Therapies for valve disease continue to evolve with advances in transcatheter valve therapy (TVT) complementing more traditional surgical approaches. Evidencebased valvular care continues its march into the mainstream of cardiovascular care, propelled in part by refinement in the technology, accumulating outcomes data, and the creation of the multidisciplinary heart team. In the arena of transcatheter aortic valve replacement (TAVR), the procedure has been simplified and complications reduced. The MitraClip is addressing mitral valve disease, and many experts expect expansion of other transcatheter approaches for mitral valve repair and replacement. Without a doubt, expanded treatment options are transforming the care of patients with valvular heart disease. Or, perhaps it is more accurate to say, it has the potential. Reaching all the patients who would benefit from treatment remains a major challenge. While the more glitzy and exciting aspects of interventions, like the technology and headlining results, grab most of the limelight in the medical journals and conferences, the more earthbound tasks of identifying patients with valvular heart disease and proper diagnosis tend to get short shrift. A roundtable on evolving valve management strategies held at ACC’s Heart House headquarters in Washington, DC, generated intriguing ideas and concepts to address these, and other, challenges. Handheld echocardiography, cloud-based imaging hubs, and e-consults are among some of the innovative concepts being explored to increase detection and create efficient and effective referrals. POCUS: A Handheld Solution to Screening for Valve Disease? Could the first pass at echocardiography be as simple as reaching into your pocket? Especially for primary care physicians (PCPs), who are the initial gatekeepers, point-of-care ultrasound (POCUS) could be an advantage to better identify patients with underlying heart disease and who warrant referral to a cardiologist. This is especially true in the elderly, in whom the symptoms of valve disease are common because of their age, making it more difficult to distinguish or suspect valve disease. Even with careful auscultation, cardiac murmurs can be difficult to recognize, and many elderly people have a benign heart murmur that may not require referral. Along with the size, the prices are getting smaller too. Now devices are available that work with a smartphone and a pocket-sized transducer, and more are coming to the market soon. Laptopsized devices also are widely available. Some pricing is in the $2,000 to $7,000 range. The high-quality ultrasound images obtained with these devices can simplify the physical exam, with the physician only needing to identify whether the aortic valve is abnormal or the mitral valve is leaky, for example. Patients with such features on a screening study would be sent for a more complete echo. Naturally, there is a learning curve for acquiring a good quality image and interpreting it. Yet, Catherine M. Otto, MD, FACC, believes PCPs can gain this expertise and this will be an effective strategy to improve detection of valve disease. And with machine learning, automated interpretation may be another advance for this technology. In the U.S., POCUS is used to screen for structural heart disease in student athletes, and evaluate patients for left ventricular function or wall motion abnormalities in the emergency department or intensive care unit. In Asia and Africa, well-trained individuals who have some medical background use it to screen for valve disease in patients with rheumatic heart disease. The next generation of U.S. physicians are already being taught to use POCUS in medical school. “Research is needed to estimate the prevalence of undiagnosed valve disease in the community, and to determine whether point-of-care ultrasound improves detection over the history and physical examination,” says Otto, to move this forward. Further, this will need to be related to the impact on treatment and outcomes. Other factors to address will be quality and control of the images, archiving the images, and reporting. Image Enhancement: Is the Cloud the Answer? Too often a referral for evaluation after a standard echo leaves both the patient and cardiologist frustrated. And another echo must be acquired. In about half of cases, estimates Stephen H. Little, MD, FACC, the disc the patient brings to the clinic cannot be opened or the images viewed, because of a lack of a packaging standard for images and interoperable software. “Even when it’s possible to view the images, this is a fairly cumbersome, time-consuming, and ineffective process,” says Little. A cloud-based repository for images that uses standardized tools by the hub and the referring centers could address these issues. An echo performed at the local site is read by the interventional echocardiographer. With a good quality image, the candidacy of patient anatomy for a specific intervention can be assessed and best therapy determined, and communicated quickly back to the referring center. Or, if the image is not sufficient, the