In the last 10 to 15 years, technological advances have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist. Despite its unquestionable benefits, and because of earlier trends of increased utilization, medical imaging has been an area of focus by policymakers at the state and national level, as well as private payers; attempting to control who can perform imaging tests and where, through administrative protocols or state and federal laws as a means of reducing health care costs.

In my newest President’s Page in the Journal of the American College of Cardiology, I take a closer look at the past, present and future of cardiovascular imaging.  In particular I focus on what I consider to be a new imperative for medical imaging in light of the trend towards a more value-driven health care system and the fact that technology will continue to improve, enhancing our ability to diagnose and treat patients earlier. Novel technologies need to show a positive effect in patient care and outcome since ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

The ACC has developed several tools to address over- and under-use of procedures and technologies and is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care. 

Notably, appropriate use criteria (AUC) define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians with their imaging utilization, use of AUC also encourages the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

Further, the College’s “Imaging in FOCUS” (FOCUS) tool, a self-directed, quality improvement software and interactive community was developed to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike Radiology Benefit Managers (RBMs) which have been criticized by health care providers for delaying or denying unnecessary administrative burdens, basing decisions on inconsistent rules and practices and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities, and in some cases, incentives, for improved AUC adherence.

Along the line of appropriate use, this past spring the ACC released a list of “Five things Physicians and Patients Should Question” as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care. Three of the five recommendations were imaging related:

• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
  

As we continue to work towards implementing quality tools and efforts to address over- and under-use of procedures, I am proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.

This post was authored by William R. Lewis, MD, FACC, chair of the ACC’s shared decision making workgroup and a member of the patient centered care steering committee.

In the current health care system, patients have traditionally played relatively passive roles in their own health care. They have little knowledge of their disease(s) and treatment options, leaving them not only ill-prepared to communicate their needs and wishes to their health care team, but to implement health plans when necessary. They have primarily relied on their physician for the majority of their medical information and have essentially left medical decision making up to their doctor.

Shared decision-making is one concept that is garnering closer attention for its ability to potentially improve outcomes, while at the same time facilitate patient involvement in their own health care decisions. The purpose behind shared decision-making is not to persuade but to improve patient knowledge and to provide information about the disease and clarify the risks and benefits of treatment or screening options and their associated outcomes. An article published in the Annals of Internal Medicine found that “patients who ask questions, elicit treatment options, express opinions, and state preferences about treatments during office visits with physicians have measurably better health outcomes than patients who do not.”

Key to shared decision-making is the ability of patients to become acquainted with the options available, the risks of each option and the outcomes anticipated from treatment with each option. Cardiovascular disease is particularly well-suited for the devel¬opment of shared decision-making tools that enable doctors to provide patients with an understanding of their options. Guidelines and evidence-based therapies form a solid foundation from which evidence can be distilled and shared with patients. In addition, there are many validated risk models of outcomes that can be used to inform patients of the outcomes of previously treated patients.

Cardiovascular care also involves many treatments for which small differ¬ences in outcomes exist, allowing opportunities for patients’ values and perspectives to play larger roles in the decision making process. For example, while bare metal stents result in more frequent repeat procedures than drug eluting stents, they require fewer blood thinners. As a result, patients concerned about bleeding or bruising, or who can’t afford medications, may select a bare metal stent, even if a drug eluting stent might minimize the likelihood of repeat coronary blockage.

Challenges of implementing shared decision making include lack of physician time to fully inform patients on all aspects of their treatment options including incorporating their values into the equation. Even if they did, the information retained during a single physician visit is limited, especially when there is additional stress involved.

In addition, patients need to know that the information they are reading is unbiased and complete. The solution to these problems is for a trusted organization, like the ACC, to build a website which can act as an extension of the physician’s office. With a tool like this, patients could gain the knowledge needed to make a quality decision and use tools to incorporate their values into the decision and develop questions for their doctor. The next physician visit then becomes a high quality meeting.

Other challenges involve aligning the goals of insurance companies with those of patients. Additionally, physicians are often judged on “quality measures” which, if contradictory to a patient’s values, might jeopardize a physician’s standing on a particular measure. For instance, if a patient chooses to take a lower dose of a cholesterol-lowering drug to avoid symptoms of muscle pain, their physician may be penalized for failing to achieve that lower cholesterol level.

