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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIn this article, the American Heart Association (AHA) and Heart Rhythm Society (HRS) discussed the implications of guidelines, some of their limitations, and where guidelines fit in the new paradigm of health care. Specific topics include limitations of the current system of guidelines and how they fit with the new paradigm of health care, the impact of the Medicare and Medicaid services, and the disconnect between indicated ICD therapy as outlined in the ACC\/AHA\/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities [Epstein J et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2008] and CMS reimbursement rules.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIn this special joint session of the American Heart Association (AHA) and Heart Rhythm Society (HRS) speakers discussed the implications of guidelines, some of their limitations, and where guidelines fit in the new paradigm of health care (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Improving Quality\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-846192914\u0022 data-figure-caption=\u0022Improving Quality\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13186\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-3\u0022 class=\u0022first-child\u0022\u003EImproving Quality\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EGWTG= Get With the Guidelines; NCDR ICD=National Cardiovascular Data Registry Implantable Cardioverter Defibrillator. Reproduced with permission from M Estes, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-4\u0022\u003EPhysicians are increasingly hearing about accountability for quality metrics and performance measures and the programs that seek to bridge the gap between the guidelines and practice. N. A. Mark Estes, MD, Tufts Medical Center, Boston, Massachusetts, USA, discussed some of the limitations of the current system of guidelines and how they fit with the new paradigm of health care.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EFactors that may prove problematic as we move forward to evidence-based medicine and pay-for-performance are the differences between clinical trial patients and those seen in clinical practice and the fact that \u0026lt;15% of the current guidelines are based on randomized trials [Tricoci P et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2009]. Other factors include the slowness of the current process (the average update takes \u223c2 years) and the gap between the number of physicians who say they know the guidelines (95%) and those who treat to goal (18%) [Pearson TA et al. \u003Cem\u003EArch Int Med\u003C\/em\u003E 2000].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EDespite their limitations, Dr. Estes believes that guidelines will become the basis for quality metrics and performance measures as we move forward. In this new paradigm, pay-for-performance is incorporated into healthcare reform and accountability will be measured and reported with registries, databases, and electronic health records serving as the instruments of assessment. The shift will be from a quantity- and procedures-based system to a system based on quality, performance, outcomes, and value. Professional societies will need to take a leadership role in developing the necessary education vehicles and registries.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EDavid E. Haines, MD, Beaumont Health Systems, Royal Oak, Michigan, USA, discussed the impact of the Medicare, Medicaid, Children\u0027s Health Insurance Programs; Transparency Reports and Reporting of Physician Ownership or Investment Interests Rule, (the Sunshine Act). Under this rule all payments or transfers of value \u0026gt;$10 made to physicians and teaching hospitals will be posted on the Centers for Medicare \u0026amp; Medicaid Services (CMS) website with data aggregated, downloadable, and searchable. Data collection for the new rule starts August 1, 2013, for reporting to CMS on March 31, 2014 (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13187\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13187\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13187\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EExamples of Relationships With Industry\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EThe new rule will make possible independent validation of the relationships with industry statements issued by societies, professional organizations, and physicians. However, such a policy may also serve as a disincentive to physician-industry collaboration on new technologies. Given that many of the advances in electrophysiology and pacing are due to a unique collaboration between physicians and industry, Dr. Haines believes that the HRS needs to establish strict ethical standards to protect the credibility of the society and its members. Current policies with respect to writing groups prohibit ownership of equity interests, stocks, or stock options or ownership, partnership, or principal interest in a financially interested enterprise, excluding mutual funds. Members may not have the potential to profit financially from the recommendations of the document. One chair must be free of all \u201crelevant\u201d relationships with industries, and all authors must disclose their relationships with industry for the previous 12 months and update as relationships change.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EGuidelines serve several purposes, but primarily they exist to convert the clinical evidence base into clinical instructions. John Camm, MD, St. George\u0027s Hospital Medical School, London, United Kingdom, noted that it is not unusual for several different organizations to issue treatment guidelines on the same subject. As an example, he noted that four societies have issued new\/updated guidelines on the management of atrial fibrillation (AF) in the past 2 years. National differences are not surprising and are frequent. Differences are seen on several levels ranging from language (eg, softer in Europe vs more directive in the United States) to the basis on which a particular therapy should be selected. By way of example, Prof. Camm discussed how the use of the US-designed CHADS\u003Csub\u003E2\u003C\/sub\u003E scoring system versus the European designed CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASC scoring affects the treatment recommendation on the choice of an oral anticoagulant in AF. While most differences are not critical, clinicians need to be aware that they exist and understand why these differences may occur.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe 2006 American College of Cardiology (ACC)\/AHA\/European Society of Cardiology (ESC) Guidelines for the management of patients with ventricular arrhythmias and the prevention for sudden cardiac death [Zipes DP et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006] provide the only guidance on arrhythmogenic disorders in terms of the use of defibrillators and medical therapy. Silvia G. Priori, MD, PhD, University of Pavia, Pavia, Italy, reviewed some of the current recommendations in need of updating. One of these is the Class I recommendation for an ICD in patients who have survived a cardiac arrest. Prof. Priori suggested that it is important to consider whether the cardiac arrest occurred before initiation of \u03b2-blockers. If so, drug therapy may be more appropriate, especially in long QT syndrome Type 1 (LQT1) patients. Another recommendation in need of revision is the Class lib recommendation concerning ICDs as primary prophylaxis in patients with LQT2 and LQT3. Dr. Priori suggested that even though these genetic forms have a worse outcome, other risk factors play a role in the treatment decision. For example, an LQT2 with a QT that is almost normal is at less risk than an LQT1 with a QT of 550.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EHugh Calkins, MD, Johns Hopkins Hospital, Baltimore, Maryland, USA, discussed the disconnect between indicated ICD therapy as outlined in the ACC\/AHA\/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities [Epstein J et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2008] and CMS reimbursement rules. He told the audience that the HRS hopes to address the gaps by developing a consensus statement in collaboration with the American College of Cardiology Foundation (ACCF) and the AHA [Kusamoto F et al. Submitted]. The statement covers ICD therapy in patients not represented in clinical trials. Topics include ICD implantation\u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \n            \u003Cp id=\u0022p-13\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003Ein the setting of an abnormal troponin that is not due to a myocardial infarction (MI);\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \n            \u003Cp id=\u0022p-14\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003Ewithin 40 days of an MI;\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \n            \u003Cp id=\u0022p-15\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003Ewithin 90 days of revascularization; and\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \n            \u003Cp id=\u0022p-16\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003E\u0026lt;9 months from the initial diagnosis of nonischemic cardiomyopathy.\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-17\u0022\u003EGuidelines will continue to provide important information about how new drugs and device therapies and additional clinical evidence for older therapies, affect clinical practice; however, it appears that they are taking on additional significance as we progress to a new healthcare paradigm.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/3\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzny6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzny6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzny6p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}