This initiative was most technically up to date and comprehensive in its review of the evidence on current cardiovascular disease management. While thorough, the innovation is difficult to ascertain. In fact, with such a well-established research and advocacy consortium, the entry never explains exactly what innovation you would build using the grant money. There is a mention of meetings, advocacy, and powerpoint presentations, but there simply is not enough explanation of the plans. Your organization clearly does good work within the system, but does not appear to be innovating outside established norms.
William Henry Bestermann Jr MDIn answer to the question posed by the Changemakers Team, the disruptive innovation here can be best understood by using your own example of the Minute Clinic. There were parts of this innovation in use prior to the Minute Clinic, but the new ground was broken by bringing them together. The potential impact of a cardiovascular center of excellence is much greater than that of the Minute Clinic.
While the science supporting the efficacy of medical management and life-style change in preventing heart attack and stroke in stable patients is irrefutable, the whole medical world stills functions as if fixed stenosis is the problem. Therefore, current practice is to do tests to establish the presence of blockage and then to do some sort of procedure to bypass the narrowing or open it up. In the WISE study mentioned in the application, the women received their catheterizations but only a small minority were on anything for their pressure and cholesterol a year later. The acute condition received proper attention as usual, but the chronic conditions underlying the episode were simply not addressed. This is a system problem. If we keep doing what we are doing, we will keep getting the results we are getting. Only 7% of type 2 diabetics have all three risk factors controlled to goal at any given time. The entire medical profession is frustrated with poor risk factor control rates. The IOM has called for a total change in the way we structure the system of care for these chronic conditions, and in the 6 years since the IOM call to action, very little has changed.
The medical system approach to risk factor management has changed minimally in the last 30 years. 95% of adult onset diabetic patients are managed in ordinary office visits with primary care doctors. Hypertension is the number one cause of an adult office visit. In spite of years of education, exhortation, and lamentation, risk factor control rates have changed very little with dreadful consequences to the patients who depend on us. Obesity and the incidence of diabetes are dramatically on the rise. Even in most medical schools, the management of vascular risk factors occurs in silos-lipid clinics, hypertension clinics and diabetes clinics. These are the established norms. We are specifically talking about taking interested primary care providers, bringing them up to speed in focused vascular risk factor management and then having them practice in a clinic dedicated specifically to the aggressive management of these chronic conditions. This is a very different way of doing business. We are tying independent practices
together over the internet to create a global cardiovascular risk management registry. I know of no such registry tying independent practices together for the benefit of patients.
For decades prior to World War II, the well constructed defense was impregnable. The attack could not succeed because assaults were conducted much as they had been for 4000 years. Tanks, artillery, planes, machine guns, and repeating rifles all existed prior to that war, but it was not until these assets were brought together in mechanized infantry divisions and thrown at a weak point in the enemy defense that the attack could finally overcome the defense, totally and forever changing the art of warfare.
While we have made a great deal of progress in creating infrastructure and concept, we have been starved for cash to build and maintain the latest technology in the information infrastructure that is required. We are doing this with only two full time staff people and this lack of resources is really an obstacle to bringing optimal medical therapy in vascular risk management to those who need it The grant funding would be used to increase staff while maintaining and further developing the IT infrastructure required to house the database and registry. The funds would be used to recruit more practices to develop focused vascular clinics and connect them to the registry. Connecting the different EMRs from the independent practices and pulling the data out in usable form is all quite expensive. All of this sounds very straightforward and many take it for granted that these things are happening in medicine like they are in finance and retailing, but that is simply not the case. Medicine still functions as a cottage industry and we believe that bringing together these assets for the first time in a coordinated and integrated way will have the same impact on medical care that blitzkrieg had on warfare. The innovation is a dramatic change in the way we manage vascular disease—moving from an emphasis on expensive tests, bypass surgery, and stents to an early identification of the high risk patient with aggressive life-style and medical therapy addressed at risk factors and the medical treatment of arterial disease. Our treatment of vascular patients today is too little, too late.