The ACC is currently piloting several projects, one of which is focused on the use of ACC’s Appropriate Use Criteria for Coronary Revascularization. The goal is to use the results of these pilots to ensure that future shared decision-making models best meet the needs of patients and their families.

Additionally, CardioSmart.org is an excellent source of medical information and is trusted by patients and their cardiologists. The ultimate goal will be to develop shared decision making tools and make them interactive on CardioSmart.

If implemented correctly, shared decision making tools have the ability to drastically improve outcomes and will strengthen the provider/patient relationship.

To read more about the ACC’s plans for shared decision making, visit CardioSource.org.

This post was authored by Mike Tempelhof, MD, cardiovascular disease fellow, Northwestern University Medical Center.

Beginning January 2013, the Affordable Care Act (ACA), the Budget Control Act of 2011, the Sustainable Growth Rate (SGR) formula and additional health care reform programs as proposed by the Center for Medicare and Medicaid Services (CMS) will be implemented. Unless modified, several provisions within these policies will have a detrimental effect on the quality of patient care, physician autonomy, reimbursement and the future of medicine in America. It is imperative that health care practitioners have an appreciation of the critical health care policy issues and how their implementation will limit our ability to continue to provide high-quality, high-value health care in the future.

If implemented, the SGR formula will cut Medicare physician payments by 28 percent starting Jan. 1, 2013, and budget sequestration targets as defined in the 2011 Budget Control Act will cut Medicare reimbursement annually by an additional 2 percent. The combined 30 percent reduction in physician reimbursement will limit critical investments in diagnostic and therapeutic equipment, ultimately threatening Medicare beneficiaries’ access to quality care. These reductions in Medicare funding will have a dramatic impact on Graduate Medical Education (GME) and research funding, which will likely reduce the number of trainee positions and de-incentivize trainees from pursing specialized medical training. At a time of growing physician shortages in conjunction with an aging population, these cuts would have a significant impact on the quality and availability of US health care in the future. Finally, sequestration is estimated to reduce federal funding of all scientific research by 8.4 percent. Any reduction to the already resource deficient medical research sector will further limit the innovation and development of new medical therapies that our medical system depends on. Such setbacks would stifle the recent gains made in the morbidity and mortality associated with cardiovascular disease.

The ACC is advocating to repeal the SGR, and stabilize sequestration payments until a new reimbursement system is in place. Juxtaposed to the current volume-based payment system, the ACC is strongly advocating for payment models that align payment incentives with evidence-based improvements in health care quality and outcomes. With a proactive approach to health care reform, the ACC has implemented quality improvement tools including clinical data base registries (NCDR, PINNACLE) and appropriate use criteria into clinical practice. This practice model affords the ACC the ability to hold cardiologists accountable for reaching benchmarks in standard of care. Evidence suggests that an evidence-based, incentive payment program modeled on similar quality improvement tools will improve the quality and cost-utility of health care in America. Therefore, the ACC strongly advocates for a quality and not volume-based payment system that aligns payment incentives with evidence-based medicine.

As our health care system evolves at this time of momentous reform, cardiologists and all practitioners must remain the patient’s strongest advocate by continuing to practice medicine with beneficence; delivering effective and efficient health care to all Americans. Collectively, we must act now to repeal the SGR and the sequestration cuts scheduled for January 2013. We must advocate for a meaningful medical liability reform and a sustainable payment system that incentivizes high-quality health care. Choosing not to act, would be the greatest risk to the future our patient’s lives and quality of their care.

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!

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

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

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

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

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

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

By William J. Oetgen, MD, MBA, FACC, senior vice president of Science and Quality of the ACC.

The ACC’s NCDR® is comprised of six hospital-based registries and one ambulatory registry, known as the PINNACLE Registry®. These registries measure the application of clinical guidelines in the real world setting – which helps us target national opportunities for quality improvement.

