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

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

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

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

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

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

The topic of inappropriate use of stenting has been a hot topic this past year in several states including Maryland. As Immediate Past President Ralph Brindis, MD, MPH, MACC wrote in a previous blog entry, “To be perfectly clear, the ACC does not condone inappropriate use of coronary stenting, overuse or misuse of any cardiovascular technology or therapy. That said, what’s happening in Maryland is a prime example of how a negative situation can be turned into a positive opportunity to improve quality and appropriateness of care.”

Over the past year, the Maryland Chapter, along with the Society of Cardiovascular Angiography and Interventions (SCAI), have been advocating for oversight guidelines for cath labs performing percutaneous coronary intervention (PCI).

The Maryland Chapter has been diligently working to implement internal and external peer review, but as MedPage Today recently reported: “a Maryland plan to regulate stent procedures has elicited a push-back from local chapters of the American College of Cardiology and the Society of Cardiovascular Angiography and Interventions (SCAI).” The “public outcry over” allegations of over-stenting have “spurred a technical advisory group to the Maryland Health Commission to recommend giving the commission the authority to regulate stent procedures as well as continuing evaluation of hospitals with stent programs.” However, “both the Maryland Chapter of ACC and the Maryland SCAI chapter said a better plan would be a two-tiered system of checks that includes an internal review that meets specific standards and an external peer review as an auditing mechanism.”

Although the battle in Maryland continues, their gallant efforts have not gone unnoticed, and this past week at Leadership Forum BOG Chair-Elect Dipti Itchhaporia and I presented Sam Goldberg, MD, FACC, governor of the Maryland Chapter with the ACC Chapter award for Advocacy.

As the famous Robert Frost saying goes, “Two roads diverged in a wood, and I - I took the one less traveled by, and that has made all the difference.” I applaud the amazing efforts of the Maryland Chapter who is working to do something more effective to prevent inappropriate uses.

I was honored today to kick off the 2012 Leadership Forum in conjunction with the Cardiovascular Care Summit in Las Vegas. This is always an exciting opportunity to meet with new ACC leaders and not only introduce them to the ACC, but to get to know them on a personal level.

The packed agenda included a call to leadership by ACC CEO Jack Lewin, MD, who said great leaders have clarity and courage. He urged incoming leaders to establish direction, align people, motivate workforces and focus on dramatic and long-term change, while also playing a management role in terms of planning/budgeting, organizing staff and meeting short-term goals. ACC President David Holmes, Jr., MD, FACC; President-Elect William Zoghbi, MD, FACC; and Vice President John Gordon Harold, MD, MACC, also eloquently shared their thoughts on the topic "What is Your ACC Legacy? Standing on the Shoulders of Giants." All three leaders spoke of their leadership mentors, their own hopes for the College and advice for the future. Reinvigorating science and education, transforming technologies and establishing digital strategies and improving communications were among the priorities all three ACC leaders noted as priorities for the future. A tall order, but definitely doable!

Attendees also had the great honor of hearing Major General Hammond speak on "A Call to Duty: Leadership Lessons from the Front." Another session focused on navigating the increasing quagmire of educational requirements, including Maintenance of Certification, Maintenance of Licensure, imaging accreditation and Board certification. I can’t stress the importance for ACC leaders, both new and old, to understand these programs in order to prepare personally, but also be able to help our colleagues successfully comply and stay current with the exponential growth of new information.

In addition to the learning session, breakout groups throughout the day introduced new leaders to their roles on the Board of Trustees, Board of Governors and ACC Councils. In addition, Chapter Executives, Training Directors, Fellows in Training and current Governors and Trustees had opportunities to strategize and identify priorities for the next year. Several Fellows in Training participated in a special poster contest, the winner of which will be presenting at ACC.12. Incoming BOG Chair Dipti Itchhaporia, MD, FACC, and I also recognized several ACC Chapters that excelled throughout 2011 in the areas of Education, Membership and Community, Advocacy and Quality. Overall winners in each area included Colorado (Education), California (Membership and Community), Maryland (Advocacy) and Wisconsin (James T. Dove Quality Award). I applaud the amazing efforts of these Chapters and am excited to see how their respective activities will translate to larger programs at the national level.

This is an exciting time to be a leader of the ACC. We are charting a new global future for cardiovascular care and new and emerging leaders are critical to us all being successful. Now is the time, in the words of Dr. Holmes, to take the gloves off, never take “no” for an answer, and simply “Go for it!”

