PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF ACADEMIC
CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER 26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Task
Force 1: Clinical Care
Henry
DeMots, MD, FACC, Co-Chair, Gilbert H. Mudge,
Jr., MD, FACC, Co-Chair
OPERATIONAL
CHANGES
There
are a number of operational changes that might be considered
by academic cardiovascular programs.
Hospitalists
The
evolution of hospitalists may in fact improve the efficiency
and use of patient resources. Full-time individuals
committed to inpatient care should result in reduced
length of stay and hospital costs. However, the evolution
of academic hospitalists will require substantial restructuring
of traditional academic/clinical roles. The early involvement
of an attending physician who can direct care in a way
that moves the diagnostic workup in the most expeditious
manner, and institutes therapy and discharges the patient
at the earliest reasonable moment is essential. This
requires that alternative strategies must be created
for training programs which benefit from a more leisurely
hospital course.
Academic
medical centers can provide care with low mortality
and with acceptable lengths of stay when consideration
is given to the severity of illness found in patients
at an academic medical center (12).
In many instances the costs of this care are still higher
than in the community. These higher costs could be due
to higher utilization or other inefficiencies or cost
shifting from the educational mission and from the care
of indigent patients. To the extent that they are the
former they must be addressed.
Advantages
of a Product Line Structure
Restructuring
the delivery of cardiovascular services into a "product
line" consistent with its academic mission and
goals represents one mechanism for advancing the academic
cardiovascular division toward a more competitive position.
Furthermore, product line development links cardiologists
with the most appropriate academic colleagues: those
specializing in cardiothoracic surgery, pediatrics,
interventional radiology and cardiac anesthesia. Such
a structure might have the following characteristics
and advantages:
- Strengthened
fiscal and operational ties among physician groups
that provide related clinical service, in a structure
that provides incentive for revenue-seeking and cost-cutting
behavior.
- Alignment
of incentives between hospital and physicians.
- Facilitation
of initiatives toward maximizing quality while minimizing
cost.
- Facilitation
of specialty-oriented risk contracting, serving to
network the academic cardiovascular division and community
providers by adding value through initiatives to a)
reduce cost internally and b) implement medical and
disease management programs system-wide.
- Increased
use of clinical care teams, including nonphysician
health care extenders.
Product
Standardization
Product
standardization is difficult to implement, because specialists
tend to cling to their favorite device or implement.
In many instances the faculty members may have participated
in the development of a device or performed crucial
research to validate or improve a device or drug. When
a hospital is forced to stock numerous brands of the
same device it raises inventory costs for the hospital
and it prevents the hospital from participating fully
in volume discounts or in buying consortia that reduce
costs. Academic cardiologists will be faced by requests
from hospital administrators to use predominately a
single brand of pacemaker, defibrillator or angioplasty
catheter to offer their services to an adequate volume
of patients. In some instances their choices will be
limited by a buying consortium that is remote from the
institution. Therefore, regular meetings of a group
of cardiologists to present patient cases for discussion
to develop common practice patterns will be of importance.
An example would be weekly conferences for the interventionalists
in the catheterization laboratory. They may decide to
develop consistent strategies for a given stenosis morphology,
a specified IIb-IIIa antagonist only for angiographically
identifiable clot, and they may choose a single "workhorse"
balloon (from a single vendor) for the most straightforward
stenoses. Such an approach is preferable to having such
decisions imposed by a hospital administrator and can
drive down operational expenses.
Clinical
Pathways
Practice
patterns can be standardized by using clinical pathways,
practice guidelines and algorithms. The design and implementation
of these tools is difficult and time-consuming but,
if properly performed, can produce improvements in outcomes
and reduction of cost. Resistance is often encountered
by condemning these efforts as "cookbook medicine."
They should never be used as an excuse for failing to
meet the special needs of a patient or providing appropriate
variation in care when the clinical situation demands
it. Appropriate use, however, provides reminders for
the implementation of care, a time-conserving set of
standard orders that can be modified to fit the clinical
situation and a template from which variation can be
recorded. The greatest value of pathway development
may accrue from the act of development in which experts
and other providers come together to research current
practice patterns in the hospital and agree on a uniform
approach based on best evidence. Usually these groups
can agree on a best approach, but when legitimate disagreements
occur it provides a basis to compare the financial and
clinical outcomes of patients treated in different ways.
In
cardiology there are a number of conditions that are
suitable for pathway development such as chest pain,
myocardial infarction, pacer implantation or pulse generator
change and coronary angiography for stable angina. Other
conditions such as congestive heart failure will be
more difficult, because the clinical course of a patient
may be driven by a number of comorbidities that are
found in these patients. In many complex conditions
found in an academic medical center the best guidance
may come from practice guidelines or algorithms which
apply branching logic at key decision points rather
than the linear course provided by a clinical pathway.
Communication
of the pathways and guidelines is a challenge for academic
medical centers because of the inclusion of fellows
and residents in the care model. Geographical concentration
of like patients allows nurses to become important promoters
and educators of the residents in standard procedures.
Storing materials on easily accessible and user-friendly
electronic media or web pages complete with references,
tables, diagrams and preprinted orders promotes use
of the path and offers an educational resource for the
trainee. Limiting the number of faculty attending physicians
to a small expert group who perform attending tasks
regularly rather than assigning the attending task to
a large group for one month per year favors standardization
of practice and use of these tools. Finally, the use
of "hospitalists" and physician extenders
will also be important for accomplishing these goals.
