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).

The ACC and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) have a longstanding relationship, and as a result, have developed a variety of tools for physicians and their patients to use to encourage participation in cardiovascular rehabilitation (cardiac rehab). 

As clinical practice guidelines highly recommend cardiac rehabilitation after cardiac events such as a myocardial infarction to improve mortality, quality of life and functional capacity, the ACC’s Hospital to Home (H2H) program stresses that it is important for a patient to have a referral for a cardiac rehab program within 7 days following discharge after a myocardial infarction. This recommendation is not by chance – there is now good evidence showing that the sooner a patient enrolls in cardiac rehab, the better their likelihood of attending regularly, which will then lead to better outcomes.  There is also evidence that participation in cardiac rehabilitation improves adherence with preventive medications and decreases depression and anxiety.

Just in time for Cardiac Rehabilitation Awareness Week, the ACC and AACVPR worked together to update the cardiac rehab resources in the “See You in 7” toolkit available on the H2H website. The resources allow for managers, nurses, and others working on care coordination to appropriately incorporate cardiac rehabilitation into patients’ treatment to help decrease readmissions related to misconceptions about medications or symptoms.

In order to emphasize the importance of cardiac rehab, the ACC and the AACVPR have developed multiple resources for several of the success metrics of the H2H “See You in 7” challenge, including highlights of the 2010 ACC Foundation (ACCF)/ American Heart Association/ AACVPR Cardiac Rehabilitation Performance Measures. In addition, CardioSmart.org has a great overview of cardiac rehab on its newly redesigned website, in addition to a cardiac rehab fact sheet developed by AACVPR available in both English and Spanish, and a CardioSmart Video: Journey Back to Heart Health, about cardiac rehab that can be used in office or hospital settings.

Smart cardiac rehab teams will be making sure that others working on hospital readmissions in their community are aware of H2H and of the materials within the H2H website that can be used to promote cardiac rehab enrollment. It's time for ACC and AACVPR colleagues within local communities to meet to figure out how and when to use this information, in order to break down barriers to participation in cardiac rehab and improve patients' health outcomes.

By: Judy Tingley, MPH, RN, member of the ACC’s Clinical Quality Committee.

The Centers for Medicare and Medicaid Services (CMS) readmission payment penalties went into effect on Oct. 1.  Mandated by the Patient Protection and Affordable Care Act, this quality improvement initiative imposes financial penalties on more than 2,200 hospitals with Medicare readmission rates above the national averages.  The unintended consequence of these penalties is yet to be determined.

This new crackdown will have the greatest impact on the “safety net” hospitals that treat our poorest patients.  Current studies demonstrate that much of the variance in readmissions is due to factors beyond the hospital's control.  Many of these community hospitals have limited resources, antiquated medical records systems, serve late presenting and/or underinsured clients, and are at greatest risk for financially failing.  This reality reaffirms that quality metrics identification and measuring outcomes has never been more important.  As we move toward data driven reimbursement models, it is critical that the implementation of “patient centric quality metrics” does not get lost in the quagmire of financial and regulatory demands.  Quality needs to remain the focus of “quality metrics.” 

Of late, safety measure techniques used by the airline industry have been meaningfully translated to health care delivery systems.  Pre-operative checklists (modeled after pre-flight checklists) have significantly improved patient safety.  Just as regular and consistent communication between the crew and air traffic control helps thwart potential problems and keep the skies friendly, so should regulators, payers, hospitals, patients and practitioners communicate to keep patient safety at the forefront.  If not, we should brace for the impact of the unintended consequences of making worse a system that is very much in need of patient centric reform.  

Our population is changing and if you’ve seen one patient, you’ve seen one patient.  There will never be a one-size-fits-all model to eliminate readmission.  Therefore, the impact of demographic characteristics, co-morbidities, socioeconomic parameters, post-discharge environmental factors and regional health care delivery disparities all must be considered in strategically planning meaningful cost efficient care.  As our patient population ages the economic impact of this reality is yet to be seen:

• Half of older women 75+ live alone
• Persons reaching age 65 have an average life expectancy of 18.1 additional years
• The 85+ population is projected to increase to 9.6 million in 2030
  

Improved efficiency and reduction in avoidable readmissions is imperative.  Methods to better identify patients at risk for readmission, reduction of hospital complications, improvement in transitional care and overall communication between providers and patients are important ways of improving quality care.