William Henry Bestermann Jr MD
This is provided by Deborah Wirth-Simmons
COSEHC Executive Director
From the early 1980s, various organizations have issued guidelines for individually managing cardiovascular risk factors, such as hypertension, dyslipidemia, and Type 2 diabetes. The individualized risk factor management approach (silo therapy) has had a limited benefit on outcomes. Rather, we believe that the primary care physician equipped with a guideline for comprehensive management of these risk factors can offer the best management for patients.
Our intervention , is to implement the already developed and published COSEHC cardiovascular risk factor tool and treatment guideline in community primary care practices across the southeast region of the United States. The target population served by this project will be the patients seen by the regional community healthcare providers. To achieve this, our plan is to: 1) identify primary care practices across the southeastern United States and work with COSEHC physician experts to provide the education on the use of the tools, 2) utilize the current COSEHC Cardiovascular Centers of Excellence program to transform these primary care practices into Centers of Cardiovascular Excellence recognized in their community as physician practices which provide an integrated approach to manage cardiovascular care, 3) collect data from these primary care practices through the COSEHC Cardiovascular Centers of Excellence network database to evaluate if patients are achieving treatment goals when their physicians follow the guideline, and 4) provide ongoing quality improvement feedback to primary care practices through monitoring and benchmarking reports.
Improved outcomes utilizing this treatment methodology could have significant impact in changing the current paradigm of managing patients with cardiovascular disease. Environmentally, if the tools both assess patients at risk earlier and better achieve therapeutic target goals, more practitioners will recognize the importance of intervening early with an integrated approach. Policy implications are also possible if our project is successful at improving care and reducing costs. The proposed treatment guideline could become the “model of choice” for health plans and government payers as a basis for Pay4Performance and other reimbursement strategies. Utilizing the risk factor tool should also result in earlier detection and treatment of cardiovascular disease, leading to a reduction in long-term healthcare costs.
1. Describe the data collected and results to date or describe the data collection plan.
Although not broadly tested, COSEHC has collected data utilizing the cardiovascular risk factor tool and treatment guideline within their cardiovascular centers of excellence network. One practice has followed 450 type 2 diabetes patients and consistently maintained average HbA1c levels of 6.8-7, systolic blood pressures of 130 mmHg, and 86% of the patients in the group achieved LDL cholesterol levels under 100 (45% of these are under 70). One of the larger Centers of Excellence has reduced costs four-fold compared to the average national to manage type 2 diabetes patients.
2. Explain why this is an innovative practice.
The Institute of Medicine (IOM) clearly advocates in their Crossing the Quality Chasm document that “a paradigm shift in healthcare is needed; the current system of delivering healthcare is not working.” The IOM has made strong recommendations for fundamental changes that focus on preventive health measures rather than acute episodes of care. However, very few guidelines to date are based on preventive treatment, when considering conditions such as hypertension, diabetes, stoke, peripheral vascular disease, and end-stage renal disease. The COSEHC treatment model does just that. It attempts to bridge the current chasm that exists between the existing “silo” approach of cardiovascular care and a comprehensive integrated system of prevention and management. We believe that the Center of Cardiovascular Excellence model, with a focus on multiple factors in patients at risk, is indeed the “new paradigm” in managing cardiovascular health.
3. Describe your plans for in-state replication or spread and what is required for adoption in other settings or states.
The tools used are easily replicable to other practices, regions, and states. Accrediting practices as Cardiovascular Centers of Excellence in their community makes this project an attractive proposition to community primary care practices. Replication to other states outside the southeastern region could be easily done.
