Cardiac Care 5-Year
Horizon Project Report
 

Executive Summary

   

  • Over the next 5 years, basic science and technologic developments will continue to have a significant effect on the direction of cardiac services, as will increasing demand from aging "baby boomers." New concerns are developing regarding the appropriateness of care, how best to reduce variability in health care outcomes and how to evaluate quality of care.
  • Unless there is a process for measuring the outcomes of cardiac care, regardless of clinical pathway, it will be very difficult to assess either the quality or the appropriateness of care being provided.
  • Clinical practice will change direction frequently as new technologies affect which types of physicians are responsible for diagnosis and treatment decisions, the decision tree followed by those physicians, the techniques and equipment available to them, the demand for new non-invasive techniques, etc. State agencies will need to use foresight tempered by appropriate clinical judgment to craft regulations that facilitate desired outcomes.
  • A significant development in cardiac care has been the increasing isolation of invasive cardiology from the other specialties involved in treating coronary artery disease (CAD). The isolation of cardiology might be the most important organizational development in cardiovascular care over the last decade because of its effect on clinical pathways for CAD patients - for example, its effect on which patients are referred for cardiac surgery. If it continues, this isolation will have a significant effect on how clinical and technologic advances actually affect care in the future. Advances in medical therapies, catheter-based diagnostic and treatment procedures and cardiac surgery might all prove less effective in reducing mortality and morbidity from CAD if the choice of which therapies are applied to a particular patient is made not on the basis of a "gold standard" and consensus on what benefits that patient most, but instead is a function almost exclusively of who is making the decision: a non-invasive cardiologist, an interventional cardiologist, or a cardiac surgeon. The best course of action for both patients and physicians would be to encourage joint decision making among specialists diagnosing and treating CAD patients.
  • One potential new technology with important organizational as well as clinical ramifications is coronary MRI. There are strong differences of opinion on the potential of coronary MRI to displace angiography but if, as some expect, it eventually becomes the principal diagnostic tool for coronary artery disease, two important issues will arise. First will be resistance from cardiologists to the de-coupling of angiography and angioplasty if MRI replaces coronary angiography as the diagnostic imaging method of choice. It might well be that the adoption of MRI, even if it is the equal of or superior to angiography (in addition to being non-invasive) could be slowed by the current close relationship of the catheter-based diagnostic and treatment procedures, as represented by the increase in volume of "look-see" procedures. A second issue will be the potential for a "turf war" over control of the diagnostic procedure, since MRI is traditionally the responsibility of radiologists and it has the potential, if it replaces coronary angiography, (currently the responsibility of cardiologists) to reshape the clinical decision tree for diagnosing coronary artery disease.
  • One area on which there was unanimity regarding appropriate use and the emerging importance of a catheter-based treatment modality was primary angioplasty for AMI patients. Instead of appropriateness, the issues here seem to be the need for cardiac surgery back-up, what minimum volumes or other proxy measures are appropriate safeguards of quality, and whether this procedure should be regionalized in high-volume facilities to serve population centers or allowed to develop in as many facilities as possible.
  • There is nothing in future projections to suggest that the trend to treat older patients surgically, including the eldest of the elderly, will change over the next 5 years. In fact, the percentage of such patients presenting for surgery has the potential to create a subspecialty of geriatric cardiac surgery.
  • There is some possibility that surgeons might begin to develop skills in catheter-based therapeutic interventions, to position themselves as "full service" cardiac care providers.
  • With population-based rates of CABG surgery across the country steady or declining, it might be unwise to allow the proliferation of new programs in markets where volumes and reimbursement will not be sufficient to support them. Existing inner city cardiac surgery programs depend on the payer mix they enjoy by attracting Medicare and commercially-insured patients from the suburbs. If new suburban programs took those paying patients away, the financial viability of inner-city programs would be threatened, and with it the access to services for minority populations who we know, from a growing body of research, have problems gaining access to tertiary cardiac care.
  • Both patient and physician education are paramount in dealing with uncertainties in the quality and appropriateness of current treatment for CAD, and with the rate at which new therapies are developed and disseminated throughout the health care system.
  • In the absence of other information, volume is still the best proxy measure for quality in cardiac procedures. Even though it is a proxy measure and not a direct indicator of quality, the use of volume standards for quality is increasing as more public - and private-sector purchasers are attracted to the availability of information and the ease with which the information can be communicated and understood.
  • New Jersey's academic medical centers (AMCs) play a relatively minor role (compared to neighboring states such as New York and Pennsylvania) in providing clinical leadership within the state. This means that new techniques, procedures and equipment do not have an informal but widely accepted portal into the state's practice community where they can first be properly assessed before spreading throughout the hospital industry - something that does not happen in community hospitals, even those with teaching programs.
  • Although this report focuses on hospital-based cardiac services, it would be an oversight to omit mention of the significant role that prevention strategies can play in the reduction of the burden of heart disease on New Jerseyans.

Report Cover

 

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