Author + information
- James T. Dove, MD, FACC, ACC President⁎,
- Harlan T. Krumholz, MD, FACC and
- John E. Brush, MD, FACC
- ↵⁎Address correspondence to:
James T. Dove, MD, FACC, American College of Cardiology, c/o Padmini G. Rajagopal-Moorehead, 2400 N Street NW, Washington, DC 20037
It is easy for physicians to be discouraged in today’s medical environment. Physicians strive to deliver quality care under increasing pressure to prove its quality. Tactics cloaked as being quality improvement are often designed to cut cost, reduce choices for patients, and promote the economic interest of payers and government.
The practice of medicine is being squeezed between increasing overhead cost and decreasing reimbursement. Everyone is demanding higher quality yet there is a lack of universal agreement on what quality is, how it should be measured, how to ensure its delivery, and who should cover the cost. System redesign is needed to meet these challenges.
We Are the Antidote
The antidote is for the profession to take charge of the quality agenda and become the voice of patients in guiding positive change. Aspiring to improve quality of care should be as fundamental to our profession as is keeping up with the latest medical evidence. Our practices should be continuously examined, evaluated, and elevated to eliminate wasted effort in promoting ever better patient outcomes. We should be invigorated by sharing practices that increase the efficiency of our work and the effectiveness of our action. Leadership to follow this course should come from within our ranks. The resolve to move forward can be fostered by a community spirit committed to the best interests of patients and supported by the strongest science.
Reform Is Coming
Policymakers, insurers, purchasers, patients, and physicians recognize that health care at a societal level is very costly. A national debate for health care reform is gaining momentum. Most current presidential candidates recognize the current trends in health care cannot continue. Fundamental restructuring is necessary. Current efforts that focus on dollars and volume do not promote quality.
As a professional organization, we have an obligation to represent the broader interest of patients in the health care debate. By focusing on quality, we can insist on improving value for our patients and resist efforts of those who simply seek care that is cheap. There are those who believe that a professional society is too conflicted to be involved in this debate. The facts are that the American College of Cardiology (ACC) is best suited to play an integral role in health care reform.
Over the last several decades we have seen a new field emerge that has provided us with important observations on quality of care, new methods for analysis, and new techniques to stimulate quality improvement. The ACC has helped develop that field. Many of our members continue to make major contributions as the field advances. In the national debate, our organization should be an educational resource on what quality of care means and how it can be measured and assured.
ACC and Cardiology Taking the Lead
The cardiology community is well ahead of other specialties in defining and achieving high-quality care. We have witnessed enormous advances in research and technology. These advances have shown true value by extending the lives of our patients. Clinical research has given us a solid evidence base that has enabled the ACC, with the American Heart Association (AHA) and other organizations, to develop clinical practice guidelines. Guidelines as national consensus documents have become the foundation on which we have built an impressive quality improvement infrastructure.
Guidelines allow us as a professional community to come together, sift through the emerging evidence, and circulate recommendations to create a high standard of care. Once the standards are set, we can build on the guidelines by producing performance measures. Performance measures can then be used to measure our quality, set achievable benchmarks, and compare performance over time. The ACC, in partnership with the AHA and others, has been a leader in developing performance measures.
Setting standards and goals is not enough. We must have methods to measure progress through data collection. Data registries allow practitioners to close the loop on quality by measuring our own performance and linking that to outcomes. The National Cardiovascular Data Registry, with standard data definitions has eased the burden of data collection, while enabling benchmarking of performance. The relationship of performance measures to outcomes can be hypothesis generating for future research and further improvement.
Addressing quality and embracing change is not easy. We have sponsored quality improvement initiatives Guidelines Applied to Practice (GAP), Door-to-Balloon (D2B): an Alliance for Quality, and Take Action—to help practitioners understand quality improvement and to facilitate their efforts. One focus of the D2B campaign has been engaging the College’s chapters in quality improvement by creating a closer link with the front-line practitioners who care for patients with ST-segment elevation myocardial infarction (STEMI). The Take Action Initiative will increase the impact of the National Cardiovascular Data Registry’s new Action Data Registry in improving the care of patients with acute coronary syndrome.
We have developed appropriateness criteria to help practitioners assure that imaging procedures are justified. Advanced imaging technology has created an opportunity to extend the care that we deliver, but appropriate patient selection will maximize the value of new imaging techniques.
Focusing the Year on Quality
Although we have accomplished a great deal, there is more to do and we are working to make this the “year of quality” at the ACC. At ACC.08, we are creating a Quality Spotlight Session and a quality track throughout the meeting. We are working to “turbocharge” guideline development through greater use of information technology in making guidelines timely and relevant. We are extending the D2B project by planning an effort D2R (door to reperfusion), which will reach out to hospitals that treat STEMI patients. We are developing new registries for outpatient longitudinal data collection, imaging, and other quality improvement initiatives. We are working with the AHA on their “Mission Lifeline” initiative to increase awareness, responsiveness, and access for STEMI patients. We are working with payers to use appropriateness criteria and align the incentives for quality improvement. On many fronts we are continuing to move the quality agenda forward.
For these efforts to reach their full potential, it will require the adoption of the electronic health record and electronic performance reminder tools. There are many extraordinary examples of quality-of-care initiatives among our members’ practices. We need to collate and disseminate these best practice models.
Despite all of our accomplishments in a quality field, we cannot rest on our laurels and let others dominate the debate on health care reform. Although our accomplishments speak for themselves, we will need to assert ourselves into the debate on behalf of our patients and our profession. We have an individual duty to our patients as professionals and we have a collective organizational duty to strongly speak for quality that is based on science that seeks to achieve the best possible outcome for patients.
We will see a lively health care debate on the shape and structure of health care reform. It will be important to ensure that those changes are positive and do not disrupt our ability to provide excellent care. Health care reform should focus on quality-appropriate care with a cost structure that promotes the best care. The current health care reform debate focuses on cost with little regard to quality. As we move forward, we will ultimately succeed if we remain true to sound scientific principles and if we remain focused on what is in the best interest of our patients. Comprehensive health care reform focused on quality is likely to cost more than the current system but it would be a system unlike any other healthcare system in the world—uniquely American. The ACC has always been there to help its members strive for excellence. In the debate on health care reform we must remember that excellence in patient care is what matters.
- American College of Cardiology Foundation