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Reign : 1984-86

Theismann was quickly overtaken when Marino produced the best season to date by a quarterback in 1984, one that set multiple passing records at the time and holds up as one of the five best quarterback seasons ever to this day. Marino won his lone MVP that year. He wasn’t able to beat the 49ers in that year’s Super Bowl, but Marino would be the first-team All-Pro quarterback in 1984, 1985, and 1986, leading the league in passing yards and passing touchdowns during each of those campaigns.

Reign : 1987-90

Montana’s first great regular season was 1987; he came up short to John Elway in the MVP balloting, but Montana arguably had better numbers and had the beginnings of his legendary postseason cachet to fend off Elway for the title. The 49ers actually lost at home to the Vikings in a divisional-round game this season, and Montana would struggle to stay healthy in 1988, but he would outduel that season’s MVP, Boomer Esiason, to win Super Bowl XXIII. Montana then won the MVP award in 1989 and 1990, adding another Super Bowl to his collection in 1989, before Scarosso Andrea Cognac nF6U1T
, suffering a torn elbow ligament that sidelined him for the entire 1991 season. 4

Reign : 1991

The 49ers had a ready-made replacement for Montana in Steve Young, but Young wasn’t healthy during the 1991 season and missed six games. The All-Pro quarterbacks for the year were the guys who represented the two participants in that year’s Super Bowl, Jim Kelly and Mark Rypien. Rypien might have won the game, but I think it’s pretty clear that Kelly was the better quarterback.

Reign : 1992-94

Once Young got healthy, he immediately became the man. He won MVP trophies in 1992 and 1994, settling for first-team All-Pro in 1993. Troy Aikman might have won two Super Bowls during this run, but he was a second-team Pro Bowler behind Young each year, and his numbers couldn’t match up to what was being produced out west.

Reign : 1995-98

Young’s next injury coincided perfectly with the ascension of Favre, who somehow made the Pro Bowl while leading the league in interceptions in 1993 before being left out with a 33-to-14 touchdown-to-interception ratio in 1994. Favre was unfazed, starting a four-year run with three league MVP trophies, three first-team All-Pro appearances, four Pro Bowls, two passing titles, and three passing touchdown leaderships. Both he and the Packers took a step backward in 1999, just in time for the unlikely arrival of …

Reign : 1999-2001

The 1999 Rams actually would have been a team that generated some underrated buzz in this space if Grantland existed back then; they were 1-6 in games decided by a touchdown or less in 1998, underperforming their Pythagorean expectation by 1.4 games. Of course, replacing Tony Banks with a guy who threw 41 touchdowns and completed 65 percent of his passes helped, too. Warner was unstoppable in 1999 and close to unstoppable for most of 2001, winning league MVP both years. He missed five games with injuries in 2000, but nobody doubted that he was still the most dangerous quarterback in football. And then in 2002? An 0-6 record, three touchdowns, 11 interceptions. What a weird run.

For the total exercised group of 201 patients, the LV outflow tract gradient increased from 4±9 mm Hg at rest to 45±49 mm Hg after exercise ( Figure 2 ). Of these exercised patients, 106 (52%) developed dynamic LV outflow gradients ≥30 mm Hg, including 76 (38%) that were particularly substantial, ie, ≥50 mm Hg. The remaining 95 patients (47%), ie, those with gradients <30 mm Hg at rest and with exercise, were regarded as having the nonobstructive form of HCM ( Table 2 ). Each of the 11 patients with rest gradients of 30 to 49 mm Hg developed gradients ≥50 mm Hg with exercise.

Figure 2. Changes in LV outflow tract gradient from basal (rest) conditions to immediately after exercise in 201 HCM patients. Each individual exercised patient is depicted by a line connecting the 2 gradient measurements. indicates mean value.

View this table:

TABLE 2. Demographic, Echocardiographic, and Exercise Data in 201 Patients With HCM

The 3 participating centers did not differ significantly with regard to the percentage of exercised patients who generated provocable gradients of 30 to 49, ≥50, or <30 mm Hg ( P =0.8). The 20 patients taking cardioactive medications at the time of exercise testing developed LV outflow gradients (≥30 mm Hg) no more frequently than did the exercised patients with medications withdrawn (10 of 20 [50%] versus 86 of 181 [47%], respectively; P =0.9); the average exercise gradients in these 2 groups also did not differ significantly (31±32 versus 46±51 mm Hg, respectively; P =0.2).

