Cardiovascular Disease (Mis)Management: Billions For Acute Care, Crumbs For Prevention

Everyone in health care pays lip service to prevention. Wellness programs are all the rage among employers. But Dr. Daniel E. Forman, director of cardiac rehabilitation at the Brigham and Women’s Hospital, and Dr. Philip A. Ades, director of cardiac rehabilitation and prevention at the University of Vermont College of Medicine, assert that in reality, prevention efforts are undervalued, and physicians that focus on prevention are marginalized by the medical community. Among other problems, prevention and rehab programs are meagerly reimbursed. But the overarching obstacle, they say, is there remains, “a preference for hospitals and caregivers to promote expensive, high-tech procedures that garner prestige and immediate profit in a fee-for-service healthcare model.”

This post, jointly written by Dr. Forman (who is set to launch the Brigham’s new cardiac rehab center in Foxborough later this month) and Dr. Ades, focuses on cardiac rehabilitation, where the economic divide between prevention and aggressive treatment is particularly stark. It offers an important lesson for policy makers trying to revamp a system so profoundly entrenched:

The capacity of interventional cardiologists to dramatically avert death during an acute heart attack by deploying coronary stents has led to disproportionate financial and political prioritization for what is only one aspect of therapy for coronary artery disease (CAD). In fact, the underlying atherosclerotic process, which involves the thickening and hardening of the artery walls, is a lifelong and diffuse disease, starting in one’s early life and progressively worsening over decades as cardiac risk factors and their detrimental impact accumulate. So even while urgently placed stents can save the lives of heart attack patients by restoring vital blood flow through a discrete arterial blockage around the heart, they do little to moderate the overall progression of disease. With or without stents, there remains a powerful mandate for prevention as the most fundamental aspect of CAD management, i.e., only prevention (exercise, nutrition and medications) can moderate progression of the atherosclerotic process to minimize cardiac symptoms, heart attacks and other coronary events.

Nonetheless, in contrast to the glamour and heroics associated with an acute intervention to stave off death, the lifelong self-discipline and medical detail needed for effective CAD preventive therapy rarely commands similar attention or resources among patients or even their physicians. Given today’s national discussion regarding health care costs, it seems particularly important to emphasize that CAD prevention can extend life and prevent costly cardiac procedures and hospitalizations for acute coronary events. Nonetheless, cardiac rehabilitation and other cardiovascular prevention programs are often undersized or even closed as there remains a preference for hospitals and caregivers to promote expensive, high-tech procedures that garner prestige and immediate profit in a fee-for-service healthcare model.

JM is a clinical case that exemplifies the ironic dynamics that replay themselves on a regular basis in our best cardiovascular centers. He is a 54-year-old male with several weeks of chest pain (CP) that occurs when he exerts himself. While he was not on any medication for his chest pain, he arrived at the hospital during one of his episodes, and within minutes he was referred for an emergency catheterization. The catheterization images showed diffuse coronary artery disease including a discrete 70% lesion in one vessel. A coronary stent was recommended by the cardiologist. The CP resolved. The bill was over $25,000 for this successful procedure.

JM was also overweight, hypertensive and had a high blood glucose and an abnormal cholesterol profile. Over the decade preceding his symptoms of CP, he was sedentary and progressively gained weight with little attention to the quality of his diet. Moreover, he worked long hours in an office that had become very tense as the economy deteriorated. Exercise and healthful lifestyle routines languished amidst JM’s escalating professional and personal pressures. He started eating more and sleeping less and saw his physician only rarely.

After his catheterization, while JM went to his internist’s office 3 times over 12 months, each visit lasted 10 minutes and consisted only of brief physical exams by the physician assistant. JM’s blood pressure medication was increased once, but still his weight, glucose, blood pressure, and lipid parameters all worsened and he developed Type II diabetes. On his third visit, JM complained of feeling tired for which he was referred back to the cardiologist. However, even before seeing the cardiologist, a nuclear stress test (costing over $3,000) was ordered and based on its results, JM was told he needed another catheterization and probably another stent. Ultimately, the stress test, a repeat cath, and 2 additional stents cost $35,000. Following this JM still felt tired, and now was now more anxious and even depressed about the fact his CAD was worse. He was also struggling with the new complexities of kidney disease as his kidneys were harmed as a side effect of the heart procedures in the setting of his diabetes.

JM’s story highlights today’s typical under-emphasis of preventive measures, and over-emphasis of medical procedures. Even while stents provide unequivocal benefit to reduce mortality in the face of a heart attack, their benefits for chronic CAD, especially in those without progressive or severe CAD symptoms, are less certain. While considerable attention and expense are accorded to the American Heart Association (AHA) and American College of Cardiology (ACC) initiatives to improve timely access to stents in acute heart attacks (termed “door-to balloon times”), a similar response to AHA/ACC’s initiatives on prevention has not occurred. Few researchers are measuring the “door to cardiac rehab time.” Hospitals and physicians tend to promote high-tech procedures and facilities as they are perceived (or misperceived) by patients and caregivers alike as key measures of quality and secondarily because they garner relatively superior profit.

