23rd Bethesda Conference Access to cardiovascular care November 21–22, 1991

JACC VW 19, N ., 7 Jucc 1992.1441-92

23rd BETHESDA CONFERENCE Access to Cardiovascular Care November 21-22, 1991

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JACC Val . 19, No . 7 Jove 1992:1441-92

BETHESDA CONFERENCE REPORT

23rd Bethesda Conference : Access to Cardiovascular Care* MELVIN D . CHEITLIN, MD, FACC, CONFERENCE CHAIRMAN

This Conference, sponsored by the American College of Cardiology, was held at Heart House, Bethesda, Maryland, November 21 to 22, 1991 .

Participants FORREST H . ADAMS, MD, FACC Professor of Pediatrics (Cardiology) University of California Los Angeles P .O. Box 8066 Rancho Santa Fe, California 92067

CAROLYN M . CLANCY, MD, FACP Public Citizen Health Research Group 7914 Long Branch Parkway Takoma Park, Maryland 20912 Paklic Citizen Representative

TRUMAN 0. ANDERSON, MD, PBD Chief, Section of Allergy Department of Medicine University of Illinois, MC 787 840 South Wood Chicago, Illinois 60612

LEIGHTON E. CLUFF, MD, MACP, ScD Distinguished Physician U.S . Department of Veterans Affairs Veterans Affairs Medical Center 1601 S.W. 45th Boulevard Gm nesville, Florida 32608-1197

D . K . BAIRD, MB, BS Head, Department of Cardiolhomcic Surgery Royal Prince Alfred Hospital 100 Carillon Avenue Newtown, N.S .W. 2042 Australia

RUTH L. COLLINS-NAKAI, MD, FACC, FRCP[C Professor of Pediatrics 2C3.86 Walter Mackenzie Health Sciences Center University of Alberta Edmonton, Alberta TM] 207 Canada

ROBERT BERENSON, MD, FACP 7206 Meadow Lane Chevy Chase, Maryland 20815 W . VIRGIL BROWN, MD President, American Heart Association Emory University School of Medicine 201 Woodruff Memorial Building P .O. Drawer AG Atlanta, Georgia 30322 American Heart Armciation Representative MELVIN D . CHE:TLIN. MD, FACC Chief of Cardiology San Francisco General Hospital Room 501 1001 Potrero Avenue San Francisco, California 94110 Co,reooe Clminnan

C. RICHARD CONTI, MD, FACC Eminent Scholar (Cardiology) Professor of Medicine Dirtor, Division of Cardiovascular Medical Chief of Cardiology University of Florida P.O . Box 100277 1600 Archer Road, Room M401 Gainesville, Florida 32610-0277 P. WILLIAM CURRERI, MD Executive Vice President Stratagem Incorporated Hilton Square Suite 630 3103 Airport Boulevard Mobile, Alabama 36606 Physician Payment Review Commission Representative

ALOYSIUS B . CUYJET, MD, FACC Associate Director of Medicine United Hospitals Medical Center Department of Medicine 15 South 7.h S:.w: Newark, New Jersey 07107 Aafooiation of Black Cardiologists Representative ANTHONY N. DEMARIA, MD, FACC Professor of Medicine Chief of Cardiology Division University of Kentucky College of Medicine Division of Cardiology, Room MN 670 800 Rose Street Lexington, Kentucky 40536-0084 F. DANIEL DUFFY, MD, FACP Chair, Board of Governors University of Oklahoma College of Medicine Tulsa 2808 S. Sheridan Road Tulsa, Oklahoma 7,129 American College ofPhysician Representative HARRIET P. DUSTAN, MD, FACC Emeritus Professor of Medicine 28 Flagon Drive Essex, Vermont 05452 ARNOLD B . EPSTEIN, MD, MA Chief, Section on Health Services and Policy Research Division of General Medicine Department of Medicine Brigham and Women Hospital ; Associme Professor of Medicine Harvard Medical School Department of Health Care Policy Parcel B, 1st Floor 25 Shattuck Street Boston, Massachusetts 02115

*The recommendations set forth in this report are those of the Conference participants and do not necessarily reflect the official position of the American College of Cardiology . Address for reodnts: American College of Cardiology, 9111 Old Georgetown Road, Bethesda, Maryland 20814 . Attention: Griffith Resource Library. 01992 by the American College of Cardiology

0735-109719L45.00



cHEm .aN ±;rd RETHESOA CONFERENCE: PARTICIPANTS

IACC Vol. 19, No. 7 Tune ]992 :1441-92 S . ANN EVANS, RN, MS, MBA . CNAA Eaecmive Director The Heart Instimle al Tallahassee Mcmorinl Magnolia Drive and Meecosuuee Road Tallahassee, Florida 32308 American Aeociarfon of Crlrlcal Care Nooses Representmive

