Heart-Earned Results

Family pledges $8.3 million to establish the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology

Dr. ZimetbaumWhile the phrase “heart attack victim” might conjure up an image of an overweight, middle-aged man clutching his chest, the reality today is far different. Widespread initiatives to reduce smoking and poor eating habits over the last decade have actually lowered heart attack rates in patients middle-aged and younger. Instead, the heart attack victims rushed into emergency departments across the country now tend to be significantly older, more frail—and consequently more difficult to treat. The full picture of this epidemiological change in cardiovascular disease came from evaluating outcomes data from hospital billing information over a 10-year period and is critically important in determining how clinicians best allocate health care resources and accurately evaluate future outcomes. “We are just beginning to understand the value of looking at large amounts of data, not just at the institutional level, but at the national level, to guide the best clinical decisions,” says Peter J. Zimetbaum, M.D., associate chief of cardiology and director of clinical cardiology at Beth Israel Deaconess Medical Center. “The field of cardiology, particularly at BIDMC, has been a leader in this area of looking at outcomes to drive clinical care.”

Outcomes research is fundamentally about understanding how we treat disease in real-world practice. It requires both valid, accurate data as well as a robust set of statistical and epidemiological methods to make inferences about that data. As access to data becomes increasingly available and the number of different therapies offered to patients expands, clinicians at BIDMC are actively looking to make sense of all this new information to make improvements in health care. “A home run in discovery that would have a huge impact on survival when it comes to heart disease isn’t coming in the next few years,” says Duane Pinto, M.D., M.P.H., director of the cardiac intensive care unit. “What we need to do is actually apply the technologies and strategies that we already have to more patients in a more effective way.”

Longtime BIDMC supporters and grateful patients of Zimetbaum, Richard A. and the late Susan F. Smith recognized the value of this research and pledged $8.3 million to support this work in the Division of Cardiovascular Medicine at BIDMC. A portion of their gift established the Richard A. and the late Susan F. Smith Center for Outcomes Research in Cardiology. The pioneering program, which was the brainchild of Zimetbaum and is the first of its kind in Boston, will capitalize on clinical observations and rigorous data analyses to evaluate health care policy as well as treatments and devices for patients with cardiovascular conditions. Its goal is to ultimately produce safer and more personalized care. Support from the Smith family’s gift has allowed the center to purchase expensive data sets and hire leadership and programmers with the necessary expertise to properly evaluate that data. “They are quite visionary,” Robert Yeh, M.D., M.Sc., says of the Smith family. A national leader in the field of cardiology outcomes research, Yeh was recruited as director of the Smith Center last fall. “They see the importance of developing a better understanding of the safety, cost effectiveness, and ethical implications of the work that we do in trying to prevent and treat cardiovascular disease.”

The gift will also establish an endowed Harvard Medical School Professorship in clinical cardiology at BIDMC in honor of Zimetbaum. A national leader in electrophysiology, Zimetbaum is highly regarded for his groundbreaking cardiovascular research studies and personalized, expert patient care. This rare clinical professorship will serve as a testament to the role he has played in advancing the discipline of cardiovascular medicine and will also provide future generations of cardiologists with exciting opportunities to lead their field. But it is the creation of the Smith Center that could define Zimetbaum’s legacy. “It is the highest mark of leadership to initiate a transformational outcomes program at a time when such information is so critically needed and the faculty is so incredibly motivated to make it work,” says Jeffrey Popma, M.D., director of interventional cardiology. “I really have to commend Dr. Zimetbaum for his vision in identifying an area of unmet clinical need for the institution and recruiting the individuals who would be able to navigate the sustained growth of this vital program.”

While outcomes research has been conducted in silos within the Harvard hospitals and select locations across the country for years, the Smith Center at BIDMC will be one of only a handful of dedicated programs across the country and the only center created from the ground up with a substantial financial foundation. “We have always wanted to have a place where people interested in these ideas could come together, cross pollinate, interact, and become national and international leaders in developing new ideas for this space,” says Yeh. “None of the other centers have started with the types of resources that we have. We can really create something unique.” The Smith Center also places BIDMC at the nexus of a field that will only become more critical in the years ahead as health care reform places a greater emphasis on providing high-quality, cost-effective care that is centered on the patient. “If there is any place in the country that should be able to bring together people who know how to do this research at a very high level and whose results will stand up and generate effective policy, it is here,” Zimetbaum says.

Experts within the Division of Cardiovascular Medicine at BIDMC have an extensive history of managing the full spectrum of heart conditions from coronary artery disease to cardiac arrhythmias. The division has been internationally recognized for its contributions to cardiovascular medicine over the last 60 years, including the invention of the concept of cardiac pacing, defibrillation for cardiac arrhythmias, and multiple “first-in-man” procedures. In addition to their leadership in the clinical arena, cardiologists at the former Beth Israel Hospital started the Cardiovascular Data Analysis Center (CDAC) in the mid-1990s; this center was the pivotal analysis group for many of the new device trials across the country and around the world, and became widely known for its data integrity and analysis. Now with better access to quality data and the creation of the Smith Center, BIDMC is looking to change the way health data is analyzed once again. “Cardiology is a natural place for outcomes research because there is so much rich data in this area,” Yeh says. “We also have more capability of actually answering the questions that maybe 20 years ago we couldn’t understand.” Yeh and his team have already hit the ground running with a number of projects investigating public policy as well as comparative effectiveness research that could have immediate impact on patient care.

