The only frustration I felt during the TCT was during the Town Hall Meeting.

  Meant to give insight into the function of the FDA/NIH/CMS and a preview of things on the horizon,  the town hall meeting seemed to be the best place I could ask my question, the grand-daddy of all questions to the one person in this world that might be able to wave the magic "do something" wand and make things happen.  Dr. Marcel Salive, Director of the Division of Medicare and Surgical Services within the Coverage and analysis Group of the Center for Medicare and Medicaid Services (CMS) in the US Department of Health and Human Services spoke for about 15 minutes on generalities.  He was gracious to fill in for Dr. Phurrough and amply qualified having held leadership positions with the NIH and the FDA and has led, developed and served on research teams for outcomes data and is a fellow of the American college of preventive medicine and the AHA.  So, who better to answer my question, or at least point me in the right direction?

 Before I reveal what exactly the "question" was, I'll give a little insight into my thinking.  The TCT meeting seems the best meeting possible to discuss and explore new gadgets, widgits, wires, guides, stents, etc. To make a Golfing comparison,   It's like the PGA in that its business is  promoting the best ideas from the brightest minds in the field.  In the case of our country's approach to  Coronary intervention, with regard to how far we've come ,  it seems that we have access to all the right golfing equipment but maybe don't have the basic rules of the game down quite yet.  To make a comparison, it would be like our having the best gloves, the best clubs, the nicest shoes, nifty range finders, extravagant club houses but we  don't quite understand where the next hole is and the best route to get there.  We are all dressed up in our fancy polos and pants, but we don't understand yet where to hit the ball, how to stand, how to follow through, etc.  Simply put, we aren't organized in the US in such a manner that allows us to do our best for the patients who need it most.....our acute MI's. 

Now for one simple question, as asked to Dr. Salive:  "Why do we NOT tie reimbursement to AMI strategy?  Why not make it manditory that every single hospital in this country, in order to receive medicaid and medicare funding HAVE A PLAN to treat AMI's?  I can tell you there are piles of cash to solve Dr. Shurin's problem of funding at the NIH just by organizing our approach to AMI care , which would reduce CHF spending" (our most expensive DRG, which I've said 1 billion times, but should say 25 billion times because that's how much it costs us every single year in America"), which would yield enormous pay- offs in human life and health care dollars. 

The answer?  Well, even after listening for a couple of minutes, I couldn't understand it.  I can't even blogg it.  It was something like,......we're looking into........? Sorry, I can't even tell you what it meant.  But in all fairness, I've been obsessed with this question for 2 years and Dr. Salive heard it for the first time.  So, maybe after this meeting, he might think about it more and even see that it's a fair question and a good question and he just might help us. 

The answer I had hoped for?  "Excellent question. (it's my fantasy, so I get to put in whatever dialogue I want) Since places in the world like the Czech Republic, Poland, Denmark have made huge dents in pump failure due to organized AMI care, we should definitely make it a goal by 2011that every single hospital in America have a plan for transporting AMI's to PCI capable hospitals. Every single EMS system should have prehospital ECG in place unless it's geographically impossible. MISSION LIFE LINE shouldn't be an experiment, it should be a requirement.  It's about as logical as doing a study on asystole vs. sinus rhythm  just to see which one is associated with the longest longevity.   Every single hospital in America without a cath lab should DIVERT AMI's to hospitals with cath labs.  Every single hospital in AMerica should have chest pain center accreditation, which teaches us that it's not the specifics of the plan that matter so much as just having a plan and honing it to our  best capability.  Every single hospital who performs PCI should be mandated to report outcomes and D2B times in order to continue to receive medicare funding.  The Joint Commission, famous for making you quake in your boots if you haven't recorded a family history on your consult form, that's already on the chart 4 times from other consultants and on the initial history,  should ask you about the time it takes to recognize an AMI, or that same joint commision that causes great consternation over whether or not  your hospital's basement pipes can pass the "white-glove" inspection,  should spend their time on more lofty goals, like "what are you going to do for your patient if their ST's are up? " Yes, it's an excellent question and far more important that knowing which stent goes where and so basic that all other issues should take a back seat to this one question".  (Yes, dreaming now). 

I know it's a major fantasy, but with a little effort, optimal AMI care could become a reality in this country and soon.  Until folks like Dr. Salive get behind this notion, we are going to continue to boast the best equipment and anticoagulation protocols, the biggest hospitals and some of the brightest folks in the field, but still continue to allow our AMI's to languish for lack of an organized approach to AMI care.  We need to stop saying how difficult it is and start putting in the necessary time it takes to solve it and put folks like Dr. Salive with all of his talent and genius onto it. 

Back to the golf analogy:  If I can putt, chip and birdie  every time, but can't find my way to the next hole, there will be a lot of folks who won't be able to play very efficiently with me. Folks will be backed up at their tee's for ever.  Some will quit out of frustration.  Others won't get home until midnight. Some golfers will die of old age just for their chance to Tee off.    Right now, our  American AMI's are still waiting for us to learn to play our best game and there are plenty of Tiger Wood  caliber players out there in other countries who can give us a few pointers about organization .

  We just need to listen and roll up our polo sleeves and go to work on it.

Melissa

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