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COLLABORATION IN CARDIOVASCULAR INTERVENTIONS : A NON-ZERO SOLUTION

COLLABORATION IN CARDIOVASCULAR INTERVENTIONS : A NON-ZERO SOLUTION. Mark J. Russo, MD, MS Assistant Professor of Surgery Co-Director, Center for Aortic Diseases. ASSERTIONS.

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COLLABORATION IN CARDIOVASCULAR INTERVENTIONS : A NON-ZERO SOLUTION

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  1. COLLABORATION IN CARDIOVASCULARINTERVENTIONS: A NON-ZERO SOLUTION Mark J. Russo, MD, MS Assistant Professor of Surgery Co-Director, Center for Aortic Diseases

  2. ASSERTIONS • Traditional barriers between medical specialties result in a provider-centric rather than a patient-centrichealthcare system • These barriers are not compatible with the effective application of today’s hybrid technologies • Elimination of these barriers improves patient outcomes (win) and offers a non-zero opportunity for providers (win-win) • -> WIN-WIN-WIN

  3. Traditional barriers between medical specialties result in a provider-centricrather than a patient-centric healthcare system

  4. DISCONNECT BTN PATIENT PRESENTATION AND ORGANIZATION Patients present with Conditions-Disease Process Providers organized by Specialties-Skills/Knowledge Cardiology Interventional Cardiology Cardiac Surgery Vascular Surgery Radiology • Coronary Artery Disease • Valve Disease • Heart Failure • Aortic Disease • Peripheral Vascular Disease

  5. CARE IS DECENTRALIZED Interventional Cardiology General Cardiology Treatment Surgery

  6. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

  7. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

  8. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

  9. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

  10. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology ? Treatment Surgery

  11. IMPACT OF DECENTRALIZED CARE System Perspective Patient Perspective Wastes patients’ time increase in indirect costs Patients lost in system delays care Patients lost to system go elsewhere Patients forced to make decisions based on complex information provided by multiple disparate sources with competing interests Lost opportunity for shared decision making • Poor information transfer • Duplicative care • increases in direct costs • Decreased quality

  12. Relative to 4 other comparable countries, U.S. patients more likely to: • -undergo duplicative testing • -tell the same story to multiple HCPs • -experience delay in reporting of results

  13. QUICK POLL • What is the difference between a “root aneurysm” and a “AAA”? • They are both types of aortic aneurysms • Who/how is most appropriate to manage these conditions? • Cardiology? • Interventional Cardiology? • Cardiac Surgery? • Vascular Surgery? • Radiology?

  14. ANSWER • Most physicians don’t know the differences and appropriate treatment . . . Why do we expect patients to know where to seek care. . .

  15. PATIENT CENTERED MODEL Diagnostics Disease-Specific “Clinic” (eg, CAD, Valve, HF, Ao) w Cards/Imaging/IC/CVS Referring Treatment

  16. IT IS POSSIBLE. . . • 87yo h/o B THR and L TKR, severe PHTN, walks w a cane but highly functional p/w severe AS; eval for TAVR • Thurs: Referral secured by outreach team • Facilitated direct MD-to-MD contact • Tues: Next Valve Clinic date seen by Cards, CTS, IC, Vasc • TTE (Cards) – previously unscheduled • CTA C/A/P (Rads) – previously unscheduled • Fri: Returned to referring MD for cardiac cath • Sun: Spent Mothers Day with family • Mon: Underwent TF-TAVR • Uneventful case • Awake and extubated < 30 mins after the procedure • Fri: Discharged on POD #5; 2 weeks and 1 day after referral • Home before the NATO riots Yes, but . . . this should NOT be a case study . . . it should be the standard of care

  17. LESSONS FROM OTHER SPECIALITIES UCSF/Carol Frank Buck Breast Cancer Center • In a single visit the patients • Obtains mammography • Reviewed together by Surgeon and Radiologist • Surgeon tells patient results • Treatment plan is developed • Patient seen by: Geneticist, Fertility Specialist, Social Worker, Psychologist • Volume increased • 1993: 40/mo • 1997 175/mo • 2003: 1300/mo Patient-centered, disease-specific care may be a novel concept in CV medicine . . . but in other disease processes (eg, cancer, txp) it was implemented 20 years ago 30-fold increase in volume over 10 years . . .

  18. These barriers between specialties are no longer compatible with the effective application of today’s hybrid therapies

  19. ONCE UPON A TIME… TREATMENT OPTIONS WERE DISCRETE • Its clear who provides services • More likely to be complementary, less likely competing Medical Physician Surgeon Drugs Open Surgery

  20. INTERVENTIONAL ERA: RECENT PAST • Technologies were competing and mutually exclusive, eg: • PCI (IC) vs CABG (CTS) aka “The Stent Wars” • Open distal bypass (VS) vsperipherial stenting (IC/IR) Drugs Open Surgery Interventions

  21. HYBRID ERA: PRESENT • Differences are obscured • Its unclear who provides which services/treats which pts Drugs MIS Open Surgery Interventions Hybrid

  22. TAVR PROCEDURE

  23. TAVR PROCEDURE

  24. TAVR PROCEDURE

  25. TAVR PROCEDURE

  26. TAVR PROCEDURE

  27. TAVR PROCEDURE No single specialty competent to do all parts based on traditional training/skills. . . A TEAM IS REQUIRED

