Effect of managed care on cardiovascular specialists: involvement, attitudes and practice adaptations.

OBJECTIVES: This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993. BACKGROUND: The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons. METHODS: A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration. RESULTS: Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency. CONCLUSIONS: Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.

Evaluation of thoracic aortic dissection using breath-holding cine MRI.

OBJECTIVE: Our goal was to determine if breath-hold cine MRI in transaxial planes can be used for the evaluation of thoracic aortic dissection instead of conventional cine MRI since rapid imaging is required in this clinical setting. MATERIALS AND METHODS: Twelve patients with thoracic aortic dissection were imaged using a 1.5 T imager. Breath-hold images were acquired with fast cine MR sequence (TR/TE = 9/2.8, 20 degrees flip angle) using segmented k-space data acquisition. Conventional non-breath-hold cine MR images (TR/TE = 22/7.5, 35 degrees flip angle, 2 averages) were taken with flow and respiratory compensation. RESULTS: Sharpness of edges of the vessels on fast cine MR images was better than that on conventional cine MR images in 34 (57%) of 60 images. Inhomogeneous blood signal in aortic lumen due to motion artifacts was found in 2 (3%) of fast cine MR images and in 15 (25%) of conventional cine MR images. The contrast-to-noise ratios of fast cine MR images were significantly better than those of conventional cine MR images (26.4 +/- 9.1 vs. 18.5 +/- 10.1; p < 0.05) when the region of interest for noise was placed to include ghosting artifacts. CONCLUSION: Breath-hold cine MRI is a rapid technique that gives high quality images of thoracic aortic dissection and can provide a diagnosis in < 10 min of imaging time.