Task Force VI: Evaluation of

Cardiovascular Care

Quality of and Access to

LEWIS (Chairman), MESSER (Cochairman), BAROFSKY, BEALL. BLACKBURN, BUNKER, CLAFLIN. GESSNER, SEUBOLD, YURCHAK

The charge to this Task Force is somewhat different from that of the other five. Other groups have focused on the study of cardiovascular manpower and the edu- cation, training, distribution and efficiency of cardiol- ogists. In contrast, this group was charged to examine the quality of and access to cardiovascular care. As such, the focus was not directed primarily at cardiologists, but rather the services provided to patients with cardio- vascular problems.

ment) and psychosocial factors related to a physician’s in- ability to promote patient compliance with recommendations for treatment.

The group began by recognizing that the manpower study involved only physicians listing themselves as cardiologists. It is estimated that these persons provide 10 to 15 percent of all care for patients with cardiovas- cular problems in the United States.’ An initial as- sumption was made by the Task Force that its recom- mendations should be addressed not only to the care provided by cardiologists, but also to access to and the quality of’ cardiovascular care provided by all health professionals.

3. Quality of care: This has traditionally been measured in three ways”: (1) through examining the structural properties of the system/provider, that is, the accreditation of training programs and the certification of physicians; (2) analysis of the processes of care, or the review of the performance of physicians accomplished through medical care audits, explicit criteria review, and other practices; and (3) examination of the outcomes or end results of care. In each case standards or criteria have been established by “knowledgeable experts.” In the past such assessments have generally been considered to be within the province of the profession rather than the public, but there is considerable evidence that in the near future laymen will be significantly involved in all three types of evaluations.” It should be noted that the processes of care are not necessarily associated with the outcomes of care, particularly when patient behavior is a significant determi- nant of outcome.”

It was deemed important to begin by providing working definitions of terms or concepts central to the subject of this report, including the following:

1. Cardiovascular care 2. Quality of care 3. Access 4. Regionalization. After the presentation of these definitions, this report

attempts to identify problems related to access to and quality of cardiovascular care; to assess past and present efforts to deal with these problems and, finally, to rec- ommend actions for the future.

Definitions

4. Regionalization: A regional system of care is charac- terized by (1) primary care units that represent the point of first contact for care of most patients; (2) secondary care fa- cilities, typically represented by community hospitals that serve as the first point of referral from primary care activities; and (3) a tertiary facility, typically a university hospital or an institution affiliated with an academic health center that provides the ultimate in sophisticated facilities and resources necessary for diagnosis and treatment of those relatively few patients who require this level of care. A “region” is therefore characterized by the presence of a system involving these three interacting levels of care, rather than by a defined geographic or political unit; that is, in some areas only a few census tracts may constitute an adequate population base and set of re- sources for a region, whereas in others, an entire state might represent one regional system.

1. Cardiovascular care: Cardiovascular care includes activities related to the diagnosis and treatment of problems related to the cardiovascular system as well as efforts directed to prevention of cardiovascular disease. This definition implies that cardiovascular care involves activities other than the diagnosis and treatment of disease. The activities include preventive and rehabilitation measures and the assessment of complaints referrable to the cardiovascular system that are not organic in nature.

Access to Cardiovascular Care

2. Access to care: Access implies both the utilization and the opportunity for utilization of services. It is appropriate to describe problems related to access in terms of barriers that inhibit access for individual consumers, as well as barriers related to the production or delivery of cardiovascular services. Among the former (patient-related) are costs of care and psychosocial factors resulting in delay in seeking care. Barriers to the provision of care include the number of practitioners available, their geographic location, the scope of services available to them (barriers that a physician may face in re- ferring a patient for more sophisticated evaluation or treat-

The problem: A variety of studies have indicated that access to cardiovascular care is not adequate for all subgroups of the population. This is related to several factors including the lack of a regional system for car- diovascular care, unequal geographic distribution of cardiologists, unequal ability of individual patients to pay for care, the delay of patients in seeking care in the face of symptoms, the lack of interpersonal communi- cation among physicians, and underutilization by physicians of new types of health manpower.