The PINNACLE Registry currently has 5.3 million patient encounter records covering 1.5 million unique patients, submitted from over 550 office locations nationwide. Of those patients, nearly 320,000 have atrial fibrillation (AFib), which is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes. Due to the growing need for the understanding of treatments and practice patterns for AFib, last year we announced the expansion of the PINNACLE Registry to include a new platform focusing on AFib, and include the next generation of anticoagulants coming online.

As new treatments are introduced to the market, assessing shifts in care patterns – and the impact of these shifts on patients – is a top clinical and research priority. The Registry can provide a means to monitor practice pattern changes over time while we rigorously assess current practice patterns and provide feedback reports to help providers evaluate and improve adherence to established guidelines and performance measures. We are also interested to see if these new medications coming online change the way doctors think about stroke prevention, which will ultimately help us close a long-standing quality gap in anticoagulation.

PINNACLE-AF is already yielding powerful clinical insights, and a study published last year in the American Journal of Cardiology used the PINNACLE Registry to look at treatment rates with warfarin in outpatients with nonvalvular AFib who were at moderate to high risk for stroke, as well as the extent of patient- and practice- level variation in warfarin use. The investigators found that warfarin treatment in AFib was suboptimal, with large variations in treatment observed across practice, and noted that their findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AFib and define a benchmark treatment rate before the introduction of newer anticoagulant agents.

Because global anticoagulation patterns, especially in emerging markets, are less understood, the ACC recently conducted a transnational survey of AFib patterns the U.S., U.K., Germany, Brazil, India, and China, in order to develop a broader understanding of the causes of gaps in anticoagulation. The October issue of CardioSource WorldNews details the results, so be on the lookout for your copy hitting newsstands in the coming weeks. As mentioned in a previous blog post, the College is currently in the early stages of developing a comprehensive initiative to address gaps in treatment and encourage compliance with guideline-recommended care.

The power of registries is immense, and we encourage the use of this quality improvement tool – all in the name of improving quality and outcomes for patients. Expect to see more data and research come to fruition in the coming months, especially in the topics related to kidney function and bleeding risk and events which are areas of clinical import with the next generation of anticoagulants.

This post is authored by Joe Allen, director of Translating Research into Practice at the ACC.

We have come a long way over the past few years with the implementation of Appropriate Use Criteria (AUC) and recognizing the value it provides for patient and physician decision making. The College is often credited by our members, payers, members of Congress and other stakeholders for taking proactive efforts to identify care with minimal benefit and provide tools to guide more appropriate, cost-effective care.

There is a positive outlook for AUC, as accreditation agencies, MOC Part IV, and Physician Quality Reporting System (PQRS) participation in 2013 all offer incentives in many states for use of AUC that can enhance the value of these efforts in a direct way.

Originally, AUC moved the discussion away from self-referral and allowed us to focus on quality with legislators avoiding several efforts to remove the Stark exemption. Congress has approved a specific demonstration project on AUC now being implemented by Centers for Medicare and Medicaid Services (CMS). This bill allowed us to offer an alternative to various payment cuts and avoid movement toward radiology benefits managers (RBMs) for now by CMS.

Several payers have begun discussions with ACC about implementing an alternative to RBMs through a FOCUS decision support tool and Quality Improvement program. Maryland and several other states were able to use AUC as a part of discussions about how standards should be set for review of percutaneous coronary intervention use.  Several states had their own efforts begun to develop their own state based standard and dropped theirs to adopt the ACC AUC.

Some RBMs, although not 100 percent concordant, have changed their policies for approval to more closely align with ACC over time. Some plans also have aligned coverage policies with the AUC, including expanding coverage in some cases for computed tomographic angiography. AUC are being used by the ACC Wisconsin and Florida Chapters to engage payers and the business community in a dialogue about how to stabilize and reform payment using AUC measures and shared decision making.

While there are instances in which AUC have been linked to review, authorization, and other policies that misuse the AUC for individual case review, these policies often preceded the AUC or would have occurred anyhow using more arbitrary criteria. Proactive adoption of AUC tools, review of AUC registry data, engagement in quality improvement efforts like FOCUS, and patient outreach like the Choosing Wisely Campaign can help obviate the need for such third party review in the future. The Criteria are never a perfect match for every patient and thus they should be used to inform and not dictate care for individual patients. AUC are best used to engage patients and practices in discussions of appropriate use, as a mirror to understand patient case mix over time, and to benchmark patient populations against others.

