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Heart Teams: A New Paradigm in Health Care

2018; Elsevier BV; Volume: 34; Issue: 7 Linguagem: Inglês

10.1016/j.cjca.2018.02.028

1916-7075

Thierry Mesana, N. W. Rodger, Heather Sherrard,

Health Systems, Economic Evaluations, Quality of Life

Cardiovascular patients have become increasingly complex as has the development of new technologies and novel treatment approaches. This has resulted in more challenging decision-making, frequently crossing disciplines. It is not surprising that the concept of the heart team has garnered more attention recently. This concept is associated with a multidisciplinary, team-based approach involving a group of cardiovascular medical experts and various health care professionals, each of them bringing their own level of expertise, and working together toward patient-centred care. In this article we examine the heart team landscape in Canada, explain why dedicated centres such as heart institutes or similar centres with models of integrated cardiovascular care are well positioned to lead the way, highlight the challenges facing heart teams, and the opportunities that heart teams offer for improved patient-centred care. The University of Ottawa Heart Institute (UOHI) conducted a survey to assess the heart team landscape in Canada and presented the findings at the Canadian Cardiovascular Society Annual Meeting in Montreal in October 2016. The survey was distributed to 38 major centres across Canada with 21 (55%) of centres responding. Nearly half (47.6%) of the respondents to the survey indicated that their organization did not have a single heart team. However, 50% of these organizations indicated that they planned to create a heart team. Most heart teams were reported to be organized around transcatheter aortic valve implantation (TAVI) procedures with none, outside of our organization, organized around coronary artery disease (CAD) revascularization. Those with heart teams had at a minimum a cardiac surgeon and a cardiologist as part of the team. Other team members included a nurse (85%), imaging specialist (75%), anaesthesiologist (70%), gerontologist (31%), among a few others. All teams confirmed that the main goal of the heart team was to determine treatment options and patient selection. Clinical research was also considered an important part of the work to be done by heart teams with 75% of the teams collecting key metrics. Only half of the heart teams were operating without an institutional budget. Overall, most centres were satisfied with their heart team(s), citing the main benefit as collaborative decision-making with shared accountability and transparency. Other benefits cited included the improvement in communication among providers, improvements in patient care and outcomes, and interprofessional learning for new approaches and technologies. The main challenge cited as impeding the performance of heart teams was the logistical difficulties for coordinating schedules and physician availability. Other significant challenges were related to institutional resources and financial aspects such as physician billing, level of funding for procedures, infrastructure concerns regarding lack of space for teleconference facilities limiting stakeholder participation, access to specialized operating rooms such as hybrid operating rooms, and the absence of dedicated databases. The survey also identified issues around corporate culture related to competition between services, although most respondents highly valued the team model. Although the survey was limited to larger cardiovascular centres, we concluded that heart teams are evolving in Canada and that there is no single model. Heart teams need to expand beyond TAVI to other areas of structural heart disease and even more broadly to other areas of cardiac care. In addition, the role of heart teams needs to evolve beyond patient selection and procedure performance to include innovative practices and clinical research. Such recommendations have been reiterated in many recently published reports and a recent US survey under the auspices of the Society of Thoracic Surgeons published online in The Annals of Thoracic Surgery in April 2017.1Bavaria J.E. Prager R.L. Nauheim K.S. et al.Surgeon involvement in transcatheter aortic valve replacement in the US: a 2016 Society of Thoracic Surgeons Survey.Ann Thorac Surg. 2017; 104: 1088-1093Google Scholar Dedicated teams have been in place for clinical programs requiring a high level of care co-ordination (ie, complex heart failure and congenital heart disease) as well as low-volume, high-risk procedures (ie, heart transplantation and circulatory assist devices) for decades. Typically, these early teams were in heart institutes or tertiary hospitals so the concept did not rapidly spread. In the past 5 years, there has been a resurgence in the call for heart teams, which has been reinforced by prominent professional societies on both sides of the Atlantic as part of the guidelines for myocardial revascularization of CAD and TAVI.2Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Google Scholar, 3Windecker S. Kolh P. Alfonso F. et al.Authors/Task Force members2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur Heart J. 2014; 35: 2541-2619Google Scholar This is in part because of the rapid advances in technology—providing patients and families with more options. It has also been influenced by the challenges of evidence-based medicine in the face of multiple guidelines, occasionally discordant studies, and the difficulties of applying findings from randomized controlled trials in the real world. As we look back to see the way forward there is evidence to show heart failure and transplant teams produced improvements in outcomes.4Passeri J.J. Melnitchouk S. Palacios I.F. Sundt T.M. Continued expansion of the heart team concept.Future Cardiol. 