There remains much work to be done in order to transform today’s health care into the efficient quality centric delivery system needed for the future.  The ACC has taken the lead in providing tools to help practitioners review and provide a transition of care plan.  Specifically, Hospital to Home (H2H) is a national quality improvement initiative developed to help hospitals reduce all-cause readmissions among patients with heart failure or acute myocardial infarction.  As health care providers, we must continue striving toward a coordinated multi-disciplinary strategy to effectively address improving quality of care in a fiscally responsible way.  If we fail, brace for impact!

Medication non-adherence is a growing public health concern because there is evidence that this is prevalent problem which is associated with adverse outcomes and higher costs of care. Addressing the problem is especially critical as the number of Americans affected by a chronic condition requiring medication therapy is expected to grow from 133 to 157 million by 2020. Nearly three out of four Americans admit that they do not always take their medication as directed, a problem that causes more than one-third of medicine-related hospitalizations, nearly 125,000 deaths in the U.S. each year, and adds $290 billion in avoidable costs to the health care system annually.

One of several ways the College is working to encourage medication adherence is through the Script Your Future campaign led by the National Consumers League (NCL), a 113-year-old Washington, DC-based consumer advocacy organization. The campaign addresses the need for tools and resources to support medication adherence across the country and opens dialogue between health care professionals and patients about the health consequences of non-adherence. Advocates have found that the messages about the importance of adherence need to come from a variety of places in order for patients to absorb them, and the campaign faces that challenge head-on by partnering with diverse groups, and working to reach patients in a variety of places, and via a variety of relationships – through open dialogue with doctors, pharmacists, nurses, caregivers, and other health care professionals.

This spring marked the first anniversary of the three-year campaign that targets those who suffer from three chronic conditions: cardiovascular, diabetes and respiratory. Script Your Future is operating at both the national level and in six regional target markets across the country – Baltimore, Birmingham, Cincinnati, Providence, Raleigh, and Sacramento – hosting local, grassroots efforts on the ground in these communities to educate patients and their loved ones about the importance of taking medication as directed and to initiate new conversations between patients and their healthcare professionals. 

Moving forward, Script Your Future offers several opportunities for Chapters, both in the target markets and nationally as part of the Million Hearts campaign, to increase patient education around the benefits of medication adherence as it relates to the treatment and prevention of heart disease. It also affords opportunities to promote CardioSmart tools, such as the new CardioSmart Med Reminder app. This app is free to iPhone and iPad users and is intended to serve as a medication and prescription refill reminder, as well as a personal medication record, to help patients communicate with health care providers about the medications they are taking.

This summer the ACC and CardioSmart are promoting a “Don’t Take a Vacation from Your Medication” campaign on our social media channels to curb the trend of medication non-adherence and to encourage patients to not forget about taking their medication. Get all of the tips and tools on ACC and CardioSmart’s Facebook pages. Also be sure to follow @ACCinTouch and @CardioSmart on Twitter. You can also learn more about medication adherence in the July/August issue of Cardiology magazine, hitting newsstands later this month, and in the July issue of CardioSource WorldNews. The College’s Hospital to Home (H2H) campaign also has medication adherence as a key component of reducing unwarranted hospital readmissions. You can learn more and take part in the H2H “Mind Your Meds” Challenge at h2hquality.org.

This post was authored by William J Oetgen, MD, MBA, FACC, ACC's senior vice president of Science and Quality.

