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Multidisciplinary teams, shared decision-making may improve valvular heart disease care
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A two-tiered approach for valve centers may increase the identification of patients with valvular heart disease and improve outcomes through the use of multidisciplinary teams and shared decision-making, according to an expert consensus systems of care document from the American College of Cardiology and other societies published in the Journal of the American College of Cardiology.
“The impetus behind this document is a general desire among the professional societies to highlight the need to improve the care of patients with valvular heart disease so that best outcomes can be achieved as often as possible while balancing the important aspect of access to care,” Patrick T. O’Gara, MD, MACC, director of strategic planning in the division of cardiovascular medicine at Brigham and Women’s Hospital, Watkins Family Distinguished Chair in Cardiology Professor at Harvard Medical School and co-chair of the writing group, told Cardiology Today’s Intervention. “This is one of several documents that the societies have published over the course of the past 5 years or so that speak to the appropriate dissemination of novel technologies for treatment of patients with valvular heart disease recognizing all of the obstacles that may present themselves to achieve this idealized state.”
Two-tiered approach to care
Rick A. Nishimura, MD, MACC, chair of the division of structural heart disease and consultant in the division of structural heart disease at Mayo Clinic in Rochester, Minnesota, and co-chair of the writing group, and colleagues detailed a two-tiered approach to optimize the care of patients with valvular heart disease that is similar to the management of patients with stroke.
“In some ways, for example, you could examine this process from the same lens that the process of acute stroke care in the United States has evolved over the past 10 to 15 years with designation of centers of being capable and experiences to perform some services,” O’Gara, who is also past president of the ACC, said in an interview. “There is a graduated level of services that can be performed depending on the size of the institution, the expertise and the experience of the personnel, the level of infrastructure in imaging and support services that are present. ... We are identifying more of a chronic disease here against acute stroke or acute ST-elevation myocardial infarction, but we’re placing a premium on the reality that not every self-designated valve center has the requisite amount of personnel, experience, expertise and infrastructure to be all things to all patients with all types of valvular heart disease.”
Level II centers focus on the local level and consist of community providers and primary valve centers that would communicate and collaborate with a level I comprehensive center, according to the document. A patient would move through this system of care depending on the disease complexity while maintaining their relationship with their health care providers.
Multidisciplinary teams serve an important role in centers that have been designated as having valvular heart disease expertise, as they can assess and manage patients based on guidelines while participating in shared decision-making with their patients, according to the document.
Practice-level and primary care clinicians would serve as “vital gatekeepers” within this system of care by assessing patient evaluations and echocardiography. If a patient is suspected or confirmed to have significant valvular hear disease, they would be referred to a regional or local CV specialist for evaluation and management.
Centers that are designated as comprehensive valve centers, or level I centers, should have capabilities and resources for interventional and surgical procedures and advanced imaging modalities. A primary valve center, or a level II center, would at least have the resources and expertise to perform surgical and transfemoral transcatheter aortic valve replacement. In addition, this center may also have the ability to perform mitral valve repair, although it is desirable to be defined as a level II valve center, according to the document.
Both levels of centers should have the expertise to perform catheter-based techniques to evaluate and manage patients with valvular heart disease. Facilities and personnel at comprehensive valve centers should also be able to perform nontransfemoral TAVR including extrathoracic and transthoracic approaches.
Isolated surgical AVR with or without CABG should be able to be performed at both levels of centers, although more complex surgical procedures should be performed at comprehensive valve centers for the treatment of other patients with valvular heart disease.
Multidisciplinary teams at both levels of centers should consist of personnel such as a dedicated valve program coordinator to help patients navigate the shared decision-making process, according to the document. This team should meet preferably every week to discuss topics such as a patient’s individual needs and preferences, management decisions, outcomes, quality and imaging results. Other disciplines such as nephrology, geriatric medicine and neurology can be involved if necessary. These teams would also work together during surgical and interventional procedures.
Quality assessment
A scientifically rigorous approach to measure performance and assess quality must be developed and implemented by valve centers, professional societies and multidisciplinary teams, according to the document. This includes active participation in registries such as the Society of Thoracic Surgeons/ACC Transcatheter Valve Therapy Registry.
Both levels of centers are recommended to lead investigative efforts focused on improving clinical management and on new technologies for the treatment of patients with valvular heart disease. First-in-man and early feasibility studies can be performed at select comprehensive valve centers, whereas both types of centers can participate in pivotal device trials if there is sufficient research infrastructure, according to the document.
Both levels of centers should offer ongoing education for clinicians at conferences and should discuss with each other how to establish a shared understanding on when patients should be referred for more complex care. Comprehensive centers can offer on-site education and support to primary centers that focuses on topics such as patient evaluation, intervention timing and procedural and technical aspects of intervention.
Comprehensive and primary valve centers should focus on assessing performance and quality of care through a comprehensive approach to gather patient-level data that would be shared with an analytic center to develop reports with validated performance metrics that are benchmarked against other centers, according to the document. Heart valve centers should then be evaluated based on available outcomes for each procedure and procedural volumes rather than just volumes alone.
The committee developed a three-star system for public reporting of performance measures at valve centers, which would be based on outcomes reports from both types of centers.
There are several limitations to implementing this valvular heart disease system of care including access, communication, cost, institutional and professional skepticism, and knowledge and performance gaps, according to the document.
“We identified in the document several fundamental obstacles, but it would remain our hope that this will initiate the discussion necessary to try to bring a greater degree of order to the process and recognition that we think we can do better with resources that we have,” O’Gara told Cardiology Today’s Intervention. “We are not certain that everybody should or could have all of the same resources, and we want to put some objectivity around what it means to be a full-service comprehensive valve center rather than a title that many institutions self-designate. We are trying to get to some objectivity here in terms of how patients as well as patient advocates as well as payers might be able to assess the competence of any particular site or operator at that site.” – by Darlene Dobkowski
For more information:
Patrick T. O’Gara, MD, MACC, can be reached at Brigham and Women’s Hospital, Division of Cardiovascular Medicine, 75 Francis St., Boston, MA 02115; email: pogara@partners.org.
Disclosures: O’Gara and Nishimura report no relevant financial disclosures. Please see the document for all other authors’ relevant financial disclosures.
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