As we enter 2008, many diverse influences are acting on cardiologists, tugging us in multiple directions. First, we still do not know whether we will be the object of a 10% reimbursement reduction from Medicare. In addition, there may be additional cuts for imaging, as the costs for such have increased greatly over the past few years and are not sustainable at the current annual increase in volume. We also recognize that the cost of healthcare in the US ($6,100 per capita in 2004) is now almost twice that in most other Western countries. The work carried out by Drs Elliot Fisher and Jack Wennberg at Dartmouth also shows that there is substantial variability in the utilization of cardiovascular procedures but no apparent associated differences in outcome.
Reimbursement reductions are of great concern as we are all trying to increase the number of quality measures that are obtained in both the hospital setting and outpatient practices. Every hospital now has a dashboard of quality indicators and a team working to improve results, and the bar continues to rise each year. This is a good thing for both our patients and our profession. We are also fortunate in cardiology that we have many clinical trials upon which to base best practice. However, we are poorly prepared to gather these indicators. Few of us have electronic medical records, and even those that do lack quality measures embedded within them to aid in the process. Many of us therefore have ‘quality teams’ in our hospitals that read and abstract medical records and create separate databases for reporting results to many different agencies. In the office, some of us use paper records or our own primitive databases to attempt to make sure we deliver the right treatments to the right patients at every encounter, as well as having measures to prove to others that we have done so. Although my institution has had an electronic medical record for over 15 years, we had difficulty participating in the current Physician Quality Reporting Initiative (PQRI) project aimed at measuring our individual performance regarding patients with a history of myocardial infarction or congestive heart failure. The cost of reprogramming our electronic record, however, would have been more than the additional reimbursement received for participating, so we needed to resort to a more primitive collection instrument. If reimbursement declines, how can we afford to move this agenda of improving quality forwards at the pace it demands? I am a firm believer that any exercise in this area needs measures. Talking about improving quality is not the same as actually doing something about it.
So, what does all of this mean to us and our patients? What should be our professional and societal priorities? To begin with, we all need to support the agenda of universal coverage to reduce the episodic and random care often received by the uninsured. However, universal care does not have to be single-payer care—there are many good things about our current insurance system and to abandon a system that works for most would not be prudent. Second, we must be leaders in efforts to have a single individual identifier for all of our patients. We also have to push for government funding to incentivize the adoption of electronic health records, and our societies, such as the American College of Cardiology (ACC), need to work on defining the common variables required to track quality and patient satisfaction that must be standard in all electronic records.
Now for the frontline issues: you and I must each define small, doable quality improvement efforts for our practices—this requires not just being a passive participant, but instead being a leader and change agent.
This issue of US Cardiovascular Disease contains information about exciting new therapies for patients with arrhythmias and structural heart disease. Cardiology has set the template for how to adequately evaluate the safety and efficacy of new therapeutics. We must now lead others in demonstrating how to implement and measure both appropriate and quality care down to the individual level. It is the right thing to do, and our patients are counting on it.