Among the panelists listening in on yesterday's presentation by Ken Thorpe of Emory University (Atlanta) at the second annual Chronic Care Congress was John Lewin, MD, CEO of the American College of Cardiology (ACC; Washington). Lewin briefly highlighted the role of cardiovascular medicine in cutting into the cost of chronic disease care, stating that "we have had a stunning 29% reduction in morbidity and mortality" over the past couple of decades, but the "costs are also stunning."
"The opportunities for continued progress are out there," Lewin promised, reminding attendees "cardiovascular care is 43% of Medicare costs." Consequently, any progress on heart diseases, which are somewhat related to lifestyle issues, would "make a big difference and possibly slow that growth curve."
He said that ACC started developing guidelines for cardiac care quality in the late 1980s with the American Heart Association (AHA; Dallas). "We began doing this a long time ago, and we have dozens of guidelines" and have started on treatment-appropriateness guidelines. "The problem is getting that into the point of care," which he said "has proven to be very daunting."
"Only about 54% of the time do we apply evidence-based medicine," Lewin said, acknowledging that some large cardiovascular practices hew to standards of care about 99% of the time. When the exceptional patient shows up, healthcare information technology will allow the cardiologist to explain any departures from the standard of care, Lewin said.
Lewin said that "in 2,400 U.S. hospitals, our registries are operating today" for all kinds of in-patient cardiac procedures. "What we're lacking is the outpatient registry systems," he said, but also stated that ACC will "roll out an outpatient registry system" next year, which will "change a lot of things."
The ACC chief tried to explain some of the reluctance among physicians to sign onto reform proposals. "Part of the reason that people push back is that they think those who are doing the measures have their own conflicts" of interest, he said, but many doctors are also worried about claims data that lack clinical data. He said that registries for cardiovascular disease that make use of clinical data that will make transparency "much more palatable."
"I think the fastest progress will be when we engage the professions" and the medical boards, "and build trust that we're using valid data," Lewin said. He mentioned the door-to-balloon (D2B) initiative for treatment of ST-elevated myocardial infarction. "The science tells us we have 90 minutes" to get a patient into the cath lab in order to avoid scarring of vital arteries, "but if you just measure the performance of the ER team" in isolation, it would appear that ER doctors perform very well. "But it doesn't matter if it's after 90 minutes ... and the patient didn't benefit."
A year ago, 70% of participating cardiac care centers were not getting to patients within the 90-minute window, but 85% of those centers are getting to the patient in that span. All it required was better information, Lewin said, and "didn't require payment or anything else."
"I think what's lacking is those major practices" have had a 10% reduction in income because of fewer admissions and imaging sessions. "It's hard to sell this across the country and say 'let's all do it and get paid 10% less.'"
— Mark McCarty, Washington Editor