Heart House Roundtables: Leading Through the Gray Every day in clinical practice, the cardiovascular professional and members of the cardiovascular care team must make treatment decisions for aspects of care where the knowledge is either lacking or equivocal or there is no clear guidance from clinical practice guidelines because of the lag time between knowledge generation and assimilation into a guideline. The ACC is addressing this need for practical guidance, particularly in areas of emerging science where the evidence is limited and gray areas exist, through its Heart House Roundtables. The interactive, multidisciplinary roundtables bring together invited experts and stakeholders to explore the practical issues in highvalue clinical areas. Envisioned to be a catalyst for action, the Heart House Roundtables serve as a springboard for the development of solution sets for ACC members. “These solutions sets are designed to provide practical, comprehensive guidance for patient care and improving outcomes,” says Richard J. Kovacs, MD, FACC. Kovacs is the chair of the ACC’s Science and Quality Committee, which oversees the Roundtables and the creation of the tools comprising the solution sets. The ACC hosted consensus conferences at the first Heat House located in Bethesda, Maryland to discuss topics of importance to the members. The Bethesda Conference format, reinvigorated by James T. Dove, MD, MACC, around the time of his presidency of ACC in 2008 and an earlier attempt at health care reform, was embraced as a model for today’s Heart House Roundtables. The current series began with the Anticoagulation Consortium Roundtable held in September 2013 and held every year since. The rapid change in the anticoagulation arena, with multiple new medications that were presenting new challenges for cardiovascular professionals, along with gaps in care and wide practice variations identified in published papers and in surveys, meant this was a clinical area that was ripe for attention. In an effort to identify and address gaps in anticoagulation care, Kovacs worked with ACC staff Lea Binder, Team Leader, Physician Clinical Pathways, to convene the first Anticoagulation Consortium Roundtable, which would serve as the framework for future Heart House Roundtables. “The first Anticoagulation Consortium Roundtable served as an incredible forum to bring the top experts together in one room for a deep-dive into the most pressing clinical issues and gaps in care. This series of roundtable meetings has directly contributed to the development of a solution set for the practical management of anticoagulation care,” says Binder. More than just a meeting, the Roundtables were created with specific objectives and criteria, including selecting the topic experts and ensuring the diversity of participants. The methodology for these Roundtables will be published in an academic paper soon. “The Heart House Roundtables are a powerful way to rapidly obtain a view of the always-changing cardiovascular healthcare environment,” says James L. Januzzi Jr., MD, FACC, chair of the ACC Task Force on Expert Consensus and Healthcare Policy. So far, Heart House Roundtables have been held focusing in five clinical areas selected to provide high value for patients and clinicians: anticoagulation, lipid management, emerging valve management strategies, heart failure, and cardiovascular risk in diabetes. This fall, a Roundtable on prior authorization will be held. Each Roundtable is carefully crafted through approximately six months of planning. Key to meeting the objective of tangible outputs from the day-long meeting is having the right people in the room, from topic experts to patients, to ensure all relevant stakeholders are present and contributing. Equally important, and accomplished through the devoted work of the chairs and multidisciplinary planning committee of a Roundtable and the ACC staff, is focusing the agenda on the core issues and writing the most pertinent questions for the facilitated discussions that are held throughout the day. “Everyone is heard on every question,” says Kovacs, adding this is a critical facet of the Roundtable. “This is about listening to each other and learning,” and ultimately finding solutions that serve our patients. A diverse group of experts representing a wide variety of professional societies relevant to each topic, as well as other key stakeholders such as patients, federal agencies, health plans, integrated health systems and others, are invited to Heart House for the Roundtable. “Heart House is where ideas are hatched,” says Kovacs, “and this professional home for the entire cardiovascular care team inspires all who visit.” A member of the ACC’s Presidential Team welcomes the participants to Heart House and participates in the Roundtable. The Roundtables are an efficient way to scan the environment, identify issues, gaps and barriers; and learn potential solutions from each other and collaborate on solutions. The diversity of the voices in the room is critical, and contributes to the ability to go beyond the trial evidence