Among the specific areas of focus at the Smith Center is work related to evaluating public health policy. “One of the big problems and one of my great frustrations in my career is watching payers and the government make decisions about how we can practice based on poor data,” Zimetbaum says. “Data that is done in a way that doesn’t stand the test of time and then months later, years later, we find out it was wrong and end up changing policies that we suspected were poorly conceived all along.” As part of health care reform and in an effort to build trust with patients, the health care system has experienced a strong push toward increasing transparency. Massachusetts has been on the forefront of this movement and one of the first states to adopt public reporting of outcomes for some cardiovascular procedures. While on the surface, this openness seems like it would be beneficial for patients, there are a number of unintended but potentially harmful consequences of the policy.

Angioplasties are surgical procedures to repair or unblock blood vessels, and a paper published by Yeh last year in the Journal of the American College of Cardiology showed that in states with public reporting of angioplasty outcomes, patients who present with heart attacks receive fewer of these procedures and have higher rates of mortality than in states with no public reporting. Since the current methods used to determine the clinicians’ publically reported outcomes do not take into account the patient’s condition at the time of the procedure, it may be that some doctors are actually choosing to avoid performing angioplasties on the increasingly prevalent high-risk patient population for fear of skewing their published numbers. Meanwhile, the same states have reported better outcomes for angioplasty procedures overall because clinicians may be selecting more low-risk patients instead. These results are not only deceiving to the public but also incredibly dangerous for the patients. “No one wants someone who can potentially benefit not to receive life-sustaining therapy because of an admirably intended program like public reporting,” says Pinto, who serves as the governor and president of the Massachusetts American College of Cardiology chapter. As state and federal lawmakers look to potentially publicize all surgeons’ outcome statistics in the future, clinicians at BIDMC are leading the charge to evaluate the implications of this particular health policy and better understand what that means for patients. Pinto has been working closely with the Massachusetts Department of Public Health to refine the way the clinicians’ scorecards are calculated to minimize these adverse consequences. “Transparency is important but the consequences are something that should be on the minds of those making policies,” Yeh says.

Clinicians in the Smith Center are also focused on comparative effectiveness research, or evaluating the efficacy, benefits, and potential harms of different treatments for specific patients. One of the biggest advantages of the center compared to stand-alone outcomes research is its access to large amounts of real patient information. One such database is Centers for Medicare & Medicaid Services (CMS) billing information. “We have a cache of 40ish million patients who are registered in an administrative database that captures their individual use of medical services over time,” Popma says. The database contains more than 10,000 procedure codes assigned to patients across all subspecialties and organized by demographics such as age, race, and co-morbidities. “Without actually meeting the patient, we will be able to get a very good impression of the overall health status of the patient by combining complication and co-morbidity codes,” he says. Using this information, Popma plans to explore how patients in the United States are treated for structural heart disease, specifically aortic valve disease and mitral valve disease. “We can use the tools that are currently embedded within the database both to identify the risk of the patients and to determine what their outcomes have been,” Popma says. Using specific algorithms to analyze that data, clinicians can then determine which future patients may be the best candidates for a particular treatment. “It is really going to provide phenomenal insight into patient outcomes that will serve to enhance their medical care in the future,” he says. To start, the Smith Center will use the data from CMS and electronic medical records from hospitals around the country along with results from clinical trials to evaluate safety and effectiveness of cardiovascular devices, medical technologies, and therapies. “We will have a whole new understanding of our capability to take advantage of these new sources of data to understand medical safety and efficacy,” Yeh says.

As word spreads about the work being conducted in the Smith Center, BIDMC becomes a major draw for those interested in this burgeoning field, both as students and experienced clinicians and researchers. “We want to be a magnet for the best and the brightest to come and learn how to do this research and facilitate their training with the best mentors in the world,” Zimetbaum says. And while initial efforts of the Smith Center are focused in cardiovascular disease, this methodology can be expanded to other specialties throughout the medical center and health care at large. “This is going to allow us to understand how certain disease states are managed in the United States and the bandwidth is limited only by funding,” Popma says. “There is really no limit on what can be done in terms of analyzing disease states.” A new influx of philanthropic funding will provide clinicians with the critical resources to enhance the infrastructure of the Smith Center, such as additional research staff, new databases for research, statisticians, and fellowships for those interested in a career in outcomes research. “This is an opportunity for people to participate in changing health care in a significant and tangible way,” Zimetbaum says.

Cardiologists at BIDMC have been innovators in care for decades, and the establishment of the Smith Center is no exception. “It is realistic to think within five to 10 years that policy changes, with regard to things like public reporting and implementation, with regard to how we do our procedures and apply our medications, are going to come out of this center,” says Pinto. And as the Smith Center gains traction in the outcomes research arena, its success is measured not just by papers published and/or policies changed, but by overall improvement in patient care. “The goal is to increase our understanding of how we are treating patients in a way that translates to improving outcomes,” Yeh says. “We want to tackle the pressing challenges in health care today and use scientific methodology to understand those questions and develop better solutions for patients everywhere.

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