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.

What an exciting weekend! I can safely say that the Cardiovascular Care Summit is not something that happened in Las Vegas that should stay in Las Vegas. Whether it was hearing from national health plan representatives on the role of the cardiologist and the cardiovascular program in a reformed reimbursement environment, or discussing best practices for building and managing a cardiovascular service line, this unique conference offered solutions for the entire cardiovascular care team to thrive in a time of change.

David Lansky, PhD, president and CEO of the Pacific Business Group on Health; Deborah Ness, president of the National Partnership of Women and Families; Lonny Reisman, MD, chief medical officer at Aetna; and Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group kicked off the Summit by providing a unique perspective on the cardiovascular community’s role in payment reform. Whether examining the components of value-based purchasing, helping to reduce patient readmissions, there are a number of opportunities to share our expertise and work with health plans.

The Summit also featured discussions on the future of health care reform and how the physician community as a whole can affect this process and lead change. Obviously, one of the key areas requiring substantial change is physician payment. Following on the heels of the health reform session, Summit attendees were able to take part in a panel discussion that looked at a variety of compensation models and their potential roles in the changing reimbursement environment. Breakout groups also offered opportunities to discuss major financial changes, ranging from contract negotiations, winning academic business models and how to financially survive in private practice.

Outside of payment and health care reform, the Summit also focused substantially on data collection and management, providing a focused look at the myriad of data available today and why accurately reporting data will be so critical in the future. The writing is on the wall, whether we like it or not, and future compensation models will be based at least in some part on quality of care and outcomes. We have the experience with NCDR to make sure this is done in a way that is transparent and accurately reflects the quality and appropriateness of care being provided.

Finally, the final day of the Summit really provided a comprehensive look at issues related to the cardiovascular service line. Physician management of the cardiovascular service line is today’s contemporary approach to a physician-driven, professionally managed cardiovascular program.

The integration of physicians into the management of the service line provides an opportunity to strategically and operationally align hospitals and physician groups. ACC leaders and other stakeholders involved in service line management provided first-hand reports and best practices for designing and leading a successful cardiovascular service line model.

I’d like to thank and recognize ACC leaders and staff involved in making this Summit a great success. It was a true testament to the many ways the ACC and its leaders are working to meet the needs of the entire cardiovascular care team in this time of rapid change. Viva Las Vegas!

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.

Under the leadership of Alice Jacobs FACC, the ACCF/AHA Task Force on Practice Guidelines and ACC/AHA guidelines staff held a Methodology Summit in mid-December as part of AHA and ACC’s ongoing efforts to improve the guidelines methodology and rigorous development process. With the American Heart Association, our partner in these regards for almost three decades, we together also want to compare and contrast the current ACCF/AHA guidelines methodology with the standards proposed in the Institute of Medicine’s (IOM) two recently published reports, Clinical Practice Guidelines We Can Trust, and Finding What Works in Health Care: Standards for Systematic Reviews.

Last August, the Task Force initially commissioned five Workgroups to consider what, if any, changes or improvements should be implemented to enhance our development process and evidence review and evaluation. Each Workgroup was charged with 1) reviewing the IOM Report recommendations and sections of the current tools available for developing/conducting systematic reviews relevant to their topic; 2) comparing and contrasting the recommendations with our current ACCF/AHA methodology, including an analysis/discussion of the gaps and barriers; and 3) drafting recommendations/considerations for changes and improvements to the evidence review process and the COR/LOE including a discussion of why we may or may not implement changes.

The invited members of each Workgroup (including all Task Force members), in addition to guests at the Summit, brought a diversity of experience and expertise to this initiative. Participants included methodologists, biostatisticians, clinical and research cardiologists, epidemiologists and nurses as well as leadership from both the ACC and AHA. An official report which will include the final proposals and recommendations developed during the Methodology Summit is being prepared. This report will be shared with the leadership of the ACCF/AHA and then published.

We are also thinking to increase the technological ability to search the huge volumes of clinical recommendations we have amassed to allow clinicians to be able to more effectively and instantly use this science and knowledge more effectively at the point of care. Dr. Rick Nishimura wowed the Task Force with a strategy and plan to create what I’d call a ‘virtual curator’ IT system that could re-structure the data in our future (and present) guideline data to make it available in new ways. It’s time!

If you are attending ACC.12 in Chicago, be sure to check out the session “What’s New in the ACCF/AHA Guidelines,” on Sunday, March 25, from 4:30 – 6:00 p.m. in McCormick Place North, N228.
The session will discuss the recently published ACCF/AHA Clinical Practice Guidelines as well as an update on changes to the ACCF/AHA methodology.

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!

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.

The Department of Health and Human Services (HHS) yesterday launched the exciting new Million Hearts initiative aimed at preventing 1 million heart attacks and strokes over the next five years.

The public/private program, which will build on work already underway as a result of the Affordable Care Act, is focused on empowering Americans to make healthy choices such as preventing tobacco use and reducing sodium and trans fat consumption, as well as improving care for people who do need treatment by encouraging a targeted focus on aspirin, blood pressure control, cholesterol management and smoking cessation. It will be led by Thomas Frieden, MD, director of the Centers for Disease Control and Prevention, and Donald Berwick, MD, administrator for the Centers for Medicare and Medicaid Services, along with ACC’s Janet Wright, MD, FACC, who is leaving her post as ACC's SVP for Science and Quality to serve as director of the program.

