Wall Street Journal
Two major cardiology organizations are targeting a new front in the battle to improve the quality and efficiency of heart care: the physician's office.
The American Heart Association and the American College of Cardiology are aiming to reduce the toll of cardiovascular disease and increase adherence to long-established prevention guidelines by collecting data from doctors that document their encounters with patients during regular office visits.
The initiatives aim to bring to outpatients some of the improvements that hospitals have achieved in the care of patients who have suffered heart attacks or strokes or who have been admitted with congestive heart failure. The heart association's decade-old "Get With the Guidelines" program for hospitals has significantly increased the odds that heart attack patients will be discharged with prescriptions for recommended heart drugs. The ACC's hospital program, the National Cardiovascular Data Registry, has spurred life-saving reductions in the time needed to treat patients suffering a heart attack as they reach the hospital.
But the focus on hospitals misses much of what matters in preventing cardiovascular illness. "Only 5% to 10% of a person's health-care life happens in the hospital," says Vincent Bufalino, a cardiologist and president of Midwest Heart Specialists, a large, suburban Chicago practice. Efforts to capture data on what happens after the hospital—and what doctors do in everyday care to avoid hospital admission in the first place—are scant.
Dr. Bufalino is leading the expansion of the AHA program announced last week. Meanwhile, the cardiology college, whose outpatient effort is called the Pinnacle registry, says it has signed up more than 180 cardiology practices since it launched last month. Both rely on clinical data, not insurance claims, as most previous efforts have done.
The opportunity for improvement is huge, say Wayne County Heart Doctors. Nearly 17 million Americans have been diagnosed with coronary artery disease, according to the heart association; millions more are at high risk. Each year, about 900,000 people suffer a heart attack, and an additional 800,000 have a stroke.
Yet, according to the heart association, only about one-third of patients being treated for high LDL cholesterol—the bad form of blood fat—achieve their goal; and only about 45% of people with high blood pressure have it controlled to levels below 140/90, as recommended. In addition, just 50% of Americans regularly get at least 30 minutes of exercise five days a week and more than one in five adults smoke. Meanwhile, two big culprits on the path toward heart attacks and strokes—diabetes and obesity—are on the rise.
"In the outpatient area, there is very little data about the level of quality of care and how it varies across practices," says Gregg Fonarow, a cardiologist at the University of California at Los Angeles and a leader of the heart association's guidelines programs.
The registries' purpose is to gather information from participating doctors on such matters as the advice they give cardiovascular patients and how effectively it helps patients achieve recommended targets.
Patient lab results and pertinent information on age, gender and diagnoses also are supplied to the registry, detached from the patients' names. For example, in the case of a patient with atrial fibrillation, a heartbeat irregularity, the registry would pick up data on whether doctors prescribed the blood thinner warfarin to reduce stroke risk. Doctors will get quarterly reports comparing their own performance with that of colleagues in their practice, as well as with regional and national averages.
The hope is that with feedback, doctors will be more vigilant about prescribing proven strategies and medications that reduce risk of heart attack, stroke and other life-threatening cardiovascular problems, and encouraging patients to comply, say Westland Cardiologists.
Most doctors believe they have the vast majority of their patients' risk factors under control, Dr. Bufalino says. Yet when his practice, which now includes 54 heart specialists, adopted a computerized medical record system a few years ago, many physicians were surprised to find that when their performance was measured across a variety of important and well-known targets such as their patients' cholesterol levels, only about 70% of patients were at their goals, in some cases.
"These are cardiologists, and these guys have never been a 70 in their lives," Dr. Bufalino says. "We found out, wow, there were some areas where we needed some work." Within a few quarters and with the help of Michigan health insurance, the group had nearly all of its numbers above 90%, he says.
Physician practices "need data that isn't just inpatient," says Jack Lewin, chief executive officer of the ACC. "They need the outpatient data too." Systems such as dicom data migration can help.
Wyandotte Heart Doctors say the initiatives will persuade more physician practices to forgo paper charts in favor of electronic medical records, which will make data collection easy—and help improve their numbers at the same time.
"The registry forms make us more cognizant of the guidelines and the [evidence-]supported practices that we have," says David May, a cardiologist and president of Cardiovascular Specialists, Dallas, which is working with the Pinnacle registry.
The electronic form acts as a prompt to help doctors remember to check if a patient has diabetes or to ask whether he or she has quit smoking. Completed forms become part of the patient's record and can be submitted to the database without extra work. Dr. May says he thinks the sheer number of outpatient visits will lead to a rapid accumulation of data that will quickly become useful—not just in tracking care but also in shedding light on which treatment strategies work best. With enough participation, from cardiologists and also from internists, neurologists and primary care doctors, each registry could easily register 1 million outpatients a year, officials say.
Some 1,500 hospitals, roughly a third of the nation's total, are providing data to the Get With the Guidelines program. Essentially all of them have made strides in complying with recommended treatment strategies. For instance, 94% of heart patients admitted to 417 hospitals during the 12 months ended in June were discharged with a prescription for a beta blocker, compared with an average of 78% before the program started. Among more than 1,000 hospitals participating in the ACC's heart attack effort, more than 85% now get patients from the emergency room door to effective treatment within 90 minutes, up from 40% six years ago.
