Prevention: The Most Effective Heart Medicine
Innovations in cardiac care don’t necessarily include wires, plastic and metal. Though shiny new interventional devices get a lot of attention from the medical press, investors in device manufacturers and cardiac surgeons, what Twin Cities’ employers should care about most are innovations in patient care delivery that prevent workers from needing invasive heart procedures in the first place or those that keep employees as healthy as possible afterward, so they don’t need to go for more care.
That’s where the money is in terms of lost productivity at work on the front end and higher claims and premiums on the back end.
Twin Cities Business spoke with cardiologists and administrators from several major heart programs in the metro area about the innovations they’re making in cardiac prevention, intervention and wellness, plus the tips they can offer employers to keep their workforces heart-healthy.
Identifying at-risk patients
As the health care industry transitions from a reimbursement model based on volume (the number of procedures done) to one based on value (were the outcomes of those procedures worth the cost?), providers increasingly are focused on population health. They’re assuming the financial risk for the health care needs of a given population under value-based reimbursement contracts with health insurers, which pay providers a fixed amount per person per month. Consequently, it’s in the providers’ best interest to keep that patient population as healthy as possible.
One heart program focusing on population health is the Minneapolis Heart Institute at Abbott Northwestern Hospital, part of Allina Health. The MHI runs a preventive cardiology clinic dedicated to identifying patients at risk for heart disease or in the early stages of heart disease, before they require more serious interventions.
“Preventative cardiology is its own specialty now,” says Dr. William Katsiyiannis, clinical director of the heart rhythm management program at the MHI.
One of the cornerstones of that specialty is the coronary calcium CT scan, which essentially scans the arteries of the heart for specks of calcium that are correlated to artery-narrowing plaque in blood vessels. The results determine a score that estimates the patient’s risk of developing heart disease or having a heart attack. Although the test has been available for several years—the MHI now does about 8,000 per year, according to Katsiyiannis—the innovation that the clinic helped popularize in the Twin Cities market is charging a flat $100 fee for a scan.
“We think it’s the best $100 you can spend in health care,” says Katsiyiannis, who describes himself as a believer in health care price and outcome transparency.
Cost-conscious employers would be smart to cover such scans as a health benefit or pay for them directly. Employees with good calcium scores will be encouraged to continue behavior that has led to good heart health, and employees with poor calcium scores will be incented to adjust their behavior to improve their heart health and avoid costly cardiac interventions later.
The University of Minnesota Heart Care program also takes a preemptive approach to heart disease at its Rasmussen Center for Cardiovascular Disease Prevention. The center offers two-hour screenings with a variety of noninvasive and blood tests to determine heart disease risk. The center says about 50 percent of screened patients have no risk; 20 percent have minor risk that can be addressed by lifestyle changes; and 30 percent have moderate risk that can be dealt with by medication.
“Our focus has changed from illness to prevention,” says Dr. Gary Francis, a cardiologist at University of Minnesota Heart Care, noting that the university’s new five-story Health Clinics and Surgery Center, which opened in February, features an executive health center presumably focused on keeping the hearts of hard-working business leaders pumping as furiously as ever.
For the equally hard-working rank and file, there’s the ASCVD Risk Estimator from the American College of Cardiology and the American Heart Association. Dr. Marek Kokoszka, cardiology department chair and medical director of the heart program at Park Nicollet Health Services, owned by HealthPartners, says he’s a big fan of the Risk Estimator because it’s valid, useful and inexpensive (as in free). By filling in just nine fields in the Risk Estimator, users get an assessment of the risk for cardiovascular disease and recommended course of treatment based on that risk.
The disruptive innovation is making the Risk Estimator accessible to anyone with an Internet connection and giving consumers easy, first-hand knowledge of their own heart health rather than requiring them to navigate a complex health care system to find out how strong their ticker is.
“It would be the most fantastic thing if employers asked their workers to use it,” Kokoszka says. “They could see how their risk changes if they work on their cholesterol or their blood pressure.”
At a minimum, the use of the Risk Estimator could spark visits by employees to their primary care physicians, if only to get their cholesterol checked or their blood pressure taken to complete the fields in the estimator. That could lead to a discussion about heart health and a formal cardiac risk assessment, for which HealthPartners medical clinics charge a flat fee of $50, according to Kokoszka.
The emphasis on prevention is reflected in data from the Minnesota Department of Health that show incidents of heart disease dropping in the state, along with the death rate from heart disease (see chart).
Innovations in interventional cardiology abound
Innovations targeting heart disease before it happens won’t guarantee that employees will avoid complications from heart disease. Some are predisposed to it genetically, and others simply won’t follow directions, no matter how beneficial to them health-wise. Consequently, the pipeline of new devices, techniques and medications to treat people with heart disease is as clogged as ever.
Dr. Ganesh Raveendran, a cardiologist from University of Minnesota Heart Care, ticked off a few examples he says he’s excited about and looking forward to using in the near future “when patients don’t listen to good medical advice. That’s where I come in.”
