From Chaos to Consistency: How One Michigan Hospital Built a Heart Team That Works
On the first Tuesday in March, several people sat facing each other in an eighth-floor conference room in one of Michigan’s highest volume cardiac centers. The sun had barely risen, its first rays inching through the east-facing window as if to help illuminate the discussion that had begun some 20 minutes earlier.
Of those present—advanced heart failure physicians, interventional cardiologists, noninvasive cardiologists, surgeons, an anesthesiologist, a physician assistant, a coordinator, and a nurse manager—about half were clad in scrubs, having already rounded on patients or prepped the cath lab for the day’s cases. One cardiologist was only there digitally, a disembodied voice crackling out of the speakerphone in the middle of the V-shaped table.
Each knew the weekly routine. They flipped through the binder in front of them and glanced at the echocardiograms and cardiac MRIs playing on a screen at the front of the room as Richard McNamara, MD, presented the third case of the morning.
A 68-year-old outpatient who had been complaining of weakness and shortness of breath since eating a jalapeno dish on Super Bowl Sunday was originally thought to have a relatively simple case of anterior MI. But after testing showed a nonviable LAD with a large apical protruding thrombus, the course of treatment became less clear. “What is the benefit of bypass surgery versus medical therapy versus PCI if indeed the anterior wall is not viable and we could not get a LIMA to the LAD?” McNamara asked the group.
They quickly ruled out PCI given the patient’s high Syntax score and three-vessel disease. A surgeon cited the STICH trial as evidence that CABG would result in the best outcome. Another questioned whether a left internal mammary artery (LIMA) graft should even be used, much less where to put it. A cardiologist asked if it was worth doing an apical aneurysm resection at the same time given the apical clot.
Within 10 minutes, the group had decided on a course of action, and by 8:30 that morning, McNamara had communicated the plan to the patient. “He’s pretty anxious and thought he was going to have surgery in 3 days,” McNamara told TCTMD, adding that after explaining how 15 experts had thoroughly discussed the case and decided it would be best to wait a bit longer for surgery, the patient relaxed.
‘Let’s Give It a Try’
While the Heart Team concept evolved to bridge the often steel-walled siloes within the specialty, cardiologists, surgeons, and nonphysician staff openly admit its use in practice is inconsistent and needs improvement. Some hospitals, however, have been creative in making it work for their practitioners and their patients.
For the team at Spectrum Health (Grand Rapids, MI), the management of their cardiac patients was not always so streamlined. Before the fall of 2014, “our process was very chaotic,” said McNamara, an interventional cardiologist who serves as codirector of Spectrum Health’s Heart Team. Much of the discussion on complex patients happened “in the hallway or just when it was convenient,” he said, adding that physicians making treatment decisions rarely had simultaneous access to all of the available patient data.
“What tended to happen before is you’d have part of the conversation,” McNamara explained. “You’d say ‘Well, severe LV dysfunction, last remaining vessel, we can do an Impella-assisted PCI, but what if it fails? Are they going to be an LVAD candidate? Or what’s plan B?’ And we’d never have plan B very well worked out.”
From his perspective as a Spectrum Health cardiothoracic surgeon and Heart Team codirector, Theodore J. Boeve, MD, told TCTMD that cardiologists and surgeons “had more head butting before we had the Heart Team than we do now.” Given that there are multiple cardiology groups—with varying practice beliefs—and only one cardiac surgical team at Spectrum, before Heart Team meetings began it was hard to know if a referring cardiologist was sending him patients more as a formality or because surgery was absolutely required, he said.
McNamara originally spearheaded the effort to start Heart Team meetings at Spectrum out of pure frustration. The program had a less than “auspicious beginning” due to him oversleeping after a night call—for the first time in his career—and missing the first meeting, despite having been plugging it around the hospital for weeks. What drew providers to come, McNamara said, was the simple desire to improve patient care. The fact that the 2014 American Heart Association/American College of Cardiology guidelines lists the Heart Team as a class 1 recommendation for TAVR helped to “put a little bit of structure and muscle behind it,” he said, but “we have always been absolutely dedicated to [excellent outcomes]. Once we had identified this as a problem . . . we said, ‘This looks like a potential solution. Let’s give it a try.’”
