A joint report that proposes an integrated model of care for patients with valvular heart disease (VHD) was recently released by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI) and Society of Thoracic Surgeons (STS). This collaboration was published with the aim of optimizing the care received by patients with VHD.
With the elderly being the fastest growing segment of the population in the United States, the prevalence of VHD is expected to increase. Currently, it is estimated that the proportion of patients over 75 with moderate or severe aortic and mitral valve disease is 4% and 10% respectively. Additionally, with the advances in noninvasive imaging and surgical techniques, the diagnosis and management of VHD have changed significantly over the past decade. There are two main issues with the way VHD is currently managed: (1) Despite the presence of an indication for intervention, some patients are not being referred for treatment. Studies have estimated that 30-50% of patients with VHD who meet the guideline criteria for intervention have not been treated. The delay in treatment of VHD can lead to irreversible changes in left ventricular function, repeated hospitalization and worsening quality of life. (2) For those patients who are recognized as needing intervention, they may be offered an inappropriate treatment. For example, physicians may be unaware that a patient is a candidate for TAVR. Additionally, resources and the treatment options available may differ from one center to another.
“The increasing burden of VHD, coupled with the emergence of improved imaging techniques, better surgical outcomes, and transcatheter therapies, has stimulated discussions regarding optimal strategies for care delivery. The focus of this document is not to ask whether there are too many, too few, or just the right number of self-designated advanced valve centers, but rather to initiate a discussion regarding whether a regionalized, tiered system of care for patients with VHD that accounts for the differences in valve center expertise, experience, and resources constitutes a more rational delivery model than one left to expand continuously without direction.” – Rick A. Nishimura, M.D.
The report proposes a system of care for patients with VHD with the goal of optimizing outcomes for all patients, ultimately improving the care of VHD at all centers. The authors describe a multi-tier model with an emphasis being placed on the role of the first tier: recognition and consideration for referral. This would typically be done by a primary care physician, advanced practice provider or general cardiologist. The next step would be a referral to a local general cardiologist who would then refine the diagnosis, start medical treatment and identify patients who would need surgical intervention. Once care is established with a cardiologist, and further intervention is deemed necessary, the patient would then be referred to a specialized center. The report highlights the necessity of a multidisciplinary team (MDT) and shared decision making throughout the entire process.
The authors then continue to describe the necessary elements for the success of this proposed model of care. They describe the procedures and level of expertise that should typically be available in a specialized center (Level I and Level II centers, with a Level I center being more advanced). Also, the authors describe the need for “transparency, public reporting, mandatory participation in national registries, ongoing analysis of processes and outcomes, and a commitment to research”. The authors also emphasize the importance of a bidirectional line of communication between the MDT and the referring physicians/centers. Finally, they underscore the importance of informed consent, the patient experience, and individual choices. The authors then go on to describe the performance metrics that can be used for different procedures including transcatheter aortic valve replacement and mitral valve repair.
Finally, the authors acknowledge some of the obstacles associated with this proposed model of care. The authors realize that many patients may be unwilling or unable to travel to remote centers to continue their VHD care. Seamless communication, including sending health records and digital imaging data, is not available in all healthcare systems in the United States. Finally, the authors describe the need to address the current knowledge gap. This can lead to variability in the quality of care as well as clinical outcomes. The authors write, “The increasing burden of VHD, coupled with the emergence of improved imaging techniques, better surgical outcomes, and transcatheter therapies, has stimulated discussions regarding optimal strategies for care delivery. The focus of this document is not to ask whether there are too many, too few, or just the right number of self-designated advanced valve centers, but rather to initiate a discussion regarding whether a regionalized, tiered system of care for patients with VHD that accounts for the differences in valve center expertise, experience, and resources constitutes a more rational delivery model than one left to expand continuously without direction.”