American College of Cardiology

FLETCHER ET AL., 33RD BETHESDA CONFERENCE: Preventive Cardiology: How Can We Do Better?
J Am Coll Cardiol 2002;40:4:579-651

BETHESDA CONFERENCE REPORT
33rd Bethesda Conference: Preventive Cardiology: How Can We Do Better?

Gerald F. Fletcher, MD, FACC, Conference Co-Chair

Summary Recommendations—
Preventive Cardiology: How Can We Do Better?

Cardiovascular disease (CVD) prevention can play a dynamic and important role in combating the leading cause of disability and death in America today. The summary recommendations that follow reflect the detailed and resourceful work of the writing groups and participants of the American College of Cardiology (ACC) 33rd Bethesda Conference—Preventive Cardiology: How Can We Do Better? These recommendations highlight the research, funding, policy, and clinical-educational changes needed to effectively implement preventive cardiology in the existing health care system of America.

Research

• Support intensive research to determine which strategies are most effective in promoting healthy lifestyles and adherence to CVD prevention in the community, in health care organizations, by providers, and by patients in a variety of clinical care settings.
• Promote studies that translate efficacy research into effectiveness trials and community-based demonstration projects in ethnically, geographically, and economically diverse groups. These studies should examine the biases, selection problems, unrealistic intervention intensity, and sequence effects that result in study outcomes failing to translate into real-world outcomes.
• Give a higher priority to research into understanding the barriers associated with adherence to CVD prevention guidelines at the community, health care provider, and
  patient levels.
• Conduct studies of various risk-factor interventions, including the manner in which interventions should be sequenced with regard to the psychosocial state of the patient (e.g., stage of change and motivation).
• Gain increased understanding of the extent to which patient and provider beliefs, expectations, and preferences influence provider-patient communication.
• Place special focus on vulnerable groups, including the economically disadvantaged, the elderly, and ethnic minorities.
• Encourage the development and testing of creative, nontraditional ways to promote healthy life styles—such as social marketing.
• Study the efficacy of policy and legal changes in reducing CVD risk factors (e.g., tobacco taxes and mandated school-based physical education programs).
• Increase research regarding the cost-effectiveness of CVD prevention.
• Conduct further research to resolve measurement issues. This applies not only to measurement of medicationtaking behavior but also to the ability to monitor and verify behavior in other areas such as smoking, diet, and physical activity.
• Develop research proposals that aim to survey the attitudes, beliefs, and behavioral changes of practicing cardiologists and those in training that are used to foster the development of plans for comprehensive cardiovascular (CV) training program change.
• Reinitiate the Preventive Cardiology Academic Awards to foster preventive research, training, and clinical care for the current generation.

Funding

• Increase funding support for federal agencies, including the Centers for Disease Control (CDC), the Agency for Healthcare Research and Quality, and the National Institutes of Health to promote research and implementation of CVD prevention.
• Structure reimbursement to compensate physicians and other health care providers (nurses, physiologists, physician assistants, and health educators under physician supervision) for the delivery of preventive cardiology services; increase the reimbursement for these allied health care services, motivating physicians to set up programs that are revenue generating rather than cost-neutral or revenue losing.
• Reduce the reimbursement disparity between the technical/procedural and the cognitive CV services delivered by physicians.
• Utilize quality improvement indicators of adherence to preventive care and financially reward providers and institutions that effectively implement prevention.
• Fund the development and provision of informatics for CV risk assessment and care delivery which are userfriendly and transportable to clinicians.
• Fund more population-wide prevention strategies for a broader variety of risk factors.
• Fund the implementation of community health care initiatives, projects, and programs.
• Fund programs to support faculty innovations in the improvement of preventive education, and support teaching of prevention in medical and other health science schools.
• Reinstate reimbursement for cardiac rehabilitation/secondary prevention programs for fee schedules existing prior to the cutbacks that occurred in year 2000 related to the ambulatory payment classification initiative. These cutbacks led to program closures in some states and, because of low reimbursement status, reduced the fiscal motivation to start new programs.
• Fund CDC/National Heart, Lung, and Blood Institute (NHLBI)/American Heart Association (AHA)/ACC sponsored preventive cardiology applied training, as additional
  training after CV fellowship and/or as a summer two-week applied course, similar to the AHA/NHLBIsponsored CV epidemiology annual course.

