Monday, 24 October 2011

Shared Care Decisions, Technology Assessment and Heart Teams

In recent years, there have been a number of technological developments in the management of patients with cardiovascular disease. PCI (percutaneous coronary intervention) with insertion of stents into dilated diseased coronary arteries has arisen as a possible alternative to the coronary artery bypass operation. Patients with aortic valve disease now have a catheter based treatment available to them - TAVI or transcatheter aortic valve Implantation. This avoids the need for open heart surgery and replacement of the aortic valve. 

Decisions about which treatment any particular patient receives are being taken by a multidisciplinary group consisting of the patient's cardiologist, an interventional cardiologist and a surgeon. The concept of MDT discussions for cardiac treatment was introduced in the UK. The idea was taken from the successful experience of cancer MDTs. The idea is gaining ground in  Europe and in the USA where the groups are known as Heart Teams.  
These groups have to take various considerations into account when deciding on the optimal treatment. The surgical treatments have excellent durable outcomes but are associated with all the morbidity associated with major heart surgery. On the other hand, the catheter based treatments are probably less durable but patients receiving them recover quickly. This dichotomy does not only make life difficult for teams but also for guideline issuing bodies such as NICE (National Institute for Health & Clinical Excellence) who have to make an assessment of these different technologies.
The advent of shared care decision making, (the involvement of the patient in all aspects of their treatment) makes clear that the one crucial person who needs to be part of the heart team is the patient. This currently does not take place. There are a number of reasons for this - medical paternalism of a single doctor has possibly been superseded by paternalism from a group of doctors.  The logistics of involving every single patient in the decision making process during the proceedings of an MDT discussing many patients in a single session, is also a contributory factor. 
I suspect that the presence of the patient during the discussion may obviate alot of the agonizing that I know takes place as the group attempts  to make the right choice. Technology, such as the use of webcams, can be used to sort out logistical problems.
The presence of the most important person during these meetings will have great returns and is surely the only way forward.