Page 170 - Simplicity is Key in CRT

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Reorganization of outpatient HF care has been introduced and broadly accepted in the last decades. In order to cope with the already vast burden on the healthcare system, studies have shown outcomes in HF patient nurse-lead care to be at least as good as, if not better than usual care [24, 25]. To maintain high quality in care for CRT patients and to be able to cope with increasing demands, implementation of CRT care into the already broadly implemented nurse-led HF outpatient clinics seems inevitable.
While checklists have been used before in HF treatment, they have not been used in CRT practice yet. The IMPROVE- HF prospective multicentre registry included over 30.000 patients from over 160 US clinics. In this study the introduction of clinical decision support tools and algorithms provided significant improvement of adherence to guideline recommended treatment on 5 to 7 performance indicators among which medication adherence, ICD and CRT implantation and HF education [26]. These results prove the value of the translation of extensive guidelines into practical tools for the implementation of evidence-based medicine. Altman et al. [27] specifically addressed the CRT patient population and recognized the complexity of the combination of HF and device care in this population. The effect of a structured multidisciplinary care program was compared to a retrospective usual care cohort at the same site. They constructed a care pathway for CRT patients in which a structured evaluation of CRT patients was performed by both HF specialist and electrophysiologist at predetermined times of follow-up until discharge into normal care at 6 months post-implantation. Compared to usual care, they found a significant improvement in event- free (hospitalization, transplantation and death) survival after 2 years follow-up. Mullens et al. [28] also investigated a protocol-driven approach to CRT patient management. Focussing on finding reasons for suboptimal response in CRT patients referred for optimization, a designated nurse and cardiologist evaluated CRT patients in a structured follow-up program. The intervention group showed a significantly lower event-rate (all-cause mortality, cardiac transplantation, LVAD implantation and first HF hospitalization) within 6 months of follow-up [28, 29].
Whereas these studies support the idea of a structured, protocol driven optimization pathway, interventions rely on time and extensive material resources or highly specialized personnel available for the process. The aim of the benchmark CRT care pathway presented in this thesis is to reassure structured, evidence-based CRT care, without relying on specialized personnel or increasing local health care burden. In contrast, by including detailed information on ‘minimal’ resources needed we offer a chance to cut away ‘waste’ from the process in order to reduce unnecessary resource use, in a way ‘simplifying’ the CRT care process without losing quality of care.
Pathway development and implementation strategies have only recently been introduced to optimize processes in HF care management [30]. Reviewing reports on care pathway introduction into HF care, this exclusively concerned in-hospital treatment of HF patients. The introduced interventions led to a decrease of mortality rates and length of hospital stay, but did not have any effect on readmission rates or hospital costs [30]. Though, in-hospital treatment of HF patients seems difficult to manage in a care pathway because of high variability of patient presentation. As outpatient HF care generally addresses patients in the stable phase of the disease, this would perhaps be a more suitable phase of the disease to be managed in a structured way.
In chapter 9 we describe the implementation of the aforementioned care pathway into the Maastricht University Medical Centre (MUMC) outpatient HF care program. In order to implement the care pathway and reorganize outpatient management processes, lean six sigma methodology was used. This methodology has been used in the outpatient clinic previously for the introduction of an outpatient syncope pathway in 5 European hospitals [31]. The