Dr. Bestermann has earned nationwide attention recently with a blog entry titled The New Science of Vascular Disease. Dr. Bestermann is Medical Director for Integrative Services and a Preventive Cardiologist at the Holston Medical Group. He contends in his latest health care blog that 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 reduce disability and mortality while reducing costs in the management of chronic conditions.
The take-away message of that article is: "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." Dr. Bestermann's most current article uses military history and tactics for a comparative look at the way medicine is practiced today. He skilfully makes the point that: “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 and 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 model 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."CLICK HERE for the full report.According to Dr. Bestermann, "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."