On his list of options are the next generation of cardiac stents, which often are described as tiny sections of metal scaffolding that hold open blocked heart arteries. In October, the FDA approved Boston Scientific’s Synergy stent. The stent’s drug coating and polymer, which time-releases the drug coating on the stent, both dissolve and are absorbed by the body in three months. Abbott Vascular, meanwhile, is seeking FDA approval for its fully dissolvable stent called Absorb.
The University of Minnesota’s new medical facility cost $165 million.
Another recent innovation is the transcatheter aortic valve replacement (TAVR) procedure to replace a bad valve in the heart, says Katsiyiannis at the MHI. Rather than opening up the patient’s chest to replace a heart valve, surgeons can insert the new valve using a thin catheter threaded into the heart via a vein or artery. The less invasive process reduces complication rates, reduces length of stay and is safer for patients less able to handle surgery because of other medical conditions, he says. The MHI performed nearly 200 TAVR procedures in 2015, more than double the number in 2013.
This year will mark the fifth year that the Heart Center at Regions Hospital has been doing TAVR procedures, according to Dr. Katie Moriarty, who chairs the center, which also is owned by HealthPartners. She estimated that Regions does about 40 to 50 TAVR procedures a year.
That experience has given Regions the confidence to start a new procedure this year: implanting a wireless sensor developed by St. Jude Medical in the pulmonary artery of heart-failure patients. The sensor transmits pulmonary artery blood pressure readings to cardiologists. Moriarty says the sensor will serve as an early-warning system for heart failure, giving practitioners time to intervene with medication before acute heart failure hits and requires hospitalization.
“Everything is continuing to become smaller, miniaturized,” Katsiyiannis says.
He points to small, leadless pacemakers being developed by St. Jude and Medtronic as examples of next-generation heart devices that can be implanted with less invasive procedures to help control heart rhythm.
Other devices, procedures and medications mentioned by several cardiologists in the Twin Cities that will be appearing soon, if not already on patient bills: n Implantable cardioverter-defibrillator (ICD) systems that are MRI-compatible, from Medtronic.
- The Watchman device from Boston Scientific, designed to reduce the risk of stroke in patients with atrial fibrillation.
- The Lariat Suture Delivery Device from SentreHeart, also designed to reduce the risk of stroke in patients with atrial fibrillation.
- PCSK9 inhibitors, medication manufactured by several drug makers to lower LDL cholesterol levels in patients who can’t tolerate statins.
- Entresto, a medication from Novartis to treat heart failure.
- Corlanor, a medication from Amgen, also designed to treat heart failure.
Reducing repeat business
Innovations in interventional cardiology come at a high price, however, and don’t necessarily manifest themselves in better outcomes.
The Twin Cities’ health care market enjoys a reputation for providing high-quality health care and being on the leading edge of medical innovation, particularly in heart care.
But a look at data on the federal government’s Hospital Compare website shows that in most cases, the major heart programs in the Twin Cities market perform no better or worse on readmission and mortality rates for heart attack, heart failure and heart bypass cases than do other hospitals nationwide (see chart).
For employers, the value from innovations in heart care must be squeezed from keeping employees out of the hospital and then, if they do need hospital care, keeping them from going back for more.
That’s one of the responsibilities of Linda Wick, senior director of ambulatory nursing for University of Minnesota Physicians. According to Hospital Compare, the University of Minnesota Medical Center’s 30-day readmission rate for heart failure patients is statistically similar to the 22 percent rate for hospitals nationally. That means more than one in five heart-failure patients discharged from the medical center is readmitted within 30 days.
The medical center has deployed a remote home health monitoring system to decrease its readmission rate for heart-failure patients, Wick says. “The system alerts us to things going on with a patient at home that need immediate attention before they get worse.”
The remote home monitoring system takes basic vital sign readings like weight, blood pressure and pulse rate, and it transmits them electronically to computers at the medical center that are monitored by clinicians. Readings that hint at a deteriorating medical condition are referred to care coordinators who contact patients to ensure they are eating, drinking and taking their medications properly, Wick says.
In some cases, patients have implanted cardiac sensors that remotely alert clinicians to changes in heart rate, rhythm and pulmonary artery blood pressure. In other cases, patients can use mobile applications to do their own electrocardiograms (EKGs) and transmit the results to clinicians at the medical center.
A low-tech but equally effective strategy to keep heart patients from coming back is the Minneapolis Heart Institute’s Curbside Cardiology program. The program offers free cardiology consults to general practitioners who have questions about their patients’ heart health or have concerns about changes in their patients’ conditions that could signal a change in heart health.
The phone service operates from 7:30 a.m. to 5 p.m. Monday through Friday, and cardiologists at the MHI rotate through the service, taking their respective turns answering calls.
“We consider it an investment in population health,” Katsiyiannis says. That’s the type of investment that will produce a big return for the business community.
David Burda is editorial director, health care strategies, for MSP-C, where he serves as the chief health care content strategist and health care subject matter expert.