THE FUTURE OF CARDIOVASCULAR CARE: FROM AFFORDABLE CARE TO THE ACADEMIC MEDICAL CENTER.

We are presently seeing exponential advances in medical knowledge and development of therapeutic and diagnostic tools. We have also begun to experience an historic restructuring of our health care system. But health care costs continue to rise, disparities persist, and the chaotic, disjointed, and often thoughtless discourse in Washington threatens to roll back the prior advances. Improvement in patient care will be severely stymied if the threats to academic medical centers are not countered. This paper will explore our present state through the lens of cardiovascular care. It will 1) examine clinical trends; 2) dissect the value and challenges to the Patient Protection and Affordable Care Act; 3) highlight limitations and alternatives to relying on the federal government; and 4) present the Academic Medical System construct, as a structure designed to retain and advance the academic mission.

[Future vascular medicine: inauguration of a cardiovascular hybrid concept]. / Gefäßmedizin von morgen: Vorstellung eines kardiovaskulären Hybrid-Care-Konzepts.

The demographic developments will lead to an exponential increase of cardiovascular diseases. Additionally, technical developments of conservative and invasive treatment modalities will be added to distinguished, organ-orientated therapeutic concepts. This will also require a new orientation of vascular services. This concept implies that specific contents are referred to and contained in partner specialties. Since the heart and vascular system function as an anatomic and functional union, implementation of vascular medicine within cardiovascular centres represents a logical consequence.

[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]. / "Fare di più non significa fare meglio". Le proposte dell'ANMCO.

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.

The use of imaging for electrophysiological and devices procedures: a report from the first European Heart Rhythm Association Policy Conference, jointly organized with the European Association of Cardiovascular Imaging (EACVI), the Council of Cardiovascular Imaging and the European Society of Cardiac Radiology.

Implantations of cardiac devices therapies and ablation procedures frequently depend on accurate and reliable imaging modalities for pre-procedural assessments, intra-procedural guidance, detection of complications, and the follow-up of patients. An understanding of echocardiography, cardiovascular magnetic resonance imaging, nuclear cardiology, X-ray computed tomography, positron emission tomography, and vascular ultrasound is indispensable for cardiologists, electrophysiologists as well as radiologists, and it is currently recommended that physicians should be trained in several imaging modalities. There are, however, no current guidelines or recommendations by electrophysiologists, cardiac imaging specialists, and radiologists, on the appropriate use of cardiovascular imaging for selected patient indications, which needs to be addressed. A Policy Conference on the use of imaging in electrophysiology and device management, with representatives from different expert areas of radiology and electrophysiology and commercial developers of imaging and device technologies, was therefore jointly organized by European Heart Rhythm Association (EHRA), the Council of Cardiovascular Imaging and the European Society of Cardiac Radiology (ESCR). The objectives were to assess the state of the level of evidence and a first step towards a consensus document for currently employed imaging techniques to guide future clinical use, to elucidate the issue of reimbursement structures and health economy, and finally to define the need for appropriate educational programmes to ensure clinical competence for electrophysiologists, imaging specialists, and radiologists.

[Heart failure patient management: evolution, organization, application on a local scale]. / Prise en charge du patient insuffisant cardiaque evolution, organisation, application à l'échelle locale.

Heart failure is a severe disease which prevalence and incidence are steadily growing, with high morbidity and mortality rates, and responsible for significant financial cost. This evolution requires our therapeutic approach to be modified, by favouring multidisciplinary management and including patient education. The proof of the effectiveness of these measures is brought by many studies, and therapeutic education is now recommended by the European Society of Cardiology. This new approach of management is set out according to various procedures. In Le Creusot, the therapeutic unit of heart failure management was created in September 2004 and operate on a day hospital pattern. The results are satisfactory knowing that the average duration of spells fell by 33% after one year. Further local initiatives are spreading and need shall arise to pooling equipment and personnel as well as reinforcing collaboration between public and private professionals in order to improve heart failure patients' management. In the meantime a more sustained involvement of the authorities is to be hoped.

[Why is integrated health care appropriate for modern German cardiology?]. / Warum Integrierte Versorgung (gerade) in der Kardiologie?

Integrated Health Care is a new tool in German legislative means to overcome the traditional separation of outpatient and inpatient health care sectors. In this paper, it is outlined, that cardiology meets several criteria that make the introduction of Integrated Health Care especially in cardiology promising. Among these criteria, evidence-based medicine, guideline-based medicine, good statistical information, large numbers of performed procedures, high costs of performed procedures, performance of procedures both in the outpatient and inpatient sectors, chronic course of treated diseases, a high degree of dependence on other medical specialities as well as a high need for the implementation of innovations in clinical cardiology are mentioned.Concluding, the paper explains the purposes of this supplement for the comprehension of different views on Integrated Health Care in cardiology as well as the information on already implemented Integrated Health Care. These experiences should facilitate the formulation of the requests for the cardiology community for new definitions of Integrated Health Care beyond 2007/ 2008.