At first, meetings were held monthly. Practitioners submitted their cases to McNamara for presentation. Someone recorded minutes. But many of the cardiologists and surgeons who were most wanted didn’t show up. “We had a lot of skepticism about its value,” Spectrum Health’s cath lab director David Wohns, MD, told TCTMD. Also, he said, finding a time that worked for everyone was the hardest logistical issue, since surgeons start rounding on patients earlier than the cardiologists do. They eventually settled on 6:45 am.
From there, the hospital hosted a multiday roundtable event in February 2015 to comprehensively delve into all of the inconsistencies and miscommunications in cardiac care from diagnosis through follow-up. In addition to Boeve and McNamara, there was a quality control manager, nurse managers, rounding nurses, midlevel providers, pharmacists, cath lab techs, and even representatives from the emergency department. “We brought everyone involved that had a little bit of a stake in this,” McNamara said. “What we found was that everyone was doing something different . . . and we never had standardized work.”
Surgeons complained of patients expecting to undergo surgery after being sold on the idea by their cardiologists. Cardiologists were frustrated by what they saw as unnecessarily long hospital stays during which surgeons ordered excessive tests. While the requests were all seemingly well-intentioned, the variation in processes dragged everyone down and created waste.
“We found that these big problems don’t have easy solutions, and the problems are usually pretty systemic,” McNamara said, commenting that the group did a “wide sweep” over each of their practices from documenting a standard workup for a patient who is coded for bypass to asking pulmonologists and nephrologists when and how often they like to be consulted. They also decided that the meetings would be weekly and urged all cardiology and CV surgical personnel present in the hospital to attend.
Another resolution that came from this event was the need for a full-time Heart Team coordinator to assist in prepping case files for meeting attendees, curating imaging needs, and documentation. DeeAnn Stickland, who had worked as a clinical cardiology nurse at Spectrum Health for many years and had been helping out with the Heart Team as a favor to McNamara, was chosen for the position in October 2015.
Treating cardiac patients can often pit cardiology and surgery teams against each other, Stickland said, and “crossing over into this role, it’s interesting to see the other side. [We are] trying to get both sides to buy into this and really function more as a team.”
In 2015, the Spectrum Health Heart Team reviewed 265 patients and averaged 17-20 providers in attendance at each meeting. Diagnoses have ranged from severe aortic stenosis to heart failure, and recommendations included surgeries, medications, and interventions alike.
The importance of this exercise is not only about the recommendations, McNamara said, but “really trying to get everybody’s opinion. One of our challenges has always been that surgeons and interventional cardiologists tend to dominate the conversation, and we’re [now] trying to get [others] in there.”
Wohns agreed, commenting that the Heart Team “breaks down traditional disciplinary barriers and brings in a variety of opinions and perspectives for the care of the patient. I’d say our program has been revolutionary in accomplishing that for us.” This paradigm shift, however, is not limited by the walls of the meeting. Collaboration has increased among Heart Team participants during the rest of the week, he said, since they have gained a greater understanding of what their colleagues “are capable of and how they think.”
In a survey taken of the Spectrum cardiology and surgery staff last fall, almost all respondents reported that they valued the Heart Team highly and that poor communication was the biggest issue they faced before its implementation. In fact, 17% wanted to meet even more often than once a week.
Patients seem to appreciate the new process as well. “When you tell a patient, ‘We can do the surgery, but I’m concerned about the risks of this or that, and I really want to get the input of another 10 or 12 experts,’ they love that,” Boeve said.
Stickland said the feedback she receives from patients is very positive. She ensures that each patient knows when and how they are going to be presented during the Heart Team meeting and that they can expect a consultation with their doctor soon after to discuss the ultimate recommendation. Still, she is careful to stress that the final decision lies with the patients and that “they are an active player in the team.”
Homing in on the Holdouts
There’s still pushback, McNamara said, adding that some providers “like the way that they make their decisions, and they really don’t prefer to have a lot of other input.” No one specifically complains about attending Heart Team meetings, he reported but a small number of critics—mostly referring cardiologists based off-site—simply do not come.
