EHJ: Multidisciplinary CRT care improves patient outcomes
Jagmeet P. Singh, MD, PhD, director of the Cardiac Resynchronization Therapy Program at Massachusetts General Hospital Heart Center in Boston, and colleagues observed that multidisciplinary care has been shown to reduce HF hospitalization in patients with congestive HF. In the CRT arena, some patients don’t respond to the therapy and require hospitalization. However, care often is fragmented among subspecialists who don’t communicate with each other.
Massachusetts General set up a clinic in 2005 designed to integrate care for these patients through a model that brings together referring physicians, primary cardiologists, HF cardiologists and electrophysiologists. The team approach also includes nurse practitioners, technologists and support staff who work with physicians in a patient management regime that requires three clinic visits within the first six months of implantation. At each visit the patient undergoes a six-minute walk test, a quality of life assessment, device interrogation and assessments by subspecialists.
Singh and colleagues reasoned that they could test the impact of a multidisciplinary approach in CRT care using a clinic population and compare that with a group of patients who received conventional care. To be included in the multidisciplinary care group, patients had to undergo de novo CRT device implant or upgrade from a pacemaker or defibrillator and be seen in the clinic between September 2005 and February 2010. Patients who received CRT and were seen as needed at Massachusetts General between March 2003 and November 2009 were eligible for the conventional care group.
The multidisciplinary care group consisted of 254 patients; the conventional care group totaled 173 patients. Patients were followed for two years. Clinical endpoints included all-cause mortality, HF hospitalization, left ventricular assist device implantation and heart transplant. At baseline, the patient characteristics generally were similar.
The multidisciplinary care group had better survival rates compared with the conventional care group, of 89 percent vs. 78 percent at one year and 77 percent vs. 65 percent at two years, respectively. Event-free survival was higher in the multidisciplinary care group, at 73 percent vs. 61 percent at one year and 61 percent vs. 46 percent at two years.
All in all, the multidisciplinary care group had a 38 percent reduction in the relative risk of HF hospitalization, transplantation or death over the two-year follow-up. A secondary analysis also showed the multidisciplinary care group had a significant improvement in ejection fraction compared with conventional care patients.
“Current post-device implant care is lacking on many fronts, namely: attention to device diagnostic information, evaluating and optimizing device programming in patients, and early identification and treatment of non-responders,” Singh and colleagues wrote. “The present study showed the positive impact of these collective interventions in a patient population through a multidisciplinary clinic.”
They pointed out that the study included a real-world patient population that was sicker with more comorbidities than patients evaluated in clinical trials. They noted benefits of multidisciplinary care were observed across patient subgroups, including those who might be excluded in clinical trials. They also observed that the multidisciplinary model allowed clinicians to identify potential non-responders early for timely interventions.
“To ensure the early detection of non-response to CRT, and trigger remedial actions through modifying drug therapy or device settings, the communication lines between the electrophysiologist, echocardiographer and HF specialist need to be open and fluid," they wrote. "An integrated MC [multidisciplinary care] model may make this process achievable, and could improve the two-year event-free survival in patients receiving CRT.”
The study was based on data from a single center, was not randomized and used prospective data for the multidisciplinary care group and retrospective data for the conventional care group. They recommended a prospective randomized trial and an assessment to determine if a multidisciplinary approach would be cost-effective.
The study was funded in part by St. Jude Medical.