Future of Cardiovascular Care Doesn’t Need a Magic 8 Ball

There is no better way to assess the current state and push the possibilities of the future state of cardiovascular (CV) care than by getting thousands of physicians in a room to share their thoughts. Conference season for the CV community is in full swing, with the American College of Cardiology (ACC), Heart Rhythm Society (HRS), and Society for Cardiovascular Angiography and Interventions (SCAI) all hosting their annual meetings over the last few weeks.

These meetings offer an opportunity to engage cardiovascular clinical leaders and disseminate knowledge, research and insights to the broader CV community. While that 1 session in the small room at the end of the hall may have been truly groundbreaking, collectively, the hundreds of presentations provide a glimpse into what CV care may look like in the future, without the need for a Magic 8 Ball.

CV services are ripe with technologies that are changing patients’ lives; however, disease management through population health is becoming increasingly important in CV care. In fact, the ACC made a goal to embrace population health, highlighting the move to value-based care and the need for cardiology to be part of the solution.

In case you missed the conferences, highlights regarding technology, medical management and value-based care follow.

Technology Updates

Data Point to Expanded Indication for TAVR
Transcatheter aortic valve replacement (TAVR) therapy continues to steal the spotlight, with the PARTNER 2 Trial supporting TAVR as a reasonable alternative to surgical aortic valve replacement (SAVR) in intermediate-risk patients. The study showed no difference in mortality and stroke between patients undergoing TAVR vs SAVR. These data support an expanded indication for TAVR to the intermediate-risk group, which could be announced by the FDA later in 2016.

In addition to this pivotal trial, insights gleaned from the Transcatheter Valve Therapies (TVT) TAVR registry data are suggesting volume does matter. Implanting centers with greater TAVR experience, particularly those with >100 cumulative cases, showed lower mortality rates than those with <100 cumulative cases. These data reinforce the need for strong program support for TAVR.

Atrial Fibrillation (AF) Ablation Volumes Continue to Grow
AF ablation is to the electrophysiology (EP) world what TAVR is to the interventional world. You can’t go a day without seeing something new. The procedure continues to increase in use for the management of patients with AF. The 2 primary modalities are cryoablation (using extreme cold to destroy or damage tissue) and radiofrequency ablation (RFA; using heat generated from medium-frequency alternating current to destroy or damage tissue).

Results from the FIRE and ICE trial comparing these 2 modalities confirmed what many had anecdotally observed, there is no difference in outcomes between cryoablation and RFA. While the efficacy and safety profiles of the 2 techniques look similar, cryoablation is a much simpler procedure. The study could result in more centers performing AF ablation, given the ease of cryoablation and clinical acceptance of this modality.

The idea of risk factor modification for AF control continues to gain steam. More data from Australia were presented supporting the role of weight loss as an AF management tool. Novel to their findings, significant weight loss of >10% of baseline body weight was shown to actually reverse disease progression, taking patients from persistent to intermittent (paroxysmal) AF. Are we ready to embrace this type of disease management strategy? The data are certainly pushing us in that direction.

Medical Management

New Clarity Emerges Regarding Blood Pressure and Cholesterol Management
Hypertension and cholesterol management have been on a bit of a roller coaster ride over the last few years, with interventional treatments not panning out and guidelines being updated. However, a very interesting study (HOPE-3) looking at treatments to lower both blood pressure (BP) and cholesterol in patients at intermediate risk for coronary heart disease brought some clarity: both cholesterol-lowering therapy alone and cholesterol-lowering therapy combined with BP-lowering therapy showed benefit, but BP-lowering alone only benefited if BP was high to begin with. So, treat those who need treating, but give everyone at risk a statin. Expect more to come from the societies on this topic.

Redesign Care Protocols for Complex Heart Failure Population
The heart failure population remains top-of-mind; organizations are continuing to redesign their care protocols for these complex patients. A study of over 600 congestive heart failure patients enrolled in a hospital-to-home (H2H) program at the University of Virginia Medical Center found that early follow-up and support for discharged patients reduced the cost of care by close to 70% at 30 days and 50% at 1 year. In addition, mortality was decreased for program participants. The use of nurse navigators significantly increased patient participation. This is a high-touch patient population, but it is nice to see confirmation that the extra attention has positive results.

Value Is Here to Stay
A common thread at these conferences was that cardiology again wants to be on the leading edge of the transition to value-based care. In fact, the ACC is making prevention and population health top priorities moving forward; these concepts were highlighted at multiple sessions, but notably in the ACC plenary session by ACC President Kim Allan Williams, MD, FACC. Like most changes in care delivery, the transition to value-based care is driven both by sticks and carrots. It is clear that cardiology would prefer the carrot.

Prepare for Tomorrow
Don’t put your future in the hands of the Magic 8 Ball! Focusing on value will require striking the right balance between technology, innovation, patient access and individual behaviors. If cardiology takes the lead here, maybe we will decrease mortality rates for cardiovascular disease in a similar fashion to the progress made on readmissions. It’s worth the effort!

  • Appropriate integration of new technology requires the support of disease-based programs to maintain volumes necessary for a high-quality offering. Organizations should focus on the program, not the procedure, when assessing the viability of technology adoption.
  • Creating a consumer-centric offering ensures easy access for referring physicians and patients, optimizes care, stems leakage, and captures growth.
  • Guidelines and registry data improve quality and financial performance.
  • Transparency around cost, quality and outcome variability throughout a care episode allows organizations to engage physicians and standardize protocols to improve programs.
  • Partnerships with post-acute care providers can improve quality and reduce costs, which is critical for success in progressive payment models (eg, bundled payments, Medicare

Sources: American Heart Association. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. December 16, 2015 [Epub ahead of print]; Leon MB et al. N Engl J Med. 2016;374:1609–1620; Carroll JD et al. Relationship between procedure volume and outcome for transcatheter aortic valve replacement in US clinical practice: insights from the STS/ACC TVT registry. American College of Cardiology 2016 Scientific Sessions, April 3, 2016, Chicago, IL. Abstract 405-16; Kuck KH et al. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. April 4, 2016 [Epub ahead of print]; Middeldorp ME et al. Prevention and regressive effect of weight loss and risk factor modification on atrial fibrillation (REVERSE-AF). Heart Rhythm Society 2016 Scientific Sessions, May 6, 2016, San Francisco, CA. Abstract AB21-05; Yusuf S et al. Blood-pressure and cholesterol-lowering in persons without cardiovascular disease. N Engl J Med. April 2, 2016 [Epub ahead of print]; Welch T et al. Cost analysis of heart failure readmission intervention program. American College of Cardiology 2016 Scientific Sessions, April 4, 2016, Chicago, IL. Abstract 1285M-01; Impact of Change® v16.0; HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2013. Agency for Healthcare Research and Quality, Rockville, MD; OptumInsight, 2014; The following 2014 CMS Limited Data Sets (LDS): Carrier, Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; The Nielsen Company, LLC, 2016; Sg2 Analysis, 2016.

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