2015; 11: 219-228Crossref PubMed Scopus (6) Google Scholar It is not unreasonable to expect that new heart teams, if carefully implemented, will also have positive effects. In addition to clinical outcome improvements, we expect the heart team concept will facilitate collaborative research and the emergence of a new generation of experts and clinical investigators in various fields of cardiovascular disease. Engaged leadership committed to the collection of high-quality clinical data for research is critical to the success of the heart team model supporting validation of benefits and demonstrating improvements in outcomes, especially because of the lack of evidence in the literature. The heart team model will facilitate the development of large institutional databases with harmonized data collection designed with a holistic view independent of the type of cardiac disease, treatment, or specialist. Such large databases are central to the evaluation of innovative procedures and novel strategies. Heart teams also have the ability to significantly transform education and high-level training across specialties. The combination of new cardiovascular technology with increasing patient complexity is bringing physicians and trainees from different specialties together and breaking down traditional silos. Surgeons are eager to perform less invasive procedures, and are becoming more familiar with intraoperative imaging and acquiring catheter skills. Interventional cardiologists are acquiring more knowledge of valve disease, consulting with surgeons on the anatomical and physiological challenges they are facing. We are seeing an increasing number of innovative percutaneous solutions reproducing techniques used for decades in surgery, such as the mitral valve clipping reproducing the edge-to-edge surgical suturing of mitral valve leaflets introduced in the 1990s by a cardiac surgeon (Alfieri) to repair mitral valve prolapse. Sharing practice and knowledge between interventional cardiologists and cardiac surgeons and similarly electrophysiologists and surgeons will inevitably increase, and we will see more hybrid procedures and specialists working together in hybrid operating rooms. Medical schools will need to keep up with these advances and augment curricula for subspecialty training with guidance from heart teams. We will see highly qualified specialists and new leaders emerge with a new culture of working across specialties and promoting advanced patient-centred care, which should be the ultimate goal of medical training. The benefits of these new heart teams have not yet been quantified. It should be the role of early adopters to build the models, the metrics, and work together to create a gold standard model of care.5Holmes D.R. Rich J.B. Zoghbi W.A. Mack M.J. The heart team of cardiovascular care.J Am Coll Cardiol. 2013; 61: 903-907Crossref PubMed Scopus (172) Google Scholar, 6Sanchez C.E. Badwar V. Dota A. et al.Practical implementation of the coronary revascularization heart team.Circ Cardiovasc Qual Outcomes. 2013; 6: 598-603Crossref PubMed Scopus (21) Google Scholar One of the main logistical challenges with heart teams is coordinating schedules and physician availability. This is especially challenging in teams that require prompt review of cases such as complex CAD patients undergoing cardiac catheterization who fall into the “grey zone” (triple vessel CAD, left main disease, and diabetic patients with disease of the left anterior descending artery). These patients should ideally receive a surgical consultation while they are still on the table, but in practice this can be logistically difficult to implement, particularly at high-volume centres such as ours with 4 cardiac catheterization labs running simultaneously. Consequently, excessive use of ad hoc percutaneous coronary intervention (PCI) can become a reality; one that can limit the successful deployment of the CAD heart team. Taking these patients off the table who would have been deemed a PCI candidate upon heart team review can be seen as inefficient and an inconvenience to the patient. For inpatients this can extend the length of stay. There is also the risk and/or perception that a patient’s clinical status might deteriorate while waiting for a review and rescheduling. Even when real-time review is not necessary, coordinating schedules for same day or