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Multidisciplinary Care for HF Patients with Resynchronization Devices: Interview with Jagmeet P. Singh, MD, PhD
The long-held view that the structure and organization of clinical care meaningfully influence clinical outcomes was a central thesis of my work with Michael E. Porter and several Harvard Business School case studies ("ThedaCare," "Ledina Lushko," and "MD Anderson Cancer Center") that we authored on the subject. Example after example demonstrates that organizing care around patients, co-locating and coordinating necessary services and specialists, and anticipating and responding to clearly articulated needs lead to better care and, often, lower costs.
Jagmeet P. Singh, MD, PhD, an electrophysiologist at Massachusetts General Hospital (MGH) and associate professor of medicine at Harvard Medical School, has recently worked to apply these principles to the management of HF patients with cardiac resynchronization devices. In a 2012 paper Dr. Singh and his colleagues published in the European Heart Journal, an integrated approach to care was found to improve event-free survival in patients undergoing cardiac resynchronization therapy.
I spoke recently with Dr. Singh about the care model he has implemented for care of patients and opportunities to diffuse multidisciplinary care to other arenas of cardiology.
Can you describe the need for a multidisciplinary clinic for cardiac resynchronization?
Patients who receive cardiac resynchronization therapy (CRT) devices are a frail group of ambulatory individuals with refractory HF. The care of these patients is complex and requires input of several subspecialists inclusive of electrophysiologists, and HF and imaging specialists. It is well known that a substantial proportion of patients receiving CRT will not respond adequately to this therapeutic modality. Many patients nonresponsive to this therapy come to our attention when they have already worsened significantly or have been hospitalized for HF. This deterioration often occurs because of the lack of an integrated care approach and the absence of a structured cross-talk and communication between the multiple caregivers. A multidisciplinary clinic provides the opportunity to be proactive, share information, and work as a team to ensure the best clinical outcomes for this cohort of patients. To elaborate on just one aspect of integrated care, these implanted CRT devices provide a host of information regarding the clinical state of the patient. These could be data on arrhythmias or data pertinent to the HF status. Device-based impedance measures of fluid overload, the nocturnal heart rate, heart rate variability, or physical activity log index all provide a better understanding of the clinical trajectory of the patient. This information can be shared in real time via a coordinated clinic environment. Also, importantly, a multidisciplinary clinic provides the opportunity to individualize the programming of these CRT devices to enhance the optimal delivery of resynchronization therapy. Can you walk me through "usual care" for patients undergoing cardiac resynchronization?
In usual practice, patients with CRT devices are seen by their cardiologists, HF specialist, and electrophysiologist, and undergo cardiac imaging (with and without device optimization) at separate times, most often on different days and even several weeks apart. Sharing of the information among the group of physicians looking after these patients is logistically challenging and usually not temporally relevant in the course of their disease, especially if the patients are tenuous. The deleterious impact of this lack of real-time integrated care is predominantly germane to the subgroup of patients who are not clear "immediate" responders to resynchronization therapy. How is the model adopted by your clinic different from usual care?
Our clinic model ensures that, during the same visit, the patient is seen by the HF specialist and electrophysiologist to have their devices interrogated and optimally programmed with echo guidance. As part of an endeavor to gather objective clinical data during each visit, patients also undergo a 6-minute walk test and complete a quality-of-life questionnaire. It may seem quite complex to have a patient go through this rigmarole, but we have it down to a science. We have a very experienced CRT nurse practitioner (Mary Orencole, ANP) and a team of study coordinators who help keep us all on track and ensure that the clinic flow is well maintained. On average, we see approximately 8-12 patients per clinic session. Patients are seen in the clinic at 1, 3, and 6 months post-implant to ensure that they are on the right trajectory, following which they graduate and follow up with their own primary cardiologist. They get referred back to the clinic only if they are not doing well and need to be re-evaluated for a lead revision, image-guided re-optimization of their device programming, or an investigative protocol. Even though our program is first and foremost a clinical service, nearly 70% of our patients are involved in one or more of our research protocols. The beauty of the program is that we have piggybacked our research component onto the service component in a rather seamless way, which enables prospective research without compromising or changing the clinical care provided to the patient. The data acquired and the lessons learned from our research are quickly brought back into clinical practice. So, we are constantly learning and improving the way we deliver our therapy. Can you describe the quality and cost results of your trial of multidisciplinary care for cardiac resynchronization?
