Today the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health Information Technology (IT) released an important report, Transforming Health Care: The Role of Health IT, which outlines recommendations for the most effective use of health IT to achieve the triple aim through new models of care delivery and payment reform. I am a member of the task force – we’ve been working on this plan for over a year.

Following the authorization of up to $30 billion to support health IT under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the report was created to identify real-world examples and best practices that facilitate coordinated, accountable and patient-centered care; and to make recommendations for ensuring that current health IT efforts support delivery system and payment models shown to improve quality and reduce costs in health care, in ways that best utilize scarce public and private resources.

I joined the Bipartisan Policy Center’s co-chairs, former Senators Tom Daschle (D-S.D.) and Bill Frist, MD (R-Tenn.), and former Governors Ted Strickland and John Engler, at a policy briefing featuring prominent leaders in the field to release the report and discuss how to make it happen.

The report identifies key gaps and barriers to achieving widespread adoption of health IT, including: misaligned incentives; a lack of health information exchange; limited level of consumer engagement using electronic tools; limited levels of Electronic Health Record (EHR) adoption; privacy and security concerns; and multiple federal priorities that all require focus and attention.

The task force also identified several goals and recommendations to overcome these barriers including: aligning incentives and payment with higher quality, more cost-effective health care, accelerating health information exchange efforts, accelerating and supporting engagement of consumers using electronic tools, expanding education and implementation assistance, addressing concerns about privacy and security, and further aligning federal health care and health IT programs. Incidentally, the task force has had a kind of brilliant idea on how to get beyond the unique patient identifier controversy – which is politically stalled. We suggest developing “patient tracking” systems to manage patients securely over the continuum.

After the press event was over I had lunch with Daschle, Frist, Strickland, and Engler to talk further about implementation ideas and how the ACC can help move this. The good news is most of the field of cardiology and the ACC with its quality tools and programs are already working to implement most of these recommendations, but as the health care landscape changes and the cost of health care increases, it is important now more than ever to adopt new models of care delivery.

For more information, visit www.CardioSource.org/HealthIT.

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.

The ACC has joined the ABIM Foundation’s Choosing Wisely^TM campaign along with eight other leading medical specialty societies and Consumer Reports to help physicians, patients and other health care stakeholders think and talk about overuse or misuse of health care resources in the U.S.

According to the Organization for Economic Co-operation and Development, decade after decade the U.S. spends more money per capita on health care than any other developed country with little progress in quality or value to show for it. The Congressional Budget Office estimates that up to 30 percent of care delivered in the U.S. goes toward unnecessary tests, procedures, medical appointments, hospital stays and other services that may not improve health. Coupled with the fact that the Centers for Medicare & Medicaid Services estimates U.S. health care spending will reach $4.3 trillion by 2019, it is clear that our current health care system is unsustainable and in need of an intervention.

As part of our longstanding effort to play an active role in addressing the quality of care, the College is joining the campaign to encourage open communication about the risks, costs and benefits of tests and treatments so that our patients can be informed partners when making important decisions about their care. We believe that partnerships between patients and health care providers are crucial to achieving better outcomes and lowering health care costs. From our CardioSmart^TM National Care Initiative, aimed at helping patients better understand and/or prevent heart disease, to our state-of-art educational programing and decision-support tools that place evidence-based guidelines at a clinician’s fingertips, we have been and will continue to be committed to ensuring the most appropriate, cost-effective care.

Over the course of the multi-year campaign, we will be working with the ABIM Foundation to identify and reduce waste in the health care system. With the medications, devices and imaging technology available to cardiologists today, we can save and improve the lives of patients who would not have had a chance just 15 years ago, but we also have a responsibility to use these powerful tools effectively and make sure we are choosing wisely.

To learn more about the Choosing Wisely campaign visit, www.ChoosingWisely.org.

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.

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.

Although a significant amount of data exists in relation to early clinical outcomes after transcatheter aortic valve replacement (TAVR), there are few data on outcomes beyond one year. As such, a new study released today in the Journal of the American College of Cardiology (JACC) provides a much-needed look at the long-term outcomes after TAVR in high-risk patients with severe aortic stenosis.  

In 2007, the UK established a national registry – the United Kingdom Transcatheter Aortic Valve Implantation Registry – to coordinate and monitor the practice and dissemination of all TAVR procedures, regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term. The new study, based on data from this registry from January 2007 through December 2009, found that, overall, midterm to long-term survival after TAVR was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.   

