Where Theory Meets Practice: Getting to the Heart of the Heart Team

 

This is Part 1 of a 3-part series looking at the Heart Team in practice: what works, what doesn’t, and what the future may hold. Read Part 2 here and Part 3 here.

Attend any large cardiology meeting this year, and you’ll lose track of the number of times you hear the term “heart team.” But ask anyone what it actually means in practice, and you won’t hear the same thing twice. 

Is it activated for all cardiology patients or just those with complex structural disease? Does the team involve only cardiologists and surgeons or do these members also invite the opinions of anesthesiologists and palliative care specialists? Is it a Heart Team (note the capitalization) that meets at a scheduled time once a week, or are informal heart team discussions held in the hallways when convenient? What roles do nonphysicians play? Who on the team is responsible for following up with the patient postprocedure? How are all these efforts reimbursed?

Ajay Kirtane, MD (Columbia University Medical Center, New York, NY), told TCTMD that he has observed “a lot of disagreement” over the Heart Team concept. When people use the phrase at national meetings, some “have a specific idea” of what it entails, he said. “Other people really just mean it as a more nebulous idea that could mean as little as: ‘We took the patient off the table.’ What really happens is a range of everything from stopping to discuss the case to actually engaging in a team-oriented discussion.”

On paper, the notion of a team of healthcare professionals working together to improve the outcomes of a cardiology patient seems to be a good one. However, the environment in which many of the world’s leading physicians have been trained has historically fostered more of an autonomous approach—the “captain of the ship” mentality. In the last decade, a shift toward greater cooperation has been encouraged by institutions and sometimes mandated by governments and payers, but these efforts have had to challenge deep-seated attitudes and hierarchies.

As a result, while the idealized Heart Team makes sense in theory, “its implementation in real life for patients [runs] into some very expected challenges, which have to do with the culture of medicine that has been very ingrained, to really bridge divisions and different cultures that have been in existence for decades,” Ori Ben-Yehuda, MD (Cardiovascular Research Foundation, New York, NY), told TCTMD.

Giving a “fancy name” to a process does not inherently alter practice, he added. The whole notion of what the team should look like and how it should work “is very dependent on generation and varies by institution,” he said, adding. “To change that culture requires putting processes [in place and] forcing people to work together, but also giving them the resources so that they’re incentivized to do it.”

Kirtane agrees that people use the term loosely. “Just because you can put the word ‘team’ after something doesn’t necessarily mean it’s functioning in that way,” he observed. Many physicians will say they are part of an organized Heart Team, for example, but in reality, the multidisciplinary conversation never happens, he added.

Furthermore, every Heart Team will have its champions and its followers, cardiothoracic surgeon Kendra Grubb, MD (University of Louisville and Jewish Hospital, KY), told TCTMD, and it is “hard to say” how interactions between the two parties differ among institutions. “There’s not one Heart Team model that’s going to work right for every institution. . . . Who exactly is there and how often you meet, that is going to be something where each institution will define what’s right for them,” she added.

Bridging the Silos

The phrase “Heart Team” was first used formally during the SYNTAX trial, published in the New England Journal of Medicine in 2009. To best assess whether patients with severe coronary disease would benefit more from CABG or PCI, consultations were required by both a cardiac surgeon and an interventionalist, and the two practitioners decided together on a treatment plan. Some might argue the merits of such a small two-person “team,” but at the time, even this type of multidisciplinary communication was unusual.

“Traditionally cardiovascular care has been metered out in territorial silos, with medical cardiologists, interventional cardiologists, and surgeons all operating pretty much in their own strictly defined areas without as much cross-communication as would be needed, and sometimes with more competition and antagonism than is constructive to patients,” Martin Leon, MD (Columbia University Medical Center), said.

“Before this concept was brought about, the criticism of interventionalists was that patients could be evaluated in the cath lab and be treated without ever even consulting a surgeon,” Kirtane added. “I’ve had patients that were referred for surgery [but] never even told that they had an option of PCI, and that’s also wrong.”

Physicians of course discussed their patients, but collaboration “wasn’t really applied with the same level of rigor and intensity,” Leon added. “Now, it’s spreading to everything.”