Factors

A. The lack of a regional system of care that provides patient care at appropriate levels of need

Assessment: The concept of regionalization is not new.5 However, a variety of approaches to creating re-

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gional systems have not been successful. For example, the initial report of the Commission on Heart Disease, Cancer and Stroke recommended the establishment of regional systems of care for patients with these disor- ders. However, the legislation created a program con- cerned primarily with professional education. The past history of Regional Medical Programs suggests they were not effective in encouraging regionalization.6

The Comprehensive Health Planning Act (Public Law 89-749) was passed to implement planning for health services at the state and local levels. It proved largely ineffective for a variety of reasons, including underfunding and the absence of any real delegated authority to “enforce” or encourage such endeavors.7

Public Law 93-641, requiring the designation of health service areas and subsequent regional planning activities, is the most recent legislative effort to achieve this goal. If this attempt fails, further efforts toward this goal may involve direct federal regulation of facilities and resources. There is some evidence that federal regulation may have adverse consequences for all con- cerned.s

Recommendation: It is essential that the American College of Cardiology and the American Heart Associ- ation collaborate in efforts to implement the objectives of Public Law 93-641. We are not overly optimistic about the success of any intervention designed to pro- duce “regionalization.” However, support of this pro- gram is important in an effort to avoid direct govern- mental control and regulation with their possible ad- verse consequences for patients as well as practitioners.

B. The geographic distribution of cardiologists

Assessment: Although the manpower study reveals an unequal distribution of cardiologists, this inequality in itself may not have adverse effects or may not be amenable to any “intervention” short of involuntary conscription. It is not surprising to find cardiologists located near large health care centers where necessary resources are available for complex diagnostic and therapeutic procedures.

There is little evidence to suggest that a variety of techniques employed to influence the geographic dis- tribution of physicians in general, including loan-for- giveness,g preceptorshipslO or increasing their numbers (annual outputll), have been effective or would be in the case of cardiologists. However, cardiologists do have the responsibility of increasing access to cardiovascular care by improving the ability of noncardiologists to provide these services.

Recommendations: 1. Cardiologists should assume increased responsibility for the cardiology content of training programs for general internists and family practitioners since it is unlikely that efforts to redis- tribute physicians with formal cardiovascular training will significantly affect access to cardiovascular care.

2. There should be exploration of approaches other than bringing the cardiologist to the patient, such as transportation systems for patients, application of computer technology, establishment of electronic-

TASK FORCE VI

communication linkages with remote sites and prepa- ration of certain patient groups for increased self-care.

3. The exchange of faculty and students with prac- titioners is proposed as a possible means of encouraging the location of new graduates in certain areas, and a realistic means of upgrading practitioners’ performance, especially with reference to the management of certain urgent cardiovascular problems such as arrhythmias and cardiogenic shock. This might also promote ap- propriate referral patterns.

C. Inability of individuals to pay for care

Assessment: Legislation to date has created inade- quate coverage under various health insurance pro- grams. l2 Inability to pay should not affect access to care.

Recommendations: It is uncertain what future changes may occur in governmental financing of care. Although members of the Task Force held divergent views about the relative merits of different approaches to financing, it was agreed that future financing pro- grams should create the means for promoting quality of care and more appropriate use of resources.

D. Health-related behavior patterns of patients

Assessment: Failure to seek care in the face of sig- nificant symptoms, overutilization of care for non- biologic problems and noncompliance with recom- mendations for treatment are all barriers to access to care. Studies have demonstrated that up to 20 percent of persons delay in seeking care,i3 that 10 to 15 percent of persons (without serious medical disease) in a pop- ulation account for 50 percent of all visits to the doctor14 and about 30 to 40 percent of patients comply with prescribed therapeutic regimens15; nevertheless, few physicians are aware of these data or have methods for dealing with these phenomena.

Although health education has been promoted as a means of correcting these problems, evidence suggests that such efforts have generally been ineffective.r6 Lack of knowledge by patients has been shown to be unre- lated to these problems.17

Recommendations: 1. The level of physician awareness of these factors should be increased through input into professional training programs.

2. Research should be supported and encouraged to describe further the variables related to these patterns of behavior, and also to test by clinical trials proposed interventions to alter these barriers to access. It is sug- gested that changing the roles of patients, that is, in- creasing their responsibility for decision-making in processes related to their own care, might be an effective strategy to test in this regard.

3. Health education efforts should be continued with emphasis on training children and young adults in ad- equate cardiovascular self-care (for example, training about diet, smoking, exercise). In addition, attempts should be made to provide physicians (and other health care personnel) with the skills of promoting patient responsibility for health and self-care rather than lim- iting educational efforts to provision of knowledge about cardiovascular disease and its care.

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E. Behavior of physicians

Assessment: Two aspects of physician behavior hinder access to care. One is deficient diagnostic acu- men. The other is inability to communicate with pa- tients, other physicians and other health professionals. Problems in communication with other physicians in- hibit appropriate referral patterns.

Recommendations: 1. Consideration should be given to including newly developed methods for as- sessing communications and interpersonal skills as part of the selection process of students for medical school, as soon as these are determined to be valid and reliable.