Specifically, survival at 30 days was 92.9 percent, followed by 78.6 percent at one year and 73.7 percent at two years. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction _30 percent), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model. 

A corresponding editorial commentary, suggests that “all our efforts to pursue the development of this technique should aim at improving patient selection both by a dedicated medicosurgical team and by improving procedural performance through careful training and improvement in technology, and also by adequately evaluating randomized studies as well as good-quality registries that represent real life and are a necessary complement to the former.”  

As TAVR moves forward in the U.S., we need to look closely at these results from abroad and learn from them. You can be sure that as the American College of Cardiology and the Society for Thoracic Surgeons move forward with their joint TVT Registry, the lessons learned from the UK experience will be critical as we attempt to harmonize data elements from around the world. In a recent JACC President’s Page I marveled out how the process and the need for measuring things has occupied a central role in human history, and how nowhere in the medical field is measurement more important than when new therapeutic strategies are developed. Data from registries like the one in the UK and the one being developed by us and STS in the U.S. are essential to the appropriate use of transformational technologies like TAVR.

This post is authored by Immediate Past-President Ralph Brindis, MD, MACC. 

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Health Affairs, along with co-sponsors the ABIM Foundation, the California HealthCare Foundation and the Foundation for Informed Medical Decision Making, hosted an event on Oct. 19 focused on discussions around Medicare savings ideas for the federal budget “Super Committee.”  Implantation of ICDs was one of the hot-topic areas in a session on Medicare coverage policy, with speakers highlighting overuse of the procedure among physicians as a major contributor to Medicare costs. Suggestions were made to require prior authorization as a means of reducing Medicare costs.  

It is important to note that the science surrounding ICD implantation is constantly evolving but guidelines and Medicare coverage policy take more time. That being said, it is true that recent studies have indicated a wide variation in ICD implantation. A study published earlier this year in the Journal of the American Medical Association (JAMA) found that ICD implantations were not in accordance with practice guidelines in 22.5% of patients, most commonly because of newly diagnosed heart failure (62%) or an MI within 40 days (37%). The risks of in-hospital death and complications were significantly lower when the ICD implant was consistent with practice guidelines (0.18% and 2.4%, respectively) than when it was not (0.57% and 3.2%, respectively). 

While these statistics are sobering, the ACC and the Heart Rhythm Society (HRS) already have programs and processes in place to turn the tide, so to speak, and ensure providers are appropriately using this procedure on the right patients. For one, the Centers for Medicare and Medicaid Services, has mandated that every U.S. hospital that implants ICDs for the purpose of primary prevention of sudden cardiac death participate in the ACC and HRS ICD Registry. Over the last year we have made great strides in enhancing this registry to allow for the connection of longitudinal Medicare administrative data of ICD patient outcomes -- such as mortality and repeat hospitalizations -- with our in-patient hospital registry data. This longitudinal follow-up assessment will extend our knowledge base substantially. In addition, the electrophysiology community is not only closely examining practice patterns but working more closely with staff responsible for entering ICD Registry data to ensure that the data quality is at the highest level. The ACC and HRS are also encouraging the practice of shared decision making, particularly in the elderly, for the use of ICD implants for prevention of sudden cardiac death. Recent studies actually show substantial underuse of ICD therapy for prevention of sudden cardiac death (SCD).  

Unlike prior authorization, which may reduce costs but not necessarily ensure appropriate patient care and/or change provider behavior, registry use can do all three by ensuring greater adherence to practice guidelines, providing insight into practice patterns and also extending overall physician knowledge and evidence base. At the end of the day, ICDs are effective in stopping life-threatening arrhythmias and enhancing survival and overall quality of care. We believe that we are moving in the right direction to ensure cost-savings in the Medicare system and welcome the discussion on how to do this even better.

This post is authored by Immediate Past-President Ralph Brindis, MD, MACC.

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Today, the Journal of the American Medical Association (JAMA) released a study, co-authored by Harlan M. Krumholz, MD, SM, FACC, on the significant downward trend in hospitalization for Medicare beneficiaries with heart failure (HF). Since 2008, HF hospitalizations decreased by an impressive 30 percent. There has also been a 30 percent reduction in morbidity and mortality from cardiovascular disease in the last decade and acute myocardial infarction rates were down by 23 percent from 2002 to 2007. These results highlight how far we have come in cardiovascular treatment and care and open the door for future innovation.

