Guideline and Policy Support for Optimal Medical Therapy (OMT)
New Guidelines from the American College of Cardiology call for OMT first before stents or bypass:
Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:2252-2266.
“The following are key points to remember from this state-of-the-art review on the evaluation and management of patients with stable angina:
Coronary heart disease (CHD) is a chronic disease with a wide range of associated symptoms and clinical outcomes. Adverse events from CHD are reduced or avoided through lifestyle and risk factor modifications and medical therapy. Currently, annual health care expenditures related to CHD exceed 3 trillion dollars. An estimated 5% of the US population between the ages of 25 and 64 years undergo stress testing each year for suspected angina, resulting in an estimated cost of over 11 billion dollars.
Observational studies have observed that patients with stable CHD most often report no or mild angina. The risk for major adverse cardiovascular events (MACE) is relatively low among patients with CHD and stable chest pain. Risk factor modification with medical and lifestyle therapy is the primary recommendation for such patients. Coronary revascularization is considered if optimal medical therapy (OMT) is not effective.”
Current coronary artery disease management is just one part of a broader problem. Our healthcare system is not designed to effectively manage chronic disease. The National Academy of Medicine (NAM) of the National Academy of science wrote a landmark book on the topic 21 years ago. They were not gentle in their assessment:
“Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Crucial reports from disciplined review bodies document the scale and gravity of the problems. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.”
The NAM did not merely point out the problems, they provided a roadmap for the path forward on page 10 of the executive summary.
“…the Agency for Healthcare Research and Quality should identify a limited number of priority conditions that affect many people and account for a sizable portion of the national health burden and associated expenditures. In identifying these priority conditions, the agency should consider using the list of conditions identified through the Medical Expenditure Panel Survey (2000). According to the most recent survey data, the top 15 priority conditions are cancer, diabetes, emphysema, high cholesterol, HIV/AIDS, hypertension, ischemic heart disease, stroke, arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimer's disease and other dementias (vascular), and depression and anxiety disorders. Health care organizations, clinicians, purchasers, and other stakeholders should then work together to (1) organize evidence-based care processes consistent with best practices, (2) organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions, (3) develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes, and (4) align the incentives inherent in payment and accountability processes with the goal of quality improvement.”
Simple.
Identify the priority conditions.
Bring together the stakeholders. Then:
(1) organize evidence-based care processes consistent with best practices. (Congruity Health clinical team systems and protocols)
(2) organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions. (daily updates, provider and patient education)
(3) develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes. (Congruity Health population health tool, clinical and financial analytics, OMT percentage achievement score)
(4) align the incentives inherent in payment and accountability processes with the goal of quality improvement
The guideline calls for OMT first. The NAM has laid out the path forward and still the chasm exists. We have made very little progress. We are not talking about a crack in the sidewalk. To protect the people we care about we must cross the Grand Canyon. Americans are dying and becoming disabled every day while we sit on our hands. Aren’t we out of excuses? The stakeholders are gathering at the MTVA. If you know of other organizations like this, please alert us in a comment. We have brought together several of the elements the NAM called for in their roadmap. The pieces are on on the board. It is time to move. Join us!