The Cardiovascular Care Summit began with a special payer roundtable on Thursday evening following the close of the Leadership Forum. Check out the Summit agenda here.

The College is fortunate to have wide representation of its Board of Governors from all 50 U.S. States, Canada, Mexico, the Army, Navy, Air Force, Veterans Affairs, and Public Health. We have much to learn from one another, as there are several inherent differences between our health care systems.

Our colleagues from Canada share with us “a day in the life” in latest issue of Cardiology magazine. We learn that there are a few similarities and several differences between Canada’s health system, which covers 100 percent of the nation’s citizens, and the U.S. traditional practice system.

Cardiologists in Canada work in an independent and autonomous practice style environment which includes autonomy in diagnostic testing and treatment. Emergency and acute care, including state-of-the-art STEMI care, as well as readily available access to urgent testing and procedures are hallmarks of the Canadian health system.

The private practice in Canada is similar to the U.S., as cardiologists are responsible for their office operation, overhead, staff, professional dues, and development. There is no pension plan for private practice physicians, but there is the option of professional incorporation in some provinces, which takes advantage of the small business tax program, and taxes the first $500,000 of income at approximately 15 to 16 percent.

Billing for clinical services in the Canadian system goes to a single payer, which is a provincial government agency, with some exceptions including services rendered to armed forces. The system is electronically based, taking only two to three hours per week per physician. Correct submissions receive virtually immediate payment and there is no pre-authorization required.

While the U.S. engages in the tort debate, Canadian physicians are defended by the Canadian Medical Protective Association (CMPA) which provides medical assistance, defense, and advice to physician members in times of medical malpractice disputes. Only about one out of every 10 cases go to trial, and when they do, CMPA’s defense success is about 90 percent. Thanks to provincial reimbursement programs, the cost of CMPA coverage for individual cardiologists is extremely modest.

Canadian health care does have issues of concern. Hospital bed availability, emergency room overcrowding, and long waiting lists for some non-urgent care and testing are areas in need of improvement. To address the negative impact of long waiting lists, the Canadian Cardiovascular Society (CCS) developed a set of National Waitlist Guidelines. The Canadian Medical Association’s Wait Time Alliance has adopted these benchmarks and they are increasingly used in system planning and goal setting.

Budgetary limitations also tend to stifle the ability to introduce new programs, particularly new technology to hospitals. Program and patient needs sometime come into conflict with the limitations imposed by fixed funding streams from provincial governments to hospitals. Canadians see the need for improvements and in a survey taken by the Institute of Research on Public Policy in June 2011 of more than 1,200 citizens, working with the provinces on health care ranked highest in a list of possible priorities for the federal government.

Thanks to our friends Christopher Simpson, MD, FACC, Rodney Zimmermann, MD, FACC, and G.B. John Mancini, MD, FACC, for giving us a closer look into their Canadian health system.

View the Nov/Dec 2011 issue of Cardiology Magazine here. More information about the ACC’s Chapters is available at CardioSource.org/Chapters.

Tobacco use continues to be the leading preventable cause of disease and premature death in the U.S. As such, there are many targeted efforts at the local, state and federal levels to not only educate consumers about the health risks related to tobacco use, but ban its use in public places. The new Million HeartsTM initiative, in which the ACC is a partner, lists smoking cessation as key element in reducing one million heart attacks and strokes over the next five years. Just this last week the ACC and its CardioSmartTM National Care Initiative took part in the American Cancer Society’s Great American Smokeout campaign.

At the state level, great strides have been made to enact smoke-free legislation. In fact, in my home state of Mississippi we are making headway in reaching our goal of passing a statewide smoke-free law. The Mississippi State Department of Health is undertaking a major project funded by the Centers for Disease Control and Prevention called “Smoke-Free Air Mississippi.” As a board member of the State Board of Health, I had the privilege a few weeks ago of working with the health department and State Health Officer, Dr. Mary Currier, in presenting information on the success of this project. Even though the state as a whole is not yet smoke-free, most of the major Mississippi communities are smoke-free. In fact, 80 percent of Mississippi adults and more than 50 percent of Mississippi smoking adults favor a law prohibiting smoking in most public places.

