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

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Presentation on theme: "COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Mark J. Russo, MD, MS Assistant Professor of Surgery Co-Director, Center for Aortic."— Presentation transcript:

1 COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: 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-centric healthcare system These barriers are not compatible with the effective application of todays 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-centric rather than a patient-centric healthcare system

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

5 CARE IS DECENTRALIZED Interventional Cardiology General Cardiology Surgery Treatment

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

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

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

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

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

11 IMPACT OF DECENTRALIZED CARE System Perspective Poor information transfer Duplicative care – increases in direct costs Decreased quality 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

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

14 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 Home before the NATO riots Yes, but... this should NOT be a case study... it should be the standard of care

15 These barriers between specialties are no longer compatible with the effective application of todays hybrid therapies

16 DrugsOpen Surgery ONCE UPON A TIME… Medical Physician Surgeon Its clear who provides services More likely to be complementary, less likely competing TREATMENT OPTIONS WERE DISCRETE

17 DrugsOpen Surgery INTERVENTIONAL ERA: RECENT PAST Interventions Technologies were competing and mutually exclusive, eg: PCI (IC) vs CABG (CTS) aka The Stent Wars Open distal bypass (VS) vs peripherial stenting (IC/IR)

18 DrugsOpen Surgery HYBRID ERA: PRESENT Interventions MIS Hybrid Differences are obscured Its unclear who provides which services/treats which pts

19 EXAMPLE: TAVR Procedural Steps Planning CT and echo: Aortic Valve Aorta Lower extremities Vascular access – Percutaneous – Femoral, iliac, axillary – Apical, aortic Pass large bore- sheath -- approved device is only slightly smaller in caliber than a garden hose Cross the aortic valve Position Valve under echo/fluoro Balloon valvuloplasty/valve replacement Closure of access site Perc Open Complications Valve embolization Dissection Coronaries Vascular injury Specialty most suited Cards/CT Rads/CT/VS Rads/VS/IC IC/VS VS/CT CT VS/CT IC CT/Cards/IC IC IC/VS VS/CT CT IC VS No single specialty competent to do all parts based on traditional training/skills... A TEAM IS REQUIRED

20 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

21 In baseball, team members have different skills and fulfill different roles

22 THIS IS A PITCHING STAFF… NOT A BASEBALL TEAM Curveball Submarine Split-finger fastball Leftie Knuckleballer Slightly different niches BUT… Working in parallel, not together All filling the same role

23 IN HEALTHCARE, TEAM MEMBERS OFTEN HAVE NEARLY IDENTICAL SKILLS

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

25 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

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

27 OUR WORLD IS INCREASINGLY NON-ZERO The more complex societies get... 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

28 OUR WORLD IS INCREASINGLY NON-ZERO The more complex therapies get... the more complex the networks of interdependence... the more clinicians 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 and--our patients--do better when... people [around us] do better as well.

29 REVELATION In a 25 mile radius of UofC, there are: – 75 cardiac surgery programs (more than NYS - 7x the pop) – 79 cath labs (more than Canada – 12.5x the pop) – No dominant center Each 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 ?

30 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 Methods: Sought out opportunities to collaborate Leverage unique skills and existing systems Interventional Cardiology Cardiac Surgery Anesthesiology

31 NEW SYSTEMS PRACTICES

32 TRANSPARENCY/SHARE THE WORK Eliminate the Im a hammer... youre a nail approach = Pt gets the procedure the MD can offer Instead, offer the best solution for the pt – Coronary revascularization cases discussed (IC and CTS) – Valve cases discussed in valve conf and valve clinic (Cards/CTS/IC) – Aortic cases discussed in aortic conf and aortic clinic (CTS/VS/Cards)

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

34 EXAMPLES OF CLINICAL COLLABORATION

35 AO DEBRACHING/REOP ARCH 82yo s/p repair a 6 cm Asc Ao Aneurysm in Aneurysms – Recurrent Asc Ao 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

36 AB

37

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

39

40 Vasc Surgery LCA to LSCA transposition

41 Vasc Surgery LCA to LSCA transposition Graft LCA to RCA to RSCA bypass

42 Vasc Surgery LCA to LSCA transposition Graft LCA to RCA to RSCA bypass Graft was connected to the pump used as inflow

43 Circuit allowed for: Exclusion 3 aneurysms of great vessels Decompressed Ao during reop sternotomy Allowed for cerebral protection during distal mosis by clamping LCA to initiate ACP Chest opened with decompressed aorta intact

