entailed more work, including having to endure the false alarms that are unavoidable in a system built for speed.

ACC’s D2B Alliance also played an important role in the reduction. Cardiology leaders John Brush, MD, FACC, Eva Kline-Rogers, RN, Wayne Batchelor, MD, FACC, Brahmajee Nallamothu, MD, FACC, and Henry Ting, MD, FACC, among many others, were instrumental in getting the D2B Alliance off the ground. The Board of Governors and ACC chapters launched into action and delivered volunteers and hospitals throughout the country. At the ACC, the D2B Alliance was led by Amy Stern, with support from Jason Byrd, Matthew Fitzgerald and Karen Collishaw. They have left the ACC, but their made an indelible contribution to this effort.  Betsy Bradley, MBA, PhD, at Yale was also critical to the effort. More than 1,000 hospitals enrolled – including many that participate in NCDR – and there is evidence that many other hospitals participated even if they did not formally join.  In the end, it was truly people in each location that made the difference.

The improvements that were made are now embedded in the way the work is conducted. New trainees know no other way to treat patients with STEMI than with rapid, delay-free care. This project provides us with a sterling example of what can be achieved when we work together, learn from each other, and collaborate in the best interests of patients.

However, there is still work to be done. Some exceptional hospitals are regularly achieving D2B times of ~60 minutes by strategies such as coordinating with Emergency Medical Services and dissemination of a prehospital ECG. These strategies and others should be implemented nationwide to make 60 minutes the new standard of care. Additionally, studies have shown that time is lost in the transfer of patients from hospitals without PCI capabilities to PCI-capable hospitals. We need to identify and implement strategies that can reduce transfer time.

The results of the study reflect a level of performance that would have been considered impossible a decade ago. And it was achieved not by large investment, not by financial incentive, not by the application of a new technology, but by local efforts to adopt best practices and a drive to succeed on behalf of patients.

Related Resources:

Full Circulation article

CardioSource journal scan

D2B: Sustain the Gain website 

Last Monday, I was surprised but pleased to see that a letter to the editor I quickly whipped off was actually published in USA Today responding to a series of articles finding that many hospitals rated highly by patients and/or consumer groups nonetheless had high rates of MI, heart failure or pneumonia.  

I wrote that the articles “show the dangers and potential for using administrative data care comparisons without backing up presumptions with clinical data.” For instance, when comparing death and readmission rates among hospitals, it must be considered that some excellent hospitals, because of the communities they serve, take sicker patients with fewer resources for community follow-up care once they are discharged, resulting in higher rates of readmission or morbidity.  

I touted the value of the ACC’s NCDR registries in reducing D2B times (door-to-balloon times measuring speed of treatment of heart attacks) and identifying potential overuse or underuse of some treatments, and noted that clinical data is far superior to claims/administrative data in these regards (administrative data, which has the ability to point to outliers but not clinical care differences, was used in the USA Today stories).

Yesterday I spoke at a session on practice management called “Practice Innovation: How to Reduce Costs and Increase Quality.” This session offered a high-level look at the many resources the College has available to help practices deliver high quality care while saving money.

The session had an all-star lineup: former (as of convocation last night) ACC President Fred Bove, M.D., M.A.C.C., and now current president Ralph Brindis, M.D., F.A.C.C., were the session chairs. Ralph gave a talk about the role of registries in a reformed health care system and how registries can help measure success, reduce health care disparities and serve as an important tool in comparative effectiveness research (similar to what I wrote about on Sunday).

ACC SVP of Science and Quality Janet Wright, M.D., F.A.C.C., talked about the various quality programs that ACC runs, such as the highly successful Door-to-Balloon campaign, the newly formed Hospital to Home program and medication adherence initiatives. Co-Chair of the Health IT Committee Jimmy Tcheng, M.D., F.AC.C., talked about health IT and the tools necessary to adapt to delivery system change. My presentation at the session covered ways of reducing variations in CV care through tools like appropriate use criteria.

This session goes to show all the different ways that the ACC offers members to improve quality in different areas. That said, CV practices around the country are struggling under the recent payment cuts put into effect by CMS to make fewer practice dollars go farther. It’s understandable that the thought of participating in a quality program might seem impossible at this point. However, even in economically distressing times, the ACC continues to promote quality programs because quality must be the core of what we as health care professionals do. At some point (hopefully!), practices will have the resources to fully commit and expand their participation in quality programming.

*** Image from morgueFile (jdurham). ***

Today’s post comes to us from Harlan Krumholz, M.D., F.A.C.C., the Harold H. Hines, Jr., professor of medicine at the Yale University School of Medicine. Harlan is a well-known leader in advocating for improvements in cardiovascular quality. Not only did he lead ACC’s successful quality improvement program “D2B: An Alliance for Quality,” he currently serves as the co-chair of the Hospital to Home (H2H) steering committee. Outside of his work with the ACC, Harlan is also heavily involved in the Centers for Medicare and Medicaid Services’ efforts to develop national measures for public reporting of hospital performance.

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Over the last several decades, the cardiology community has led our profession in generating new knowledge and seeing it applied for the benefit of our patients. Recently, we dramatically improved door-to-balloon times – moving in rapid progression from an era where only one-in-three patients were treated within the guideline-recommended 90-minute timeframe to now, where almost 90 percent of our patients are treated within that benchmark. Remarkable.