MARK A. HLATKY, MD. FA CC Asvociate Pont, 5.r of Health Res5reh Pol'le y and of Medicine (CY) Chief. Di,ion o f Heahh Sevkan Research Sianfo-d University Schoo'. of Medicine HRP Building, 361c1 Stenfonl . Culdurnia 94'05-INS

JLIDITH FEDLR . PhD Co-Director Cater for Health Policy Sludioo Oeorgelown University School of Medico 2233 Wisconsin Avenue, N . W ., No 525 Washieetnn, D C . 204177 Keyrole Spoof or

ROBERT W . 14UNC TE Guverranent MfairsiHcalth Care HewIet4Poohard 900 17th Str_ir %.W . Spite IitvI

CHARLES K FRANCIS, MD, FACC Professor of CEni A Medinoe Colfage of Physicians and Surgeons of Colmobis University Deader, Depart ncal of Medicine Had, Hospital Center 506 Lever Avenue, Room 14101 New York, New York 100)7 GOTFLIES-C . FRH'SINGER, II, MD, FACC 2152 Golf Chrh I-. Nashville, Teoneoee 31215 ROBERT L, FRYE. MD, FACC Chairman. Department of Medicine Mayo Clinic, Siehens 640 200 First Street, S .W . Rochester, Minoesota55905 Reridenr. Aruericon College of Cardiology ARTHUR CARSON, IV-, MD, FACE Professor of Medicine and Pediatrics Chief of Pediatric Cardiology T Chddrea c Hospital Foisted Cardiology 6621 Fannie Houston, Texas 77030 SIDNEY GOLDSTeiN, MV, FACC Dlvplen Head, Cerdiovasculo, Medicine 2799 W. cram Boulevard Room Aid Ii Detroit, Micldgan 48302 ROLF M. GUNNAR, MD, FACC Llueritus IY0retoor of Madmine The Go- Medico1 Grout, 3722 5. Harlem Avenue Riverside, IBiaas00245 MARTIN J . l{ATLIE, JD Director . Drpartrnent of Profesooed Lfahlity lee-c . American Medical Association 515 N. State Street Chicago,11hatea €41610 L-JULIAN HAYWOOD, MD Prdkrsor of Medicine LAC and USC Medical Center 1200 N. Stale Street Roan 8350 Los Angeles, Cakibrroa 90033

ADOLPH M-HUTTES, la ., MD, FACC Asoeiate Professor of 5ledicme Harvard Mheal School Phvsiriamin-Medtnne Massachusets Ganem Huspihd A.C .C . Buihlinp I5 Park .. Street. Sake 467 Baelca. Massachusetts 02114 HANS A. HUYSMANS, MD . POD Professor and Chairman Department ofCardiothaacre SurgeD Academic Hospital Rijmvurgeewee 101 2333- .U Leiden Netherlands LISA I. IEZZONL MD . Assistant P .1000, MS' Division of Amerl Medicine Beth Israel Hospital 330 Braokine .Avemte Boston, Massachusetts 022215 ROBERT H . JONES, 411), FACE Professor of Surgery Duke University Medio Cenet Duke Hospital Somh Room 4532A, Hut, Lone, Trent 13nve Durham. North Carolina 27710 Society ofTAmecic Surgrors and Amedcao Audridrinnfn TharoNe Sargeosu Rrprcserlarhe

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NORMAN G, LEViNSKY . ?1D Chairman. Deportment of Sedicioo B0ee0,, University Medical Center 88 E . Newton Street 50,000, Massachusetts 02118

SIDNEY L EYITSKY . M D. FRCS David W. and David Cheever Professor of Surgery Chief, Division of Cardiothoracic Surgery No,. England D--to Hospital, No . yC Ho Francis Street Batter, Mastechnselis 02275 Amenmn College of .Ssrgeons Reprrrenrdove MARION EIN LEWIN, MA Senior Scoff ODcer bri'Mol, or Medicine 2101 Constitution Avevoo, N .W. 0Yashiagtoa, D .C. 010618 FRED W . LYONS, In. President and Chief Executive Officer Marine Merrel Dow Inc, P.O. Doe 8480 Kansas City . Missouri 64114-4480

JOHN B . McCABE, MD, FACEP State University of New York Health Sciences Center 750 E. Adams Sreet Syraeose,New York 13210-2375 Amerrs,. College of Emergenry Pfrysiciaos Representative

HENRY D . McINTOSH, MD, FACC President Council on Lend ., Cardiology Wanton Clinic P.O. Ban 95M Sakeland. Florida 33504-5100 Council on Ceriurric Cardiology Representutivr

KATHLEEN KING, MA Specialist in Social LagislaSon Congeesioerl Reacmch Service EPW, LM 320 III InAependeuce Avenue. S .E . Warhinptuo, D.C. 20540

CABOLYNN E. MILLER, ESQUIRE Legislative Represenlalioo Nations: Federation of Independent Business 610 Maryland Avenue, S.W . Suite 700 Washington, D.C. 20024 Nariandl Federorioo of lodrprndrm Rusinus Represemmior