44 Cardiac Surgery Distal Ao under ACP (17 mins) AVR Prox Ao - new to old graft XCL time: 97 mins

45 VS and CTS Off Pump graft -> RSCA; graft to RCA Extubated on POD #2 D/ced: neuro intact nl EF baseline Cr

46 TRANS-ILIAC - TAVR Proctored case – Proctor extremely experienced w TAVR – IC does TF cases w/o surgeon – Reviewed case and recommended cancelling 2/2 poor femoral access Proposed was approach was trans-iliac w iliac conduit via RP exposure by VS/CTS – Proctor resistant b/c he had never done (seen) it – Relented based on surgeons experience w approach for other procedures Procedure successfully performed < 2hrs skin-to-skin

47 ASCENDING AORTIC PSEUDOANEURYSM 57yo s/o Type A Dissection Repair in 2007 presented with chest pain – PMHx: CRI, previous significant EtOH and smoking Found to have a PSA at prox suture line – Operative mortality >>20%

48 WORK-UP Aortic root injectionSelective cannulation of pseudoaneurysm using coronary catheter

49 THE PLAN 10mm graft to LSCA for device access (Vasc) 8mm graft to RSCA to initiate CPB (CTS) Selective catheterization of LCA (IC) Approach allowed for: Control BP/volume status for more precise deployment of device Protection if coronary covered

50 THE TEAM ICCTS VS Cards Imaging/ Anes

51 THE RESULT Successful deployment Exclusion of PSA D/ced home POD #2

52 CSB/TEVAR 72yo w large penetrating ulcer requiring CSB and TEVAR Possible approaches: – Advantages of Concomitant Approach: Single trip to the OR; Less OR utilization Potential for decrease LOS, faster recovery – Advantages of Staged Approach No physician fatigue – 2 short cases If complication occurs, we know who caused, – but…if the patient has a stroke, do THEY really case who caused it? Actual Approach - Concomitant – HD #1: Spinal drain by Anes – HD #2: 5 hours in OR; labor divided -> little stress/fatigue, max learning opportunity VS + fellow -> LCA-graft anastomosis CTS + fellow -> LSCA-graft anastomosis VS + CTS + fellows -> TEVAR – HD #4: pt discharged

53 CSB/TEVAR Secondary advantage of collaboration – prepared for complications – If arch is covered by VS – CTS likely is needed for bailout – If iliac is avulsed by CTS – VS likely is needed for bailout – If each service is not immediately available…complication is likely irreversible before help arrives – If each service is committed to primary treatment choice, they will be more committed bailout if needed

54 COMPLICATION AFTER TAVR 77yo with severe, symptomatic AS – Deemed in operable 2/2 h/o radiation to chest – Undergoes uneventful TAVR procedure – LFA sheath pulled in ICU – At MN, noted to have no pulses below L knee – Vascular surgeon involved in pts original TAVR case was consulted – Taken immediately to OR for embolectomy No discussion of possible vasospasm, trial heparin, watchful waiting – Pulses regained in OR – Pts remaining hosp course uneventful

55 R/O AoD 68yo w substernal pain x 5 hrs presents to an OSH – Reported to have moderate to severe AI and moderate pericardial effusion – Presumed diagnosis: Type A AoD Outside ED called – Transfer center paged covering surgeon, but in OR (unable to be reached) – CT Surgeon was reached….accepted the pt – UCAN (helicopter) dispatched Pt directly to OR – TEE revealed: mild AI, trace effusion, moderate TR – No evidence of AoD, but (+) RV dysfunction Pt transferred directly to cath for aortography, diagnostic cath possible PCI RCA stent placed Repeat CT and TEE on HD#1 – no evidence of AoD Discharged on POD#3 Even more compelling when hybrid room is available

56 AoD 61 yo M presented to OSH with substernal chest pain radiating to the back – Diagnosis: Type A AoD Outside ED called > paged Ao pager Reached Vasc Surgeon 1st….accepted the pt – Pact to Just say YES eg AoD accepted by cards, AAA by CTS, Type As by Vasc – Without collaboration, vasc surgeon will tell OSH to find a CT surgeon OSH may call other hospital

57 UCAN DISPATCHED

58 PROCEDURE Pt directly to OR – TEE confirmed Type A – AoD w severe AI Cardiac surgeon made a 3F valved conduit in preparation for aortic root replacement (30 mins) Concurrently vascular surgeon performed R axillary cannulation in preparation for CPB – Saved mins... and possibly the patients life