interventional echocardiographer can provide the details for what is needed; these technical tips and pearls improve the quality of this and future referrals. Another advantage of such a hub-and-spoke imaging hub is a more effective and efficient patient visit with the specialist, and it ensures that the images have been reviewed by an interventional echocardiographer, who may not always be the specialist scheduled for the clinic. Proof of the benefits of this concept comes from a cloud-based imaging environment used by Kaiser Permanente throughout southern California. For its thoracic aneurysm and dissection program and now its valve disease program, some 200 offices are connected across a large geographic region, uploading images to a central cloud for review. This speeds decision making between physicians, greatly improves communication, and reduces driving times for patients, says Somjot Brar, MD, MPH, FACC. Accessible onsite or offsite through a secure network, prompted by an alert or email, the specialist can review the image and reply to the referring physician through secure email, or depending on the urgency, a phone call. A secure instant messaging system is being rolled out. Feedback can be given to the imager when it is fresh in their mind, which provides informal training and better images in the future. “Just yesterday, a patient underwent a successful MitraClip procedure at a hub hospital, that had been planned completely based on a transesophageal echocardiogram obtained at a spoke, referring, hospital, and viewed through the imaging hub,” says Brar. This approach streamlines the assessment, diagnosis, and planning before the procedure and the post procedure follow-up, and often eliminates the patient having to travel to the hub. Expanding this on a national level will require standardizing software, interoperable electronic health records (EHRs), and leadership of the charge, and, as always, funding. Recognizing that many academic health science centers may have the capacity to create their own cloud-based hub and to link referring sites, Little comments nationally standardized software is best for meeting long-term goals in the valvular heart disease arena. The centralized imaging hubs used in clinical trials is another prototype that provides a solid track record for guiding this effort. Ideally, this would be led by professional medical societies that also could provide accreditation. Further increasing its value, the cloud-based imaging hub is a resource for research. As a mandated database, the data can be mined to answer a host of questions, such as the presently unknown rate of appropriate and inappropriate referrals. Or, it can be used to evaluate long-term durability of devices. Currently, Kaiser Permanente uses the imaging hub to systematically follow aortic dissection through serial computed tomography. While reimbursement for this approach must be worked out, it is expected to be cost effective by reducing the need for repeat imaging studies and optimizing the physician’s time, among other factors. Increasing the rate of referrals is an incentive. “The time is ripe for embracing this,” as we transition from payment for service to payment for value, notes Brar. Electronic Consult Platforms for Referrals A robust e-consult platform is required to support a cloud-based imaging hub, marrying the referral with the delivery of the image. The value of a robust platform extends the full spectrum of care of the patient with valvular heart disease, from the consult through follow-up, reducing the common concern of fragmentation of care. Efforts to create platforms and tools to improve communication and coordination between primary care and specialty care have been a focus of the Association of American Medical Colleges for several years. Their CORE (Coordinating Optimal Referral Experience) Project was created as an innovative model to address the shift from volumebased to value-based payment, and now includes their eConsult and Enhanced Referral tools. The eConsult is embedded within the EHR and allows the primary care physician to obtain support from the specialist to manage a patient. Through an asynchronous exchange, the PCP can query the specialist about a specific problem and receive guidance within 48-72 hours. This has improved the quality of the so-called curbside consult, and reduced the number of unnecessary and lower value consults to specialists. “The relationships and network created through the eConsult platform also leads to more referrals to the specialist,” says Scott Shipman, MD, MPH. The referring physician and the specialist each receive a relative value unit credit. The Enhanced Referral tool, also embedded into the natural workflow through the EHR, has reduced variation in the quality of the referral and improved longitudinal management of patients. Conditionspecific templates, for example, for a patient with palpitations, provides a degree of decision support and guidance for the PCP for testing and treatment, and ensures that the appropriate testing is conducted before the