and truly dig into the practical issues. Very importantly, the Roundtables accelerate the discussion, providing a focused, intensive deep-dive into the topic. A Sustainable Effort The Roundtables have created many ongoing relationships with other societies and entities, simply because of the invitation to Heart House and to participate. These personal and working relationships have contributed to a sustaining effort that has led more proposals for other collaborations with other societies and groups. The Heart House Roundtables also connect cardiovascular professionals and cardiovascular team members with clinical colleagues who may not otherwise collaborate, says Kovacs. ACC members and ACC staff who don’t typically collaborate also have been brought together through the Roundtables demonstrating a clear ripple effect touching on other areas in education and clinical policy through the cross-pollination and collaboration. “The Roundtables provide a great opportunity for the ACC to partner with a broader group of other medical professional societies to ensure that all perspectives are heard as we work towards both identifying and closing gaps in care to improve patient outcomes,” says Binder. The New Kid on the Block In June, the Managing CV Disease Risk in Diabetes Heart House Roundtable was held. The fifth topic to be tackled in this successful format, it was selected by the Science and Quality Committee because of the volume of groundbreaking trial data and new classes of antidiabetic drugs that have been shown to benefit patients with diabetes and reduce cardiovascular events. As this particular landscape changes, with its fair share of gray areas, the College has committed to leading the efforts to understand how this may change practice and provide solution sets to assist cardiovascular professionals and their team members. Solution Sets for Clinicians In just four short years, since the first of these roundtables was held, solutions sets have been developed with range of different tools that are being employed in practice, along with academic papers that have been published. “From a select group of experts, which may include clinical trialists, clinicians, regulators and others, we obtain a broad view of hot subjects within a specific area; from that point of view, we are then able to inform plans for subsequent development of Expert Consensus Decision Pathways (ECDPs), Systems of Care Documents, educational tools, decision aids and other highly impactful output,” says Januzzi. The Anticoagulation Consortium Roundtable is a model of the variety of these products. An ECDP on Periprocedural Management of Anticoagulation in Patients with Nonvalvular Atrial Fibrillation was published and another one on Management of Bleeding in Patients on Anticoagulants will be published later this year. A state-of- the art review paper on the practical management of anticoagulation in patients with atrial fibrillation was also published, along with a survey of current bridging practices. Two mobile apps have been developed – the AnticoagEvaluator and the BridgeAnticoag app that translates the periprocedural pathway. “Expert Consensus Decision Pathways provide practical guidance for clinicians in areas that are often considered a ‘gray area’ where evidence may be limited, new and evolving, or answer some, but not all, relevant clinical questions,” says Pamela B. Morris, MD, FACC. Morris served as the vice chair of the writing committee convened by the ACC to develop the 2016 ECDP on the Role of Non-Statin Therapies in response to a critical gap in care that was identified by participants who voiced the need for guidance to incorporate these therapies into treatment strategies for higher risk patients. “The outputs from the Roundtables have already strongly influenced clinical practice, and guided future efforts to support the needs of cardiovascular clinicians,” states Morris, chair of the Committee on Heart House Roundtables. Tools for the patient are also developed, for example, decision aids for aortic stenosis and mitral regurgitation, which are available at CardioSmart.org. Januzzi, who co-chaired the Heart Failure Roundtable, adds that they are in the final stages of completing a powerful ECDP on novel therapies for the diagnosis of heart failure. This will be followed soon by an online application to help clinicians understand, apply and titrate these therapies. “Other efforts from the Heart Failure Roundtable continue to be queued up,” says Januzzi, “it really invigorates the creative process, and allows us to recognize where to apply our efforts in the most efficient and powerful manner.” “The Heart House is a symbol of the College’s dedication to patient care, education and research,” says Kovacs. “The Roundtables held here are a part of its strategy to address issues that are important to members and help them in their clinical practice.” Visit ACC.org/ HeartHouseRoundtables to learn more and access the tools.
Published by American College of Cardiology. View All Articles.
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