Many of the initial Heart Teams operated similarly to the long-running multidisciplinary tumor boards in oncology and transplant teams in cardiology. With the advent of transcatheter aortic valve replacement, where the pivotal trials were led together by both interventional cardiologists and surgeons, it became clear that additional perspectives were needed to inform treatment decisions in frail, elderly patients with complex disease. Geriatricians, anesthesiologists, imaging specialists, nephrologists, and social workers were—many of them for the first time—invited to participate in collaborative decision making. Leon, who was a principal investigator for the PARTNER trials, said his team during the course of that research “made a conscious effort” to ensure the active participation of multiple physicians who were “able to make correct decisions on the basis of what’s in the best interest of the patient.”

This collaboration became so essential that in 2012 the Centers for Medicare and Medicaid Services (CMS) mandated a Heart Team approach for all patients receiving TAVR as a prerequisite for reimbursement. For patients with coronary disease, the European Society of Cardiology guidelines recommended the concept as a Class I indication as of 2010, and the US guidelines followed suit in 2012.

Of course, multidisciplinary care has been a mainstay of cardiovascular medicine for much longer than the past few years. “We’ve always had a cath lab team. Always,” said Bernadette Speiser (VA Palo Alto Health Care System, CA), a nurse manager who has worked in cardiology for more than 30 years. Now, this cooperation is merely being taken one step further, she noted. “The Heart Team has really only . . . come to fruition in a logistical way with the introduction of some of these cardiothoracic procedures that are now done in the cath labs.”

Follow the Money

Along with Grubb, Mathew Williams, MD (NYU Langone Medical Center, New York, NY), is one only a few cardiologists trained in both interventional cardiology and cardiac surgery—a Heart Team unto himself, although he told TCTMD that he values having the perspective of another physician before treating a complex patient. In fact, all cardiac patients at his institution are seen by at least two physicians, and all their echocardiograms are reviewed by an imaging specialist.

But while the concept of the Heart Team is good, according to Williams, the big problem is reimbursement. The traditional hospital model in which the cardiology department operates independently of the cardiac surgery department inevitably puts the two in competition for patients, for which they are independently reimbursed.

“I’m not proposing that people are doing inappropriate procedures for money, though obviously that does happen at some places,” Williams said. “But I think if my incentive is to just make sure we treat the patient the best we can at my institution, that’s very different than being told I have to do X number of surgeries, because those types of things influence your decision. So if it’s a true Heart Team . . . where you’re not looking at those numbers, then it becomes less biased.”

Similarly, Ben-Yehuda said that for the Heart Team to evolve, “we have to get to a model that pays for what we want people to do.” In the current fee-for-service system, clinicians are financially motivated to increase their productivity, so time spent in nonreimbursable meetings or consultations can limit their compensation potential. “Someone has to pay [for] that time,” Ben-Yehuda observed. “Time is money, effort is money, and if it’s not reimbursed, it’s not going to happen in a consistent manner.”

However, Kirtane said he would be “very, very reluctant to mandate beyond what’s already happened and tie reimbursement to successful performance of a heart team-based approach, because what it actually means to do this is so institution-dependent.”

Leon, likewise, pointed out at not all Heart Team participants could be reimbursed equally. Beyond the procedure itself, he said, “it’s very difficult to account for everybody’s time, contribution, and reimbursement level for every aspect of [care].”

Williams pointed to institutions with what he phrased as “so-called” heart teams, where essentially the second provider—either the surgeon or interventionalist—participates “just to bill” and not to help with decision making. This usually happens, Williams continued, when either a surgeon is so “pro-surgery so they won’t sign off on any patients getting TAVR” or an interventionalist is “not as open-minded” to teamwork.

Who Belongs on the Team?

Apart from who should be paid, and how much, it is unclear exactly who belongs on the Heart Team and, in particular, which nonphysician members play essential roles.

Clinical decisions made within a Heart Team setting are typically made by a mix of cardiac surgeons, interventional cardiologists, referring cardiologists, anesthesiologists, and imaging specialists, but nurses, physician assistants, social workers, and others can also be active members. “The reality is without the nonphysicians, there is no Heart Team,” Leon said. “Any level of arrogance that suggests that this is a physician-only game is ridiculous.”

But attitudes are slow to change. Looking back on her career, Speiser said she remembers a time when nurses would have to stand up to give physicians their seats and also go on coffee runs. While the Heart Team has “absolutely” improved relations among hospital staff, “there are [still] physicians that say, ‘You are going to do it my way, and you’re a nurse and I’m a doctor,’ and they throw their initials out there,” she said. Most of this hostility, Speiser noted, comes from insecurity and egocentricity.

