The Urgent Science of Chronic Medical Conditions: An Introduction

As I was developing this site, I mentioned it to my good friend Bill Bestermann. Dr. Bestermann is a very progressive, leading edge and nationally recognized vascular physician. When you talk with Bill, it’s very clear that it really is all about the quality of the care. After he’d chewed on the idea of the site, he called with a suggestion. “You could have a section called ‘Urgent Science’ that clearly describes for clinicians the science behind modern management of chronic conditions. We could develop a straightforward resource that shows what actually works and why, so it can be easily translated into clinical practice.”

That seemed like a great idea. What follows is Dr. Bestermann’s explanation of how it can work, followed by an article he wrote almost two years ago called “The New Science of Vascular Disease.”

We are very proud to offer this approach, and hope that interested physicians with deep knowledge of a particular discipline will send us review articles that can be candidates for this service.

Brian Klepper

WILLIAM H. BESTERMANN, MD

The science and systems exist today to dramatically improve care and reduce costs. Despite multiple recommendations from the Institute of Medicine (IOM) and others credible professional groups, our system remains focused on the care of acute episodes and our approach to chronic diseases is largely ineffective.  We spend nearly one dollar out of five on health care and the rate of increase continues to be a multiple of inflation.  Most of the increased spending over the last two decades is related to patients with four or more chronic conditions. We have still done very little to improve the effectiveness of that spending and to improve the health of our friends, neighbors, and families.  Education and exhortation have not worked. It is time to get serious about new science, new organizational structures, and new systems.

The IOM report Crossing the Quality Chasm is nearly a decade old.  That document helped us understand that it takes nearly 17 years for new science to be widely applied in medical practice. Even then the application is highly variable.

There is no better example of this reality than in the treatment of cardiovascular diseases.  While our system functions as if heart attack is due to a slow progression of a fixed blockage, the first reports showing that heart attack is due to plaque rupture and clot appeared in 1988.

The investigators in that study realized that fixing focal blockages would not prevent myocardial infarction and that reducing the impact of that disease would require aggressive management of cardiometabolic risk or optimal medical therapy.  The weight of the medical evidence since that study has confirmed that conclusion and yet, to this very day, nearly 90% of patients who are receiving a stent for stable angina believe that stent will prevent a heart attack or cardiovascular death despite all of the evidence to the contrary.

Important new science found in studies like the COURAGE and Steno II trials tells us that optimal medical treatment has dramatic effects to reduce the number of cardiovascular deaths, heart attacks, strokes, stents, amputations, end-stage renal disease, and visual impairment. Cardiac interventionists who continue to defend procedures as the primary strategy in stable angina say that optimal medical therapy does not exist in the community.  They are wrong.  Optimal medical therapy is a product and that product is being produced today in communities consistently by applying new science and systems.

In Crossing the Quality Chasm, the first recommendation was that stakeholders “develop evidence-based protocols consistent with best practices” for chronic conditions.  That is the purpose of “The Urgent Science of Chronic Conditions.”  We hope to close the 17 year gap in the application of new science for the benefit of our patients.  By it’s very nature, this will always be a work in progress and our core articles will change over time.  The centerpiece will be an evidence-based protocol very much like that used in COURAGE and Steno II.  This protocol will provide evidence-based guidance for the treatment of diabetes, hypertension, hyperlipidemia, heart attack, stroke, angina, TIA, peripheral arterial disease and congestive heart failure.  All of these conditions are the result of abnormal metabolism and their best treatment involves improving the metabolic environment in a coordinated and integrated manner.  We will provide links to the evidence that supports the protocol to  help you achieve comfort with the validity of the recommendations.  We will provide referenced journal-type article to further advance your knowledge of the new science. It is our hope to provide that core science in one place that will serve as an easy resource to assist you in consistently producing optimal medical treatment.  Many of our resources will be “living documents” and will change as new information becomes available.

We are also learning that other chronic conditions like asthma, COPD, and cancer have the same metabolic underpinnings.  All of this points to a central role of primary care. Who else is going to coordinate and integrate the application of the new science and systems?  There is no one else.  We have been delivering care in the face of many myths.  The common understanding is that primary care is less challenging, that the management of cardiometabolic risk is simple and can be relegated to those with far less training than those in specialty disciplines.  Nothing could be further from the truth.  Integrating the science to support the protocol is the most challenging intellectual exercise in existence-it really is rocket science and that is part of the problem.  Our primary care doctor is being asked to digest several large complicated texts, thousands of journal articles, and a host of guidelines. He is expected to bring all the information together perfectly to produce up to date optimal medical therapy.  It is impossible.  We hope to bring information together here in a user friendly format to help you.

We hope to serve as a vehicle to facilitate innovation in the application of new systems and science in the management of chronic conditions.  The protocol is important as a way to spread quality and the product optimal medical therapy.  It is important to have a standardized basic protocol and supporting tools that are consistently applied, so that when we compile the data, we can say: “This is how we did it.”  We will strive for clarity and simplicity in the materials we provide.

The best people to improve this practice are those who do it every day.  We know that we are not the only ones who get this.  Help us to make this site better and more useful to you as you work to improve care and reduce cost.

Bill Bestermann is an internist focused on vascular diseases. He is Medical Director of Integrated Health Services at the Holston Medical Group in Kingsport, TN.

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3 Responses to The Urgent Science of Chronic Medical Conditions: An Introduction

  1. David C. Kibbe says:

    Bill: Wow! It has long been a dream of mine to bring innovative medical science down off the shelf, and mix it up with innovations in policy, IT, economics, and ethical discussion. Reading your piece above is so exciting, because we’re finally doing just this! Your role in Care and Cost is an essential one, because you are the practicing physician, the primary care expert in complexity, who has stuck with the patient’s interest for long enough to bring the science to bear on treatment. With positive results in terms of care improvement and lowering of cost. This is, as you say, an “urgent” endeavor.

    I have a ton of questions. Let me start by suggesting that most readers, regardless of their professions, would be shocked to hear that the procedural and interventional approach to cardiovascular disease — e.g. stents — has not worked. Can you make that case with the studies that have been done to date? Can you help us translate the science so as to underscore that proposition that “best treatment involves improving the metabolic environment in a coordinated and integrated manner” ?

    Kind regards, DCK

  2. Bill Bestermann says:

    Hello David,

    The first evidence for the failure of stenting to prevent heart attack and and cardiovascular death goes back to 1988 and an article by WC Little and colleagues in Circulation. These cardiologists looked at patients who had had a cardiac cath and then later had a myocardial infarction. There was no correlation between the blockage on the first catheterization and the later development of clot that blocked the artery and caused the heart attack. The authors in the last two paragraphs concluded that opening the arteries would not prevent heart attack and that global approaches with medication and life style aimed at the entire artery would be required. Erling Falk and others summarized four studies like this in Circulation in 1995. Then the COURAGE trial in the New England Journal laid the issue to rest with a randomised clinical trial that showed no advantage of stent plus optimal medical therapy over optimal medical therapy alone in patients with stable angina in preventing heart attack or death. Still, nearly 90% of patients who actually have stents for stable angina believe that the procedure will prevent these disasters. You have to ask yourself-why?

  3. Judith Tribbett says:

    Reading earlier today on the number of stent insertions (and the associated dollars for both physician and hospital) that were not even justified under the standard criteria and now this. I wish you the best in helping us figure out how to promote medical guidelines.

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