AUC can and will evolve in the future in response to member concerns about cookbook medicine, barriers to care, and misuse of the AUC.  However, the items above are just a few of the many ways AUC have been used to empower physicians and patients and counter the desire for third party regulation of clinical practice.  By doing so, the profession demonstrates the value of various procedures while helping all stakeholders engage in a dialogue on the value of various procedures for different patient populations.

The ACC’s 2012 Legislative Conference is coming up on Sept. 9-11. Also don’t miss the Annual Scientific Session of the American Society of Nuclear Cardiology (ASNC) held Sept. 6-9 in Baltimore, which will cover the latest advances in nuclear cardiology and multimodality imaging. Click here to register.

This post was authored by Eric Stecker, MD, FACC, member of the ACC’s Clinical Quality Committee.

Last week I made the argument that value (efficient provision of quality care) is a critical but under-recognized component of successful health care reform. Today we’ll briefly address several potential elements of health care reform that cardiologists should be facile with.

How do you measure quality care?
It is no longer sufficient to say we provide high quality care; we must demonstrate it objectively. Quality metrics remain imperfect but will improve over time and provide important information for patients and policymakers. Patients who see cardiovascular physicians participating in programs like ACC’s Imaging in FOCUS, and using registries such as those that fall under the ACC’s NCDR^® umbrella, can be assured the appropriateness and quality of their inpatient and outpatient care is being monitored and in most cases continuously improved.  The ACC’s clinical publications, including practice guidelines, consensus documents, appropriate use criteria, data standards and health policy statements are also excellent resources when it comes to guiding the most appropriate, evidence-based care.

Financial incentives for providers and patients
Medicare has initiated “value-based purchasing” programs to incentivize health care systems to improve quality. These programs could expand considerably in the future if proven successful. Individual health systems and insurers have experimented for many years with various financial programs to incentivize physicians to improve quality metrics or outcomes. The impact of these pay-for-performance programs has been mixed, but as pointed out by Ryan and Blustein, appropriately targeted and scaled monetary incentives are likely to have an impact.  Programs to incentivize patients by lowering or eliminating copayments (“Value-Based Insurance Design”) have proven very effective and are critical to aligning both the “supply” and “demand” aspects of high value care.

Managing individuals versus managing populations
Physicians are accustomed to caring for individual patients who engage them in the clinic, emergency department or procedural suite. However, by necessity the measure of a population’s health is made at the population level, not the individual level. Federal, state and local governments as well as businesses and employers have become more sophisticated and motivated to track aggregate health measures.  As a result cardiologists will become increasingly responsible for reporting and improving the health of all of the patients in their practice as a whole.  It will be important for cardiologists to gain the familiarity and skill to manage populations, but also retain sensitivity to issues that could harm individual patients so that policies and metrics can be modified accordingly.

If health care reform efforts are appropriately structured, cardiologists can thrive by focusing on efficient provision of high quality care for individuals and populations.  This will be best achieved when cardiologists align with and achieve leadership roles in health systems that focus on and incentivize quality systems of care.

By Eric Stecker, MD, FACC, member of the ACC’s Clinical Quality Committee 

The Supreme Court’s decision upholding most elements of the Affordable Care Act introduced certainty that major structural changes in health care will continue to rapidly evolve.  Most discussions of reform have centered on access to coverage, access to care and potential mechanisms of cost savings.  But this is only half of the story.

A critical factor differentiating the current round of health care reforms from the managed-care reforms of the 1990s is an emphasis on “value” across the spectrum of reform approaches.  High value medical services maximize quality while minimizing cost.  The ACC has led efforts among medical societies to structure the debate in Congress to emphasize quality considerations. 