Speiser points out that a well-oiled Heart Team includes the hospital janitors and secretaries playing ancillary parts. “There is this microcosm of members out there who all affect your primary team’s work,” she said, adding that each contributor should be recognized for what they add, even if their participation is not required by society guidelines or mandatory for CMS reimbursement.

Then there are the patients themselves. As much as the term “Heart Team” is used in cardiology, “patient-centered care” is heard with even greater frequency throughout contemporary medicine. With physicians striving more than ever for their patients to have optimal informed consent, it would only make sense that these people would also be considered members of the Heart Team.

However, in a TCTMD survey, more than half of 247 respondents said the patient does not belong on the Heart Team, and a corresponding 31.6% said they never consider the patient to be a participant. Although patients “should be clearly part of the decision,” Kirtane said, “whether or not they are part of the initial assessment of eligibility for medical therapy, PCI, and surgery is somewhat of a semantic point.”

A balanced way of thinking about it, Grubb said, is to leave the patients out of the imaging review and frank conversation that often occurs among the care team. They can later be brought into the fold once all the professional Heart Team members have weighed in and a recommendation for care is determined. “Then not only is it important for the patient to be part of the Heart Team, they’re an essential key member,” she said. “They are the driving force behind it.”

More Than a ‘Slogan’

In the future, the Heart Team will evolve “as therapies become less dependent on one subspecialty or another,” Leon said. “What therapies are available will dictate the necessary components of the Heart Team.” While some interventionalists might think that surgeons will not be necessary on a TAVR Heart Team one day, “that’s a myopic viewpoint,” he said, because surgeons gained years of knowledge in treating valvular heart disease before percutaneous devices were available. Their expertise in mitral and tricuspid disease will prove even more valuable “as we get into extended areas now,” Leon predicted.

Training programs will also evolve, with more physicians choosing to cross over between specialties. Grubb estimates “there are about 5 or 6 of us” who have concurrently trained in CV surgery and interventional cardiology. Contacted by TCTMD, none of the professional societies representing surgeons or cardiologists could confirm whether this number is indeed on the rise, nor could a number of major device manufacturers provide estimates of how many surgeons have been seeking catheter-based training. In the past, Williams argued, surgeons have sometimes been the “weak link” of the Heart Team “because they refuse to get the training. They just sit there and bark out what the appropriate treatment is but don’t necessarily have the training to comment on the transcatheter approaches.”

Agreeing with Leon that structural heart disease will more often be treated percutaneously than surgically in the future, Williams suggested that surgeons may need to evolve some of their skillset. This could enable them to “become more important contributors [to the Heart Team] rather than just showing up for the procedure so they can bill for half of it,” he commented.

Outside of TAVR and catheter-based mitral valve interventions, Speiser thinks the Heart Team concept will “expand to other disciplines.” Hospitals will see its practice as “a necessity” from the patient’s perspective, she said, and “there will be ways in the future to code and bill for it.” Additionally, as demographics change, “you are going to see how important it is that communication and very clear delineations of the patient’s care plan are all maximized,” Speiser said.

As sticklers for evidence-based medicine, some physicians have called for data supporting a rationale for the Heart Team. Williams, however, believes such a study “would be tough,” requiring as much analysis of psychology and management as of patient outcomes.

Kirtane agreed, noting that at this point, a randomized trial of Heart Team versus no Heart Team would be unethical. A multicenter study would be “incredibly messy” because of varying practice patterns, he added.

Ultimately the Heart Team should not merely be a “slogan,” Leon argued, but rather “something that’s substantive [and] embedded into the fiber of how we manage patients with complex cardiovascular disease.”

So while not every cardiologist, surgeon, nurse, or administrator may agree on an exact definition and application of a Heart Team, the need for collaboration is clear. “If you have time to seek other people’s input for any decision—whether it’s medical, buying a house, or buying a car—it’s always better to get other inputs into the decision,” Kirtane said. “It did not always happen before. The key is that the decision shouldn’t be swayed by the best salesperson, because it’s someone’s health that is in the balance.”

And most experts agree, the hurdles can be overcome with the right planning, the right definitions, and the right reimbursement. “It’s like anything else in life,” Leon said. “If people are committed to do it, you find a way to do it. But you can easily find all of those as excuses for why it shouldn’t be done.”

This article was produced as part of the Health Care Workforce Media Fellowship run by the Center for Health, Media & Policy at Hunter College (New York, NY). The Fellowship is supported by a grant from the Johnson & Johnson Foundation.