When asked why, usually the response has something to do with timing, Stickland said, although she acknowledged that morsels of politics and animosity might also come into play. “Let’s face it. No one wants to go to a 6:45 meeting in the morning. You just have to believe in it and think it’s important,” she said.
Beginning this year, Spectrum Health is mandating that its physicians attend at least 75% of all relevant meetings to maintain good citizenship standing in the institution. So missing Heart Team meetings could potentially affect reimbursement, McNamara said.
Confirming this, Penny Wilton, MD, Spectrum’s department chief of cardiovascular services, told TCTMD that in early 2015 her institution switched from a relative value unit (RVU)-based compensation model to one that is designed to reward value and quality. This coincided with when many of the hospital’s physicians—including cardiologists but excluding anesthesiologists—also became employees. It was also serendipitous that this was around the same time the Heart Team meetings began, she said.
Rather than “be a sausage factory and churn through as many cases as possible,” Wilton explained, physicians are now graded individually and as a group on “scorecards” that include measures like patient satisfaction, clinical excellence, research, education, and citizenship.
Most contemporary physician compensation models have revolved around the fee-for-service principle, especially among independent practitioners, Wilton said. So there was no financial incentive to attend meetings like the Heart Team if a physician could use that hour to be in the cath lab or operating room. But in the last few years many hospitals have begun prioritizing value and quality over productivity, and she estimated that some factor these categories into as much as 20% of overall physician compensation.
“We don’t incentivize coming to a meeting that just by turning up you get a check or something. Absolutely not,” Wilton emphasized. “But there is a very strong focus in our organization both within the employed physicians and even the independent physicians toward an alignment with quality and value being very important.”
Boeve believes a surgeon’s pay in general should be more dependent on participating in quality improvement measures than it currently is. Spectrum’s new value-based compensation model enables him to “feel like the hospital employs me to make these decisions and do surgery, not just do surgery,” he reported.
Collaboration is at the core of medicine, and most doctors inherently enjoy working with one another, Boeve said. “We tend to lose [touch with] it as everybody gets busier and busier, but I think [once everybody gets] in the room, you kind of recognize you’re on the same team,” he said. “You’re all trying to do the same things. You’re trying to get the patient better and get them home.”
Show Me the Data
The team does not yet have enough data to show an improvement in patient outcomes since commencing the meetings, but the recommendations and outcomes of all patients reviewed are being catalogued in a database so that the team might analyze them at a later date.
These details will be pivotal in supporting the continuance of Spectrum’s Heart Team, according to McNamara. “I don’t want this to be another academic exercise,” he said. “I’d like this to be important and truly beneficial.”
Boeve said that the effort is already saving the hospital money, as “there’s been a modest reduction in the cath-to-CABG times for most of the months that we’ve run the Heart Team.” Additionally, he said, operators are collectively making better decisions when selecting patients on whom to operate.
All of the Spectrum Health Heart Team representatives TCTMD spoke with advocated for more hospitals to enact programs like theirs. “It’s easy to replicate,” Boeve observed, adding that administrative support is also needed in terms of setting aside time and a room. “Maybe you have to serve breakfast,” he suggested.
Wohns said he does not cast judgment on centers that have not established standardized heart teams, as “it’s hard to do for anyone in a private practice setting.” McNamara agreed but conceded that “most places in the United States aren’t strict academic centers.” No matter the practice setting and the associated challenges, though, he said that making the meetings so that all parties involved want the Heart Team will ensure that they all will come.
“The beauty of the Heart Team is [that] you just can’t get that group of minds together to sit down and have an intense review and conversation about patients to that level otherwise,” Stickland commented.
Despite his initial skepticism, Wohns said that for him personally the Heart Team is “empowering” and has helped him feel that he now brings “the collective wisdom of a very experienced group” to his patients. “We’re totally dependent on it now,” he said. “I think it’s here to stay.”
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.
- Boeve, McNamara, Stickland, Wilton, and Wohns report no relevant conflicts of interest.