I personally like some of the slogans from the campaign: "Every child deserves to breathe smoke-free air;" "Breathing smoke is not on any job description;" "Breathing is not optional—smoking is.” Communities with casinos have been hard nuts to crack, and the restaurant industry was initially a main opponent to the project, but once several prominent restaurateurs invoked no smoking rules in their restaurants, they actually saw their business improve. This was especially true for family-focused restaurants. Now many restaurants are strong supporters of ordinances in their community, as well as the goal of a statewide smoke-free law.

Do smoke-free laws improve health? Surely they do, and the data are impressive.  A study from Mississippi State University involving three hospitals, including my own, showed that during the 900 to 1,000 days following implementation of the smoke-free ordinance, there was a 27 percent reduction in one community and a 14 percent reduction in another in heart attack admissions. To me this is incredible information since it even shows the short-term effects of active and passive smoking.

Currently, there are twenty-nine states, DC, Puerto Rico and the U.S. Virgin Islands, plus numerous cities and counties that have enacted smoke-free laws. The National Conference of State Legislatures, of which the ACC is a Foundation Member, has compiled a map (current to November 2010) of states that have indoor smoke-free laws. This is a key issue that the ACC State Advocacy team follows, and they will continue to work with ACC members and stakeholders to pass laws that support smoke-free environments.

I congratulate all of the states and communities that have enacted smoke-free laws, and I have hope that one day it will become the law of the land!

As the recent Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease recommend, “[e]very tobacco user should be advised at every visit to quit.” The single most important thing that clinicians can do is to encourage patients to stop smoking. CardioSmart has several useful resources available online for patients looking to quit, and is supporting the National Cancer Institute’s SmokefreeTXT program, geared toward teens and young adult smokers.

An interesting study from the New England Journal of Medicine on weight-loss techniqueswas presented this morning at the AHA’s Scientific Sessions in Orlando. The Practice-Based Opportunities for Weight Reduction (POWER) trial examined theeffectiveness of weight-loss programs in obese patients with high bloodpressure, high cholesterol, or diabetes. Outpatient treatment of obese patients at risk of heart disease has been a struggle for physicians everywhere and alternative, convenient solutions that encourage weight-loss and a healthy lifestyle are much needed.

The goal for patients in the 24-month long study was to lose five percent of initial weight within six months. Two methods were explored: one with in-person health coaches and one driven by technology where patients were counseled on weight reduction over the phone. Both methods engaged primary care physicians as an integral part of the support team. The study found that patients who received information over the phone were equally as likely to lose weight and keep it off as patients who met directly with coaches.  Fifty three percent of patients enrolled in the phone driven program, which also had an interactive website component, achieved their goal. This outcome has the exciting potential to change the way weight-loss programs are developed and delivered in the future, increasing patient access to essential counseling and tools.

I will be excited to follow the impact this study will haveon patient access, especially in my home state of Mississippi. Given the high obesity rates of the South and the increasing rates across the country, effective solutions for weight-loss are greatly needed andhave been an ongoing struggle to develop. The results of the POWER trial can open the doors to a whole new way to treat overweight patients at risk for heart disease.  This trial demonstrates that information can be disseminated to a wide-range of patients not only nationally, but also globally, using common communications channels.

Finding innovative and flexible weight-loss education programs is key. Here at the College, we identified the importance of patient education several years ago with the launch of CardioSmart, which has been a successful initiative to get out in the community and promote a healthy lifestyle. NASCAR Track Walks that couple fitness with entertainment have been a huge hit and create the foundation for making smart choices. The Health and Wellness Center on CardioSmart has a section devoted to diet and exercise, providing patients with the tools and information they need to reduce their risk of heart disease. The Walk With a Doc program featured in the latest issue of Cardiology is another successful grassroots program that has seen tremendous success ininspiring and educating patients. Thinking outside the box and finding practical solutions to problems we encounter every day can truly impact the care and outcomes of our patients.  

AFib is catching a lot of buzz lately. Two weeks ago, the PINNACLE Registry announced the expansion of its outpatient registry with a new platform focusing on atrial fibrillation that will include the next generation of anticoagulants and will be free for all cardiology practices. The new registry will help providers evaluate and improve adherence to established guidelines and performance measures and will strengthen future research and innovation. PINNACLE, part of NCDR, is the largest cardiovascular outpatient database in the country and currently has 2.1 million patient records representing valid patient encounters from hundreds of outpatient practices nationwide. Of the 2.1 million patients, more than 100,000 have AFib. Stay tuned for more developments as the registry becomes operational in 2012 and delves into collecting data that will improve patient care.