referral. Importantly, the template also clarifies who will follow the patient after the referral, with the PCP simply checking a box for a one-time referral, co-management, or solo management of the patient. In the valvular heart disease arena, Shipman sees this platform as a useful avenue for communication and referrals between PCPs, cardiologists, and valve centers – a foundation for more efficient, higher quality care. Patients benefit from receiving care at the most appropriate of these levels, and hopefully with less long-distance travel, and specialists benefit from a process that provides easier access to the right patients. Stronger relationships are created between specialists and subspecialists, as well. Twelve sites in the U.S. are now using this platform, and all have a cardiology component for consults and referrals between PCPs and specialists. The development of a specialist-to-specialist component is now on the radar, says Shipman. Initially, funding was through a grant from the Center for Medicare and Medicaid Innovation. But, the proven value with the platform has motivated the sites to fund its implementation themselves. The College has created its own documents to improve the quality and efficiency of the referral of patients with mitral valve disease to specialists. These and other tools being developed by the College could lend themselves to inclusion in such e-consult platforms. The Mitral Regurgitation Referral Toolkit (see sidebar) was created by a working group from a previous roundtable on valvular heart disease in response to the concerns raised about the complexity and confusion amongst PCPs and cardiovascular specialists for managing these patients. The Expert Consensus Decision Pathway for the Management of Mitral Regurgitation developed by this group is coming soon. As with all efforts described here, the goal is to bring the right piece of information from the guidelines to the right person at the right time within their usual workflow – and provide resources for two-way support and referral. Managing Valve Disease: A Team Sport As the College and others continue to grapple with the challenges of improving the process of identifying, treating, and managing patients with valvular disease, there will be continued discussion on novel approaches to best connect PCPs and cardiovascular specialists. The ACC is working to establish policy around what constitutes an advanced or comprehensive valve center for the delivery of TVT to ensure the delivery of highquality care. “As a system of care is designed, we need to account for increasing levels of complexity of patient care,” says Rick A. Nishimura, MD, MACC. For some patients with valve disease, the ACC/AHA Guidelines are sufficient to guide the patient to make treatment decisions. However, not every patient meets the parameters in the guideline, requiring the physician to have access to additional information to guide optimal clinical decision making. “In systems of care for patients with valvular disease, it will be essential to collaborate with experts in the field, particularly for the complex patient with multivalve disease and multiple associated comorbidities. This starts with the discussion between the primary care provider and the valvular heart specialist,” says Nishimura. First steps have been taken towards creating a system by making the guideline more accessible through the new tools. Next steps aim to establish this two-way communication New Toolkit Brings Clarity to Evidence-Based Guideline Management of MR The Mitral Regurgitation (MR) Referral Toolkit is the newest offering from the Emerging Mitral Regurgitation Clinical Care (EMC2) initiative. Along with its sister initiative, Managing Aortic Stenosis, it was launched to improve valvular care through appropriate diagnosis, referral and treatment, particularly with the introduction of new valve technologies. “The MR Referral Toolkit is a graphic presentation of the clinical pathway from echocardiography-based diagnosis to treatment,” says Vinay Badhwar, MD, FACC. This was created to bring clarity to the evidence-based guideline and help primary care physicians and cardiovascular specialists understand how to implement the recommendations within their clinical practice and help their patients. The toolkit consists of a comprehensive treatment algorithm and interactive MR referral worksheets, including patient case summary, MR treatment and referral decision, clinical next steps, referral packet checklist, and a packet for building MR referral into the electronic health record. An expert panel led by Patrick T. O’Gara, MD, MACC, Paul Grayburn, MD, FACC, and Badhwar have developed two contributions to help interpret the evidence-based guideline management of MR. The writing committee has developed the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation that will be published later this year. The MR Referral Toolkit was developed by members of the writing committee along with allied health professionals, and patient representatives
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