Policy
Health care providers, the ACC, and other professional organizations should advocate for measures that promote CV health and reduce CVD risk factors. These are outlined under the key area "Funding" and also include:

• Reimbursement for preventive strategies, including screening and treatment of CV risk factors and cardiac rehabilitation for heart failure and all coronary artery disease patients.
• Implement preventive interventions that are economically attractive (e.g., offer good value), when compared with widely adopted health care choices.
• Foster the concept that cost-effectiveness analysis should be used as a component of policy making but that budget neutrality for prevention is not reasonable and is "bad" public policy.
• Promote a universal public health infrastructure that is integrated with health care services.
• Provide access to care for all members in society including full insurance for all citizens and legal immigrants.
• Implement procedures to monitor racial and gender bias in CV care and ensure that such bias is eliminated.
• Encourage employers and insurers to provide incentives for healthy lifestyles and health-promotion program participation.
• Foster healthy lifestyles and behaviors in schools.
• Improve education in prevention and nutrition in schools.
• Promote daily physical activity, healthy nutrition, and smoke-free campuses.
• Increase opportunities for physical activity in community, school, and work settings (e.g., the provision of incentives to employers who offer appropriate recreational facilities or physical activity opportunities).
• Change food policy to foster the reduction of sodium in the food supply leading to a 5% per year decline, the labeling of the nutritional content of menu items in national restaurants, and the support of legislation to limit the sale of junk food in schools and enhance the quality of food provided in schools.
• Eliminate opportunities for exposure to second-hand smoke.
• Foster social marketing.
• Promote the value of a prevention-oriented lifestyle.
• Create an environment wherein stairs are more attractive than elevators and portion sizes are not inversely related to caloric expenditure.
• Increase the visibility of preventive cardiology at national meetings of the ACC and other organizations whose attendees include CV specialists and/or primary care providers.
• Encourage coordination between professional organizations such as the ACC, AHA, Preventive Cardiovascular Nurses Organization, American Association for Cardiovascular and Pulmonary Rehabilitation, and American Public Health Association to develop policies and programs in preventive cardiology.
• Mandate that the American Council on Graduate Medical Education requirements are consistent with ACC Core Cardiology Training Symposium Guidelines for Training in Adult Cardiovascular Medicine (COCATS) and that both subspecialty board certification and fellowship training program certification are linked with these requirements.
• Strengthen ACC COCATS preventive training for all fellows to include a mandatory one-month block on prevention.
• Encourage the American Board of Internal Medicine to increase the CVD prevention content to a minimum of 15% for internal medical and CV subspecialty board examinations.
• Develop an annual ACC Prize for Excellence in Preventive Cardiology.

Clinical-Educational

• Familiarize and equip ACC members and other health care organizations with materials and skills to implement CVD prevention programs (critical pathways) in the hospital and out-patient setting.
• Encourage clinicians to use global risk-assessment tools.
• Encourage clinicians to follow ACC/AHA and other evidence-based guidelines for the prevention of CVD.
• Make the ACC membership aware of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) criteria for CVD prevention.
• Foster the development of cardiologists and primary care physicians to be medical champions and community leaders in the preventive effort.
• Establish systems to address the multilevel contexts that influence the development and maintenance of prevention-related health behaviors.
• Develop mechanisms for the systematic integration of social, health, governmental, and policy-level factors with individual-level approaches.
• Encourage hospitals and health care systems to develop and provide preventive cardiology services and systems for the community.
• Develop a partnership between ACC and JCAHO/National Committee for Quality Assurance/Centers for Medical and Medicaid Services to recommend that those hospitals/health care organizations providing interventional CV care (cardiac surgery and cardiac catheterization) should also provide a Director of Cardiovascular Preventive Services. Such a person will serve to develop, coordinate, and supervise the implementation and growth of preventive CV services.