2. The teaching of these skills should be required as part of the curriculum in all medical schools, as well as postgraduate training programs for all physicians.

3. Intradisciplinary communication (among inter- nists, cardiologists, and cardiovascular surgeons) should be encouraged to promote appropriate utilization of resources, thus affecting access to cardiovascular care.

F. New types of health manpower

Assessment: In considering requirements for man- power at any level it is important to separate manpower requirements for the performance of certain specific services from the general manpower requirements for a certain discipline. In other words, surgeons should be trained because there is a need for more surgeons, not because existing surgeons need assistants. The latter can be prepared to perform a limited set of technical func- tions at lower cost and without the concomitant pro- duction of more surgeons.

Access to cardiovascular care can be increased by the appropriate utilization of new types of health man- power. There have been many changes in state laws governing the practice of physician assistants and nurse practitioners18 but there are no national standards for such legislation or, in the case of nurse practitioners, for accrediting training programs or certifying graduates. Paramedics and emergency medical technicians rep- resent another source of cardiovascular care. Although there is considerable evidence of the acceptance by patients of these new practitioners,lg their utilization by physicians is variable.20

Recommendations: 1. Further steps should be taken to improve awareness and acceptance by physicians (often through personal experience) of these practi- tioners.

2. Training in cardiopulmonary resuscitation should be encouraged for all groups (professional and lay).

3. Technicians should be prepared to assume service roles whenever it is clear that the use of physician- trainees for such roles is not indicated to increase the future supply of manpower in a specific specialty.

Quality Assurance

The problem: The current level of quality of car- diovascular care in the United States is not commen- surate with the level of knowledge available. This is related to several factors including the lack of effective mechanisms for quality assurance, patient behavior, physician behavior, rapid dissemination of technical

advances and inadequate training and utilization of support personnel.

Factors

A. Lack of effective quality assurance mechanisms capable of altering physician behavior

Deficiencies exist in standardized criteria for training programs for providers of cardiovascular care and per- formance criteria for practitioners of specific functions, such as electrocardiographic interpretation, cardiac catheterization and angiography and coronary care. Although recommendations exist,21,22 there is a lack of enforceable standards for facilities necessary to the provision of acceptable cardiovascular care.

Assessment: Existing legislation creating Peer Standards Review Organizations and Health Service Areas appears inadequate to assure quality cardiovas- cular care without active cardiovascular professional participation. Eligibility for recertification and licensure based upon evidence of receipt of didactic instruction alone is considered inadequate as a quality assurance mechanism.23

Recommendations: 1. The American College of Cardiology should support research and development of new methods for quality assurance. Direct physician incentives to participate must be emphasized, including the use of mechanisms involving payment for profes- sional services.

2. The American College of Cardiology should stimulate the development of multidisciplinary practice groups and other professional organizations for the provision of health care, since such arrangements may encourage the implementation of internal incentives, continuing education, intrasystem communication, accountability and the assembly of optimal components for the provision of quality cardiovascular care.24

3. Public participation in the assessment of cardio- vascular care should be encouraged. Public awareness of optimal training and facilities for cardiovascular care should be fostered.

4. Educationally accredited medical centers should assume major responsibility for continuing cardiovas- cular education in cooperation with the established professional organizational programs.

5. The American College of Cardiology should sup- port the certification of technical competence in special procedures such as cardiac catheterization, angiography, echocardiography and electrocardiography.

B. Patient behavior, such as failure to comply with medical recommendations

Assessment: No legislatively funded efforts exist to resolve this problem. A variety of patient education programs have been of variable, but minimal, success.

Recommendations: 1. In addition to those recom- mendations included previously in item D under Access to Cardiovascular Care, physician awareness of this essential component of quality assurance requires em- phasis.

2. Improved methods for modifying patient behavior should include more than a knowledge of health prob-

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TASK FORCE VI

lems, emphasizing patient awareness of personal re- sponsibility for and the positive benefits of compliance with physician recommendations.

C. Physician behavior

Assessment: The willingness and ability of physi- cians to communicate with each other, with patients and with others in the health care system are essential to adequate cardiovascular care.

Recommendations: 1. In addition to those recom- mendations included in item E under Access to Car- diovascular Care, methods must be developed to en- courage referral of patients to appropriate levels of care, including the acceptance of the possible economic im- pact of such referral practices.

2. Methods must be improved for the transmission of patient-related and educational information among physicians within a regional health care referral net- work, utilizing currently available communication technology.

3. Physician compliance with established manage- ment programs must be increased through improved awareness of current knowledge concerning risk/benefit ratios of various diagnostic and therapeutic techniques.