Redesign
Teaching Models
None
of these efforts will be successful in producing the
required results if the teaching model that has been
used for decades continues without modification. In
its most extreme form residents were permitted to evaluate
and treat the patient with input sometime during the
course of the admission from an attending physician
who concentrated on the interesting pathophysiologic
mechanisms and left the details of care to the residents.
In many instances decisions with major cost implications
have been made before the attending physician intervenes.
The resident, who feels more pressure to be complete
than to be cost-effective, orders more tests than necessary
and relies on the laboratory examination rather than
the history and physical examination to establish the
diagnosis.
Whenever
possible the attending physician must be expert in caring
for the condition with which the patient presents. Relying
on consultations in an academic medical center predisposes
to the use of more resources and longer lengths of stay.
Residency review committees which favor general wards
for medical patients rather than specialty wards should
reexamine their position. Patients whose reason for
admission is cardiovascular disease should be cared
for by cardiologists and patients with other illnesses
should not be cared for by cardiologists in the academic
setting, nor should cardiologists carry teaching responsibilities
on noncardiovascular services.
Trainees
are not and should not be faced with the primary responsibility
of maintaining the fiscal integrity of the academic
medical center. They should, however, be taught to practice
medicine in a cost-effective manner, for that will be
their obligation for the remainder of their careers.
It is the obligation of their teachers to provide this
education. Most important, many referring physicians
want to communicate exclusively with the attending subspecialist
and not with trainees. The commitment of the academic
faculty to excellence in all the nuances of effective
clinical care and communication must be identical to
their commitment to excellence in research.
Disease
Management
Disease
management and medical management services: rationale.
The future viability and competitiveness of academic
cardiovascular divisions will depend on offering value
to the community, particularly as services continue
to shift to the community and community-based cardiologists
assume more and more of the financial risk for health
care. Academic cardiovascular divisions continue to
have unique expertise, facilities and stature that place
them in an excellent position to add value through development
and implementation of disease management and medical
management services.
Medical
management is an interactive process through which a
medical manager interfaces with clinicians providing
care, reviews the medical advisability and necessity
of anticipated services, screens for service duplication
and offers cost-effective alternatives. It has proven
highly effective in reducing health care costs, but
requires sophisticated information networking and processing.
Disease management is a methodology designed to increase
cost-effectiveness of care associated with a specific
disease entity.
There
is a substantial opportunity to network with community
providers by offering subspecialty risk carve outs to
primary care providers receiving capitation. Academically
based cardiologists can offer such carve outs alone
or in collaboration with community-based cardiologists.
Medical management and disease management programs represent
the principal strategies through which academic programs
can help to manage down the cost for the community provider,
while maintaining or improving quality of care.
Vying
for the delivery of disease management services.
The academic medical center will be competing with a
number of different contenders vying for the delivery
of disease management services. These include commercial
vendors, Health Maintenance Organizations, nonacademic
and for-profit delivery systems and community-based
management services organizations. The academic delivery
system is in an excellent position to compete for delivery
of disease management services, if it can a) leverage
the expertise of its specialty services, particularly
cardiology and b) forge the proper relationship with
community-based providers.
The
expertise and credibility of academic cardiovascular
divisions create an immediate advantage over commercial
vendors in the development and delivery of disease management
services. Furthermore, the academic cardiovascular division
need not make an immediate direct profit on the disease
management services that it develops. Rather, it can:
a) leverage the value of the product toward network
development and b) derive value in the long term through
managing down the costs of its own patients and those
of its networked community physicians. Therefore, in
contrast to commercial vendors, the academic cardiovascular
division is positioned to deliver a less costly and
more cost-effective product.
The
challenge is for the academic medical center and the
academic cardiovascular division to overcome the obstacles
that impede them from benefiting from their natural
advantages. These obstacles include the sluggish, unresponsive
nature of the typical academic bureaucracy and reluctance
to invest without demonstrable short-term gain. It is
essential for the leadership of academic cardiovascular
divisions to meet this challenge.
Marketing
Strategies of Academic Medical Centers
Academic
medical centers are in a unique position to develop
and enhance their capabilities in conventional marketing
strategies. A marketing and planning department of an
academic medical center may be an integral part of its
success. This will contribute to an understanding of
the marketplace and marketplace issues, and represents
an opportunity to study, and then shift market share
into academic programs.
Although
contrary to the original purpose of academic medical
centers, the marketing department of an academic medical
center brings a new perspective to its mission by focusing
on activities which reflect priorities and strengths,
building value and loyalty among target markets. In
such marketing efforts, the image of quality and integrity
can be maintained, supporting the role of the academic
medical center. Such marketing activity can include:
- Market
analysis and market research, to make customized market
information available to administrative and clinical
management.
- Development
of regular reports on referring physician information,
by demographics, number of referrals and so forth.
- Addressing
the responsiveness of academic medical centers to
customer preferences by internal reorganization, improving
the often unfriendly customer service attitudes that
prevail within academic medical centers in responding
to referring physicians' needs.
Telemedicine
An
academic marketing and planning commitment also entails
a commitment to the evolution of telemedicine. Telemedicine
capabilities expand the access of academic medical centers
to referring physicians and consumers. Interactive marketing
techniques, including the Internet, CD and telemedicine
capabilities, represent unique opportunities for academic
medical centers in the future.
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