The results of our study were published in 2012 in the European Heart Journal. Our study examined the clinical outcome in 254 patients receiving multidisciplinary care compared to 173 patients who received conventional care. The multidisciplinary group was followed prospectively in an integrated clinic setting by a team of subspecialists from the HF, electrophysiology and echocardiography service at 1, 3, and 6 months post-implant. All patients had ECG-guided optimization at their 1-month visit. Long-term outcome over a period of 2 years was measured as a combined endpoint of HF hospitalization, cardiac transplantation, or all-cause mortality. There was a 38% relative risk reduction for HF hospitalization, transplant, and/or mortality over a 2-year follow-up in the group receiving multidisciplinary care versus clinical care. These differences remained significant after adjusting for all clinical covariates and accounting for procedural adverse events. A cost-effective analysis is currently underway and hopefully we'll be able to share those results with you soon. MGH appears to be one of the first centers to establish multidisciplinary care for cardiac resynchronization. Are other centers implementing or considering this approach? That's correct—MGH is one of the first to have established a multidisciplinary program to manage this group of HF patients with implanted devices. It's always difficult to change conventional practice and even more challenging when you're trying to bring a group of subspecialists together. Fortunately, most of us at MGH thought this was the right thing to do and we had the support of the leadership, which made it pretty straightforward to implement. We now have four electrophysiologists, three HF specialists, two physician echocardiographers, three sonographers, one dedicated CRT nurse practitioner, three study coordinators, four research fellows, and administrative support, as well as a host of other collaborative efforts with other divisions. The program is very streamlined, with staff rotating through the clinic on assigned days. The satisfaction of providing integrated, multidisciplinary care along with a productive research environment has kept everyone motivated and desirous of being involved. In terms of other centers, we've had an influx of physicians, visiting fellows, and nurse practitioners from all over the country visit. We've even had some European colleagues spend time with us. I know that quite recently a few of the bigger academic centers have also set up similar multidisciplinary clinics, some of them primarily for established nonresponders to CRT and some, like our center, cater to all patients with implanted CRT devices. What do you see as obstacles for diffusing this model of care more broadly? Does the movement towards accountable care organizations (ACOs) and bundled payments help your cause?
That's a very important question. I think the biggest obstacle is changing the mindset. We have to gradually move away from current practice patterns of working in our individual silos towards coming together to provide integrated care. Besides that, resources and the logistics of putting such an operation into play are significant additional barriers. I agree that the transition to ACOs will bring significant changes in access to health care providers, reimbursement rates, and payment structures. We are going to be held more accountable for our outcomes, whether it is for long-term survival after ICD implants, HF hospitalization in CRT recipients, or better AF control after ablations. As that becomes a reality, we are all going to be faced with the inevitable: that we cannot achieve these lofty goals without working together. Using CRT as the example here, as an electrophysiologist, even though I may implant the CRT device and the pacing leads in the most appropriate manner, there are many unpredictable dynamic situations that may lead to hospitalizations in this frail group of patients. To try to orchestrate the best long-term outcome, I will need the help of my colleagues to deliver appropriate post-operative care, device optimization, titration of drugs, and management of HF. I do believe that bundled payment strategies linked to better clinical outcomes (coupled with enhanced revenue sharing opportunities) will force us to move towards adopting this multidisciplinary care model. I will go out on a limb and say that current incentive strategies for physicians that inadvertently encourage internal competition will need to be modified and re-aligned to induce synergy. Are there other areas of cardiology where a multidisciplinary model of care can be used to improve quality and reduce costs?
Yes, several. I think any area of cardiology where more than one subspecialist is involved in the decision-making process has the potential of benefiting from a multidisciplinary model of care. At MGH, we have several of these multidisciplinary programs. Just to name a few: the thoracic aorta program, adult congenital heart program, heart valve program, hypertrophic cardiomyoapthy program, and a cardio-oncology program. Again, the quality of care and cost effectiveness of this model in some of these areas needs yet to be determined, but clearly seems to be the right way to move forward. What are the next steps for your multidisciplinary clinic?
We are looking to measure the cost effectiveness of this model and see if we can streamline, strip the fat, and further enhance the efficiency of this clinical service. As I mentioned to you earlier, we have a pretty good research program piggybacked onto the clinic. While attempting to provide the best possible clinical care, we are always looking for new and improved strategies to enhance response in this group of patients. We rely on frequent 360 Feedback Surveys to help us evolve, morph, and further tweak our clinic flow and protocols. Among the eight physicians affiliated with the program, we now have 19 different clinical research protocols underway. Many of these are investigator-initiated, single-center studies, and some are international multicenter trials. Some of our next steps have involved expanding our patient cohort to include those with implantable hemodynamic sensors. We have also moved into the realm of autonomic modulation and are looking at newer devices and interventions to favorably modify the sympatho-vagal balance to enhance ventricular remodeling. Some of the more recent multidisciplinary investigative efforts we are involved with are in the arena of biomarkers, as well as regenerative cell therapy. For now, we're going to keep on doing what we're doing, but strive to do it even better. Disclaimer: Dr. Jain recently accepted a position as chief medical information officer at Merck. This column was written and submitted prior to his accepting this position. The fact that this column is published in CardioSource WorldNews is not meant to imply endorsement or approval of Merck products or initiatives by the ACC, the ACCF, or the editors of CardioSource WorldNews. Sachin H. Jain, MD, MBA, is chief medical information and innovation officer at Merck and Co. He previously served as an advisor in the Obama Administration, where he helped launch the Centers for Medicare and Medicaid Innovation and the HITECH Act's Meaningful Use provisions.
