A tiered system for valvular heart disease (VHD) treatment centers akin to that for stroke and trauma treatment was jointly proposed by several medical societies.
Such a system would divide hospitals into Level I (Comprehensive Valve Centers) and Level II (Primary Valve Centers), with the former being able to perform all interventional and surgical procedures and have advanced imaging modalities; and the latter capable of at least transfemoral transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement, among other criteria.
“The focus of this document is not to ask whether there are too many, too few, or just the right number of self-designated advanced valve centers,” according to the writing committee co-chaired by Rick Nishimura, MD, and Patrick O’Gara, MD.
Rather it was “to initiate a discussion regarding whether a regionalized, tiered system of care for patients with VHD that accounts for the differences in valve center expertise, experience, and resources constitutes a more rational delivery model than one left to expand continuously without direction,” they wrote.
Their expert consensus statement was published online in the Journal of the American College of Cardiology representing the American Association for Thoracic Surgery, the American College of Cardiology, the American Society of Echocardiography, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons.
“The development of an integrated model of care for patients with VHD is based on the concept of a graduated system in which the first tier has the critical function of recognition and consideration of referral. Subsequently, the patient is matched on the basis of disease complexity with the required center expertise, experience, and availability of resources,” according to the group.
Yet implementing a tiered system wouldn’t solve the current problem of limited access to care that many face due to their geographic location, Nishimura and O’Gara’s group acknowledged.
As things stand, there are over 600 TAVR centers, more than 250 MitraClip centers, and thousands of hospitals that “do a smattering of the procedures that fit the definition of a level I center as described” in the report, noted Paul Sorajja, MD, of the Minneapolis Heart Institute, who was not involved with the consensus report.
“I believe centers of excellence should be defined more by outcomes with consideration of the case mix of morbidity and risk, rather than the breadth of procedures. The document focuses heavily on ‘what’ is offered by a center, rather than ‘how’ it is offered. It is the latter that matters most to patients,” he commented to MedPage Today.
“Quality initiatives to improve the care of patients with valvular heart disease are always important and welcomed. We do have to be mindful of the considerable heterogeneity of VHD and the therapies that are available, and binary definitions of centers have to be very carefully determined,” Sorajja cautioned.
Besides proposing a tiered system, the societies recommended that centers be evaluated using both procedural volumes and certain available outcome metrics for each procedure. Moreover, there should be a 3-year grace period for new centers to accumulate cases before they are fully accountable for patient outcomes, the authors suggested.
New TAVR volume requirements proposed by the Centers for Medicare & Medicaid Services cut back on the number of certain procedures that hospitals have to do to maintain or start a TAVR program.
“There is a great deal of detailed work ahead to realize the goals of this proposal to the satisfaction of patients and the many other stakeholders involved,” the consensus document acknowledged. “Transparency, public reporting, mandatory participation in national registries, ongoing analysis of processes and outcomes, and a commitment to research are essential.”
Nishimura and O’Gara disclosed no relevant conflicts of interest.
Several writing committee members reported ties to industry.