Another chance to lead lies before us. On Oct. 22, the ACC, in partnership with the Institute for Healthcare Improvement, will launch a major quality improvement initiative called Hospital to Home (H2H)… this time focusing our quality efforts on readmission rates. Currently, about 20-25 percent of our patients hospitalized with an acute myocardial infarction (AMI) or heart failure are back in the hospital within 30 days. Many of these admissions are preventable through improvements in the transition from inpatient to outpatient status. Unfortunately, we have often neglected this vulnerable transition period for patients.

Gaps in Care
We have many obvious gaps in care – patients often leave without information about the hospitalization being transmitted to other caregivers in a timely way; without access to medications; without appointments being set; and without an emergency plan for if their condition suddenly worsens. Studies have shown since the 1990s that improving the handoff between the hospital and the “home” can lead to a reduction in readmissions by addressing these gaps. Our fragmented health care system places many barriers in front of health care providers in putting known methods into practice. To reduce readmission rates, we’ll need to make special efforts to focus on transitions and most importantly – to focus on the patient, specifically, making efforts to ensure that the patient is ready and knowledgeable enough to manage their care – and that the system is poised to provide the support they need.

H2H Goals – Just the Beginning
H2H will assist providers in overcoming the systemic barriers to improving readmission rates. The initiative is committed to reducing 30-day all-cause, risk-adjusted readmission rates for patients with a diagnosis of heart failure or AMI by 20 percent nationally by 2012. In HF, that would take the rate from about 25 percent to about 20 percent. This goal is ambitious – but we aspire to produce a substantial benefit for patients.

H2H will leverage other national initiatives contributing to a reduction in readmission rates and will harness the collective knowledge, creativity and energy of its key strategic partners -- Kaiser, the Veterans Administration, the American Hospital Association, The Joint Commission, PREMIER, HCA -- and others to reach this goal. In my opinion, the 20 percent reduction is just the beginning of what we can achieve through our collaborative efforts. The path is more challenging than ever because of our goal of actually affecting patient outcomes, but we are bringing together expertise, resources, tools and a mechanism for us to learn from each other to meet this goal.

For those of you who want to be part of this effort, you will not be alone. We already have more than 250 facilities (e.g., hospitals and medical practices) that have joined us. Teams will be anchored at hospitals but will stretch across the continuum of care. We will track progress and, ultimately, assess whether we decreased preventable readmissions through improved care. We want this effort to equip teams for success.

Join Us in Reducing Preventable Readmissions
For more information, visit: http://www.h2hquality.org/, or email hospital2home@acc.org. H2H officially launches Oct. 22 with a Webinar explaining the initiative in greater detail. To join the Webinar, please register in advance online. If you are unable to attend on Oct. 22, you will be able to access the Webinar archive through our Web site.

We want to again show the nation that the cardiovascular community knows how to get results for our patients. We hope you’ll join us for this exciting initiative.

* Dr. Krumholz's post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!

A paper published in the May 19 issue of the British Medical Journal found delay in door-to-balloon (D2B) time is associated with higher mortality rates in patients undergoing PCI. (Surprise!) The study was based on data from the ACC's National Cardiovascular Data Registry (NCDR). Median D2B time was 83 minutes. The adjusted mortality rate for PCI by 30 minutes was 3.0 percent, while those with D2B times of 240 minutes had a mortality rate of 10.3 percent. The goal of the D2B Alliance for Quality (90 minutes) yielded a mortality rate of 4.3 percent.

The authors state that "their data support calls for an 'as soon as possible' standard for patients undergoing primary percutaneous coronary intervention." But how fast is too fast? Share your thoughts ...

Tomorrow in Room W101, ACC.09 will feature a “D2B: Sustain the Gain” symposium featuring experts in the field discussing current topics in STEMI care. If you’re asking yourself right now: I thought it was called “D2B: An Alliance for Quality?” – you’re right, it was. “D2B: Sustain the Gain” represents Phase 2 of the campaign. Since Phase 1 (An Alliance for Quality) was such a success [go to the Participant’s Workshop tomorrow morning, from 7 – 9 a.m. at the Rosen Centre Hotel, Salon 3, to hear why], the ACC is using D2B: Sustain the Gain to figure out how we can maintain those gains. It’s clear that there are many challenges inherent in sustaining D2B times of 90 minutes or less. We’ll be developing materials and support tools that hospitals need to continue their success.

Quality efforts like D2B are crucial in making a difference in health care reform efforts. The federal government doesn’t have to tell cardiologists to improve quality – cardiologists are working together to do it themselves. Through D2B, we’re making serious in-roads in improving quality – and I know from my visits to the Hill, lawmakers are taking notice.

Meanwhile, stay tuned this summer for the ACC’s newest national quality improvement initiative, Hospital to Home (H2H). With H2H, we’ve set a measurable goal of reducing the 30-day all-cause readmission rate for patients with heart failure or heart attack by December 2012. To register for this program in advance visit: www.acc.org/h2h/enrollment. This is an exciting opportunity to improve patient care and reduce preventable and costly readmissions. We have a great partner in IHI for this initiative as well.