59

60 PROCEDURE Type A repair w aortic root replacement and hemiarch under ACP At end of procedure, lactate = 10 – Gen surg consult; diagnostic lapscopy in OR: (-) ischemic bowel

61 FAMILY LETTER Id like to thank you for saving my fathers life last week. My dad is not only alive, but is walking, talking, and ornery as ever all thanks to your expertise. It truly has been a surreal week to say the least. I feel very fortunate to know that my father was in such good hands. I wanted to extend my most sincere gratitude towards you and your extremely skilled and professional team at U of C for your amazing and miraculous work. Thank you a million times over, from the bottom of our hearts (and the top of my fathers newly grafted aorta). Best regards

62 NEXT STEPS

63 BLURRING LINES Cross coverage – Disease-specific pagers TAVR covered by IC/CTS Aortic covered by VS/CTS – Clinics Aortic staffed by VS/CTS/CV Radiology Valve staffed by Cards/Cards Imaging/IC/CTS/VS – Cases Pact to Just say YES (eg.AoD accepted by cards; AAA by CTS; Type As by Vasc) Cross training: – in combined cases, attempt the part less comfortable w under the supervision of more experience operators

64 COMMON OUTREACH CME w outreach team Disease specific contact/pager – Aortic disease: (UCCAD)/8222 – TAVR: (TAVR) – Worked with the call center to initiate a phone tree Websites – Visits/day: ~200 – Pageviews/day: ~300 – Clinic Visits/week: 1-3 – 4 OR cases per mo – Retention of clinic patients – Bottom line < $3000

65 POTENTIAL BENEFITS Patients Providers Healthcare System

66 POTENTIAL BENEFITS: PATIENTS Care focused on patients condition – Avoid competing sales pitches Higher quality – Receive appropriate therapies – More eyes on the pts (attendings/fellows/APNs/PAs from multiple service) Decreased costs – Direct and indirect – Decreased delay in care Higher patient satisfaction

67 POTENTIAL SUCCESS: PROVIDERS Better working environment – Common mission – No finger pointing – Egos checked at the door Easier acquisition of others input – Planning procedures, management, complications Providers more invested in al CV patients Broader understanding of disease process and available therapies Learning new skill sets CCF Effect – MDs refer to team/organization, not a specific MD – Decreases hurt egos when a CTS refers a complex CTS pt to an outside CTS; IC a complex IC pt; or VS a complex VS pt

68 POTENTIAL SUCCESS: PROVIDERS Expanding practice – TAVR, Frozen Elephant Trunk, Asc Ao Stent Graft, Ao Arch Stent, Antegrade Ao Stent, Perc Closure of PSA, Perc Closure of Aortic Valve, Pararenal Snokel, MD-Modified Stent Graft Increased volume – TEVAR: , 2011 – 8, 2012 – 20+ (through Aug; 40 projected) – EVAR: up 40% over previous year Academic productivity/TAVR Team – 2011: 50 publications – 2012: 40 (to date)

69 POTENTIAL BENEFITS: THE HEALTH CARE SYSTEM Decreased resource utilization – Decreased duplicative testing – Decreased need for multiple encounters Higher quality care – More appropriate/balanced use of technology Team polices themselves for appropriateness rather than leaving it to an outside non-clinical entity (eg govt, insurance) – Better outcomes

70 OBSTACLES Playing field – need a hybrid room; available in Feb The Division of...Cardiac Surgery/Cardiology/Vascular Surgery... – Artificial divisions exist between groups that should naturally work together, particular in our 100% hospital-based employment model Resources – no mechanism to share across disciplines; different services Billing – who gets the RVUs; how to divide Personal Incentives Reimbursement – Prob not maximizing Existing Culture – buy-in not universal

71 THE FUTURE? Presenting ourselves separately?

72 FUTURE Single CV Service Line Integrated Interventional Service – Structural heart, PCI, TEVAR/EVAR, Hybrid cases Cross training/covering – Present: CT and VS cross cover aortic cases – Future: CT and IC; IC and VS cross cover cases IC/CT/VS -> CVI VS/CT -> CVS

73 PVD AORTICDISEASE HEARTFAILURE VALVEDISEASE EP CORONARY DISEASE CORONARYDISEASE

74 For Providers: Win-Win For Patients: Win Win-Win-Win


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