Over 5.8 million Americans suffered from HF in 2006 alone, making it the number one cause of hospitalization and rehospitalization for aging adults. Additionally, we are all too familiar with the excessive amount of resources that HF eats up, pushing cost of care limits during a time when Medicare spending has run rampant.  Given these circumstances, HF is an area that greatly benefits from these and future reductions.  

However, the recent JAMA findings also point to areas that need improvement in the way of HF. The rate of hospitalization for black men declined at a lower rate than the national average and a substantial variation by state remains.  Additionally, the one-year mortality rate was only reduced slightly over the ten-year period, remaining high at 29.6 percent. This sobering statistic reminds us of how much more work needs to be done in applying our evidence-based medicine to this vulnerable cohort of patients and of the research that is still needed to alter the fairly dismal prognosis of this lethal disease.

These findings follow on the heels of an August paper in Circulation that unveiled stunning improvements in door-to-balloon (D2B) times.  The study found that D2B times were reduced by over 30 percent, from 96 minutes in 2005 to 64 minutes in 2010. The percent of patients treated within 90 minutes increased from 44 percent to 91 percent over those same years. Even more remarkably, the percent of patients treated within 75 minutes increased from 27 percent to 70 percent.

The importance of programs focused on increasing quality and decreasing health care costs is confirmed by these studies. The ACC remains dedicated to appropriate use criteria, guidelines and initiatives such as Hospital to Home (H2H) and the D2B Alliance and is leading the way to further reductions in hospitalizations and rehospitalizations across the country.  

We should all be proud to be a part of this win for our patients and the institution of cardiology!

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For some time now, the lack of continuous care for congenital heart disease (CHD) patients who are transitioning from the pediatric to adult care settings has been a concern for adult cardiology practices.  Although many CHD patients require specialized care, many more still end up in adult cardiology clinics. I experienced two scenarios when seeing CHD patients in my nonurban practice; a basic layman’s history is provided or several storage boxes of records are presented that must be reviewed and summarized.  One is inadequate; the other is cumbersome and subject to errors of oversight.  A complete, organized patient history is difficult to come by and ultimately can threaten the quality of care as these cases continue to increase in volume. Enhancing collaboration between a coordinated care team, to include congenital heart specialists, and CHD patients would open the doors to consistent and efficient treatment.

I have come up with the acronym DOORRS to sum up the essential information patients should easily be able to provide their cardiologist upon an initial visit. 

D  Initial Diagnosis 

O  Operations Chronologically with institution and surgeon 

O  All Operative Notes 

R  Most Recent diagnostic studies and results 

R  Recommended follow up 

S  Special considerations or previous complicating factors unique to this patient 

I have received positive and encouraging feedback from colleagues and the College on this issue, which affects us all but to which there is no easy solution.  I know the ACC’s Adult Congenital and Pediatric Cardiology (ACPC) Section is on top of this issue and is dedicated to collaborating with patient advocacy groups, such as the Adult Congenital Heart Association, on promoting professional and patient resources for CHD patient care.  For the College’s part, several ACC chapters have supported past National Congenital Heart Lobby Day activities, which have focused primarily on advocating for national CHD surveillance tools.  

The Congenital Heart Futures Act (included in the ACA) authorizes establishing a population-based surveillance registry (through the CDC's existing National Center on Birth Defects and Disabilities). However, the funding for this expansion has not been appropriated.  

To compound the issues related to care of the CHD patients, limited outcomes data regarding CHD treatment is available. The NCDR’s IMPACT Registry™ (IMproving Pediatric and Adult Congenital Treatment) has been established to assess the prevalence, demographics, management and outcomes of pediatric and adult patients with CHDs who are undergoing diagnostic catheterizations and catheter-based interventions. The collection and analysis of this data facilitates performance measurement, benchmarking and quality improvement initiatives.  The IMPACT Registry, which has collected over 3,000 patient records so far, will provide significant contributions to the knowledge base and outcomes associated with CHD. While this is exciting and a big step forward, gaps in data collection and outcomes reporting remain in other CHD care settings, most notably the ambulatory setting.  

I look forward to hearing your thoughts on ensuring congenital heart disease patients receive appropriate care as they age and move out of the pediatric setting.  What have you done in your practice to increase efficiency for adult CHD patients? What resources and educational tools would be helpful to your care of adult CHD patients?  

Make sure to check out the Nov./Dec. issue of Cardiology Magazine for an article on ACHD.

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.