The Institute of Medicine Committee Report “Best Care at Lower Cost: The Path to Continuously Learning Health Care”
2012; Lippincott Williams & Wilkins; Volume: 5; Issue: 6 Linguagem: Inglês
10.1161/circoutcomes.112.968768
ISSN1941-7705
Autores Tópico(s)Healthcare cost, quality, practices
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 5, No. 6The Institute of Medicine Committee Report "Best Care at Lower Cost: The Path to Continuously Learning Health Care" Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBThe Institute of Medicine Committee Report "Best Care at Lower Cost: The Path to Continuously Learning Health Care" T. Bruce FergusonJr, MD T. Bruce FergusonJrT. Bruce FergusonJr From the East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC. Originally published1 Nov 2012https://doi.org/10.1161/CIRCOUTCOMES.112.968768Circulation: Cardiovascular Quality and Outcomes. 2012;5:e93–e94The new Institute of Medicine (IOM) report, entitled "Better Care at Lower Cost: The Path to Continuous Learning Healthcare in America"1 promises to have the same impact on US healthcare as the prior IOM reports on quality and safety from a decade or more ago.2–4 Importantly, this report drew on information generated by the IOM Roundtable on Value and Science-Driven Healthcare, which produced 11 volumes exploring the challenges and opportunities in US healthcare delivery. Many leading cardiovascular providers participated in this roundtable effort and contributed to these volumes, so it is not surprising that the impact of "Better Care at Lower Cost" is likely to catalyze the transformation of cardiovascular healthcare delivery in the United States in the near future.A careful perusal of the report illustrates how much the current cardiovascular care environment needs to change to meet the "Better Care at Lower Cost" mandate of the report, while highlighting the enormous opportunity for cardiovascular care inherent in this transformation.The essential characteristics of a learning healthcare system as applied to cardiovascular disease care delivery are accurately reflected in the dimensions of science and informatics, patient-clinician partnerships, incentives, and culture. To meet the characteristics of these 4 dimensions, evolutionary changes will need to occur in each area:In science and informatics, cardiovascular disease has in many ways led all organized medicine with respect to its nationally focused specialty-society databases and the data-driven information management systems typically used locally in cardiovascular medicine that allow collection, reporting, and analysis of data to drive process, quality, and outcomes improvement. Our efforts to use these data systems to improve the quality of care5 and to understand the implications of long-term outcomes6 are unprecedented. As noted in the report, however, this specialty database model, with its current national focus, must be reconciled with the emergence of electronic health records, real-time data collection and analysis, and real-time feedback of process and outcomes information at both the local and health system levels. Creating future value from these clinical database systems in the framework of the report will likely include providing more support for integration and real-time analysis of database clinical data at the local level and in conjunction with electronic health record platforms of these local and health system participants, continuing the important outcomes and performance benchmark generation contributions, and realizing the inherent value of the society networks created by the database infrastructures, with the ability to organize and conduct real-time clinical trials based on these national networks of providers.In terms of patient-clinician partnerships, interventional cardiovascular providers have embraced the concept of heart teams for decision making in patients with complex coronary artery disease and aortic valve disease, and heart failure and transplant providers have partnered with each other and patients to provide care that most closely approximates patient-centered care in the cardiovascular domain. Beyond these efforts, however, this report sets the expectation for the cardiovascular community to extend this patient-centric perspective across the entire cardiovascular spectrum of care, including the broad adoption of responsibility for outcomes and quality across multiple specialty and subspecialty providers engaged in every episode of care of every cardiovascular patient. In this way, this patient-centric partnership view is challenging the fundamental organization of academic and private practice cardiovascular care provision because the silos of these traditional structures were not designed to accommodate this level of integration. cardiovascular institutes, departments of cardiovascular sciences, Comprehensive service lines, or their equivalents that are organizationally, completely integrated and operating with new business models will be crucial to achieving this patient-centered learning health system in cardiovascular care.Likewise, medical society organizations will be challenged to rethink their historic specialty-focused perspectives to and determine how to evolve to more collaborative and effective partnerships across all specialty groups in cardiovascular disease to be instrumental in the evolution of a comprehensive learning cardiovascular healthcare system.Finally, this domain will particularly challenge providers and these specialty organizations in terms of cross-specialty learning and competencies. In this case, the competencies in functional and effective collaboration will be as important as the cross-specialty knowledge. Excessive individualization of a specialty/subspecialty agendas will inhibit the overall cardiovascular community of providers from first developing and then accessing tools and resources, including these competencies, for patient-provider-family–centered learning healthcare delivery. Successful cardiovascular society integrative collaboration, however, could be an exemplary illustration of the true potential of this continuously learning healthcare system.No less complex is the dimension of incentives. The reason is that, at some points in the past, organizational, financial, personal, academic, and specialty-society incentives have been to some degree malaligned compared with continuous learning and patient-centric care. In the broad sweep of cardiovascular