Aortic stenosis: Lifelong learning in the 21st century

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 - Structural Heart, severe aortic stenosis, heart valve
Stenotic heart valve

Transcatheter aortic valve replacement (TAVR) for eligible patients with severe aortic stenosis holds great promise but much still needs to be learned. The American College of Cardiology (ACC) is piloting an initiative that is designed to help valve centers in the U.S. improve quality and achieve good outcomes.

There are a growing number of patients with aortic stenosis in the U.S., related primarily to the increasing age of the population. Symptoms are relieved and life extended when patients with aortic stenosis are referred for surgery in a timely manner. However, there remains a subgroup of aortic stenosis patients who are either referred for intervention too late in the course of their disease or not referred at all.

In many cases, the patient is felt to be too old or frail to undergo intervention. The introduction of TAVR has changed this landscape and appropriately selected elderly patients can now undergo intervention safely with excellent outcomes.

In light of this change, the American College of Cardiology (ACC) conducted a comprehensive needs assessment with input from multiple stakeholders. Key findings from the assessment included:

  • Knowledge gaps regarding the diagnosis and natural history of aortic stenosis, as well as currently available treatments;
  • Lack of understanding and utilization of surgical risk and frailty assessments in this elderly population;
  • Inadequate patient and family education, with limited attention to shared decision-making; and
  • Problems with transitions of care between providers and treatment centers.

Working with 10 accomplished valve centers and their referring communities, the ACC has developed an educational pilot program, Championing Care for the Patient with Aortic Stenosis (Championing Care) that is focused on developing tools customized at both the individual provider and systems level to address these deficiencies. The basic foundation of the program consists of the following elements:

  • Live educational sessions to enhance knowledge of aortic stenosis and potential treatment options;
  • A tool to assess and provide a patient's level of frailty;
  • A tool to simplify the interpretation of the echocardiogram in patients with aortic stenosis;
  • Tools to improve transitions of care; and
  • Creation of a provider community to promote "best practices."

Metrics have been designed prospectively to evaluate the effectiveness of each tool and learning intervention and the degree to which patient assessment tools are incorporated into practice.

Operational design

The initial learning activity at each center will begin with a review of local practice patterns through our surveys and data collection. The progression of the initiative will include core knowledge modules as well as demonstration of diagnosis and risk assessment with the aid of specially designed point-of-care (POC) tools.

Learners will share challenging aortic stenosis cases and test the suite of POC tools in real-time. After the course, participants will complete branching case studies using the POC tools to assess their clinical decision making.

The POC tools will include:

  • Heart sound simulations;
  • Algorithmic approaches to the interpretation of echocardiographic findings;
  • Frailty assessment;
  • Shared decision-making;
  • A semantic search tool pointed to ACC/American Heart Association Guidelines for the Management of Patients with Valvular Heart Disease;
  • Checklists for communication and transitions of care; and
  • Interactive patient education on CardioSmart.org.

A "test and control" approach will be used to assess the effectiveness of the program. Quality of care across the valve centers will be evaluated. Dynamic analysis of the appropriate use of technology and POC tools will be incorporated. Interventions will allow pre/post (30 and 60 days) assessment of the utilization, effectiveness and areas for improvement of each of the tools (J Contin Educ Health Prof 2009;29[1]: 1-15).

The program can be adapted by the individual learners to teach subsequent groups of providers and patients.

Funding

Support for this new model has been provided by Edwards Life Sciences, St. Jude Medical, Boston Scientific and Medtronic. All aspects of the program, including needs assessment, educational programming, quality improvement tools, POC tools, and patient outcomes will be designed, implemented and assessed independently by ACC.

Future directions

This quality improvement initiative represents an effort to combine critical local market data across medically