The Hospital to Home (H2H) initiative was launched in 2009 as a joint effort of the ACC and the Institute for Healthcare Improvement. Three years later, the goal of H2H continues to be a 20 percent reduction of hospital readmissions within 30 days for patients admitted with either acute myocardial infarction or heart failure. Three important activities that address core concepts have been identified as targets for improvement:

1. Medication Management Post-Discharge: Is the patient familiar and competent with his or her medications and is there access to them?
2. Early Follow-Up: Does the patient have a follow up visit scheduled within a week of discharge and is she or he able to get there?
3. Symptom Management: Does the patient fully comprehend the signs and symptoms that require medical attention and whom to contact if they occur?

In addition, H2H strives to create a learning community that shares expertise, experience and tools – and works together to improve the transition from hospital to home. The H2H community was developed to address these “challenges.” And, in a remarkable example of collegiality and cooperation, H2H members are collaborating and sharing information to help each other.

Over the past few years since H2H was established, individual and hospital participation in H2H has steadily increased. Currently, 2,294 individuals and 1,326 hospitals (39 percent of all U.S. hospitals) have united around the shared goal of lowering the risk of readmission.

Members of H2H have engaged in lively discussions of challenges and success strategies on the H2H listserv and on webinars designed to share experiences and best practices. We are continuously seeking ways to encourage participation and easier ways to access the tools and resources of the community.

During an ACC.12 session in Chicago, a panel of experts convened to discuss and identify tools and ideas to reduce hospital readmissions including a neighborhood watch solution that enlists trained volunteers from nearby universities to educate patients and make follow-up phone calls. We had several great ideas presented and the discussions underscored how the best way we can find the answer is by working together.

Reducing readmission rates is not straightforward and each institution must tailor its strategy to its particular setting and resources. Research in this area is still evolving, but with available knowledge it is now possible to make progress. In order to be successful and reach our goal, we must continue to learn from what we do – and from each other.

For more information on H2H visit www.H2Hquality.org.

Geisinger Health Plan recently announced that a telehealth-based remote monitoring program for heart failure patients has significantly cut the readmission rate for those patients by 44 percent. The program uses interactive telemonitoring tools to supplement case management. Over 1,000 patients are enrolled in the program. The majority of patients use the tool to input symptomatic information on a regular basis, allowing care managers real-time access to the patient's condition. Based on its success, Geisinger plans to extend the program to diabetes and hypertension patients. This, my friends, is the future for all cardiology chronic disease outpatient care.

Don’t miss these sessions at ACC.12 and ACC-i2 with TCT in Chicago that focus on remote disease management, H2H and readmissions:

• Can Remote Disease Management Improve Clinical Outcomes?
  Saturday, March 24, 2 – 3:30 p.m. (McCormick Place South, S406a)
• Tools to Improve the Care Transition: The Hospital to Home (H2H) Experience
  Sunday, March 25, 8 – 9:30 a.m. (McCormick Place South, S501a)
• Improving Outcomes and Reducing Heart Failure Readmissions
  Monday, March 26, 3:45 – 5:15 p.m. (McCormick Place South, S406b)

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:

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.

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.

An article in JAMA earlier this month provides support for the importance of early follow up for patients discharged from the hospital following heart failure. The paper was written by Adrian Hernandez FACC, who chairs our Hospital to Home (H2H) Measurement & Evaluation workgroup, and co-authored by AHA President Clyde Yancy FACC and others. In short, it found that Medicare patients discharged from the hospital with higher rates of follow up, as defined as receiving outpatient evaluation within one week of discharge, had lower readmission rates. Not too shocking, right?

ACC’s Hospital to Home has been touting early follow up as one of its ways of reducing readmissions. The easy first lesson of H2H is the importance of seeing the patient within the outpatient setting within one week of discharge. As this study so nicely points out, this could go a long way in reducing readmission rates (talk about bending the cost curve!).

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). ***

There's just two days left before the official launch of Hospital to Home, ACC's quality initiative to reduce 30-day all-cause, risk-adjusted readmission rates for heart failure or AMI by 20 percent nationally by 2012. Check out this video with Harlan Krumholz (following his blog post here). Also, don't forget to enroll in the initiative and register for Thursday's launch Webinar (1 p.m. EDT) at http://www.H2HQuality.org.