Debra Simmons
Executive Director, Consortium for Southeastern Hypertension Control (COSEHC)
PO Box 5097
Winston-Salem, NC 27113-5097
Phone: 336-716-1130
Fax: 336-716-6644
Comentarios
This initiative was most technically up to date and comprehensive in its review of the evidence on current cardiovascular disease management. While thorough, the innovation is difficult to ascertain. In fact, with such a well-established research and advocacy consortium, the entry never explains exactly what innovation you would build using the grant money. There is a mention of meetings, advocacy, and powerpoint presentations, but there simply is not enough explanation of the plans. Your organization clearly does good work within the system, but does not appear to be innovating outside established norms.
Thank you,
Changemakers Team
William Henry Bestermann Jr MDIn answer to the question posed by the Changemakers Team, the disruptive innovation here can be best understood by using your own example of the Minute Clinic. There were parts of this innovation in use prior to the Minute Clinic, but the new ground was broken by bringing them together. The potential impact of a cardiovascular center of excellence is much greater than that of the Minute Clinic.
While the science supporting the efficacy of medical management and life-style change in preventing heart attack and stroke in stable patients is irrefutable, the whole medical world stills functions as if fixed stenosis is the problem. Therefore, current practice is to do tests to establish the presence of blockage and then to do some sort of procedure to bypass the narrowing or open it up. In the WISE study mentioned in the application, the women received their catheterizations but only a small minority were on anything for their pressure and cholesterol a year later. The acute condition received proper attention as usual, but the chronic conditions underlying the episode were simply not addressed. This is a system problem. If we keep doing what we are doing, we will keep getting the results we are getting. Only 7% of type 2 diabetics have all three risk factors controlled to goal at any given time. The entire medical profession is frustrated with poor risk factor control rates. The IOM has called for a total change in the way we structure the system of care for these chronic conditions, and in the 6 years since the IOM call to action, very little has changed.
The medical system approach to risk factor management has changed minimally in the last 30 years. 95% of adult onset diabetic patients are managed in ordinary office visits with primary care doctors. Hypertension is the number one cause of an adult office visit. In spite of years of education, exhortation, and lamentation, risk factor control rates have changed very little with dreadful consequences to the patients who depend on us. Obesity and the incidence of diabetes are dramatically on the rise. Even in most medical schools, the management of vascular risk factors occurs in silos-lipid clinics, hypertension clinics and diabetes clinics. These are the established norms. We are specifically talking about taking interested primary care providers, bringing them up to speed in focused vascular risk factor management and then having them practice in a clinic dedicated specifically to the aggressive management of these chronic conditions. This is a very different way of doing business. We are tying independent practices
together over the internet to create a global cardiovascular risk management registry. I know of no such registry tying independent practices together for the benefit of patients.
For decades prior to World War II, the well constructed defense was impregnable. The attack could not succeed because assaults were conducted much as they had been for 4000 years. Tanks, artillery, planes, machine guns, and repeating rifles all existed prior to that war, but it was not until these assets were brought together in mechanized infantry divisions and thrown at a weak point in the enemy defense that the attack could finally overcome the defense, totally and forever changing the art of warfare.
While we have made a great deal of progress in creating infrastructure and concept, we have been starved for cash to build and maintain the latest technology in the information infrastructure that is required. We are doing this with only two full time staff people and this lack of resources is really an obstacle to bringing optimal medical therapy in vascular risk management to those who need it The grant funding would be used to increase staff while maintaining and further developing the IT infrastructure required to house the database and registry. The funds would be used to recruit more practices to develop focused vascular clinics and connect them to the registry. Connecting the different EMRs from the independent practices and pulling the data out in usable form is all quite expensive. All of this sounds very straightforward and many take it for granted that these things are happening in medicine like they are in finance and retailing, but that is simply not the case. Medicine still functions as a cottage industry and we believe that bringing together these assets for the first time in a coordinated and integrated way will have the same impact on medical care that blitzkrieg had on warfare. The innovation is a dramatic change in the way we manage vascular disease—moving from an emphasis on expensive tests, bypass surgery, and stents to an early identification of the high risk patient with aggressive life-style and medical therapy addressed at risk factors and the medical treatment of arterial disease. Our treatment of vascular patients today is too little, too late.