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Patients who receive cardiac resynchronization therapy (CRT) devices are a frail group of ambulatory individuals with refractory HF. The care of these patients is complex and requires input of several subspecialists inclusive of electrophysiologists, and HF and imaging specialists. It is well known that a substantial proportion of patients receiving CRT will not respond adequately to this therapeutic modality. Many patients nonresponsive to this therapy come to our attention when they have already worsened significantly or have been hospitalized for HF. This deterioration often occurs because of the lack of an integrated care approach and the absence of a structured cross-talk and communication between the multiple caregivers. A multidisciplinary clinic provides the opportunity to be proactive, share information, and work as a team to ensure the best clinical outcomes for this cohort of patients. To elaborate on just one aspect of integrated care, these implanted CRT devices provide a host of information regarding the clinical state of the patient. These could be data on arrhythmias or data pertinent to the HF status. Device-based impedance measures of fluid overload, the nocturnal heart rate, heart rate variability, or physical activity log index all provide a better understanding of the clinical trajectory of the patient. This information can be shared in real time via a coordinated clinic environment. Also, importantly, a multidisciplinary clinic provides the opportunity to individualize the programming of these CRT devices to enhance the optimal delivery of resynchronization therapy. Can you walk me through "usual care" for patients undergoing cardiac resynchronization?
In usual practice, patients with CRT devices are seen by their cardiologists, HF specialist, and electrophysiologist, and undergo cardiac imaging (with and without device optimization) at separate times, most often on different days and even several weeks apart. Sharing of the information among the group of physicians looking after these patients is logistically challenging and usually not temporally relevant in the course of their disease, especially if the patients are tenuous. The deleterious impact of this lack of real-time integrated care is predominantly germane to the subgroup of patients who are not clear "immediate" responders to resynchronization therapy. How is the model adopted by your clinic different from usual care?
Our clinic model ensures that, during the same visit, the patient is seen by the HF specialist and electrophysiologist to have their devices interrogated and optimally programmed with echo guidance. As part of an endeavor to gather objective clinical data during each visit, patients also undergo a 6-minute walk test and complete a quality-of-life questionnaire. It may seem quite complex to have a patient go through this rigmarole, but we have it down to a science. We have a very experienced CRT nurse practitioner (Mary Orencole, ANP) and a team of study coordinators who help keep us all on track and ensure that the clinic flow is well maintained. On average, we see approximately 8-12 patients per clinic session. Patients are seen in the clinic at 1, 3, and 6 months post-implant to ensure that they are on the right trajectory, following which they graduate and follow up with their own primary cardiologist. They get referred back to the clinic only if they are not doing well and need to be re-evaluated for a lead revision, image-guided re-optimization of their device programming, or an investigative protocol. Even though our program is first and foremost a clinical service, nearly 70% of our patients are involved in one or more of our research protocols. The beauty of the program is that we have piggybacked our research component onto the service component in a rather seamless way, which enables prospective research without compromising or changing the clinical care provided to the patient. The data acquired and the lessons learned from our research are quickly brought back into clinical practice. So, we are constantly learning and improving the way we deliver our therapy. Can you describe the quality and cost results of your trial of multidisciplinary care for cardiac resynchronization?
The results of our study were published in 2012 in the European Heart Journal. Our study examined the clinical outcome in 254 patients receiving multidisciplinary care compared to 173 patients who received conventional care. The multidisciplinary group was followed prospectively in an integrated clinic setting by a team of subspecialists from the HF, electrophysiology and echocardiography service at 1, 3, and 6 months post-implant. All patients had ECG-guided optimization at their 1-month visit. Long-term outcome over a period of 2 years was measured as a combined endpoint of HF hospitalization, cardiac transplantation, or all-cause mortality. There was a 38% relative risk reduction for HF hospitalization, transplant, and/or mortality over a 2-year follow-up in the group receiving multidisciplinary care versus clinical care. These differences remained significant after adjusting for all clinical covariates and accounting for procedural adverse events. A cost-effective analysis is currently underway and hopefully we'll be able to share those results with you soon. MGH appears to be one of the first centers to establish multidisciplinary care for cardiac resynchronization. Are other centers implementing or considering this approach? That's correct—MGH is one of the first to have established a multidisciplinary program to manage this group of HF patients with implanted devices. It's always difficult to change conventional practice and even more challenging when you're trying to bring a group of subspecialists together. Fortunately, most of us at MGH thought this was the right thing to do and we had the support of the leadership, which made it pretty straightforward to implement. We now have four electrophysiologists, three HF specialists, two physician echocardiographers, three sonographers, one dedicated CRT nurse practitioner, three study coordinators, four research fellows, and administrative support, as well as a host of other collaborative efforts with other divisions. The program is very streamlined, with staff rotating through the clinic on assigned days. The satisfaction of providing integrated, multidisciplinary care along with a productive research environment has kept everyone motivated and desirous of being involved. In terms of other centers, we've had an influx of physicians, visiting fellows, and nurse practitioners from all over the country visit. We've even had some European colleagues spend time with us. I know that quite recently a few of the bigger academic centers have also set up similar multidisciplinary clinics, some of them primarily for established nonresponders to CRT and some, like our center, cater to all patients with implanted CRT devices. What do you see as obstacles for diffusing this model of care more broadly? Does the movement towards accountable care organizations (ACOs) and bundled payments help your cause?
