“The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”
Crossing the Quality Chasm, Institute of Medicine, 2001
Medical leadership in the United States has not yet come to grips with the level of structural and systemic change that will be required to produce the dramatic improvements in the management of chronic conditions that are required to reduce disability and mortality while reducing costs.
In this same space, I recently published an article called “The New Science of Vascular Disease.” The take-away message of that article is this: one of the most important products of our medical system is optimal medical therapy for vascular risk factors. As a system, we don’t even come close to achieving conservative goals for global risk management and the latest work from Dr. Steven Nissen tells us that plaque progresses more rapidly when the LDL cholesterol is over 70 and the systolic blood pressure is 120. Most providers are not even shooting at those targets.
The objective observer today could make a better case that medical rather than military intelligence was an oxymoron. The US military and medical systems share many common features. The scientific and industrial revolutions have changed both endeavors at a pace that can barely be digested. The tools that we use have improved dramatically and properly applied can achieve results that were unthinkable 100 years ago.
When my son was studying at West Point, I learned that they spent what seemed an inordinate amount of time studying the American Civil War and I asked him “Why do you do that?” He said, “Generals get their soldiers killed by fighting the current war with tactics that were appropriate for the last conflict.” I have been haunted by that statement ever since. By any objective standard, the US military has done a much better job than our medical system of adjusting their structure and practice to the new technology that is available to them.
Translation is a major emphasis – perhaps the major emphasis – in all military education. All army enlisted and officers are trained as generalists and the infantry, the organization of generalists, is the “Queen of Battle.” All of the specialty arms in the army serve the infantry as the main focus of army operations. The leaders of the army are required to attend sophisticated schools at each stage of promotion in part to prepare them to incorporate new technology..All of this has developed out of that concern that the stakes are enormous and leaders get their soldiers killed by not translating new technology into practice.
Unteroffizier Paul Scheytt could not believe his eyes. During the week leading up to this moment, July 1, 1914, he and his troops had endured artillery barrages so vicious that the British high command was quite sure that all German forces in that section of trench had been annihilated. Indeed, he was just peering over the wall of his fortification after a final savage artillery bombardment, and there before him were thousands of British soldiers, so heavily laden with equipment that they could barely walk, moving deliberately toward his position. He and his fellow soldiers thought the British were insane. He was watching the beginning of the Somme offensive.
In that single day Scheytt and his fellow German troops would shoot down 60,000 young British men. These attacking troops had come at the Germans shoulder to shoulder and were annihilated in a murderous hail of fire from machine guns, repeating rifles, mortars, and breach-loading artillery.
How could such madness happen? The English generals did not change the tactics of the assault to take into account the tremendous changes in weapon technology. They did not translate new technology into practice. The British general Haig, who ordered the attack, was bright, well-trained and conscientious, but he caused thousands of young men to die because they were fighting with tactics appropriate 100 years before that day. The technical paradigm and science had changed, but the leaders had not adjusted structure and tactics to address those realities.
The British forces attacked across a broad front as western armies had done for thousands of years. Even as the American Civil War began, the broad frontal assault was still a reasonable strategy. The musket that was far and away the main weapon in use was only accurate at 40 yards. In the first battles of the Civil War, lining up in parade formation with the regimental colors leading the way and the band playing was completely appropriate. The armies would line up across a front two or three miles wide, march to within 40 yards of each other and fire by volley. There were casualties, but losses were reasonable and the tactics and technology were fairly well matched.
By 1863, when the battle of Gettysburg was fought, the dominant infantry weapon was no longer the musket but the rifle, which could reliably kill a man at 300 yards. When General Pickett led his infamous charge, his troops were crossing nearly a mile of open field and the Union defenders were protected by a stone wall. Pickett’s division had no chance and evaporated before it got anywhere close to the Union position.
The Union generals observed this slaughter first-hand, but in May of 1864, General Grant ordered one frontal assault after another against Confederates in trenches armed with rifles. None of these assaults had the remotest chance of success, and the Union Army of the Potomac suffered 60,000 casualties in that one month – a loss equal to the entire strength of the Army of Northern Virginia.
The paradigm had changed, the solution existed, but leaders of the Civil War and even of WWI did not change the tactics of the assault. Millions died as a result.
The solution to the changes in warfare really fairly simple. The method of attack had to change radically, and once that change was made, the impregnable defense paradigm changed to one in which the irresistible assault was the reality of the day. In a moment, we went from a world where the attack seldom succeeded, to a world where the well-designed and executed attack seldom failed.
Our tactics in dealing with chronic diseases lag the available technology to a similar extent and with similar casualties. Multiple major paradigm shifts have occurred in the new science of vascular disease. Heart attack is not a plumbing problem. It is not a problem of a progressive fixed blockage that can be fixed with a stent. Stents do not prevent myocardial infarction in stable patients.
