A report published by the New England Healthcare Institute opened by stating that ‘Adults in the United States receive only about half of the health care they need when they need it.’[i] The report outlines the reasons why clinical care guidelines that improve health outcomes aren't being followed and proposes industry changes that would improve this.In my travels, I have met very few healthcare workers that weren’t working really hard to provide the right care each and every time. Unfortunately, our hard work doesn’t always produce the outcomes that we hope for. Although this report is now 10 years old, it reads as if it was developed yesterday. Today's statistics are not much better and they lead to a much more expensive healthcare model. Consider Medicare costs, for example. Dartmouth Institute of Healthcare Policy and Clinical Practice has estimated that 30 percent of all Medicare clinical care spending could be avoided without worsening health outcomes. That equates to $700 billion in savings. In addition, we are often surprised (or maybe not) at how our outcomes compare with other countries’ outcomes.ii The United States ranks last in health care system performance among the 11 countries included in a recent commonwealth fund study, all of which are industrialized nations.iii We certainly don’t have a healthcare system that we can necessarily be proud of.
Why is getting the right care and keeping people healthy in the U.S. so challenging? In a recent TedTalk, Atul Gawande (https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine) described the level of complexity of delivering care in the 21st century. So many diagnosis and treatment plans, and so many tools and resources have allowed us to live longer but have created a very complex environment to provide the best possible care to our patients. With all the different options, having a roadmap or evidence-based guidelines to follow can be very valuable.
In Cardiology, we can celebrate a bit in that, as a profession we have a wealth of evidence-based clinical guidelines to assist us in almost every aspect of the care that we deliver. We shouldn’t underestimate the work that has gone into the development of all of our clinical guidelines, both those that are evidence and consensus based. The fact that we have created a roadmap for effective patient care and optimal outcomes is something to be proud of.
That same study by the New England Healthcare Institute found that, compared to other professions, Cardiologists encounter fewer barriers and are far more likely to adhere to guidelines than other types of physicians. The physician survey found that the majority of Cardiologists fell into an action/adherence phase compared to less than 50% of other physicians for utilization of evidence -based guidelines.
Yet, I don’t believe that we are off the hook. There is really no argument in the need to follow the guidelines, where we fall short is their consistent execution. Multiple studies that we are all familiar with show that we are far below ideal rates of guideline driven therapy in almost all areas of CV disease – heart failure, treatment of women, cardio-oncology, atrial fibrillation, etc. So, how do we make it easier to do the right thing?
We start by learning from what we have done well in our industry. STEMI care – we do a great job with STEMI care. Think about the elements that have contributed to this:
A lot of research has been done on improving guideline adherence and interestingly, the major solutions are basically outlined above: quality incentives that support adherence, clinical decision support tools, innovation in guideline development and use, training physicians on guideline usage, enabling and promoting comparative data sharing among physicians, and team-based care delivery models. It should be noted, however that much of our STEMI Door to Balloon time work was done voluntarily without significant incentives, regulatory demands or legislation. Congratulations to all the programs that kicked off this early work voluntarily as they saw a need to improve patient care and outcomes.
As a CV industry, we've had incredible success with STEMI care. Consider what we could achieve if we developed a similar approach to hypertension management, heart failure management, atrial fibrillation management, and other conditions.
At MedAxiom, we talk a lot about purposeful standardization and driving out unnecessary care variation. We have done just that with STEMI care. We took what could be complex, with many factors and potential reasons for not meeting our goal, and made it simple and reliable. We know how to do this work and we can see in our own patients the outcomes that can be achieved. Let’s learn from the experience and continue to put systems in place to better manage other patient populations. Let's take what can be complex and make it simple through proactive development of goals, protocols, processes and team engagement all based on our own evidence-based guidelines. Think of where we will be five years from now. Could we ever get to where we have no more STEMIs because we have done such a great job with primary prevention? I think it’s possible. I think that it’s also possible that, as an industry, we can apply what we’ve learned on how to make it easy to do the right thing and improve other outcomes as well. I say let’s see what we can do as an industry, and let’s do it before someone tells us to do it.
[i] Improving Physician Adherence to Clinical Practice Guidelines, New England Healthcare Institute, February 2008, https://www.nehi.net/writable/publication_files/file/cpg_report_final.pdf)
ii https://interactives.commonwealthfund.org/2017/july/mirror-mirror/
iii Reducing Waste in Health Care. Health Affairs Health Policy Brief, December 13, 2012.