ACC NEWS
President's page: The appropriate cardiologist: Responsible stewardship in a golden era of cardiology
Michael J. Wolk, MD, FACC, President, American College of Cardiology*,
Eric Peterson, MD, MPH, FACC*,
Ralph Brindis, MD, MPH, FACC* and
Kim Eagle, MD, FACC*
* Send correspondence to: Dr. Michael J. Wolk, 520 East 72nd Street, New York, New York 10021
"Appropriate" cardiovascular (CV) care used to be solely in the headof the beholder. Before the advent of CV diagnostic breakthroughs, physicians relied on intuition and "last case result" to sort out individual treatment. Universal best practices based on evidence were a dream.
But now we are operating in a wondrous era. We have developed excellent CV patient care protocols that capitalize on captured collective data and outcomes, in the belief that we can learn from each other without stumbling through the rocks ourselves.In the past 20 years, we have seen:
- • deaths due to acute myocardial infarction reduced by one-half (1);
- • echocardiography, nuclear perfusion imaging, and cardiac catheterization become virtually ubiquitous;
- • computed tomography (CT) and magnetic resonance imaging (MRI) added to our arsenal to help us better understandcardiac pathophysiology;
- • percutaneous coronary intervention (PCI) become durable and definitive therapy; and
- • congestive heart failure yielding to evolutionary life-saving medical therapy combined with innovative use of implantable cardioverter defibrillators, resynchronization pacing therapy, and left ventricular assist devices.
These advances—translated into wonderful care guidelines—come just in time, as the "perfect storm" of aging baby boomers and the growing epidemics of obesity and diabetes gather on the horizon. Yet, consistently applying this clinically helpful power "on the ground" is easier said than done. Study after study documents wide and pervasive gaps between what our College upholds as state-of-the-art, evidence-based care and the care actually delivered in clinical practice (1–6). This "voltage drop" from discovery to application threatens to deprive patients of the benefits of new treatments. We know that the American College of Cardiology/American Heart Association (ACC/AHA) guidelines are not being used as widely as would be optimal. Physicians report either a lack of guidelines awareness or, at times, even apathy in guidelines implementation as they juggle their fast-paced and highly pressured everyday practices (7,8). Regardless of the cause, the impact of underutilization of guidelines for effective care is real for patients, as evidenced in studies showingan increasingly strong relationship between use of evidence-based care practices and patient outcomes (9,10).
While underuse of proven therapies is a concern, so is the potential for overuse or misuse when services are ordered for reasons that are not in the best interest of patients. Unwarranted tests and therapies can unduly escalate costs to patients and society. The documentation on the overuse of tests or interventions in cardiology has been challenging because criteria for appropriateness are inherently subjective.Nevertheless, over the past decade there has been a marked increase in the growth of CV imaging services, particularly in the U.S.
Since 1996, the number of cardiac imaging procedures billed to Medicare has grown 9% per year, to 10.6 million in 2002—or more than one imaging test ordered for every four Medicare beneficiaries. Interpreting such data can be risky,however, because they do not necessarily mean that overuse has occurred. Instead, they may in fact demonstrate better care for the exploding population of patients with CV disease.
Other Medicare data, as well as the Dartmouth Atlas of Cardiovascular Health Care, show a striking variability in the use of cardiac procedures from one part of the U.S. to another. Paradoxically, the data also link states having higher Medicare spending to lower quality of care (11).Studies also have found that physicians trained in a given technique tend to order that procedure more often. True, this could indicate a potential for "self-referral," but it could also simply show that patients are being referred specifically to physicians with a known expertise.Finally, explicit reviews of indications for coronary revascularization procedures have shown relatively modest rates of obviously inappropriate care (12,13).
Another issue that threatens to tarnish this golden era of cardiology is the burgeoning cost of new technology. Medical innovations cannot improve patient care if society cannot afford to use them. This might seem to be a Malthusean prediction for future generations, butthe scarcity of financial resources is at hand. A recent editorial in the New England Journal of Medicine calculates that implantable defibrillators, left ventricular assist devices, and drug-eluting stents could add billions to an already strapped national budget (14). To stave off explicit rationing in medicine, cardiologists must strive to be mindful of medical costs. We must intentionally choose innovative modalities that will give us the most "bang for the buck." Stated simply, we need to ensure that every procedure we order for our patients is backed by solid, value-added care evidence.
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The role of the ACC in promoting quality
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The revised mission of the ACC, adopted by the Board of Trustees in 2003, is to advocate for optimal patient care through the development and application of clinical practice guidelines. The major change was to place more emphasis onproactive efforts to bring evidence-based applications to the bedside. Our College is dedicated to providing CV clinicians with both the knowledge and tools necessary to deliver high-quality, safe, and effective care. To this end, the ACC is expanding and improving its quality enhancement processes by:
- • developing, in partnership with the AHA, cardiovascular data standards. These sets of standardized nomenclature and data elements will facilitate communication inside and outside the profession.
- • creating ACC/AHA guidelines that provide recommendations for optimal treatment for most CV illnesses, based on the best available clinical evidence.
- • frequently updating these guidelines and making them Internet accessible via www.acc.org, with executive summaries published in JACC.
- • proactively planning to embed guidelines into electronic medical records and into admission and discharge sheets to help us adhere daily to optimal care.
- • developing, in partnership with the AHA, explicit "performance measure" metrics from the clinical guidelines. These quality indicators will define instances in which care should—or should not—be delivered.
- • undertaking efforts to systematically measure and feed back CV care patterns to individual centers and providers. For example, the ACC-National Cardiovascular Data Registry (NCDR) catheterization and PCI registry enables hospitals to assess their catheterization lab quality by benchmarking their results against national standards. Currently, 495 hospitals participate in the registry, with more than 650,000 PCI procedures recorded (15,16).
