Integration of a Specialized Medicine Service in the Management of Patients Undergoing Trans-catheter Valvular Therapy: Development of a Novel In-Hospital Care Model

From the 2019 HVPAA National Conference

Dr. Bassam Ayoub (University of South Florida), Dr. Dae Hyun Lee (University of South Florida), Dr. Alexander Glaser (University of South Florida), Dr. Paula Burgos Hernandez (University of South Florida), Dr. Robert Ledford (University of South Florida), Dr. Fadi Matar (University of South Florida), Dr. Bibhu Mohanty (University of South Florida)

Background

Transcatheter valvular therapy (TVT), including transcatheter aortic valve replacement (TAVR) and mitral valve repair using MitraClip, are quickly becoming the standard of care for select patients with severe valvular disease. In a large, multi-practice hospital setting, in-hospital care of these patients is subject to variable practices and managed by providers without dedicated training in TVT-specific post-procedure management. Lack of invested care coordination has been implicated in delays of care, increased length of stay (LOS), intensive care unit (ICU) admissions, post-procedural complications and improper post-discharge follow-up.

Objectives

We describe a novel, cost-free inpatient peri-procedure care model for patients undergoing TVT procedures. We have developed a dedicated TVT Hospitalist Team (TVT-H) to function as the sole management service for patients undergoing TVT procedures in a quaternary multi-practice hospital with a large transplant and advanced heart failure population. This model also off-loads procedural staff from primary management duties and permits the ability to address other procedural needs. We anticipate improvement in clinical outcomes after the initiation of this care model.

Methods

Six hospitalists underwent a 3-part training program including didactic sessions on diagnostic evaluation and the pre- and post-procedural care of patients undergoing TVT procedures. Documentation templates for admission and discharge, and a post procedure electronic order template were instituted. As part of the Heart Team, the TVT-H are included in all program correspondence and are invited to our valve review board meetings. Under a standardized protocol, the TVT-H manage patients presenting for TVT procedures from admission to discharge, employing consultative support from surgical and interventional services, level of care criteria, discharge criteria, follow up-planning and standardized hand-offs. Presented here is a preliminary retrospective analysis of LOS and ICU admissions data 6 months before and after program initiation, amongst elective trans-femoral cases.

Results

There was an increase in volume after TVT-H institution from 42 to 67 TVT cases. Among 76 TAVR cases, there was a 15.9% reduction LOS (mean 3.15 to 2.65 days) and 61.5% reduction in ICU admission (18.2% to 7.0%). Among 33 Mitraclip cases, there was a respective 26.4% (2.88 to 2.12 days) and 62.2% (11.1% to 4.2%) reduction. While all trends were favorable in this preliminary analysis, statistical significance was not reached.

Conclusions

Adoption of a novel in-hospital care model with TVT-H may decrease length of stay and post procedure ICU admission. This is a preliminary analysis; we anticipate favorable statistical corroboration as data points accrue over time.

Clinical Implications

This novel care model did not require additional hiring, upfront cost, or radical work flow shifts, as all participants continued to work within their usual labor structure. However, there may be considerable cost-saving given reduction in hospital-use metrics, particularly ICU use. There may also be the secondary benefit of increased productivity for procedural specialists. Most importantly, we anticipate that with a dedicated service, clinical outcomes will be improved. Our intended final analysis of this model will be a study of 1 year pre- and post- deployment clinical outcomes and cost, including mortality, specific complication rates, and post-discharge metrics.

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