How do you use anticoagulants in your practice when dealing with AFib? Weigh in on the poll and see how others are thinking about new agents as well.

Results from the AFFIRM Trial (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) were released last week. This trial explored how individual rhythm-control agents affect cardiovascular outcomes in patients with atrial fibrillation, looking at individual antiarrhythmic drug therapies compared with rate control with propensity score-matched analyses.  It turns out that rhythm-control agents had no effect on all-cause mortality, but were associated with an increased risk of cardiovascular hospitalizations.

This month’s featured article in the Atrial Fibrillation Community covers the clinical significance of silent stroke. According to the article, “[Recent] studies raise strong evidence that ‘ablation technology and energy source matters’ since non-irrigated multielectrode ablation resulted is a significantly higher silent stroke rate as compared to other ablation techniques. Thus, regarding the mechanism(s) leading to silent stroke it is very likely that most thromboembolic events are due to energy application, i.e. charring at the ablation catheter, rather than due to mobilization of pre-existing left atrial thrombi or air embolization.” So, should we be worried? Even though there is no current evidence that silent stroke impacts cognitive function, future studies are needed that explore the factors leading to their occurrence.

I invite you to visit the AFib Community which is a great resource to stay up-to-date on AFib developments and features articles, hot topics, news, case challenges and much more.

A great man died this past week. Dr. J. Willis Hurst passed away on Oct. 1 at 90-years-old.  Dr. Hurst was chair of Medicine at Emory University for 30 years and a teacher of Emory students for 61 years. His accolades are many, his obituary is expansive, and his eulogies extolled his greatness. I would like to add to these accolades on a personal level. As I do this, I know that thousands, if not tens of thousands, could do the same. Dr. Hurst touched many lives, including those of ACC governors past and present, as well as several ACC presidents.

For me, his mentorship and friendship extended over many years. I met Dr. Hurst when he was visiting professor at the University of Mississippi Medical Center. I had the privilege of introducing him at grand rounds and then being with him at a social event. During that event, he mentioned he would have an intern from Mississippi the upcoming year. Since I was the only one applying, I felt that I had received a summons to be a Grady Hospital intern. It was a great year (in retrospect), with many morning reports before the Chief. During that year, however, I received another summons, this time from the US Navy – the last "doctor draft" got me. 

Years later, while practicing internal medicine at Ochsner Clinic, I felt the need for something different. Despite the several elapsed years since my internship and suspecting he would not remember me, I nevertheless called Dr. Hurst for advice. He responded to my call and issued another summons that forever changed my life. The next year I found myself chief resident and cardiology fellow at Emory. During Emory training, I learned immensely from Dr. Hurst, as well as from Drs. Logue, King, Douglas, Lutz, and many other outstanding staff. Dr. Hurst was a brilliant clinician and lecturer and certainly imparted much medical knowledge. However, what I most took away from him was his edict that caring for the patient always comes first. I recall vividly the day he made the lame to walk. A friend from his hometown was unable to walk and was admitted to the great cardiologist with this definitely non-heart problem. After a few moments alone with her, the door opened and they walked arm in arm down the hallway. The house staff was waiting in the hallway and he winked at us as they passed. She had major emotional problems and Dr. Hurst started her cure by listening and by advising. 

In the guest book of the Atlanta funeral home, many, and in fact most, comment on the personal touch that this great man had for them and the influence he had on their lives. One shared the memory that when she was a pediatric patient and Dr. Hurst was her doctor, he left Atlanta for Washington to take care of another patient, President Johnson.  She tearfully wondered to her parents why Dr. Hurst would leave her since she was his favorite patient.  During ACC.10 in Atlanta, I visited Dr. Hurst in his retirement apartment. His advice to me: "work as long as you can."  He was still excited, then at nearly 90 years of age, to be receiving former students and to be teaching present Emory students. These students were still coming on a regular basis to his apartment to hear his lectures and to touch the hem of his garment. 

These days we are all faced with ever increasing demands on our time, but the passing of Dr. Hurst is a reminder of the impact one person can have on our careers and on our lives.  Most everyone can probably think back on their lives and identify one person who served as a mentor. I encourage everyone to take an example from Dr. Hurst; spend quality time with your young colleagues, return that phone call from a former resident, take a moment to talk to that potential intern. To quote ACC President-Elect William Zoghbi: “[Mentorship]  is very special. It  brings about strong bonds between individuals and will help shape our future leaders.” 