D. Rapid dissemination of technical advances

This should be accomplished after such advances have been adequately assessed and the criteria for their efficacy have been established.

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Assessment: Methodology for the evaluation and control of apparently promising medical devices and techniques is under consideration by various profes- sional organizations and regulatory agencies. Legislation similar to that regulating pharmaceutical products is of questionable value in this regard, although existing alternatives have proved variably effective and often overly restrictive.25

Recommendation: The evaluation of major new approaches to cardiovascular care using appropriate experimental design should be encouraged at the non- federal level through the development of multiinstitu- tional regional or national peer group review processes.

E. Inadequate training and utilization of support personnel for cardiovascular care

Assessment: Appropriate educational and regulatory guidelines are lacking for several categories of cardio- vascular support personnel including coronary care unit nurses, catheterization technicians and paramedics. Several organizations, including the Council on Medical Education of the American Medical Association, are attempting to deal with this problem, but they have had variable success.

Recommendation: The American College of Car- diology should consider accepting responsibility for participation in curricular development, provision of educational facilities, accreditation and the continuing education of cardiovascular support personnel.

References

Based upon preliminary data from the results of the National Am- bulatory Medical Care Survey conducted by the National Center for Health and Vital Statistics (described in DHEW publication no. [HRA] 74-1335, April 1974) Denabedian A: Evaluating the quality of medical care. Milbank Mem Fund Quart 44: 166-203 (part 2). 1966 Public Law 93-641. “The National Health Planning and Resources Development Act of 1974.” January 4, 1975 Feseel WJ, Van Brunt EE: Assessing quality of care from the medical record. N Engl J Med 286:134-138, 1972 Mountin JW, Greve CH: Public Health Areas and Hospital Facilities: A Plan for Coordination. PI-IS Publication No. 42, Washington DC, Government Printing Office, 1950 Komaroff AL: Regional medical programs in search of a mission. N Engl J Med 284:758-764. 1971 This conclusion is based primarily upon testimony presented in support of legislation leading to the passage of Public Law 93-641 (see Ref 3) Havinghurst CC: Regulating Health Facilities Construction. Washington DC, American Enterprise Institute for Public Policy Research, 1974 Consad Research Corporation: An Evaluation of the Effectiveness of Loan Forgivenesses and Incentive for Health Practitioners to Locate in Medically Underserved Areas. Report on Contract HEW-OS73-68 for the Office of the Secretary, Department of Health, Education and Welfare, January 1973 Steinwald BB, Steinwald C: The Effect of Preceptorship and Rural Training Programs on Physicians’ Location Decisions. Chicago Center for Health Services Research and Development, American Medical Association, 1973 Mechanic D, Lewis C, Fein R: Increasing Access to Primary Care. New York, John Wiley & Sons, 1976

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Davis K: Financing medical care: implications for access to primary care. In, Primary Care: Where Medicine Fails (Andreopoulous S, ed). New York, John Wiley & Sons, 1974, pp 157-173 Hackett TP, Cassem MH, Raker JW: Patient delay in cancer. N Engl J Med 289: 14-20, 1973 Avnet HH: Physician Service Patterns and Illness Rates. Group Health Insurance, 1967, p 452 Marston M: Compliance with medical regimen: a review of the literature. Nurs Res 19:312-323. 1970 Green LW: Should health education abandon attitude change strategies? Perspectives from recent research. Health Educ Monogr 30125-48, 1970 Tagliacozzo DM, Ima K: Knowledge of illness as a predictor of patient behavior. J Chronic Dis 22:765-775. 1970 Hall VC: Statutory Regulation of the Scope of Nursing Practice-A Critical Survey. Chicago, Ill, The National Joint Practice Com- mission, 1975 Lewis C: The use of non-physicians in primary care. Presented at the Institute of Medicine, spring meetings, 1974 Appel GL, Lowin A: Physicians’ Extenders: An Evaluation of Pol- icy-Related Research. Minneapolis, Minnesota, InterStudy, 1975 Cardiovascular Diseases, Guidelines for Prevention and Care. Washington, DC, Intersociety Commission on Heart Disease Re- sources, p 404 Standards for Cardiac Diagnostic and Surgical Centers. New York, American Heart Association, 1973, p 6 Lewis CE, Hassanein RS: Continuing medical education: an epi- demiological evaluation. N Engl J Med 282:254-257, 1970 Egdahl RH: Foundation for medical care. N Engl J Med 288: 491-498, 1973 O’Donoghue PO: Evidence About the Effects of Health Care Reg- ulations. Denver, Spectrum Research Incorporated, 1974

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