FRANCIS J . KLOCKE, MD, FACC Director of Feinherg Cardiovascular Research lastitote Professor of Med¢me Nonhwectem Uoiversil9 Medical School 303 E, Chicago Avenue, Ward 4-182 Chicago, Wmais 60611

MICHAEL. MII.LMAN, POD Sonar Staff Officer National Academy of Sciences Institute of Medicine 2101 Constitution Avenue, N.W. Washing-, D.C .20418 lnrri+ore of .edicine Reprerenrarive



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CHEITLIN 23rd BETHESDA CONFERENCE. PARTICIPANTS

JAMES H. MOLLER, MD, FACC Professor of Pediatrics University of Minnesota Box 288, (Room 203 VCRC) 420 Dclawarc Street, S.E. Minneapolis . Minnesota 55455 BARBARA PACKARD, MD . POD . FACC Associate Direcmr for Scientific Program Operation National Hcan, Lung, and Blood Institute Building 31, Room 5A03 9000 Rockville Pike Bethesda. Maryland 20892 A6rrianu! Hea: e Lr+.;, cc l BSaod lacrirnte Reprrcentathe THOMAS A. PEARSON, MD, P0D Director The Mary Imogene Bass,,[ Research Institute Mary Imogene Bassett Hospital I A-11 Road Conpenown, New York 13326 ANNIE KING PHILLIPS . MA, MPH American Assecialian of Retired Persons 307 N Street. S .W . Washington, D .C 20024 Amedear A .eturiminn of Riuk,d P--, Repeecenmrnvc JEAN PIERRE POULLIER Organization for Economic Cooperation and Development rue Andre Pascal Paris 16, F-757'15 France JAMES L . RITCHIE . MD, FACC Professor of Medicine University of California San Francisco Health Policy lasting, 1338 Seller S!ree6 11th Floor San Francisco . California 94109

IACC Vat . 19, No . 7 June 1997 :1441-92

H . MICHAEL SCHIFFER, MA Assisant Vice President Federal Affairs CIGNA Corporation 1525 Eye St-I . N .W.. No 752 Washington, D.C. 211006

JOHN SWEENEY President Service Employees International Union 1313 L Street, N .W. Washington . D .C . 20005 Service Employees lnteeoatianal Union Representative

HUGI1 E. SCULLY, MD, FACC . FAGS, FRCS(C) Professor of Surgery Department ofCardiovascul'ar Surgery University of Toronto The Toronto Hospital 20D Elizabeth Shat Toronto. Ontario M5G 2C4 Canada

DANIEL J. ULLYOT . MD. FACC Clinical Professor of Surgery University of California, San Francisco 1528 El Caminu Real, Suite N02 Burlingame. California 94010

RICHARD SMITH Washington Business Group on Health 777 N. Capital St., N .E . Saile 800 Washington, D.C. 20002 WaaAingreo Business Group or Hecloh Represenrarive

RODMAN STARKE, MD, FACC Senior Vice President Scientific Affairs American Heart Association 7320Grcanville Avenue Dallas . Texas 75231

PAMELA STEELE, MD Chief of Cardiovascular Diseases Veteran , Affairs Central Once 810 Vermont Ave. . N .W . II IA-Room 561 Washington, D.C .20420 U.S . Department of Veterans Afire Represenrarive

MARK B . WENNEKER, MD, MPH Assistant Professor of Medicine Tufts University School of Medicine 750 Washington Street Box 345 Dos!on . Massachusetts 02111 WILLIAM L . WINTERS, JR. . MD, FACC Clinical Professor of Medicine Baylor College of Medicine 656D Found Suite 1664 Houston, Texas 77030 PERCY WOOTTON, MD American Medical Association 515 Noah State Street Chicago, Illinois 60610 American Medical Association Represenrarive LEE YERKES Senior Director Professional Education and Scientific Communication Marian Merell Dow line . 10330 Hickman Mills Drive Kansas City, Missouri 64137-1618

Conference Steering Committee MELVIN D. CHEITLIN, MD. FACC, Chairman RUTH L . COLLINS-NAKAI, MD, FRCP(C), FACC C. RICHARD CONTI, MD, FACC ANTHONY N . DEMARIA, MD, FACC CHARLES K. FRANCIS, MD, FACC GOTTLIEB C . FRIESINGER . II . M D . FACC ROBERT L . FRYE, MD, FACC ROLF M . GUNNAR, MD, FACC ADOLPH M. HOTTER. JR.. MD, FACC WILLIAM L . WINTERS. JR.. MD, FACC

Staff American College of Cardiology WILLIAM D . NELLIGAN, CAE, Executive Vice President DAVID J . FEILD, Associate Executive Vice President CHARLENE L. MAY, Director, Special Projects SUZANNE L. WILLIAMS, Secretary.'Conference Coordinator