“Heart disease causes one of every three American deaths and constitutes 17 percent of overall national health spending,” said HHS Secretary Kathleen Sebelius. “By enlisting partners from across the health sector, Million Hearts will create a national focus on combating heart disease.”

I, along with President-Elect William Zoghbi, MD, FACC, Vice President John Gordon Harold, MD, MACC, and Board of Trustees member William Oetgen, MD, FACC, attended the announcement to underscore our long-time commitment to the very issues being addressed by this program. The College is excited about the opportunity to support this effort through our CardioSmart national care initiative, as well as through our continued efforts to encourage the adoption and use of point-of-care tools and data registries. These tools and resources will be critical to helping providers not only provide the most appropriate care, but track patient outcomes.

The ACC’s 2011 Legislative Conference kicked off last night with a full dinner program to benefit the College’s Political Action Committee. ACC President David Holmes, MD, FACC, welcomed the more than 350 attendees to the 20^th annual conference, urging them to take advantage of this time for the cardiovascular community to come together and speak with one voice.

Dr. Holmes was followed by a special tribute to 9/11 victims and U.S. military members. The ACC PAC made a contribution to the Yellow Ribbon Fund that was accepted by Captain Dan Berchinski, who lost both legs in Afghanistan. The Yellow Ribbon Fund is an amazing group dedicated to helping injured service men and women and their families while they are in recovery and it was an honor to have someone who benefited from this group with us.

General Stanley McChrystal closed the evening with a thought-provoking speech on “Plywood Leadership.” General McChrystal talked about the ways that plywood by itself is a cheap, flimsy wood, but put together it is strong and can be used to build just about anything. He reminded the crowd that alone we are like single sheets of plywood, but working together and bringing our own unique strengths we can lead change.

As I participate in a panel this morning on the “State of Cardiology” with Dr. Holmes and ACC BOG Chair-Elect Dipti Itchhaporia, MD, FACC, I am reminded of just how accurate this analogy truly is. As we react to the changing health care environment we need to understand both the national and state issues that impact the care we provide to our patients. It is going to take all of us as individuals coming together to lead the nation in shaping health care policy. Like plywood we also need to remember to be flexible and open to having our ideas torn down or modified as we move forward.

See the video below for discussion of the meeting from Bo Walpole, MD, FACC, ACC PAC Chair, and Jerry Kennett, MD, FACC, ACC Advocacy Committee Chair.

[youtube:54-Rl-HdEnY]

The European Society of Cardiology kicks off its annual Congress on Sunday. The theme of the Congress is “controversial issues in cardiology.” The Hot Line & Clinical Trial Updates sessions address CV risk and complications, drug treatment, interventional and device treatments, heart rate and rhythm, and acute coronary syndromes. The trial we’ve been hearing the most about is ARISTOTLE (Efficacy and Safety of Apixaban Compared to Warfarin for Prevention of Stroke and Systemic Embolism in 18,202 Patients with Atrial Fibrillation), but I’m sure there will be other big news along the way. CardioSource Science & Quality Editor Chris Cannon, MD, FACC, has a video overview of the ESC science on CVN.

I’m looking forward to the trip to Paris. The ACC has many meetings planned with other cardiovascular societies, which we use to strengthen our relationships and build global bridges. We can never forget that cardiovascular disease isn’t just an American problem, or even a first world country problem. As the U.N. has noted of late, cardiovascular risk factors and disease are a huge problem in many developing nations as well. By building relationships worldwide, the ACC is better enabling the spread of science and education to improve patient care globally.

CardioSource is your source of coverage from ESC. Visit our meeting coverage page for trial summaries, slide sets, video coverage and comments from your colleagues. Follow @ACCinTouch on Twitter to know exactly when these are live and get direct links. Video coverage and photos will be available from our Facebook page as well.

Going to ESC? Visit the ACC Booth (E200) to learn about the latest international offerings, save 15% on education products purchased onsite and register for ACC.12 in Chicago. On Sunday, there will be a members-only meet-and-greet with ACC leadership (including me) at our stand. If interested, please RSVP.

Tort reform has significantly improved the medical liability environment in Mississippi, a new study in the journal Obstetrics and Gynecology concludes. I wrote not too long ago about the types of reforms that took place in my state in 2003. Previously published research has noted a drop in the number of malpractice claims by 91 percent between 2004 and 2009.

The new research supports these findings. The author examines data from the Medical Assurance Company of Mississippi (MACM), which is the largest medical liability insurer in the state, from years before and after the tort reform legislation was enacted. The author found that there was a steep drop in lawsuits against physicians insured by the company after implementation (a 227% drop across all specialties). Additionally, medical liability premiums have been reduced and refunded each year between 2006 and 2010.  The author concludes that the findings “indicate an association between the implementation of tort reform legislation in Mississippi and a sharp reduction in the number of medical negligence lawsuits.”

Part of the reforms that were implemented was a cap on non-economic damages. The constitutionality of this provision has been legally challenged (Sears v. Learmonth), and oral arguments were heard by the Mississippi Supreme Court in mid-June. The court has yet to make a decision, but it would seem (from my perspective) that the cap is an integral part of the success of the reforms. To remove it would be to remove a lot of progress that we’ve seen over the past five years in terms of medical liability insurance.

What do you think? Do you support caps on non-economic damages?