Hail to the Chief!

The College’s goals are three-fold:

1. Permanently repeal the sustainable growth rate (SGR) formula as part of any deficit reduction plan
2. Include medical liability reforms in any deficit reduction plan
3. Protect medical imaging from any further cuts

When it comes to the SGR, time constraints and the diminishing pool of spending offsets makes the Super Committee the only viable vehicle for addressing the flawed formulas this year. For every year that Congress postpones fixing the SGR, the cost grows. The American Medical Association (AMA) estimates that by 2016 the cost of permanent repeal would be $600 billion – a significant increase from the roughly $50 billion it would have cost in 2005. If we’re talking about reducing costs, then the SGR should be on the table.

Protecting medical imaging from additional cuts is also crucial. Imaging has been the focus of numerous drastic cuts over the past five years and continues to remain a target by Congress and regulators for potential payment reductions. Additional payment cuts and restrictions on imaging services cannot be absorbed by physician practices without impacting quality and access to high quality care. We cannot stress this enough to our members of Congress.

While at the end of the day we might not like all of the recommendations made by the Super Committee, now is our chance to stand together and at the very least educate members of Congress about the long-term ramifications if our requests are ignored. For those who think this is futile, I’ll leave you with an email that a fellow ACC governor just forwarded; he had received it from his congressman's legislative director. The governor had met with the congressional staff during the Legislative Conference. He received the email as he was about to respond to an ACC alert asking for help in generating support for a sign-on letter to repeal the SGR in the House. The email he received said: “Since we were just talking about the SGR, I wanted to let you know that my boss agreed to sign on to the letter below to the Super committee asking that they include a permanent solution to the SGR.” In the letter, the congressman stated the following important facts: "We are presented with an important choice: continue to distort the picture of our nation’s fiscal status with another short-term solution or restore fiscal transparency to the Medicare program by eliminating the $300 billion debt that has accumulated as a result of the SGR". 

Now that’s what I call Advocacy in action. OK, y'all, let’s hit the phones!

KevinMD had a great guest post recently by Mary Pat Whaley on the time associated with a patient visit. I think the title sums up the blog well: “Your 10-Minute Office Visit Needs 8 People and 45 Minutes of Work.”

As Whaley notes, even the shortest of office visits have a lot of work behind-the-scenes that needs to be done; seeing the patient is just a small part of the overall visit.  And, I would submit that far more than 8 people and much more than 45 minutes is required.   Health care is a regulation- and administration-heavy field, and this requires time to make sure the regulatory and administrative rules are followed. For example, HIPAA requires privacy forms to be filled out prior to the patient being seen. Verifying someone’s insurance information is time-intensive. Not to mention ensuring that we charge the patient the right co-pay based on their insurer and insurance plan. On top of that, pay-for-performance programs require time- and technology-intensive data collection during and after the visit. All of this, and more, makes up one “10-minute office visit.”

Whaley concludes: “The practice, the patients and the overseers of health care want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.”

I have to agree with her. The complexity of the American health care system is incredible. And, the layers of complexity account for much of the cost. Our system has been built by accretion.  We “reform” the system by adding on layers of regulation, of bureaucracy, of administration.  As you look behind the eight people figured in this visit, the cost if not the time includes coders, compliance workers, claims specialists, re-claim specialists, computer network and now electronic health record experts,  lawyers, front office personnel, and even standard maintenance personnel for the  building.

As the regulation and administrative burdens add on, the cost of practicing gets greater and it is harder to cover these expenses with income.  Add to that more and more cuts to cardiology, and it’s no wonder that a large number of private cardiology practices are integrating with hospitals. Last year, the ACC reported the results of a survey of ACC members that found nearly 40 percent of private group practices were currently integrating with hospitals or merging with other practices. An additional 13 percent of all cardiovascular practices were considering hospital integration or a merger in the next three years to help stem the financial burden.

These are uncertain times for cardiology and for the House of Medicine in general.  To be clear, the ACC supports the triple aim of better health, better health care, and at less cost. But to get there, we will have to deal with the repercussions of massive changes, and may I say probably the accretion of more layers, to our health care system. In my opinion, “dealing” with the repercussions will not be enough – we need to shape the discussions if we want to be pleased with the health care system structure of the future.  And, maybe we can even help peal away some of the layers.