Page 171 - Simplicity is Key in CRT

introduction of the care pathway showed to result in a significant reduction of time-to-diagnosis, and a significant increase in diagnostic yield. Furthermore, it resulted in a significant reduction of resource utilisation.
Currently, we are awaiting results on medical and organizational outcomes of the introduced CRT care pathway. However, when comparing 64 patients (2015-jun 2016) included in the care pathway to 41 patients that received a CRT device in the year (2012) before implementation of the care pathway significant advantages become apparent. With respect to care-related outcomes there is a significant reduction in referral to treatment (implantation) time (65 to 46 days), in-hospital stay for implantation of the device (2.1 to 1.1 days), and a significant reduction in follow- up consultation in the first six months of follow-up (3.8 to 2.6 consultations). Medical and patient related outcomes generally take more time and numbers to show significant improvement and hence echocardiographic response to CRT does not show any significant increase. Intermediate quality of care endpoints do show clear improvements, as the CRT care pathway lead to significantly better identification of possible reasons for non-response to CRT in patients. For instance, increased use of guideline recommended HF medication, increased recognition and treatment of comorbidities, and identification and reprogramming of ineffective delivery of CRT, and consideration of baseline electrical dyssynchrony and expectations of therapy. These preliminary results provide high hopes for improved echocardiographic and eventually clinical outcomes on the long term. Importantly, from the individual patient and health care providers perspective, satisfaction with CRT management seems to be greatly improved.
Results from the introduction of the CRT care pathway into our local clinic will be presented in the near future. As this prospective study has been conducted in a non-randomized fashion its results, if as anticipated, will have to be replicated in a RCT to definitively establish the value of this reorganization of CRT care.
Conclusions
The main conclusions of the present thesis are that regarding patient selection for CRT our current ECG parameters have considerable caveats which need to be overcome. The analysis in the MUG database strongly suggests that selection can be improved AND ‘simplified’ when QRS area instead of standard ECG markers QRS duration and morphology are used. Improvements in patient selection can be expected both with the sole use of QRS area, or in combination with the established ECG makers, improving selection in patients with a current class I indication and even more so in those without a class I indication for CRT implantation.
With respect to care for the patient treated with CRT the thesis provides an evidence and experience based consensus blueprint for a structured CRT care pathway. Which aims to help in reducing (unnecessary) resource use while maintaining quality of care for these patients. Preliminary results show that reorganizing local CRT care using this blueprint CRT care pathway may help establishing these goals.
In conclusion this thesis shows that ‘simplifying’ CRT patient selection and patient management may be ‘the key to CRT’.
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