The Detroit Medical Center's (DMC) new Cardiovascular Institute (CVI) has produced faster angioplasty times, or ER-to-balloon times, with lower mortality and morbidity rates and shorter hospital stays as a result. By combining CVI's Cardio Team One process of stationing cardiology specialists onsite 24/7 with acute care technology—including a percutaneous left ventricular assist device (pLVADs)—the CVI approach is saving more PCI patients than ever before, while also improving quality of life and helping to keep down the cost of heart care.
Delivering top cardiac care in record time
At the eight-hospital DMC, on which varied cardiac patient populations often depend for emergency care, the recently launched CVI has been setting records for average angioplasty ER-to-balloon time—after establishing a unique process for rapid delivery of PCI.
As documented in a groundbreaking study, presented at the Transcatheter Cardiovascular Therapeutics Conference (TCT) in 2008, CVI's Cardio Team One (CTO) system for speeding up cardiac interventions by stationing heart doctors, nurses and technologists onsite 24/7 has helped cut the average angioplasty procedure time to about 45 minutes—while the national average is greater than 90 minutes for U.S. hospitals.
More than four years in the planning, the launch of the CVI about 18 months ago also marked the implementation of "a new philosophy of cardiac care," according to CVI Founder and President Theodore L. Schreiber, MD, a veteran interventional cardiologist who began designing and assembling the CTO system of cardiac care soon after signing on as the DMC's specialist-in-chief of cardiovascular medicine in 2004.
"When it comes to caring for acutely ill cardiac patients, it's pretty obvious that time is muscle," says Schreiber. "What we set out to do at CVI was to build a PCI facility that's keenly sensitive to the benefits that can flow from treating cardiac patients rapidly, while also providing them with the latest in LV assist and other cutting-edge cardiac technology."
"Our CTO system is based on a simple, but highly effective approach. We've stationed the doctors and the other cardiac staff at the hospital around the clock—which means they're ready to go into action the moment a heart patient enters the ER."
Schreiber, who estimates that he's performed more than 20,000 heart procedures over the course of his 33-year career, adds: "For the first time, we're asking the doctors to wait, rather than the patients. After about three years of compiling data and publishing our results, it's clear that this approach is paying significant health dividends."
Schreiber, who directs a staff of about 50 cardiologists (of whom about 35 are interventional cardiologists) at CVI, presented research data at TCT 2008, showing that reducing the angioplasty ER-to-balloon time to about 45 minutes would save the lives of up to seven patients out of every 100 who could previously have died.
Since then, he says, the data compiled on CVI acute-care patients have confirmed that the CTO approach is saving lives at about that rate—and that many more cardiac patients are now enjoying enhanced quality of life, after rapid treatment at CVI protected their hearts from damage that would have occurred during longer response times.
Partly as a result of these improved cardiac outcomes, CVI's U.S. News & World Report ranking in "Cardiology & Heart Surgery" improved from No. 44 to No. 36 in last year's annual survey.
Latest & greatest of cardiac technology
While Schreiber and his CVI colleagues are convinced that rapid response in the catheterization lab is a crucial component of effective cardiac care, they also underline the importance of making sure that cardiac procedures [and planning] are "physician-run…with strong advice from cardiology staff, day in and day out."
"That's the model we work from at CVI and while to some extent it differs from the standard model across the country of administrator-run specialty hospitals," Schreiber says. "We firmly believe that the most successful hospitals in this country tend to be those that are physician-run and with physicians as CEOs."
|'Real-world’ Outcomes for High-risk, Elective PCI at Detroit Medical Center (60 patients)|
|Types of Procedures||Mean|
|Left main PCI||55%|
|Left anterior descending PCI||67%|
|Left circumflex PC:||55%|
|Right coronary artery PCI||20%|
|Bypass graft PCI||8%|
|Mean inflation time||33 seconds|
|Duration of pLVAD* support||38 minutes|
|Duration of procedure||149 minutes|
|Angiographic success rate||96%|
|*pLVAD: percutaneous left ventricular assist device. Source: Cardiovasc Revasc Med 2011;12(5):299-303.|
To illustrate his point, Schreiber points to a study of 300 top-ranked U.S. hospitals, published online in July in the Social Science & Medicine (IZA DP No. 5830), which found that quality measures were about 25 percent higher for hospitals when the doctors were in charge of clinical procedures and related administrative planning and design.
"At CVI, the physicians are running the shop, and as a result, we've been able to deliver components like CTO, with results that are clearly contributing to improved patient outcomes," he says. "The numbers speak for themselves. If heart attack patients present to an ER at the DMC without [cardiogenic] shock or [needing] resuscitation, the survival rate is 100 percent. And that's substantially better than the historical controls, which would be between 92 and 95 percent.
"This indicates that lives are being saved here and they're being saved routinely, as a matter of course—thanks to our ability as physicians to determine treatment, select and apply the latest technology and make decisions about the most effective manner of care delivery."
Nowhere is the "vital importance" of physician management of cardiac care services more evident, says Schreiber, than in the area of PCI technology—a rapidly expanding and complex field that requires constant review and evaluation by cardiology specialists. "There's no doubt that cardiac care is changing rapidly today and it's not enough to merely keep up. To continue to deliver the best possible care, you actually have to stay a little ahead of the latest technology, so physicians can take advantage of these remarkable tools and employ them in ways that are most helpful to patients, especially for patients that are acutely ill," he says.
The challenge of blending new technology with clinical practice methods is especially formidable, says Schreiber, when interventional cardiologists find themselves treating "the sickest cardiac patients of all—those who traditionally haven't been candidates for open heart surgery because they're simply too ill and too weak for it."