William Henry Bestermann Jr MD
This is provided by Deborah Wirth-Simmons
COSEHC Executive Director
From the early 1980s, various organizations have issued guidelines for individually managing cardiovascular risk factors, such as hypertension, dyslipidemia, and Type 2 diabetes. The individualized risk factor management approach (silo therapy) has had a limited benefit on outcomes. Rather, we believe that the primary care physician equipped with a guideline for comprehensive management of these risk factors can offer the best management for patients.
Our intervention , is to implement the already developed and published COSEHC cardiovascular risk factor tool and treatment guideline in community primary care practices across the southeast region of the United States. The target population served by this project will be the patients seen by the regional community healthcare providers. To achieve this, our plan is to: 1) identify primary care practices across the southeastern United States and work with COSEHC physician experts to provide the education on the use of the tools, 2) utilize the current COSEHC Cardiovascular Centers of Excellence program to transform these primary care practices into Centers of Cardiovascular Excellence recognized in their community as physician practices which provide an integrated approach to manage cardiovascular care, 3) collect data from these primary care practices through the COSEHC Cardiovascular Centers of Excellence network database to evaluate if patients are achieving treatment goals when their physicians follow the guideline, and 4) provide ongoing quality improvement feedback to primary care practices through monitoring and benchmarking reports.
Improved outcomes utilizing this treatment methodology could have significant impact in changing the current paradigm of managing patients with cardiovascular disease. Environmentally, if the tools both assess patients at risk earlier and better achieve therapeutic target goals, more practitioners will recognize the importance of intervening early with an integrated approach. Policy implications are also possible if our project is successful at improving care and reducing costs. The proposed treatment guideline could become the “model of choice” for health plans and government payers as a basis for Pay4Performance and other reimbursement strategies. Utilizing the risk factor tool should also result in earlier detection and treatment of cardiovascular disease, leading to a reduction in long-term healthcare costs.
1. Describe the data collected and results to date or describe the data collection plan.
Although not broadly tested, COSEHC has collected data utilizing the cardiovascular risk factor tool and treatment guideline within their cardiovascular centers of excellence network. One practice has followed 450 type 2 diabetes patients and consistently maintained average HbA1c levels of 6.8-7, systolic blood pressures of 130 mmHg, and 86% of the patients in the group achieved LDL cholesterol levels under 100 (45% of these are under 70). One of the larger Centers of Excellence has reduced costs four-fold compared to the average national to manage type 2 diabetes patients.
2. Explain why this is an innovative practice.
The Institute of Medicine (IOM) clearly advocates in their Crossing the Quality Chasm document that “a paradigm shift in healthcare is needed; the current system of delivering healthcare is not working.” The IOM has made strong recommendations for fundamental changes that focus on preventive health measures rather than acute episodes of care. However, very few guidelines to date are based on preventive treatment, when considering conditions such as hypertension, diabetes, stoke, peripheral vascular disease, and end-stage renal disease. The COSEHC treatment model does just that. It attempts to bridge the current chasm that exists between the existing “silo” approach of cardiovascular care and a comprehensive integrated system of prevention and management. We believe that the Center of Cardiovascular Excellence model, with a focus on multiple factors in patients at risk, is indeed the “new paradigm” in managing cardiovascular health.
3. Describe your plans for in-state replication or spread and what is required for adoption in other settings or states.
The tools used are easily replicable to other practices, regions, and states. Accrediting practices as Cardiovascular Centers of Excellence in their community makes this project an attractive proposition to community primary care practices. Replication to other states outside the southeastern region could be easily done.
Debra Simmons
Executive Director, Consortium for Southeastern Hypertension Control (COSEHC)
PO Box 5097
Winston-Salem, NC 27113-5097
Phone: 336-716-1130
Fax: 336-716-6644
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