Cardiology leaders complained that heart failure specialists may know how to treat their patients and to employ the latest therapies, but their actual reach is stunted by poor implementation within the wasteful U.S. healthcare system.
It sounds like a tale of two cities: The COVID-19 pandemic continues to overwhelm patients and healthcare workers across the country; at the same time, heart failure patients are enjoying more therapies than ever, with new SGLT2 inhibitors hitting the market and sacubitril/valsartan (Entresto) use expanding to the historically hard-to-treat population of patients with preserved ejection fraction.
Yet these advances are not being put into practice to improve the lives of many people in the U.S.
Heart Failure is Part of a Larger Problem
"The heart failure ecosystem is full of well-intentioned people, but the way it operates, like the U.S. healthcare business in general, creates a very unusual situation where the whole is much less that the sum of its parts," said former FDA commissioner Robert Califf, MD, now of Verily Life Sciences and Google Health, during a plenary session at the Heart Failure Society of America (HFSA) meeting held both virtually and in Denver.
Califf said the heart failure field is "in one of its golden moments" amid what he called the "abject failure" of the U.S. healthcare system.
The trouble, he said, is that well-intentioned people are given fragmented jobs in the healthcare ecosystem, resulting in an enormous number of financial transactions that aren't hitting the central target: the patient's care by his or her clinician. This is suboptimization in action, the phenomenon of people focused on making changes to one component of the system while ignoring all the other components, he explained.
Indeed, attempts to fix the fragmented heart failure care landscape have not succeeded.
"There's a lot of money being spent, a lot of money being made," Califf said. "The U.S. is unique in its trajectory of a shorter life expectancy at a higher cost. It's not a surprise to anyone but the trajectory is not going in the right direction before the pandemic or during the pandemic."
Califf pointed out that health disparities are leaving whole regions and groups of people behind in life expectancy. Between San Francisco and Lake County, California, just three counties away, there is an 11-year drop in life expectancy, he said, although the biggest decline in life expectancy can be observed in white males living between Arkansas and Virginia.
Tackling Health Inequity, Suboptimization
"No one can argue that COVID didn't make evidently clear the depth of health disparity in the U.S. We learned it is place that matters as much as race," said Clyde Yancy, MD, of Northwestern University Feinberg School of Medicine in Chicago, during the HFSA session.
"Achieving health equity is like treating heart failure," Yancy said. He quoted Winston Churchill: "Success consists of going from failure to failure without loss of enthusiasm."
"We have done that well in heart failure. We need to do the same to achieve health equity," he urged.
Califf emphasized the work that needs to be done in communities, not hospitals.
That has been tried with limited success so far, according to Mariell Jessup, MD, chief science and medical officer of the American Heart Association.
She recalled a multi-society initiative in creating a mobile app for heart failure patients. "Some liked it, some hated it, some wanted to add 10 more bells and whistles," she said. "It's tough. If you move into communities and have diverse voices, you may have 10 different apps ... To serve all of those people is going to mean being really innovative and a lot of pivoting."
For Califf, "Big Data" is important to fix the problems in healthcare: a common electronic health record platform can be part of a new data infrastructure system that allows for active surveillance, use of real-world evidence to support regulatory decisions, and shared data to support more efficient research.
The final piece of the puzzle would be a new payment system. Califf challenged Duke University and Stanford University (institutions where he is adjunct professor) to hold accountability for the health of their surrounding communities. As long as people make money from fee-for-service and evermore expensive procedures, clinical outcomes will stay poor, he suggested.
"Without fixing the payment system to align payment with activities that improve health, we will continue to be constrained by fragmentation and suboptimization with increased amounts of money going to efforts that don't improve the health of our patients," Califf concluded.
Disclosures
Califf disclosed board appointments at Cytokinetics, Centessa, and Clinetic; and serving as adjunct faculty at Duke and Stanford Universities.