same week review can still pose a challenge. As a result, the heart team concept can be perceived to be an impractical concept. This should not be a deterrent; rather the organization needs to find solutions that can facilitate a team-based approach such as adopting new technologies for virtual consultations and discussions. Cultural and current practice patterns can also create significant hurdles. For example, interventional cardiologists have decades of experience in performing PCI. In the early 1980s interventional cardiologists required surgical backup, but skills and technology have expanded dramatically. Millions of patients worldwide have had their lives saved by coronary angioplasty and PCI, particularly in acute coronary syndromes where time is of the essence. Consequently, some centres have developed a culture or practice of more aggressive PCI, with no pressing need for a heart team concept or discussion. In the real world, CAD patients are first referred to an interventional cardiologist for a coronary angiogram and the decision on the best course of action is often left to the individual judgement of a physician potentially unaware of new and/or improved surgical alternatives or one who is unintentionally biased toward PCI. Although in most cases a surgical opinion is not necessary, complex CAD patients who fall into the “grey zone” deserve the benefit of consultation by both specialties and informed consent. Changing these established processes and practices can pose significant challenges. The first necessary step for a successful CAD heart team is to build trust and good communication practice working together toward a “culture of harmonization” between the “PCI culture” and “coronary artery bypass grafting culture.” Professional societies such as the Society of Thoracic Surgeons and the American Heart Association will continue to play a major role in this cultural shift, but each centre must cultivate its own spirit of trust and dialogue. Financial considerations fall into 2 broad categories: organizational support for heart teams and financial reimbursement models. It is important to note that heart teams for TAVI are a requirement for Medicare reimbursement in the United States. This is not the case in Canada, although our health care system is essentially publicly funded. Results of the Society of Thoracic Surgeons survey show that a countrywide implementation of TAVI heart teams can be successful even in a highly competitive, business-driven environment such as the US health care system. Consideration needs to be given as to how heart teams can be supported in the current Canadian funding model. Because health care in Canada is federally funded, but a provincial jurisdiction, a combination of federal and provincial incentives is likely needed. There should be little doubt, however, that governments or private health care companies are becoming increasingly interested in incorporating cost and quality measures into future reimbursement models. Movement toward bundled payments with a value-added delivery model, might give a primary role to any heart team responsible for complex patient care pathways. These measures should lead to quality improvements and cost reduction. Heart teams can be a vital component of a bundled payment system where funding would be delivered to the hospital treating CAD or valve patients on the basis of quality and outcomes delivered for specific pathways. Payments could include the physician fees together with hospital payment as an incentive to promote and engage all stakeholders to improve quality and efficiency with less costs and better access to care. By not being paid or funded in silos, hospitals and heart teams could work together to provide innovative and better care at less cost. In the authors’ opinion, heart institutes and similar models of integrated Cardiovascular Centres of Excellence are well-positioned to lead the way in adopting and expanding the heart team concept. They are typically large academic centres with multidisciplinary cardiac experts (cardiology, cardiac surgery, electrophysiology, cardiac anaesthesia, etc) dedicated to preventing and treating cardiovascular disease all under one roof. These facilities have large patient cohorts that facilitate clinical research programs focused on clinical trials and longitudinal follow-up. They frequently have research programs in basic and translational sciences bringing innovation from bench to bedside. In our view, the heart institute model brings an additional value when it has a separate administration with senior medical leadership having the ability to allocate funds to strategic initiatives such as support for heart teams. However, no matter what the model, we believe success is rooted in a formal process that identifies heart teams that are required on the basis of patient needs. The teams need to be formally recognized within the organization, have a common set of deliverables, be multidisciplinary (physicians, nurses, allied health), be committed to data collection, commit to innovation and research, and have a strategy for long-term outcome