Patients who generated an outflow gradient with exercise and those who were nonobstructive did not differ significantly with respect to a number of exercise testing parameters, including rate-pressure product at peak exercise Timberland LOS ANGELES WIND SLINGBACK Platform sandals jet black vMpFzPvqe
and percent maximal predicted heart rate during measurement of the postexercise gradient ( Table 2 ). Substantial increases in mitral regurgitation from absent or mild to moderate (at baseline) to severe after exercise were evident in 14 patients (18%) with a provocable gradient ≥50 mm Hg, in 1 patient (3%) with a gradient of 30 to 49 mm Hg, and in no patient with a gradient <30 mm Hg. The average provocable gradient in the 23 patients (11%) who developed significant symptoms during exercise testing was 63±53 mm Hg and did not differ from that in other patients without symptoms during exercise testing (48±44 mm Hg; P =0.1).

Combined Patient Analysis

Overall, 225 of the 320 HCM study patients (70%) exhibited LV outflow tract obstruction at rest (n=119) or with exercise (n=106; Spring Step Pinnacle Tall Boot I1fUMq
). With only exercise gradients ≥50 mm Hg included in this assessment, the overall proportion of patients with outflow obstruction was 60% (n=195).

Figure 3. Prevalence of LV outflow tract obstruction in the overall study group of 320 HCM patients. *Includes 30 patients with modest exercise gradients of 30 to 49 mm Hg and 76 patients with gradients ≥50 mm Hg.

Clinical Profile and Predictors of Exercise-Induced Obstruction

Of the 106 patients who developed gradients ≥30 mm Hg with exercise, 17 (16%) had advanced heart failure symptoms (NYHA class III); 29 others (27%) had more moderate limitation (class II), and 60 (57%) were in class I ( Table 2 ). Of the total 77 exercised patients with heart failure symptoms (NYHA classes II and III), 46 (60%) had gradients ≥30 mm Hg (≥50 mm Hg in 33) identified with exercise ( Table 2 ).

Among selected clinical and echocardiographic variables (age, gender, left atrial transverse dimension, maximum LV and basal anterior septal thickness, LV end-diastolic and end-systolic cavity size, Valsalva-induced gradient and degree of SAM), only a Valsalva-induced gradient ≥50 mm Hg (hazard ratio, 24; 95% confidence interval, 2.5 to 194; =0.003) was an independent predictor of an exercise-induced gradient.

Each of 42 patients who developed an outflow gradient ≥30 mm Hg with Valsalva also provoked a gradient ≥30 mm Hg with exercise. However, of the 159 patients in whom Valsalva did not provoke a gradient, 25 (15%) developed an exercise gradient of 30 to 49 mm Hg, and 39 (25%) had an exercise gradient ≥50 mm Hg; 95 other patients (60%) were without a gradient after exercise.

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One of the Centers for Medicare Medicaid Services’ (CMS) top priorities is to foster an affordable, accessible healthcare system that puts patients first. To help achieve these goals, CMS has a powerful tool through the Innovation Center for testing ways to improve quality and reduce costs.

Background

In September 2017, CMS released a Request for Information (RFI) to collect ideas on a new direction for the Innovation Center to promote patient-centered care and test market driven reforms that:

The Innovation Center is a central focus of the Administration’s efforts to accelerate the move from a healthcare system that pays for volume to one that pays for value and encourages provider innovation.

The Innovation Center received a robust response with approximately 1,000 responses from the public, including consumers and consumer groups, physicians and other healthcare providers, health systems, health plans, national and state associations, community-based providers, foundations, faith-based organizations, states and technology firms. The responses focused on a number of areas that are critical to improving the quality of care for beneficiaries and decreasing unnecessary cost, such as increased physician accountability for patient outcomes, improved patient choice and transparency, realigned incentives for the benefit of the patient, and a focus on chronically ill patients. In addition to the themes that emerged around the RFI’s guiding principles and eight model focus areas, the comments received in response to the RFI also reflected broad support for reducing burdensome requirements and unnecessary regulations.

Next Steps

CMS is sharing the feedback received to promote transparency and facilitate further discussion of how to move the Innovation Center in a new direction. The RFI was a critical step in the model design process to ensure stakeholder input was available to help shape new models. Over the coming year CMS will use the feedback as it works to develop new models, focusing on the eight focus areas outlined in the RFI.

CMS will continue engaging with stakeholders to help foster the design and successful testing of care delivery and payment models that put patients first, reduce unnecessary burden, increase efficiencies and improve the patient experience.

Public comments that were received by the Innovation Center in response to the RFI are available below:

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