Pathways for Quality Care: Echocardiographers Ponder a Playbook for Imaging in Myocardial Infarction

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Geoffrey Rose, MD, Sanger Heart & Vascular Institute, Carolinas HealthCare System

Physicians in fields like cardiology have traditionally looked to clinical practice guidelines to help articulate the best evidence-based care for patients. The rapidly growing movement to value-based care is prompting clinicians—including echocardiographers—to carefully weigh a more focused and integrative approach to delivering consistent, quality medicine: care pathways.

 

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In the 1980s, Motorola led a revolution to identify and remove defects and variability from the manufacturing process. Known as Six Sigma, it spawned a bold set of analytical tools and techniques that soon became standard operating practice for the most progressive, cost-conscious companies. While few would put the medical profession in the class of early adopter, the field has been easing up to notions of process improvement and enhanced customer satisfaction through its own industry-specific methodology, known as clinical care pathways.

Signs of that movement are becoming more evident. Kaiser Permanente, the largest nonprofit health plan and integrated delivery system in the U.S., has been deploying care pathways for years through clearly defined roles and accountabilities for its multidisciplinary teams. Oncology also has gravitated over the past decade to the carefully sequenced and coordinated chain of activities that typically define a clinical care pathway. And the American College of Cardiology (ACC) released early this year what it called “decision pathways” to guide clinicians and hospitals in managing patients undergoing transcatheter aortic valve replacement (TAVR) as well as patients with nonvalvular atrial fibrillation who are on anticoagulant therapy (J Am Coll Cardiol 2017;69[10]:1313-46; J Am Coll Cardiol 2017;69[7]:871-98).

Add echocardiographers to the list of specialists warming to the value-based care approach. “Care pathways enable us to take what we know from evidence-based guidelines and from appropriate use criteria and create a kind of blueprint to navigate routine clinical situations and, in so doing, reliably achieve the best outcomes,” says Geoffrey Rose, MD, chief of cardiology at Sanger Heart & Vascular Institute with the Carolinas HealthCare System. “Care pathways should be thought of as playbooks, not cookbooks. There’s room for variation in how we treat each individual patient depending on his or her situation.”

Whether to develop a care pathway for acute myocardial infarction (AMI) will be a discussion topic when the American Society of Echocardiography (ASE) convenes its annual conference in June, says Rose, who is chairing the meeting. One of the branches of that decision tree could be, for example, guidance on how to determine post-MI left ventricular ejection fraction, one of the most important determinants of how a patient will fare over time after an AMI.

“You can get an ejection fraction from a cardiac MRI, from a CT scan of the heart, from nuclear imaging or from an echocardiogram,” Rose elaborates. “They’re all terrific modalities, but in our view a care pathway specifying echocardiography may be the most logical choice for assessing the ejection fraction question early on after an infarction.”

John Dent, MD, a cardiovascular disease specialist at the University of Virginia Health System in Charlottes-ville, envisions a care pathway that encourages the appropriate use of echocardiography following an AMI. “It could prompt the physician to order an echo at the most appropriate point in the pathway, then provide guidance on what medicines to give or which patients to send to the cath lab,” he says. “The point is not to make sure we increase the number of echocardiograms in the U.S., but to make sure we increase the number of appropriate echos.”

How much variability is there in the system? “Unfortunately, the practice of medicine is in many ways still a craft practice in that each doctor thinks they know best,” Dent says. “As a result, there are tremendous variations in how they interpret and apply clinical guidelines.” How much difference could a care pathway make for a patient who has suffered a heart attack? “We know that if we try to standardize what’s done for that patient, the outcomes will be better,” he adds, “and more importantly, it will impact waste by reducing the underuse or overuse of testing, as one example.”

Driving out waste

Variation in the quality and cost of medical care is well documented. In 2014, for example, the cost of treating Medicare patients who suffered an AMI or underwent