Given these patterns, the recently published COURAGE Trial generated attention in the medical community when it demonstrated that preventive medical management achieved similar clinical outcomes as did stents for the care of chronic CAD, i.e., the expense and priority accorded to stents for many patients with chronic CAD were not supported by the data. Another study by Hambrecht and co-workers from Germany compared the efficacy of exercise training to stenting in a group of chronic CAD patients. After one year, the patients who exercised in lieu of receiving stents had less chest pain, fewer cardiac events, better measures of functional capacity, better quality of life, and less progression of CAD throughout the rest of their coronary arteries. It is hard to read COURAGE and Hambrecht’s study and not question a therapeutic approach that prioritizes stents over prevention measures in these patients.

Certainly, these issues are not so black and white. Recent advances in catheter technology and associated anti-thrombotic therapy have led to continuous improvement in percutaneous coronary interventions (PCI), or angioplasty, such that many argue that COURAGE is essentially dated, i.e., that if repeated, contemporary stents for chronic CAD would lead to better outcomes. However, the fact that imaging and PCI are also associated with high cost and profit remains noteworthy. The estimated charges of PCI currently range from $25,000–$35,000 (for catheterization procedures and the related hospitalizations). With over 850,000 cases performed each year in the United States (US) alone, this represents over $20 billion annually for the US Healthcare System. The concept of spending a relatively greater proportion of healthcare expenses on prevention as a means to mitigate the exorbitant cost of procedures remains an important consideration independent of the evolution of technology.

Cardiac Rehabilitation (CR) provides a conspicuous example of how prevention-oriented therapy has been overshadowed by current preoccupations about stents. Initially developed in the 1970’s as hospital based exercise plans, CR evolved into multifaceted exercise, nutritional, and behavioral programs. Even in the context of modern day therapy, a recent analysis shows that CR provides an additional 25% decrease in cardiac and total mortality, along with improvements in mood, quality of life, functional capacity and cardiac risk factors such as blood pressure measures and cholesterol profiles. Yet, CR remains massively underutilized. Another recent analysis found that only 14% of Medicare patients with heart attacks and 31% of patients with bypass surgery attended CR, and fewer still among women and minorities. Even after the AHA/ACC issued guidelines to make CR a “standard of care” after heart attack or bypass surgery, abysmal referral patterns have persisted. Reimbursement for these programs is one part of the problem. Many 3rd party payers have progressively curtailed CR payments and shortened program duration for their subscribers. CR programs usually have a difficult time breaking even financially.

In Boston, a city renowned for its medical care, almost every hospital has struggled with the issue of how to even include and integrate CR into their programs, despite a perception of offering all patients comprehensive care. Whereas stents are available to all, and are prioritized by all levels of the caregiving model as an elemental part of CAD therapy, CR is an afterthought that often falls through the cracks. CR programs and referrals are similarly rare in NYC and Philadelphia hospitals. First, it is difficult for the hospitals to justify the expense of space and resources for programs which notoriously lose money despite their low-tech effectiveness. Second, it is complicated to develop efficient programming that extends to the full range of eligible patients, i.e., those from the inner city as well as those from the affluent suburbs, those who are young as well as those who are old, those who are highly educated and well-informed as well as those who are not. In some cases, CR is relegated to a suburban hospital affiliates where floo rspace and parking is relatively cheaper, but where logistic limitations serve to restrict the patient population who can attend (i.e., implicitly excluding inner-city patients without cars).

Interestingly, the CR program at the University of Vermont in Burlington has been substantially more successful. With the support of the hospital’s cardiology program, referral to CR has been considered the standard of care and thus extends to the majority of the hospital’s CAD patients. Why does CR work better in Vermont than in Boston or New York? Are city dwellers too busy to find time to exercise and focus on prevention ? Is travel to the program and parking too stressful or logistically unfeasible? Despite inherent obstacles, we suspect that if cardiologists emphasized the importance of prevention and encouraged their patients to enroll in CR as a means to get this going, more patients would participate. Parenthetically, we note that even as payments to the hospital for CR are shrinking, the vast majority of medical insurance plans including Medicare still cover CR after a heart attack, stent or bypass surgery.

Of note, Brigham and Women’s is about to open a particularly dynamic new cardiac rehabilitation program in the dazzling new Brigham and Women’s/Mass General Medical Building at Patriot’s Place in Foxborough. While distance from the Boston campus may limit access to some patients, this location also facilitates increased access to top-quality cardiovascular prevention/exercise programming to those living in its surrounding communities. The Foxborough program is gearing up for biweekly exercise/wellness sessions that extend over months as well as options for much shorter-term programs that better address the needs of patients who live further away and/or who mostly need education, guidance, and reinforcement for wellness regimens they plan to continue independently.

Getting back to JM, if his original symptoms of angina had responded to anti-anginal medications (which were never tried) and if he had been put on a cholesterol-lowering medication, aspirin, and an exercise and weight loss program, the stents would most likely not have been necessary and two costly hospitalizations would have been avoided. With exercise and roughly 10 lbs of weight loss, there is a good chance that his diabetes would have been prevented or postponed, and that the kidney damage from the combination of angiographic dye and his diabetes would have also been avoided.

However, the paradox of prevention is that he would not have been able to identify the days when his two stenting procedures were averted, nor will he know the day when a myocardial infarction did not occur, i.e., far less dramatic than the 90 minutes of tumult when the stent was placed that “saved his life,” and when the interventional doctor and the technologically advanced hospital became his heroes.