Page 150 - Simplicity is Key in CRT

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Introduction
Cardiac resynchronization therapy (CRT) is one of the most successful heart failure (HF) therapies that has emerged over the last few decades. The therapy entails the implantation of a biventricular pacemaker or ICD in order to restore electrical synchrony. Several randomized clinical trials have shown CRT to reduce symptoms of HF, improve exercise capacity and quality of life, as well as to reduce hospitalizations and mortality in selected HF patients [1-4]. Furthermore, economic evaluations have shown it to be a cost-effective therapy in HF [5, 6]. Clinical guidelines of the European Society of Cardiology and the American College of Cardiology Foundation/A- merican Heart Association endorse these results and promote utilisation of CRT [3, 7-9].
Despite guidelines and experts’ consensus, high variations in patient referral and pre-assessment, implantation procedure and follow-up management are observed [10-12]. Partly because of this heterogeneity in the care process as well as the complexity of HF care, with patients suffering from numerous co-morbidities affecting the outcomes of CRT, it is estimated that 30% of patients do not derive maximal benefit. Indeed, CRT is a complex therapy, involving more than just electrical therapy for an electrical problem. Instead, it is an electrical therapy for a combination of electrical, mechanical and haemodynamic problems, of different origins, requiring thorough patient selection, skilled implanting physicians and a comprehensive follow-up [13-16]. Moreover, multiple recent studies have shown, that successful treatment of HF requires specialised (multidisciplinary) care [3, 15]. Ideally, there should be a uniform, multidisciplinary approach incorporating all aspects of HF care in patients referred for CRT implantation [13].
Care pathways are increasingly used to structure complex interventions in health care [17]. Care pathways have goals and key elements based on Evidence Based Medicine, best practice and patient expectations by facilitating the communication, coordinating roles and sequencing the activities of the multidisciplinary care team and patients by documenting, monitoring and evaluating variances and by providing the necessary resources and outcomes [18]. In addition to the support of evidence based medicine in complex interventions, care pathways have been proposed as a strategy to optimise resource utilisation [17, 19].
The objectives of our study were (1) to develop a care pathway for CRT-care and (2) to implement it into current practice in a CRT referral centre in the Netherlands. Aiming at achieving a high quality, integrated care, tailored to the needs of every CRT treated HF patient, and a proactive and structured approach to the improvement of clinical response to CRT, as well as improvement of organisation and control of resource utilisation.
Methods
Starting from December 2012, three European hospitals that are experienced in delivering CRT care, participated in the development of a model CRT-care pathway (The Liverpool Heart and Chest Hospital in the UK, The Copenhagen Rigshospitalet in Denmark, and The Maastricht University Medical Centre in the Netherlands). These centres are large referral centres (averaging 150 to 300 CRT device implantations a year), experiencing difficulties in structuring their care for CRT patients. They were selected based on their experience in CRT and their willingness to evaluate and reorganise their current CRT practice.
To evaluate and redesign current CRT practice in these centres both the European Pathway Association (EPA) Care Pathway methodology [20] and the Lean Six Sigma methodology [21] were used. The EPA Care pathway methodology defines 4 levels of care pathways products. Using this methodology we aimed for a stepwise design of an evidence- based ‘model care pathway’ to a locally applicable ‘operational pathway’, and individual ‘assigned pathway’ (figure 1).