- • developing specific system tools to improve delivery of CV care with the recently launched web-based CathKit and our Guidelines Applied in Practice (GAP) initiative. Indeed, process of care and tool use can improve quality-of-care indicators (12,17).
- • working with health care stakeholders to formulate innovative "pay for quality" initiatives, such as the recent launch of the Virginia ACC Chapter Quality Hospital Improvement Project that makes use of ACC-NCDR data.
Beyond these efforts to ensure broader use of effective care, the College also has begun to tackle the challenging issue of procedural appropriateness directly, addressing potential overuse of diagnostic and therapeutic modalities. Appropriateness is clearly connected to clinical guidelines but has a level of complexity and detail that goes beyond their recommendations. It is the ACC's attempt to define "what to do," "when to do," and "how often to do" in the context of local care environments combined with patient and family preferences and values. Ideally, criteria for appropriatenesswould encompass "cost effective" and "benefit versus risk" analysis of available care alternatives. They should be simple, reliable, valid, and transparent. Answers to the overuse question will come through the aggressive promotion of patient care protocols and recommendations and by providing physicians with meaningful feedback on their care practices relative to national benchmarks.
Some may not see the importance of the College's efforts to address appropriateness. Some might argue that explicit guideline performance indicators can be divisive and prefer we not enter this arena. However, if we do not lead in this effort, others may set criteria that may not be wise either for us as physicians or for our patients.
Without this critically important initiative, we may become vulnerable to assertive third-party payers who may usurp our role and deny us our rightful voice in determining the best way to treat our patients. Attempts already are being made to control the rapid rise in costs for imaging and other services. Pre-certification, carve-outs of providers, reduction in payment, and mandatory lab accreditation have been instituted.
The College recognizes that failure to follow evidence-based best practices leads to less-than-optimal patient benefit through inefficient and ineffective use of resources. Although we have emphasized areas for improvement in patient care, we also recognize that the vast majority of cardiologists provide high-quality care. Our goal is to author and adopt the very best evidence-based guidelines and quality indicators in order to provide our members with as much guidance and as many tools necessary to help them in their daily practice. If we do not work collectively toward this result, others surely will step in and fill the void by monitoring our conduct, using cost-based algorithms rather than quality as the predominant driver. There is no rationale for permitting others to assume this function in our place.It is the role of our profession to self-monitor, critically review, and advance our concept of quality.We must be good stewards of the gifts—and responsibilities—that have been entrusted to us.
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Footnotes
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* Throughout his Presidential year, Dr. Wolk will present ideas important to College members, in collaboration with key ACC leaders and staff. 
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References
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1. Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) initiative JAMA 2002;287:1269-1276.[Abstract/Free Full Text]
2. Rogers WJ, Canto JG, Lambrew CT, et al. Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999: the National Registry of Myocardial Infarction-1, -2 and -3 J Am Coll Cardiol 2000;36:2056-2063.[Abstract/Free Full Text]
3. Steg PG, Goldberg RJ, Gore JM, et al. GRACE Investigators Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE) Am J Cardiol 2002;90:358-363.[CrossRef][Medline]
4. Roe MT, Ohman EM, Pollack Jr CV, et al. Changing the model of care for patients with acute coronary syndromes Am Heart J 2003;146:605-612.[CrossRef][Medline]
5. Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial infarction: results from the cooperative cardiovascular project JAMA 1998;279:1351-1357.[Abstract/Free Full Text]
6. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States N Engl J Med 2003;348:2635-2645.[Abstract/Free Full Text]
7. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement JAMA 1999;282:1458-1465.[Abstract/Free Full Text]
8. Califf RM, Peterson ED, Gibbons RJ, et al. Integrating quality into the cycle of therapeutic development J Am Coll Cardiol 2002;40:1895-1901.[Abstract/Free Full Text]
9. Peterson ED, Parsons LS, Pollack C, Newby LK, Littrell KA. Variation in AMI care processes across 1,085 U.S. hospitals and its association with hospital mortality rates Circulation 2002;106:II722.
10. Peterson ED, Roe MT, Lytle BL, Newby LK, Fraulo ES, Gibler WB, Ohman EM. The association between care and outcomes in patients with acute coronary syndrome: national results from CRUSADE(abstr) J Am Coll Cardiol 2004;43(Suppl A):406A.
11. Wennberg JE, Wennberg D. The Dartmouth atlas of cardiovascular health care. Am Coll Cardiol, Soc. Thor Surg, ME Med Ctr, and Ctr Eval Clin Sci-Dartmouth Med School, 2000..
12. Mehta RH, Montoye CK, Faul J, et al. Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use: the American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw expansion J Am Coll Cardiol 2004;43:2166-2173.[Abstract/Free Full Text]
13. Leape LL, Weissman JS, Schneider EC, Piana RN, Gatsonis C, Epstein AM. Adherence to practice guidelines: the role of specialty society guidelines Am Heart J 2003;145:19-26.[CrossRef][Medline]
14. Gillick MR. Medicare coverage for technological innovations—time for new criteria N Engl J Med 2004;350:2199-2203.[Free Full Text]
15. Anderson HV. A contemporary overview of percutaneous coronary interventions: the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) J Am Coll Cardiol 2002;39:1096-1103.[Abstract/Free Full Text]
16. Brindis RG, Fitzgerald S, Anderson HV, et al. The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR): building a national clinical data repository J Am Coll Cardiol 2001;37:2240-2245.[Free Full Text]
17. Dehmer GJ, Hirshfeld JW, Oetgen WJ, et al. CathKit: improving quality in the cardiac catheterization laboratory J Am Coll Card 2004;43:893-899.[Free Full Text]
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