Physician perceptions of a multidisciplinary endocarditis team

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis

BACKGROUND

Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown.

METHODS

This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University.

RESULTS

Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care.

CONCLUSIONS

Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Expert consensus recommendations for the provision of infective endocarditis services: updated guidance from the Joint British Societies

Infective endocarditis (IE) remains a difficult condition to diagnose and treat and is an infection of high consequence for patients, causing long hospital stays, life-changing complications and high mortality. A new multidisciplinary, multiprofessional, British Society for Antimicrobial Chemotherapy (BSAC)-ledWorking Party was convened to undertake a focused systematical review of the literature and to update the previous BSAC guidelines relating delivery of services for patients with IE. A scoping exercise identified new questions concerning optimal delivery of care, and the systematic review identified 16 231 papers of which 20 met the inclusion criteria. Recommendations relating to endocarditis teams, infrastructure and support, endocarditis referral processes, patient follow-up and patient information, and governance are made as well as research recommendations. This is a report of a joint Working Party of the BSAC, British Cardiovascular Society, British Heart Valve Society, British Society of Echocardiography, Society of Cardiothoracic Surgeons of Great Britain and Ireland, British Congenital Cardiac Association and British Infection Association.

Poor long-term outcomes of intravenous drug users with infectious endocarditis

Objectives

The optimal management of active endocarditis in intravenous (IV) drug users is still lacking.

Methods

From the years 1997 to 2017, 536 patients with active infectious endocarditis were surgically treated, including 83 (15%) with IV drug use (IVDU) and 453 (85%) without IV drug use (non-IVDU). Initial data were obtained from the Society of Thoracic Surgeons database and supplemented with chart review and national death index data.

Results

The IVDU group was significantly younger (43 vs 56 years old) than the non-IVDU group and had greater rates of psychiatric disorders, drug use, and tricuspid valve endocarditis (28% vs 8.6%). Hypertension, dyslipidemia, and diabetes mellitus were significantly more common in the non-IVDU group. Perioperative complications and operative mortality (7.2% vs 7.9%) were similar. IVDU was not a significant risk factor for operative mortality. Kaplan–Meier survival was significantly lower in the IVDU group (5-year survival, 46% vs 67%). Significant risk factors for long-time mortality included IV drug use (hazard ratio [HR], 1.92), age ≥65 years (HR, 1.78), congestive heart failure (HR, 1.87), and enterococcus endocarditis (HR, 1.54). The 5-year rate of reoperation was similar between IVDU and non-IVDU groups (2.4% vs 2.7%).

Conclusions

IVDU is a significant risk factor for long-term mortality. A multidisciplinary approach was preferred for IVDU patients to treat both endocarditis and substance use disorder and improve long-term survival.

The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients

Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients' numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon's signed rank test. Patients' NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC (p < 0.001). A significant decrease in clinic visits (p < 0.001) and healthcare utilization (p < 0.05) was also observed. Opioid and non-opioid prescriptions did not change significantly (p = 0.43). 83% of providers agreed that MDC improved patient care. While previous studies have shown the effect of multi-disciplinary care, we show notable improvements with a team established around a once-a-month MDC.

A step-by-step guide to implementing a multidisciplinary endocarditis team

Over the last several years multiple studies, primarily from European centers have demonstrated the clinical and outcomes benefits of multidisciplinary endocarditis teams. Despite this literature, adoption of this approach to patient care has been slower in the United States. While there is literature outlining the optimal composition of an endocarditis team, there is little information to guide providers as they attempt to transform practice from a fragmented, disjointed process to an efficient, collaborative care model. In this review, the authors will outline the steps they took to create and implement a successful multidisciplinary endocarditis team at the University of Michigan. In conjunction with existing data, this piece can be used as a resource for clinicians seeking to improve the care of patients with endocarditis at their institutions.

Prosthetic Valve Endocarditis Diagnosis and Management- New Paradigm Shift Narratives

Prosthetic valve endocarditis (PVE) is a major infectious disease problem due to the increasing numbers of patients undergoing valve replacement surgery. PVE can present diagnostic difficulties echocardiographically, especially when complicating transvascular placement techniques. Moreover, outbreaks of unusual PVE pathogens, such as Mycobacterium chimaera, have presented major diagnostic and therapeutic dilemmas.

The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team

BACKGROUND

Infectious endocarditis is associated with substantial in-hospital mortality of 15-20%. Effective management requires coordination between multiple medical and surgical subspecialties which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality.

METHODS

The multidisciplinary endocarditis Team was formed in May 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control utilizing propensity matching.

RESULTS

Between June 2018 and June 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria definite endocarditis and at least 1 AHA indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1^st, 2014 to June 30^th, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (p<0.0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; p=0.12). Propensity score matching demonstrated similar results.

CONCLUSIONS

Implementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications, in the presence of notable differences between the two studied cohorts. In conjunction with previous studies demonstrating their effectiveness, this data supports that widespread adoption of endocarditis teams in North America could improve outcomes for this patient population.

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called ‘endocarditis team’ in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.