That's a very important question. I think the biggest obstacle is changing the mindset. We have to gradually move away from current practice patterns of working in our individual silos towards coming together to provide integrated care. Besides that, resources and the logistics of putting such an operation into play are significant additional barriers. I agree that the transition to ACOs will bring significant changes in access to health care providers, reimbursement rates, and payment structures. We are going to be held more accountable for our outcomes, whether it is for long-term survival after ICD implants, HF hospitalization in CRT recipients, or better AF control after ablations. As that becomes a reality, we are all going to be faced with the inevitable: that we cannot achieve these lofty goals without working together. Using CRT as the example here, as an electrophysiologist, even though I may implant the CRT device and the pacing leads in the most appropriate manner, there are many unpredictable dynamic situations that may lead to hospitalizations in this frail group of patients. To try to orchestrate the best long-term outcome, I will need the help of my colleagues to deliver appropriate post-operative care, device optimization, titration of drugs, and management of HF. I do believe that bundled payment strategies linked to better clinical outcomes (coupled with enhanced revenue sharing opportunities) will force us to move towards adopting this multidisciplinary care model. I will go out on a limb and say that current incentive strategies for physicians that inadvertently encourage internal competition will need to be modified and re-aligned to induce synergy. Are there other areas of cardiology where a multidisciplinary model of care can be used to improve quality and reduce costs?
Yes, several. I think any area of cardiology where more than one subspecialist is involved in the decision-making process has the potential of benefiting from a multidisciplinary model of care. At MGH, we have several of these multidisciplinary programs. Just to name a few: the thoracic aorta program, adult congenital heart program, heart valve program, hypertrophic cardiomyoapthy program, and a cardio-oncology program. Again, the quality of care and cost effectiveness of this model in some of these areas needs yet to be determined, but clearly seems to be the right way to move forward. What are the next steps for your multidisciplinary clinic?
We are looking to measure the cost effectiveness of this model and see if we can streamline, strip the fat, and further enhance the efficiency of this clinical service. As I mentioned to you earlier, we have a pretty good research program piggybacked onto the clinic. While attempting to provide the best possible clinical care, we are always looking for new and improved strategies to enhance response in this group of patients. We rely on frequent 360 Feedback Surveys to help us evolve, morph, and further tweak our clinic flow and protocols. Among the eight physicians affiliated with the program, we now have 19 different clinical research protocols underway. Many of these are investigator-initiated, single-center studies, and some are international multicenter trials. Some of our next steps have involved expanding our patient cohort to include those with implantable hemodynamic sensors. We have also moved into the realm of autonomic modulation and are looking at newer devices and interventions to favorably modify the sympatho-vagal balance to enhance ventricular remodeling. Some of the more recent multidisciplinary investigative efforts we are involved with are in the arena of biomarkers, as well as regenerative cell therapy. For now, we're going to keep on doing what we're doing, but strive to do it even better. Disclaimer: Dr. Jain recently accepted a position as chief medical information officer at Merck. This column was written and submitted prior to his accepting this position. The fact that this column is published in CardioSource WorldNews is not meant to imply endorsement or approval of Merck products or initiatives by the ACC, the ACCF, or the editors of CardioSource WorldNews. Sachin H. Jain, MD, MBA, is chief medical information and innovation officer at Merck and Co. He previously served as an advisor in the Obama Administration, where he helped launch the Centers for Medicare and Medicaid Innovation and the HITECH Act's Meaningful Use provisions.
Keywords: Electrophysiology, Cardiac Resynchronization Therapy Devices, Risk Reduction Behavior, Ventricular Remodeling, Motor Activity, Accountable Care Organizations, Electrocardiography, Heart Rate, Heart Valves, Hemodynamics, Echocardiography
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