He adds, "In the past, there hadn't been the expertise or the technology available to deal with these 'worst cases' in the cardiac cath lab. But, now we're beginning to see technological advances—such as the Impella left ventricular assist device
The CVI chief notes that Impella can be brought into the cath lab within five minutes "on either an elective or an emergency basis. The [femoral] insertion is safe and easily managed. Lo and behold, all of a sudden you have a pump providing two and a half liters of blood a minute."
"Because of these technological advancements, and because of the extensive experience of our senior interventional cardiologists at CVI, we can now fix the most complex structural and cardiac disease-related obstructive problems in patients that have traditionally been too sick for open heart surgery," Schreiber says.
Schreiber adds that CVI patients who are too sick for CABG actually have statistically better outcomes—when assisted hemodynamically —than those who are able to undergo the trauma and infection risk of traditional cardiac surgery.
"The CVI approach to patient management has undoubtedly been a major accomplishment of our program, along with our CTO-reduction of angioplasty ER-to-balloon times. Additionally, there is new benchmark economic data demonstrating Impella's cost-effectiveness is essentially a win-win situation for the hospital and the patient."
CVI's cardiac assist program is one in which very sick patients were not only treated, but their heart muscle recovery was the main focus and goal. This program has further strengthened CVI's outcomes and enables its mission of providing optimal patient care to be realized.
With the development of this cardiac assist program and Cardio Team One, CVI has established DMC as a regional referral center for these sick patients. Now, experienced interventional cardiologists from other centers bring their high-risk patients to DMC for care.
Safety, feasibility to boot
Another significant accomplishment at CVI, suggests Schreiber, was the recent publication of a peer-reviewed study (Cardiovasc Revasc Med 2011;12(5):299-303).
This study followed 60 high-risk complex patients, all of whom had been hemodynamically supported with the new pump technology during catheterization-based removal of cardiovascular blockages. Although the patients had multiple risk factors (including hypertension, diabetes, chronic pulmonary disease, prior MI and prior bypass surgery) and had been "deemed inoperable by the cardiac surgeons or were offered bypass surgery but declined," only one patient died during a procedure—and the rates (after 30 days) of MI, stroke, target vessel revascularization and urgent bypass surgery were all 0 percent.
For Schreiber, the study powerfully underlined his own assessment of the value of aggressively and completely treating PCI patients. "The data we came up with are clear and indisputable," he says. "They show that even the sickest PCI patients have a therapeutic alternative today.
The Impella is "an increasingly important prophylactic tool for CVI because it can be used in so many different kinds of procedures where maintaining adequate blood supply is paramount." Many of these patients could not be treated prior to new technologies available today because the procedure was too risky and left the patients with no treatment options.
Attacking heart disease at the root
Along with reducing PCI treatment times and adopting new coronary care technology, CVI also has been focused on a third urgent objective: disease prevention and heart health education.
In Detroit, where soaring unemployment and a declining population have combined to create one of the most economically challenged urban communities in the U.S., high rates of heart disease that are linked to mortality and morbidity continue to be a major public health issue.
"In terms of societal importance, our challenge at DMC is to continue to find ways to prevent heart disease before the patient winds up in our ER," says Schreiber. "Detroit is one of the most economically afflicted cities in the U.S., and that's part of why it's one of the sickest cities as well." In Detroit, 70 percent of our heart patients are clinically obese and at least 50 percent are hypertensive.
"Our city has one of the highest mortality rates for heart disease in the U.S., but because of the way we've staffed our CTO program [with cardiologists] 24/7, the good news is that our cardiac patients are not seen initially by an intern or by a medical student," he says. "Instead, they get the skilled interventional cardiologist to perform their initial evaluation, while also designing their treatment plan."
Along with providing this "increased access" to the high quality heart care for a "very sick population of patients," CVI maintains a "robust and innovative" prevention and education outreach program.
"When it comes to our public education program, CVI's goal is to try to keep patients from winding up on our cath lab tables," says Joel K. Kahn, MD, medical director of wellness programs, preventive cardiology and cardiac rehabilitation at DMC. "We take a very progressive approach in which, among other things, we're reaching out to Detroit junior high schools with lots of helpful information about eating right, exercising, smoking and all the rest."
At CVI, which is now performing more than 1,800 coronary angioplasties and 1,500 to 1,600 peripheral angioplasties (along with about 200 structural heart procedures) each year, the mood is definitely hopeful and upbeat. "There's no question but that heart disease is a major public health threat in cities like Detroit these days," says Schreiber.
Mahir D. Elder, MD, who along with CVI cardiologists Hamid Sattar, MD, and Kirit Patel, MD, has extensive experience in peripheral revascularization therapy: "There's no doubt that some of the best medical care we can give people is to help them avoid the kinds of lifestyle-related risk factors that can contribute to making them patients in a CVI catheterization lab," Elder says.
For Schreiber, accomplishing CVI's "societal mission" requires some business sense—and a solid grip on the financial bottom line, accompanied by the medical savvy required to run a busy urban heart center.
"Thirty years ago, someone of my age having a small heart attack had a 20 percent chance of dying in the hospital but now any patient of any age [and even with a major heart attack] has a less than 1 percent chance of dying in the hospital, with optimal treatment," says Schreiber.
"Really, the take-home message is that CVI understands that cardiac care is changing all the time—and that the key to providing the best care for the broadest segment of the population is to keep making a constant effort to push that envelope."
Tom Nugent is a freelance writer based in Michigan.