[Integrated Health Care in cardiology: substitution or addition of new tools?]. / Integrierte Versorgung in der Kardiologie: Additiv oder substitutiv?

On the basis of broad statistical information about procedures and operations in German cardiology, the author discusses probable and already evident effects of emerging Integrated Health Care projects. Among those expectations, possibly a new group of services will emerge that adds rather than substitutes already existing services. By this effect no cost-containment, which is one of the legislative purposes for Integrated Health Care, will be achievable. Besides this pessimistic view, Integrated Health Care in cardiology has the potential to allocate financial funds in a more appropriate way than it is presently usual. For example, procedures that can be performed in outpatients, no longer need to be performed on inpatients for the only reason that hospitals are not entitled to do outpatient services.

[Integrated Health Care in cardiology: have all players used their opportunities?]. / Integrierte Versorgung in der Kardiologie: Haben alle ihre Chancen genutzt?

From the view of one of the largest public health insurance companies, in this paper it is outlined that Integrated Health Care provides opportunities to influence the largely regional structures of health care supply. This insurance company has specialized in contracts for Integrated Health Care in cardiology in order to achieve sustainable solutions for all providers of invasive and interventional cardiology that are economically reasonable. But first of all, only evidence-based medical procedures and interventions based on clinical pathways are eligible for the contracts of this company. In outlining this, it becomes evident that by far not all German public health insurance companies have yet used their opportunity.

[Integrated Health Care in cardiology]. / Integrierte kardiologische Versorgung.

Integrated Health Care forces rethinking of all partners. Health care providers need to cooperate and have to face an emerging competition among themselves. Health insurance companies are no longer the common enemy, but a business partner on an individual basis. Rethinking has already commenced. The Barmer insurance company has initiated a considerable number of similar contracts with respect to Integrated Health Care in cardiology. One of the first contracts was agreed upon at Recklinghausen (it is reported later in this volume) and a couple of them have been concluded in the Berlin/Brandenburg region (which are also reported in this volume).A special feature is the support for the general disease management programs that have been initiated in light of the new laws beginning in 2000. The Barmer company will enroll some 500,000 patients with coronary artery disease in these programs.

[Arguments in favor of Integrated Health Care as regular health care provision in cardiology]. / Argumente für die Integrierte Versorgung als Regelversorgung in der Kardiologie.

Patients are not outpatients or inpatients, they are ill or healthy. Integrated Health Care provides a real chance to bring scientific innovations quickly from the laboratory to patients--and being paid for that. Although guidelines therefore are no compulsory exercise, they are tools to implement evidence-based use of innovative medical means. Health care providers should be reluctant to agree in guarantees for the success of medical therapies, since medical decisions may be influenced in different ways by that. Bureaucracy may hinder the spreading of Integrated Health Care; therefore simple regulations should be preferred. Reimbursement should not be designed according to conventional systems for outpatient or inpatient care, but as defined sums of money. That makes people sure to know what kind of contract they have agreed in.

[Criteria catalogue for Integrated Health Care in cardiology]. / Kriterienkatalog für die Integrierte Versorgung in der Kardiologie.

This paper comprises criteria for projects of Integrated Health Care in cardiology. With these criteria, projects can be assessed for their congruence with essentials that have been assigned by the German Cardiac Society, the Association of German Hospital Cardiologists and the Association of German Practice Cardiologists. The main purpose is to ensure that evidence-based medicine is the basis for the contracts and that all valid guidelines have been observed when services have been agreed. Possibly this paper may be the basis to award an approval to projects that meet all the criteria. This paper is no model contract.

[Integrated health care at Bad Krozingen]. / Integrierte Versorgung aus Sicht des Krankenhausmanagements, Bericht über die Erfahrungen in Bad Krozingen.

This paper reports in detail on a project of Integrated Health Care in cardiology at Bad Krozingen, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

[Integrated health care at Hamburg]. / Norddeutsches Herznetz in der Metropolregion Hamburg.

This paper reports in detail on a project of Integrated Health Care in cardiology at Hamburg, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

[Integrated health care at Lübeck]. / Das "Lübecker Modell".

This paper reports on a project of Integrated Health Care in cardiology at Lübeck, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

[Integrated health care at Recklinghausen]. / Recklinghäuser Arztnetz für Information und Qualität.

This paper reports in detail on a project of Integrated Health Care in cardiology at Recklinghausen, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

[Integrated health care at Potsdam]. / ProCardio plus--Potsdam.

This paper reports in detail on a project of Integrated Health Care in cardiology at Potsdam, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

[A federal project of Integrated Health Care in cardiology]. / Integrierte Versorgung in der Kardiologie.

This paper reports in detail on a project of Integrated Health Care in cardiology at the federal level in Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.