assessment. As part of its 2015-2019 Strategic Plan the UOHI identified the heart team concept as the centrepiece for delivering patient-centred cardiac care. In addition to TAVI and Mitraclip teams formed in 2007 and 2011 respectively, the strategic plan included the formation of 6 new heart teams. The first 2 new teams to be launched in 2015 were the CAD Team and the Arrhythmia Team. These teams have medical co-leads with specific roles and responsibilities: a cardiac surgeon and an interventional cardiologist for the CAD Team, and a cardiac surgeon and an electrophysiologist for the Arrhythmia Team. In addition, both teams include a noninvasive cardiac imaging specialist, a general cardiologist, a cardiac anaesthetist/intensivist, a dedicated nurse manager and/or a nurse coordinator, medical trainees, and a patient representative. Heart teams at the Heart Institute have been given a broad mandate, which includes developing novel strategies for patient screening, triaging, and long-term follow-up; promoting adherence to best practices; developing educational and leadership opportunities; promoting collaborative clinical research; and, identifying opportunities for regional activities. Financial support is provided to the teams through a project manager funded by the Heart Institute. In addition, each team has been provided 1 additional position to help support ongoing activities of the team on the basis of their plan. Each team has the autonomy to choose projects of interest in alignment with the terms of reference. The CAD Team, for example, has elected to examine patients in the “grey zone” for revascularization. The team has used some of their funding to hire an x-ray technologist to calculate a Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score for all patients. All patients who meet the “grey zone” criteria are systematically reviewed by a surgeon and an interventionist. The CAD Team identified timely consultations as a barrier to changing current practices and is now implementing a new process, which will deliver a surgical consultation in real time. The team will continue to monitor the outcomes and processes related to the changes. Arrhythmia heart teams are gaining momentum in Europe, but not yet in Canada.7Fumagalli S. Chen J. Dobreanu D. et al.The role of the Arrhythmia Team, an integrated, multidisciplinary approach to treatment of patients with cardiac arrhythmias: results of the European Heart Rhythm Association survey.Europace. 2016; 18: 623-627Crossref PubMed Scopus (18) Google Scholar At UOHI, this team has elected to work on a number of projects including the development of a regional triage model for atrial fibrillation patients to ensure timely and appropriate referral; the STOP AFIB program, a preoperative prophylaxis protocol to reduce onset of postoperative atrial fibrillation in surgery patients, and the evaluation of long-term outcomes of catheter-based and surgical ablation patients. More recently, a Women’s Heart Health Team was launched in 2016 and the Complex Critical Care Heart Team followed in 2017. These teams, although held to the same general terms of reference, will address broader health care issues rather than disease-specific issues. The last 2 teams, Cardiac Imaging and Heart Failure, are scheduled to launch in 2018. Fundamental to all teams is the need to collect data in a systematic way that can be leveraged internally as well as externally. Teams are encouraged (with financial support) to participate in international data collection systems that allow for the collection of quality and outcome data as well as research opportunities. Additionally, the UOHI is establishing a common data platform, which will contain data on the patient care experience across the full spectrum of care. Finally, because this model is in development and not fully evaluated, each team is required to present the results of its activities and expenditures to the senior management team annually. On the basis of those results, teams might change direction, undertake new initiatives, or see changes to their financial support. In 1789, the King Louis XVI was informed that the people of Paris were seizing La Bastille; a symbol of royal prison, and asked: “Is it a revolt or a revolution?” It was obviously a revolution but the King did not see it coming. Heart teams might not bring a revolution in health care, but it is undeniably a significant new health care paradigm, triggered by clinical research engaging physicians to come across specialties. We are in a very exciting new era for cardiac care as a result of the way we are embracing new technology, and fostering cardiovascular innovation that will profoundly transform our overall care delivery. Cardiovascular Centres of Excellence can lead the way, by expanding heart teams across their organization, and defragmenting and reinventing care to better serve patients’ needs. As we better understand the success or design of these models, engagement of government and professional societies will be essential to securing the necessary supports for long-term sustainability and viability of the heart teams.