disease, this occurred despite information resources and knowledge generation that are second to none in medicine. Rather than consider this report a challenge to the way it has been, addressing this incentive dimension across cardiovascular disease is critical and an unprecedented opportunity. The "Best Care at Lower Cost" report demonstrates that as much of 30% of healthcare expenditures in the United States ($760 billion in 2010) is potentially wasted, and cardiovascular disease is no exception. Although the overall death rate resulting from cardiovascular disease has declined markedly in the past 2 decades, according to the Milken Institute, the cost of cardiovascular disease care was $165 billion in 2007 and is estimated to be in excess of $186 billion in 2023.7 If we can save 30% of this healthcare spending while continuing to improve quality of cardiovascular care, this will be an unprecedented and critically important opportunity for every component of the cardiovascular care community. Indeed, saving may equate with spending the same dollars demonstrably more effectively and efficiently. In the high-technology world of cardiovascular disease, the IOM's concept of pharmaceuticals or technologies that "radically improve the clinical quality of care, while radically reducing healthcare costs" should become an important component of this incentive dimension. This opportunity is not theoretical; it has already been demonstrated in interventional cardiovascular care.8Changes in the dimension of culture are what will make the transformations in these other dimensions sustainable over the long term. The criticality of local and system leadership9 can greatly be enhanced by collaborative specialty-society education and development of these local cardiovascular leaders. Embracing the vision articulated in the report, in which each of these dimensions influences the optimization of science, evidence, and care delivery in this integrated patient-clinician community, will transform cardiovascular care; culture change will make this transformation to the continuously learning healthcare system permanent.In cardiovascular disease, without the benefit of the concerted organization, resources, and incentives outlined in the report, we have achieved many initial milestones identified in "Best Care at Lower Cost." The innovation and energy that have been a fundamental characteristic of our area of medicine over the past 60 years make cardiovascular disease perhaps the greatest opportunity across all of medicine to transform to the vision articulated in this new IOM report. Nothing in the action plan for continuous learning is beyond the capabilities of the collaborative efforts of cardiovascular disease organizations, their member providers, the patients whom the providers care for, and the organizations and communities in which the patients and providers live and work. The "Best Care at Lower Cost" report provides the roadmap to get there. Let's get to it.DisclosuresDr Ferguson was a member of the Institute of Medicine Committee on the Learning Healthcare System in America.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to T. Bruce Ferguson Jr, MD, East Carolina Heart Institute, 115 Heart Drive, Greenville, NC 27834. E-mail [email protected]References1. IOM. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington DC: The National Academies Press; 2012. http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx.Google Scholar2. IOM. To Err Is Human: Building A Safer Health System. Washington, DC:National Academy Press; 1999.Google Scholar3. IOM, 2001. Crossing The Quality Chasm: A New Health System For The 21st Century.Washington, DC: National Academy Press; 2001.Google Scholar4. IOM, 2008. Knowing What Works in Health Care. A Roadmap for the Nation.Washington, DC: National Academy Press; 2008.Google Scholar5. Williams JB, Delong ER, Peterson ED, Dokholyan RS, Ou FS, Ferguson TB; Society of Thoracic Surgeons and the National Cardiac Database. Secondary prevention after coronary artery bypass graft surgery: findings of a national randomized controlled trial and sustained society-led incorporation into practice.Circulation. 2011; 123:39–45.LinkGoogle Scholar6. Weintraub WS, Grau-Sepulveda MV, Weiss JM, O'Brien SM, Peterson ED, Kolm P, Zhang Z, Klein LW, Shaw RE, McKay C, Ritzenthaler LL, Popma JJ, Messenger JC, Shahian DM, Grover FL, Mayer JE, Shewan CM, Garratt KN, Moussa ID, Dangas GD, Edwards FH. Comparative effectiveness of revascularization strategies.N Engl J Med. 2012; 366:1467–1476.CrossrefMedlineGoogle Scholar7. http://healthcarecostmonitor.thehastingscenter.org/kimberlyswartz/projected-costs-of-chronic-diseases. Accessed July 6, 2012.Google Scholar8. Fearon WF, Bornschein B, Tonino PA, Gothe RM, Bruyne BD, Pijls NH, Siebert U; Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) Study Investigators. Economic evaluation of fractional flow reserve-guided percutaneous coronary intervention in patients with multivessel disease.Circulation. 2010; 122:2545–2550.LinkGoogle Scholar9. Cosgrove DM, Fisher M, Gabow P, Gottlieb G, Halvorson GC, James B, Kaplan G, Perlin R, Petzel R, Steele G, Toussaint J. 2012. A CEO checklist for high-value health care.Washington, DC: Institute of Medicine. http://www.iom.edu/Global/Perspectives/2012/CEOChecklist.aspx. Accessed October 1, 2012.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By He W, Kirchoff K, Sampson R, McGhee K, Cates A, Obeid J and Lenert L (2021) Research Integrated Network of Systems (RINS): a virtual data warehouse for the acceleration of translational research, Journal of the American Medical Informatics Association, 10.1093/jamia/ocab023, 28:7, (1440-1450), Online publication date: 14-Jul-2021. 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Berjano P, Langella F, Ventriglia L, Compagnone D, Barletta P, Huber D, Mangili F, Licandro G, Galbusera F, Cina A, Bassani T, Lamartina C, Scaramuzzo L, Bassani R, Brayda-Bruno M, Villafañe J, Monti L and Azzimonti L (2021) The Influence of Baseline Clinical Status and Surgical Strategy on Early Good to Excellent Result in Spinal Lumbar Arthrodesis: A Machine Learning Approach, Journal of Personalized Medicine, 10.3390/jpm11121377, 11:12, (1377) November 2012Vol 5, Issue 6 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.112.968768PMID: 23170008 Originally publishedNovember 1, 2012 PDF download Advertisement SubjectsEthics and Policy
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