  28. WHAT IS A TEAM? • Comprises a group of people linked in a common purpose • Especially appropriate for conducting tasks that are high in complexity and have many interdependent subtasks • Members have complementary skills • Allow each member to • maximize their strengths • minimize their weaknesses • generates synergy • Improves on what is possible for an individual actor

  29. IN HEALTHCARE, “TEAM” MEMBERS OFTEN HAVE NEARLY IDENTICAL SKILLS

  30. THIS IS A PITCHING STAFF…NOT A BASEBALL TEAM Knuckleballer Curveball Slightly different niches BUT…All filling the same role Leftie Submarine Split-finger fastball

  31. In baseball, team members have different skills and fulfill different roles

  32. Elimination of these barriers improves patient outcomesand offers a non-zero opportunity for providers

  33. GAME THEORY Zero Sum Scenarios • participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s). • If one gains, another losses • Only Win-Lose possible • Example: party goer eats a piece of cake…there is less cake for the other partiers Non-Zero Sum Scenarios • a participant's gain (or loss) of utility is not balanced by the losses (or gains) of the utility of the other participant(s). • If one gains, another may also gain • Win-Win possible • Example: Prisoners’ dilemma

  34. PRISONERS DILEMMA In a NON-ZERO scenario. . . one player does not need lose for another to win. . . In fact cooperation may be rewarded. . . WIN-WIN scenarios exist Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE) Prisoners DO cooperate . . . less jail time (WIN-WIN) Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE) Prisoners DO NOT cooperate . . . more jail time (LOSE-LOSE)

  35. OUR WORLD IS INCREASINGLYNON-ZERO “The more complex societiesget . . . the more complex the networks of interdependence. . . the more people are forced in their own interests to find. . . win-win [non-zero] solutions instead of win-lose [zero] solutions. . . We find as our interdependence increases . . . we do better when. . . people [around us] do better as well.” —an ex-US President, December 2000

  36. OUR WORLD IS INCREASINGLYNON-ZERO “The more complex therapies get . . . the more complex the networks of interdependence. . . the more cliniciansare forced in their own interests to find. . . win-win [non-zero] solutions instead of win-lose [zero] solutions. . . We find as our interdependence increases . . . we and--our patients--do better when. . . people [around us] do better as well.”

  37. REVELATION • In a 25 mile radius of UofC, there are: • 75 cardiac surgery programs (NJ: 4x population/18 programs) • 79 cath labs (NJ: 4x population/43 labs) • 154 Burger Kings • 92 Taco Bells • 31 IHOPs • No dominant center • Each center—including our center--is doing a fraction of the total CV work in the area • What if we worked together? • try to take cases from the guys across the street . . . • rather than cases from the guys across the hall?

  38. OUR EXPERIMENT • Create a team composed of members with different skills sets/from different disciplines • Cardiology • Vascular surgery • Radiology • Objectives: • To expand our practice • To increase our volume • To improve our outcomes • To deliver patient-centric care • Interventional Cardiology • Cardiac Surgery • Anesthesiology

  39. METHODS • Sought out opportunities to collaborate/Transparency • Disease-specific multidisciplinary conferences • Disease-specific multidisciplinary clinics • Disease-specific outreach - CME/800 numbers/pagers - Pact to “Just say YES” • TAVR covered by IC/CTS • Aortic covered by VS/CTS • (eg, AoD accepted by cards; AAA by CTS; Type As by Vasc) • Cases • In combined cases, attempt the part less comfortable w under the supervision of more experience operator

  40. EXAMPLES OF CLINICAL COLLABORATION

  41. LEVERAGE ESTABLISHED SYSTEMS • Example: ECMO • Emergency surgery only exists in Level 1 Trauma Centers….and on TV • OR: 1-3 hours to active • Advantages • Cath lab- Faster and Cheaper • activated in 30-60 mins • Cost < 20% of the OR • Better imaging for perc access, if needed • Opportunity for collaboration • 80%+ of ECMO is now initiated in the cathlab

  42. TRANS-ILIAC - TAVR • Team - Proctored case – 2nd case as a team • Proctor extremely experienced w TAVR (over 700 cases as a sole provider) • To date, this proctor had the largest TAVR experience in the Western Hemisphere • An IC; does only TF cases (w/o surgeon) • Reviewed case and recommended cancelling 2/2 poor femoral access • Team had proposed trans-iliac approach w iliac conduit via RP exposure by VS/CTS • Proctor resistant b/c he had never done (seen) it • Relented based on teams’ experience w approach for other procedures

  43. TRANS-ILIAC - TAVR Without collaboration this pt does not receive treated…even by the most experienced single operator in the Western Hemisphere

  44. AO DEBRACHING/REOP ARCH • 82yo s/p repair a 6 cm AscAo Aneurysm in 1993 • 4 Aneurysms • Recurrent AscAo aneurysm extending into the arch (9 cm) • Innominate aneurysm (4.4 cm) • Right subclavian aneurysm (2.4 cm) • Left common carotid aneurysm (2.8 cm) -> Also had mid-descending TA (5.0 cm) and AAA (~5cm) • LAD stent placed by IC preop • To OR after 2 wks of plavix

  45. A B

  46. Apposition of the aneurysm to the previous sternotomy with compression of the vena cava and innominate veins

  47. Apposition of the aneurysm to the previous sternotomy with compression of the vena cava and innominate veins

  48. Vasc Surgery • LCA to LSCA transposition

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