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“No matter how successful we are in obtaining state-of-the-art
knowledge when we need it, cardiac care will never be
optimal until we also transform, via new technology,
our health care delivery system,” said ACC President
George A. Beller, MD, during yesterday’s Presidential
Plenary Session.
While
commending 50 years of advances that have revolutionized
the delivery of cardiovascular care, including novel
new therapies and sophisticated technologies, Dr. Beller
also warned that another revolution is needed if the
gap between average care and best care is to be closed.
Specifically, he called for an electronic revolution
in the culture of medicine—one that would allow physicians
to increase adherence to clinical practice guidelines,
to access medical knowledge anywhere and anytime, and
to eliminate over-reliance on paper charts.
“Although
the space industry has integrated its technology systems
to send a spaceship to an asteroid 117 million miles
from Earth, the medical profession is still documenting
its patient information in multiple charts stored in
multiple health care settings with no technological
linkages among them,” he said.
The
sheer volume of knowledge expansion has magnified this
concern, noted. “Physicians have an improved understanding
of the biologic mechanisms of cardiovascular disease
but, with medical science and technology advancing at
such a rapid pace, they can be overwhelmed with volumes
of medical literature and uncertainty about the effectiveness
of alternative diagnostic and treatment strategies,”
he explained.
Adding
to this frustration are increasing patient workloads,
treatment restrictions imposed by managed care organizations,
hours wasted writing redundant information in paper
charts, and myriad bureaucratic matters that limit the
time physicians can spend with their patients and keep
up with the literature.
As
a consequence, said Dr. Beller, evidence-based practice
guidelines derived from clinical research have not been
optimally translated to the everyday care of cardiac
patients. He expressed concern that quality of care
is suffering because proven interventions are underused
or are not being efficiently applied into practice.
“The treatment of patients with acute myocardial infarction
(MI) is a perfect example,” he said. Although the ACC/American
Heart Association (AHA) clinical practice guidelines
describe quality indicators for the care of these patients,
studies have shown that the actual application of these
indicators varies widely across the country. The administration
of beta blockers illustrates the point.
“Great
variability among medical centers exists regarding the
percentage of patients receiving beta blockers at discharge
for acute MI,” Dr. Beller said. He cited a survey of
a group of hospitals in Michigan that found prescriptions
for beta blockers at discharge ranged from 42 percent
to 70 percent.
“If
our MI guidelines were more effectively and uniformly
applied to practice, the numbers would range from 80
to 90 percent,” he said.
Dr. Beller also referenced studies related to heart
failure, cholesterol management, and lipid lowering.
In addition, he cited a Duke University study suggesting
that 80,000 additional lives could be saved each year
if MI patients received “ideal” care with proven effective
therapies.
Studies
like these are fueling many quality-of-care initiatives
in the United States, and the ACC is leading the way.
“We
are already making some progress,” he said. “Some medical
organizations have turned to decision-support tools
for implementing practice guidelines.”
The
University of California–Los Angeles Cardiovascular
Hospitalization Atherosclerosis Management Program (CHAMP)
has achieved substantial improvements by implementing
a variety of tools to improve the use of aspirin, beta
blockers, angiotensin-converting enzyme inhibitors,
and statin drugs for post-MI patients.
Similarly,
the ACC’s Guidelines Applied in Practice—or GAP—project
was designed to improve adherence to guidelines in patients
with an acute MI. For this project, 10 hospitals in
Michigan used a toolkit, including pocket guides, standing
orders, chart stickers, information for patients, grand
rounds presentations, and reporting of hospital performance
data.
The
ACC is also collaborating with the American Heart Association
(AHA) to develop a comprehensive, Web-based Internet
site that will enable physicians to obtain information
at the point of care. During his address, Dr. Beller
showed a video clip of KDE, or the “Knowledge Delivery
Enterprise,” as it is currently envisioned. In the video,
two physicians use a handheld device to confirm medication
decisions for a diabetic patient who has been admitted
following recurrent chest pain. Outside the patient’s
hospital room, they accessed via the wireless device
the section of the ACC/AHA unstable angina guideline
that specifically deals with beta-blocker therapy in
insulin-requiring diabetics with an acute coronary syndrome.
Finally,
Dr. Beller urged ACC 2001 attendees to play a role in
revolutionizing the delivery of health care. “I urge
you to go back to your own practices and to the hospitals
where you work, committed to improving the quality of
cardiovascular care by embracing new technology,” he
encouraged. “We need an electronic revolution in medicine
to meet the challenges of our future.”
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