Still, our system practically functions as if it is all about the blockage. Heart attacks are prevented by stopping smoking, diet, exercise, and a coordinated, integrated pharmaceutical protocol aimed at preventing plaque rupture by aggressively treating hypertension, high cholesterol and type 2 diabetes. Today, a carefully designed program of 6 four dollar prescriptions from WalMart can make an enormous difference. Multiple clinical trials have demonstrated the effectiveness of optimal medical therapy and that is clearly our challenge – to produce best medical treatment for risk factors consistently. Our current system of care has no more chance of success than the British attack at the Somme.
We require the same drastic reorganization required of the military after WWI. We are currently organized as if hypertension, type 2 diabetes, high cholesterol, high triglycerides and gout were separate conditions. They are not.
For the majority of patients, these conditions are part of the metabolic syndrome, a single condition that is the result of a diet rich in fat, sugar and processed carbohydrates, coupled with inactivity, resulting in increased abdominal weight. The metabolic syndrome and its later stages of pre-diabetes and diabetes are the leading cause of heart attack, stroke, and other serious vascular complications.
“Changing systems of care” is not just something for the worker bees. From top to bottom our system functions as if the science of the last 20 years never happened. Even our major academic centers are still organized as if these are unrelated conditions. Most medical schools have hypertension clinics, lipid clinics, and diabetes clinics. The professionals who man these clinics organize meetings sponsored by the American Society of Hypertension, the National Lipid Association, and the American Diabetes Association respectively. Then, when these anachronistic systems fail to produce optimal medical therapy and these patients experience a plaque rupture in a coronary artery and a resultant heart attack, the patient is referred to a cardiologist. When they develop a clot in a neck artery, they see a neurologist and when they develop gout we send them to a rheumatologist.
The whole arrangement is an anachronism based on decades-old science. Until we address these fundamental realities and make the adjustments in our systems of care demanded by new technical developments, optimal medical therapy will remain an elusive dream. Until we seriously attack these structural issues, we cannot produce patient centered care.
And so, the obvious question becomes: “What changes in structure and practice would be the medical equivalent of a mechanized infantry division in the management of cardio-metabolic conditions?” The best answer today would come from a combination of “Crossing the Quality Chasm” from the Institute of Medicine (IOM) and the Advanced Medical Home from the American College of Physicians (ACP).
The IOM recommended that focused programs be developed for 15 priority conditions that included diabetes, high cholesterol, hypertension, ischemic heart disease, and stroke. Peripheral arterial disease and congestive heart failure are strongly related conditions and the whole could be managed by internal medicine and family practice providers with a special interest in these conditions. A special focused effort to address all of these conditions in a coordinated integrated way could be housed in a cardio-metabolic center of excellence within a larger practice.
That cardio-metabolic center-of-excellence team would assure that the IOM system for producing optimal medical therapy was consistently implemented along four key principles:
- Organize evidence-based care protocols consistent with best practices
- Organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions.
- Develop the information infrastructure to support the provision of care and measurement of care processes and outcomes.
- Align the incentives inherent in payment and accountability processes with the goal of quality improvement.
The ACP document on the advanced medical home describes a number of models:
“In the advanced medical home model, patients will have a personal physician working with a team of health care professionals in a practice that is organized according to the principles of the advanced medical home. For most patients, the personal physician would most appropriately be a primary care physician, but it could be a specialist or sub-specialist for patients requiring ongoing care for certain conditions, e. g. severe asthma, complex diabetes, complicated cardiovascular disease, rheumatologic disorders and malignancies…Principal care, that is, the predominant source of care for a patient based on his or her needs could be provided by a primary care physician or a medical specialist..”
This is a great new opportunity for primary care to rise out of the ashes, to produce a very high value product and to be paid fairly for it. Current systems and practice do not produce optimal medical therapy consistently. The cardio-metabolic centers of excellence proposed here would be manned by generalists assembled in a kind of medical special operations unit, bringing together just the right mix of assets to accomplish the reliable production of optimal medical therapy for large numbers of patients. The expectation would be that the providers would train and retrain to continually improve their practices as the science and technology continue to change.
We could train generalists to become part of special teams that change with the science and technology. They would not practice primary care in the usual sense; they would not attempt to be everything to everyone. They would be the ideal principal physicians for patients with vascular risk factors and a history of vascular events. Half the population dies of these conditions and they produce nearly half the cost of care. Effectively addressing this single collection of chronic conditions offers the most impact for the cost and effort of any that I have seen proposed.
Over the last two years, our group has run a cardio-metabolic center of excellence. In providing coordinated integrated care for these conditions we have been able to show dramatic results in patients referred by the 140 clinicians in our larger practice. The entire practice has a quality culture and good outcomes. Even so, these patients have realized average reductions in the LDL of 60, A1c of 1.8, triglycerides of 200, BP of 11/9 and weight loss that averaged 9 pounds.
Good relationships and high provider satisfaction come as we attain good referral volumes from a doctor. Patient satisfaction and persistence with the program is very high. Still, most physicians in the group do not yet refer to the program.
Medical leadership has not begun to produce the level of structural change to adapt to new technology. We are in a time that will precipitate great change. Following the science, we can restructure medicine in ways that will improve lives and save enormous dollars.
William Bestermann, MD, is a Preventive Cardiologist and Medical Director for Integrative Services at the Holston Medical Group in Kingsport, TN.