Today’s post comes to us from Harlan Krumholz, M.D., F.A.C.C., the Harold H. Hines, Jr., professor of medicine at the Yale University School of Medicine. Harlan is a well-known leader in advocating for improvements in cardiovascular quality. Not only did he lead ACC’s successful quality improvement program “D2B: An Alliance for Quality,” he currently serves as the co-chair of the Hospital to Home (H2H) steering committee. Outside of his work with the ACC, Harlan is also heavily involved in the Centers for Medicare and Medicaid Services’ efforts to develop national measures for public reporting of hospital performance.

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Over the last several decades, the cardiology community has led our profession in generating new knowledge and seeing it applied for the benefit of our patients. Recently, we dramatically improved door-to-balloon times – moving in rapid progression from an era where only one-in-three patients were treated within the guideline-recommended 90-minute timeframe to now, where almost 90 percent of our patients are treated within that benchmark. Remarkable.

Another chance to lead lies before us. On Oct. 22, the ACC, in partnership with the Institute for Healthcare Improvement, will launch a major quality improvement initiative called Hospital to Home (H2H)… this time focusing our quality efforts on readmission rates. Currently, about 20-25 percent of our patients hospitalized with an acute myocardial infarction (AMI) or heart failure are back in the hospital within 30 days. Many of these admissions are preventable through improvements in the transition from inpatient to outpatient status. Unfortunately, we have often neglected this vulnerable transition period for patients.

Gaps in Care
We have many obvious gaps in care – patients often leave without information about the hospitalization being transmitted to other caregivers in a timely way; without access to medications; without appointments being set; and without an emergency plan for if their condition suddenly worsens. Studies have shown since the 1990s that improving the handoff between the hospital and the “home” can lead to a reduction in readmissions by addressing these gaps. Our fragmented health care system places many barriers in front of health care providers in putting known methods into practice. To reduce readmission rates, we’ll need to make special efforts to focus on transitions and most importantly – to focus on the patient, specifically, making efforts to ensure that the patient is ready and knowledgeable enough to manage their care – and that the system is poised to provide the support they need.

H2H Goals – Just the Beginning
H2H will assist providers in overcoming the systemic barriers to improving readmission rates. The initiative is committed to reducing 30-day all-cause, risk-adjusted readmission rates for patients with a diagnosis of heart failure or AMI by 20 percent nationally by 2012. In HF, that would take the rate from about 25 percent to about 20 percent. This goal is ambitious – but we aspire to produce a substantial benefit for patients.

H2H will leverage other national initiatives contributing to a reduction in readmission rates and will harness the collective knowledge, creativity and energy of its key strategic partners -- Kaiser, the Veterans Administration, the American Hospital Association, The Joint Commission, PREMIER, HCA -- and others to reach this goal. In my opinion, the 20 percent reduction is just the beginning of what we can achieve through our collaborative efforts. The path is more challenging than ever because of our goal of actually affecting patient outcomes, but we are bringing together expertise, resources, tools and a mechanism for us to learn from each other to meet this goal.

For those of you who want to be part of this effort, you will not be alone. We already have more than 250 facilities (e.g., hospitals and medical practices) that have joined us. Teams will be anchored at hospitals but will stretch across the continuum of care. We will track progress and, ultimately, assess whether we decreased preventable readmissions through improved care. We want this effort to equip teams for success.

Join Us in Reducing Preventable Readmissions
For more information, visit: http://www.h2hquality.org/, or email hospital2home@acc.org. H2H officially launches Oct. 22 with a Webinar explaining the initiative in greater detail. To join the Webinar, please register in advance online. If you are unable to attend on Oct. 22, you will be able to access the Webinar archive through our Web site.

We want to again show the nation that the cardiovascular community knows how to get results for our patients. We hope you’ll join us for this exciting initiative.

* Dr. Krumholz's post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!

A paper published in the May 19 issue of the British Medical Journal found delay in door-to-balloon (D2B) time is associated with higher mortality rates in patients undergoing PCI. (Surprise!) The study was based on data from the ACC's National Cardiovascular Data Registry (NCDR). Median D2B time was 83 minutes. The adjusted mortality rate for PCI by 30 minutes was 3.0 percent, while those with D2B times of 240 minutes had a mortality rate of 10.3 percent. The goal of the D2B Alliance for Quality (90 minutes) yielded a mortality rate of 4.3 percent.

The authors state that "their data support calls for an 'as soon as possible' standard for patients undergoing primary percutaneous coronary intervention." But how fast is too fast? Share your thoughts ...

