COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION

1. COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Department of Surgery Grand Rounds April 4, 2012

2. DISCLOSURES • No financial conflicts • Off-label uses of devices

3. ASSERTIONS • Traditional barriers between medical specialties result in a provider-centric rather than a patient-centrichealthcare system • These barriers are no longer compatible with the effective application of today’s interventional technologies • Elimination of these barriers improves patient outcomes (win) and offers a non-zero opportunity for providers (win-win)

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

5. ORGANIZED BY PROVIER SKILL SET NOT PATIENTS CONDITION Conditions-Disease Process Specialties-Skills/Knowledge Cardiology Interventional Cardiology Cardiac Surgery Vascular Surgery Radiology • Coronary Artery Disease • Valvular Disease • Heart Failure • Aortic Disease • Peripheral Vascular Disease

6. CARE IS DECENTRALIZED • Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) • Lack of centralization results in poor information transfer between providers and duplicative care • Ultimately, patients forced to make decisions based on complex information provided by multiple disparate sources with competing interests Interventional Cardiology General Cardiology Treatment Surgery

7. QUICK POLL • What is the difference between a “root aneurysm” and a “AAA”? • Who is most appropriate to manage these conditions?

8. ANSWER • When most physicians don’t know the differences and appropriate treatment . . . Why do we expect patients to know where to seek care. . . • Cardiology? • Interventional Cardiology? • Cardiac Surgery? • Vascular Surgery? • Radiology?

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

10. REASONS FOR DIVISIONS • Cultural • Education/skill sets/knowledge base • How physicians are identified • Mentors/Colleagues/Interests • Resources • Tools • Physically location • Office space • Point of service (Clinic vs OR vsCath Lab) • Competition • Resentment • “You only refer me your disasters . . . and your complications . . . and at night/weekends”

11. These barriers are no longer compatible with the effective application of today’s interventional technologies

12. TREATMENT OPTIONS Drugs Open Surgery

13. TREATMENT OPTIONS • Its clear who provides which services • More likely to be complementary, less likely competing Medical Physician Surgeon Drugs Open Surgery

14. ERA OF INTERVENTIONS • Implantation pacemaker -1958 • Balloon embolectomy - 1960 • Angioplasty – 1974 • Coronary angioplasty – 1977 • Implantable ICD - 1980 • Cardiac ablation – 1980s • Self expanding vascular stent – 1985 • Endovascular aneurysm repair – 1987 • Thoracic endovascular aneurysm repair – 1994 • Transcatheter valves - 2002

15. CONTINUUM OF INVASIVENESS OF THERAPY Drugs MIS Open Surgery Hybrid Interventions

16. TAVR

17. TAVR Procedural Steps Specialty Rads/Cards/CVS IC/VS CVS CVS/IC IC IC CVS • Planning CT and echo: Imaging for aorta, aortic valve, lower extremities • Vascular access • Percutaneous • Femoral, iliac, apical, axillary, aortic • Pass large bore sheath • Currently approved device is only slightly smaller in caliber than a garden hose • Cross the aortic valve • Balloon valvuloplasty/valve replacement • Under echo and fluoro guidance • Vascular repair

18. ACCESS FOR TAVR

19. DEFINITION • Team - Comprises a group of people linked in a common purpose

21. TEAM • Have members with complementary skills and generate synergy. • Especially appropriate for conducting tasks that are high in complexity and have many interdependent subtasks. • Allow each member to maximize their strengths and minimize their weaknesses • Improve on what is possible for an individual actor

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

24. Eliminations of these barriers improves patient outcomes and offers a non-zero opportunity for providers

25. REASONS FOR DIVISIONS • Cultural • Education/skill sets/knowledge base • How physicians are identified • Mentors/Colleagues/Interests • Resources • Tools • Physically location • Office space • Point of service (Clinic vs OR vsCath Lab) • Competition • Resentment • “You only refer me your disasters . . . and your complications . . . and at night/weekends”

26. ZERO SUM GAME • Participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s). • For one to gain, another must loss • Example: if one person eats a piece of a cake there is less cake for the other partiers

27. STENT WARS • Coronary Revascularization – different competing therapies offered by different specialties • PCI/IC vsCABG/CTS • Peripheral Revascularization – a different therapy from one field, multiple specialties offering an alternative competing therapy • Vascular vsIR vs IC • Dominate interaction between 4 fields: CTS, IC, IR, and Vasc • Not collegial but adversarial/competative

29. NON-ZERO SUM “The more complex societies get . . . the more complex the networks of interdependence. . . the more people are forced in their own interests to find. . . [non-zero] win-win solutions instead of win-lose solutions. . . We find as our interdependence increases . . . we do better when other people do better as well” —an ex-US President, December 2000

30. GAME THEORY • Zero-sum • 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 • Example: cuts and eats a piece of cake there is less cake for the other partiers • Non-zero-sum • a participant's gain (or loss) of utility is not balanced by the losses (or gains) of the utility of the other participant(s). • Win-Win (and Lose-Lose) scenarios exist • Example: Prisoners’ dilemma

31. PRISONERS DILEMMA • The gains of one player are not equally offset by the losses of the other. • If non-cooperation, they get total 40 years • If both cooperate, total 2 years in prison

32. REVELATION • 75 cardiac surgery programs and 79 cath labs in a 25 mile radius • What if we work together and . . . try to take cases from guys across the street . . . rather than cases from the guys across the hall?

33. OUR EXPERIMENT • Create a team composed of members with different skills sets/from different disciplines • Cardiology • Vascular surgery • Radiology • Looked for opportunities to collaborate to expand our services • Leverage unique skills and existing systems • Focus on patient centric care • Interventional Cardiology • Cardiac Surgery

34. KEYS TO SUCCESS

35. TRANSPARENCY/SHARE THE WORK • Coronary revascularization cases discussed with both IC and CTS • Valve cases discussed valve conf and valve clinic • Aortic cases discussed aortic confand valve clinic

36. LEVERAGE ESTABLISHED SYSTEMS • Example: ECMO • Emergency surgery only exists in Level 1 Trauma Centers and on TV • It takes 1-3 hours to open an OR • Cath lab can be activated in 30 mins or less • >80% of ECMO is initiated in the cath lab • Faster (and cheaper) • Also allows an opportunity to collaborate

37. COMMITMENT TO PURPOSE • 73yo Jehovah's Witness is transferred from OSH after being loaded with plavix with a diagnosis of Type A dissection • Accepted by cardiology (AS) • Repeat CT (KD) performed read by contained rupture AscAo • Reviewed by Vasc (RM) and CTS (MR) • Underwent replacement of AscAo/Hemiarch (MR) POD #4 • Discharged to rehab on POD #10 • Pt will return as outpatient for PCI

38. AO DEBRACHING/REOP ARCH Darwin Eton, MD Professor of Surgery

39. A B

40. D

42. POSITIVE STRESS TEST STENT LAD

45. Cervical Debranching LCCA RCCA

47. RCCA RAx LCCA LScA