As health care reforms are implemented at the national, state and local levels, responsibility for managing quality will fall on cardiologists working in concert with hospital and clinic administrators. In the past, cardiologists added significant monetary value for health systems by generating large patient encounter volumes with only crude measures of quality in a fee-for-service environment.  In the future, individual cardiologist’s importance for an organization will be defined using sophisticated measures of quality balanced with revenues and costs in a global payment (capitated) environment. To achieve this, cardiologists must identify which organizations can succeed in such an environment and work in leadership roles to help those organizations adapt as health care reform evolves. 

Anyone reading this blog who has experience with Medicare Meaningful Use could be skeptical regarding the accuracy and impact of quality improvement efforts.  Quality efforts in medicine remain in their infancy and are being rolled out across a fragmented industry that often has 1990s-era information technology infrastructure and entrenched organizational siloes. But many other complex industries have successfully approached quality improvement and some health care institutions such as Intermountain Health Care in Utah have already gained considerable traction and efficiency.

Stay tuned next Thursday for the sequel to this blog, which will address several specific aspects of health care reform that are important for cardiologists to gain familiarity with. 

A recent New York Times article reported that a hospital system in Florida is being investigated for possible overuse of cardiac procedures and percutaneous coronary interventions (PCI). Although the facts currently available to the public are limited, the mere possibility of inappropriate procedures with little regard for patient well-being evokes feelings of incredulity, shock, and dismay. The kind of clinical practice depicted in the article flies in the face of all of our ACC core values and mission—values that are wholeheartedly embraced by the vast majority of cardiologists. Unfortunately, unprofessional behavior can arise anywhere in society, through myriad circumstances. In medicine, however, even a single occurrence that puts a patient at risk is one too many. Beyond the effect on the individual patient, unprofessional behavior betrays patient trust and, when portrayed at the national level, sends shock waves into good patient-physician relationships.

The College has always emphasized professionalism and quality of care. As new discoveries are applied to practice and our knowledge increases, the ACC updates an extensive array of educational and quality improvement tools to help guide appropriate care: educational programs, comprehensive guideline and quality standards, Appropriate Use Criteria (AUC), the National Cardiovascular Data Registry (NCDR^®) and more. These tools provide a source of information to the health care team on the latest science and evidence-based medicine as well as a means to evaluate and measure quality parameters of the care rendered. Ultimately, the best care is accomplished in the context of an enduring relationship between a patient and the physician/health care team.

In recent months I’ve highlighted the importance of involving patients in their care and rekindling the patient-physician relationship. The ACC’s desire to encourage patients to take an active role in their own care is evidenced by resources such as CardioSmart. We have also invested a great deal of time and effort developing tools for physicians, such as the College’s AUC. The criteria define “when to do” and “how often to do” a given procedure based on a patient’s profile and evolving scientific evidence, combined with a physician’s seasoned judgment (click here to view a recent blog series on AUC, and check out the current issue of Cardiology magazine for a story on the purpose behind AUC).  Over the past few years, these documents have tackled a variety of diagnostic procedures and therapeutic interventions. An AUC document on coronary revascularization was published in 2009 and more recently, one on cardiac catheterization.

An independent program, Accreditation for Cardiovascular Excellence (ACE), sponsored by the ACC and Society of Cardiovascular Angiography and Interventions (SCAI), was started a few years ago to provide accreditation and continuing quality improvement services for cardiac catheterization, PCI and carotid artery stenting, as well as external peer review for coronary angiography and appropriate use. Through its external cath lab evaluation, the program can assess cath lab quality, appropriateness and angiogram film reviews to evaluate accuracy of coronary assessments.

As ACC Past President Ralph Brindis, MD, MACC, said in an ACC in Touch Blog post on the overutilization issue in 2011, “how we react to this overutilization storm will determine our future.”   The ACC’s Maryland Chapter, who at that time was faced with a similar situation, was exemplary in the way they tackled their own crisis and worked tirelessly with SCAI and state officials to advocate effectively for oversight and guidelines for cath labs performing PCI.

A medical professional carries two primary levels of responsibility: toward our profession and toward our patients. The majority of physicians are caring, competent and good-natured. Incidents that cast doubt on our collective integrity may distort our practices and relationships in numerous ways, but they also present an opportunity for each of us to reaffirm, in the strongest terms, our fundamental ethical commitments.