Tomorrow in Room W101, ACC.09 will feature a “D2B: Sustain the Gain” symposium featuring experts in the field discussing current topics in STEMI care. If you’re asking yourself right now: I thought it was called “D2B: An Alliance for Quality?” – you’re right, it was. “D2B: Sustain the Gain” represents Phase 2 of the campaign. Since Phase 1 (An Alliance for Quality) was such a success [go to the Participant’s Workshop tomorrow morning, from 7 – 9 a.m. at the Rosen Centre Hotel, Salon 3, to hear why], the ACC is using D2B: Sustain the Gain to figure out how we can maintain those gains. It’s clear that there are many challenges inherent in sustaining D2B times of 90 minutes or less. We’ll be developing materials and support tools that hospitals need to continue their success.

Quality efforts like D2B are crucial in making a difference in health care reform efforts. The federal government doesn’t have to tell cardiologists to improve quality – cardiologists are working together to do it themselves. Through D2B, we’re making serious in-roads in improving quality – and I know from my visits to the Hill, lawmakers are taking notice.

Meanwhile, stay tuned this summer for the ACC’s newest national quality improvement initiative, Hospital to Home (H2H). With H2H, we’ve set a measurable goal of reducing the 30-day all-cause readmission rate for patients with heart failure or heart attack by December 2012. To register for this program in advance visit: www.acc.org/h2h/enrollment. This is an exciting opportunity to improve patient care and reduce preventable and costly readmissions. We have a great partner in IHI for this initiative as well.

The ACC is obsessed with quality. It’s the focus of everything we do, not only for science and education but also advocacy (I mean, our health care reform campaign is called QUALITY First). In fact, this blog was created so that the College could talk about quality.

Supporting this mission, ACC Annual Scientific Sessions are always overflowing with ways to improve quality. On Sunday, there was tons of fantastic programming, including the Simon Dack and Louis Bishop lectures, and sessions on bringing quality into practice and examining the value of pay-for-performance. Other “can’t be missed” events for this year include: 

• Delivering Cardiovascular Care in Different Health Care Systems, today, 12:15 p.m. – 1:45 p.m., Room W104
• Challenges in Health Communications: Meeting and Exceeding Patient Expectations, today, 2 p.m. – 3:30 p.m., Room W230
• The American College of Cardiology Door-to-Balloon: Sustain the Gain Symposium, tomorrow, 10:30 a.m. – 12 p.m., Room W101
• Evaluating and Improving Quality in Cardiovascular Imaging: Challenges and Opportunities, tomorrow, 12:15 p.m. – 1:45 p.m., Room W110B

Also, we’re trying to gage how members feel on health care reform through a survey that can be found in your portfolio bag. If you fill it out fast enough this morning and return it to ACC Central, booth 2062, there will be a free gift waiting for you (I’m not telling what it is, but it’s quite useful). For those of you a little slower in checking out ACC Central, there might not be any gifts left – except for the gift of helping ACC better understand its membership. That could be the best gift of all.

The Joint Commission Journal on Quality and Safety recently published an analysis of hospitals enrolled in our Door-to-Balloon (D2B) Alliance for Quality to determine why hospitals enroll in quality improvement initiatives. The findings: Hospitals that enrolled in the D2B Alliance were significantly more likely to be larger, nonprofit teaching hospitals. Improving quality and “doing the right thing” were commonly reported reasons for enrolling, but hospitals also reported improving market share, meeting regulatory and accreditation requirements, and enhancing reputation as primary reasons for joining.

This is important and instructional research to help us design future quality improvement initiatives. The findings from this incredibly successful initiative are just beginning to roll out. We’ll have what I think will be powerful data on the success of the program coming this spring.

"Saving time, saves lives" – that's been the motto for the ACC's door-to-balloon (D2B) campaign. Since the launch of the "D2B: An Alliance for Quality" at AHA in 2006, more than 1,000 hospitals in the U.S. and abroad have signed up to reduce their D2B times to the guideline-recommended 90 minutes or less.

During my time at AHA there has been lots of talk about D2B and the next steps – and why shouldn’t there be? The D2B campaign has helped spark change in the practice habits of hospitals around the world and is continuing to push hospitals to make evidence-based improvements in the care they provide. These changes have had a measurable impact on patient outcomes, including the most important patient outcome of all: mortality.

The ACC is keeping up its efforts to encourage participation in this initiative; in fact, there was significant interest from our cardiovascular colleagues in China at last month’s Great Wall International Congress of Cardiology. We’re keeping up the good work! So is the AHA – they have a similar program called "Mission: Lifeline" that tackles reducing door-to-reperfusion times.

As I head back to Washington, D.C., where talk of reforming the health care system has reached a loud crescendo, it’s initiatives like D2B and events like AHA and ACC.09 that we need to promote as tools for reform. All are keys to bridging the gaps between science and practice and providing tools and strategies to improve quality. Congratulations to everyone who helped make AHA happen. I’m looking forward to the same success in just a couple of months at ACC.09!