Prevention and Treatment of Cardiovascular Disease in :20 Vision in a 20:200 World. Cam Patterson, M.D., M.B.A.

Transcription

1 Prevention and Treatment of Cardiovascular Disease in :20 Vision in a 20:200 World Cam Patterson, M.D., M.B.A.

2 A 49-year-old man is referred to you for evaluation of episodic sharp midepigastric pain which can occur with exertion or at rest. He says this has been going on for months. He works as a foreman at a textile plant and the pain does not interfere with work. Maalox sometimes helps the pain. He has never taken nitroglycerin for the pain. He has been seen annually by the plant doctor and has blood pressure checks every three months. To his knowledge, all of his prior evaluations have been normal except that he is overweight.

3 46 year old man with atypical chest pain

4 What should be done next? 1. No further evaluation needed 2. Exercise ECG 3. Exercise imaging 4. Repeat lipid profile plus hscrp, Pla2, or other biomarkers 5. CT or MR angiography or PET imaging 6. Cardiac catheterization

5 At 9 minutes on Bruce Protocol

6 Assessment Nuclear scan read as normal Treadmill positive for ischemia Patient is 46, male, obese, smokes Normal lipid profile, no DM, neg FH Cath vs CT angio vs f/u ETT-MIBI in 6 months?

7 Ca score prior to CT angio > 50 CT angio not done Direct to invasive coronary angio

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9 Lessons Learned The diagnosis of critical left main disease in this man was subtle He met Class 1A indications for CABG and will live longer as a result of our evaluation and treatment His symptoms were unrelated to his coronary artery disease There is no way to explain this concisely to a nation obsessed with health policy but lacking medical sophistication

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11 What will be our approach in 2020? Health care is changing Some changes are entirely financially driven Some changes will be for the better For our patients, and the practice of medicine to survive we will have to adapt

12 New Initiatives in Health Care: Relevance in Cardiovascular Medicine Pay for Performance Medical Homes Electronic Medical Records Accountable Care Organizations

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14 Pay for Performance (P4P) Many measures are for the care of cardiac patients There is little revenue opportunity for physicians or hospitals, rather there are primarily penalties for not meeting standards Cardiovascular medicine is one of the most evidence-based, measurable specialties. Thus, cardiovascular specialists are highly relevant and both can and must be proactive

15 Medical Homes

16 Medical Homes Not just for primary care Patients with complex heart disease need a medical home: heart failure, complex arrhythmias (AFib), complex CAD Incentives will likely change Negative incentives abound alienating referral sources, time lost No positive incentives to provide a medical home today but this may change

17 Electronic Medical Records

18 Electronic Medical Records: Far From Perfect Can save time: information is more readily available Can cost time: Order/data entry, e- prescriptions, all take more time Great for gathering data Integrating EMRs at least 10 years off Major security concerns

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21 Accountable Care Organizations

22 Accountable Care Organizations Insurance companies and Federal Payers are clamoring to start Demonstration Projects Buyers beware this looks to me a lot like the capitation paradigm of the early 1990s

23 What will be our approach in 2020? Health care is changing Some changes are entirely financially driven Some changes will be for the better For our patients, and the practice of medicine to survive we will have to adapt Cardiovascular disease is not going away. As long as we provide better and safer care for our patients we will be ok

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26 Challenges in the Assessment of CV Risk We are facing an atherosclerosis epidemic the prevalence of heart disease is increasing again This has happened in a single generation it is not principally a genetic problem

27 The CAD risk factors of the1960s are still with us albeit in different proportions Insulin Hypercholesterolemia LDL Hypertension ( hydrostatic pressure) Cigarette smoking Diabetes mellitus ( glucose)

28 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14%

29 Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14%

30 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14%

31 Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

32 Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%

33 Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

34 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

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