The American Heart Association and the American College of Cardiology are aiming to reduce the toll of cardiovascular disease and increase adherence to long-established prevention guidelines by collecting data from doctors that document their encounters with patients during regular office visits.
The initiatives aim to bring to outpatients some of the improvements that hospitals have achieved in the care of patients who have suffered heart attacks or strokes or who have been admitted with congestive heart failure. The heart association's decade-old "Get With the Guidelines" program for hospitals has significantly increased the odds that heart attack patients will be discharged with prescriptions for recommended heart drugs. The ACC's hospital program, the National Cardiovascular Data Registry, has spurred life-saving reductions in the time needed to treat patients suffering a heart attack as they reach the hospital.
But the focus on hospitals misses much of what matters in preventing cardiovascular illness. "Only 5% to 10% of a person's health-care life happens in the hospital," says Vincent Bufalino, a cardiologist and president of Midwest Heart Specialists, a large, suburban Chicago practice. Efforts to capture data on what happens after the hospital—and what doctors do in everyday care to avoid hospital admission in the first place—are scant.
Dr. Bufalino is leading the expansion of the AHA program announced last week. Meanwhile, the cardiology college, whose outpatient effort is called the Pinnacle registry, says it has signed up more than 180 cardiology practices since it launched last month. Both rely on clinical data, not insurance claims, as most previous efforts have done.
The opportunity for improvement is huge, say Wayne County Heart Doctors. Nearly 17 million Americans have been diagnosed with coronary artery disease, according to the heart association; millions more are at high risk. Each year, about 900,000 people suffer a heart attack, and an additional 800,000 have a stroke.
Yet, according to the heart association, only about one-third of patients being treated for high LDL cholesterol—the bad form of blood fat—achieve their goal; and only about 45% of people with high blood pressure have it controlled to levels below 140/90, as recommended. In addition, just 50% of Americans regularly get at least 30 minutes of exercise five days a week and more than one in five adults smoke. Meanwhile, two big culprits on the path toward heart attacks and strokes—diabetes and obesity—are on the rise.
"In the outpatient area, there is very little data about the level of quality of care and how it varies across practices," says Gregg Fonarow, a cardiologist at the University of California at Los Angeles and a leader of the heart association's guidelines programs.
The registries' purpose is to gather information from participating doctors on such matters as the advice they give cardiovascular patients and how effectively it helps patients achieve recommended targets.
Patient lab results and pertinent information on age, gender and diagnoses also are supplied to the registry, detached from the patients' names. For example, in the case of a patient with atrial fibrillation, a heartbeat irregularity, the registry would pick up data on whether doctors prescribed the blood thinner warfarin to reduce stroke risk. Doctors will get quarterly reports comparing their own performance with that of colleagues in their practice, as well as with regional and national averages.
The hope is that with feedback, doctors will be more vigilant about prescribing proven strategies and medications that reduce risk of heart attack, stroke and other life-threatening cardiovascular problems, and encouraging patients to comply, say Westland Cardiologists.
Most doctors believe they have the vast majority of their patients' risk factors under control, Dr. Bufalino says. Yet when his practice, which now includes 54 heart specialists, adopted a computerized medical record system a few years ago, many physicians were surprised to find that when their performance was measured across a variety of important and well-known targets such as their patients' cholesterol levels, only about 70% of patients were at their goals, in some cases.
"These are cardiologists, and these guys have never been a 70 in their lives," Dr. Bufalino says. "We found out, wow, there were some areas where we needed some work." Within a few quarters and with the help of Michigan health insurance, the group had nearly all of its numbers above 90%, he says.
Physician practices "need data that isn't just inpatient," says Jack Lewin, chief executive officer of the ACC. "They need the outpatient data too." Systems such as dicom data migration can help.
Wyandotte Heart Doctors say the initiatives will persuade more physician practices to forgo paper charts in favor of electronic medical records, which will make data collection easy—and help improve their numbers at the same time.
"The registry forms make us more cognizant of the guidelines and the [evidence-]supported practices that we have," says David May, a cardiologist and president of Cardiovascular Specialists, Dallas, which is working with the Pinnacle registry.
The electronic form acts as a prompt to help doctors remember to check if a patient has diabetes or to ask whether he or she has quit smoking. Completed forms become part of the patient's record and can be submitted to the database without extra work. Dr. May says he thinks the sheer number of outpatient visits will lead to a rapid accumulation of data that will quickly become useful—not just in tracking care but also in shedding light on which treatment strategies work best. With enough participation, from cardiologists and also from internists, neurologists and primary care doctors, each registry could easily register 1 million outpatients a year, officials say.
Some 1,500 hospitals, roughly a third of the nation's total, are providing data to the Get With the Guidelines program. Essentially all of them have made strides in complying with recommended treatment strategies. For instance, 94% of heart patients admitted to 417 hospitals during the 12 months ended in June were discharged with a prescription for a beta blocker, compared with an average of 78% before the program started. Among more than 1,000 hospitals participating in the ACC's heart attack effort, more than 85% now get patients from the emergency room door to effective treatment within 90 minutes, up from 40% six years ago.
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