The Massachusetts General Hospital recently announced the launch of the Mass General Institute for Heart, Vascular and Stroke Care, one of the only institutes in the world to integrate cardiovascular and cerebrovascular care. In this interview we speak with Dr. Singh, Director of the Resynchronization and Advanced Cardiac Therapeutics Program at Massachusetts General Hospital (MGH) in Boston, and Associate Professor of Medicine at Harvard Medical School.
When did the new Institute open? Why was there a need to create the Mass General Institute for Heart, Vascular and Stroke Care?
The Mass General Institute for Heart, Vascular and Stroke Care was launched in mid-September 2012. Although, as you can imagine, the thought process and the foundation work toward making this happen started several years prior. The vision of the Institute’s leadership (Drs. Michael Jaff, Bill Dec, Thor Sundt and Lee Schwamm) was primarily to create a unique environment where we could provide cutting-edge clinical care in an integrated, multidisciplinary manner to improve clinical outcomes. As we all know, the current delivery of healthcare is fairly fragmented and inefficient, and requires a makeover. One of the aspects that makes the Institute particularly unique is that it brings together for the first time the disciplines of cardiovascular and cerebrovascular medicine. This unified approach enables us to treat a spectrum of patients linked to disease processes afflicting the ‘common vascular highway.’ Additionally, the Institute construct will further strengthen our ability to undertake cutting-edge translational research work, while promoting world-wide education and playing a central role in formulating health policy recommendations within the disciplines of heart, vascular and stroke care.
How is MGH redefining cardiovascular care through the creation of this Institute? Discuss the new team-based model that involves complete integration of clinical care and research across disciplines.
The Institute’s endeavor to redefine cardiovascular care at MGH is centered around getting the physicians, nurses and the healthcare staff to gravitate away from their individual silos and work together as teams. Providing the best possible patient care in the most efficient manner is the core objective. To facilitate this thought process, the leadership has been actively looking at every area within the three disciplines, where the care and opinion of more than one subspecialist may be needed. MGH has already brought together 19 such multidisciplinary programs. Just to name a few, but in no particular order of preference, are the thoracic aorta program, adult congenital heart program, peripheral arterial disease program, heart valve program, resynchronization and advanced cardiac therapeutics program, hypertrophic cardiomyopathy program and a cardio-oncology program. All of these programs have subspecialists from more than one specialty involved in the evaluation and treatment of these patients.
To give you an example, I can elaborate on the cardiac resynchronization therapy (CRT) program, which I am most closely affiliated with. This program looks after a frail group of ambulatory patients with refractory heart failure and implanted devices. The care of these patients is fairly complex and involves the input of several subspecialists inclusive of electrophysiologists, heart failure, and imaging specialists. Now it is well known that a substantial proportion of these patients receiving resynchronization therapy, i.e. approximately one-third of these patients, will not respond adequately to this therapeutic modality. Many of these patients who are non-responsive to this therapy come to our attention when they have already worsened significantly or have been hospitalized for heart failure. This often occurs because of the lack of an integrated care approach and the absence of a structured cross-talk and communication between the multiple caregivers.
With respect to the research component, even though the cardiac resynchronization therapy program is first and foremost a clinical service, nearly 70% of the patients are involved in one or more research protocols. This program has 18 different clinical trials (multi-center and single-center initiatives) underway with nine principal investigators across the different disciplines. The advantage of the integrated program is that it is possible to piggyback clinical research on to the service component in a seamless way, which enables prospective research without compromising or changing the clinical care provided to the patient. The most important aspect about working this way allows the lessons learned from the research to be quickly brought back into clinical practice. So we are constantly learning and improving the way we deliver care to our patients.
How will cardiovascular care change for patients and physicians? For example, how will the multidisciplinary approach change the management of conditions such as heart failure, atrial fibrillation (AF), and other arrhythmias?
Thanks, that is a very good question. Integrated programs not only change the delivery of care, but they redefine the role of the individual physician and even the expectations of the patients. There is a shift in the mindset from being organ-specific to more holistically thinking about the patient. Your question is really relevant, especially taking into account the changing landscape in the healthcare arena. We are going to be held more accountable for our outcomes, whether it is for long-term survival after ICD implants, heart failure hospitalization in CRT recipients, or better AF control after ablations. As that becomes a reality, we are all going to be faced with the inevitable — that we cannot achieve these lofty goals without working together.
Let me directly address your question as an electrophysiologist who spends all day dealing with a variety of arrhythmias. Using resynchronization therapy as an example, even though I may implant the device and the pacing leads in a patient with a history of congestive heart failure, there are also many unpredictable dynamic situations that may lead to hospitalizations in this frail group of patients. To try to orchestrate the best long-term outcome, I will need the help of my heart failure and imaging colleagues to deliver appropriate post-operative care, device optimization, titration of drugs, and the management of heart failure. Working as a team coupled with remote monitoring and early intervention strategies are essential toward making this happen. The team here involves physicians, nurse practitioners, device technicians, visiting nurses, etc. Similarly for AF, structured multidisciplinary rapid response AF teams in the ER and within the hospital are necessary to provide uniformity of the delivery of care, thereby preventing unnecessary admissions, reducing length of stay, and improving clinical outcomes.
What types of expanded research opportunities will also be available through the Institute?
Research is one of the most important pillars that the Institute has been founded upon. The Institute brings together basic, translational, and clinical research under one umbrella, facilitating cross-pollination and collaborative endeavors. Just to give you an example, the Institute recently funded seven researchers via SPARK grants for innovative cross-disciplinary research projects. To give you a flavor of the diversity of projects selected, I will name a few, again in no particular order or preference. The projects included: 1) novel methods for human genetic disease using pluripotent stem cell (David Milan, MD); 2) coronary CT angiography and exome sequencing to discover genes in families prone to myocardial infarction (Sek Kathiresan, MD); 3) evaluation of surveillance strategies after percutaneous treatment of the superficial femoral artery (Mark Conrad, MD); and 4) novel markers of clinical outcomes in acute ischemic stroke (Natalie Rost, MD).
The Institute is committed to funding innovative research projects on a yearly basis that will foster translational research across the disciplines. With the current external funding environment, the onus is on us to make sure that we continue to nurture the best talent that exists within the Institute.
What changes will we see in available educational opportunities for healthcare professionals?
We have already started moving forward on this front. The intent here is to 1) have multidisciplinary educational forums to break down complex disease-related questions and address them using a team-based approach, and 2) share state-of-the-art treatment approaches fueled by the cutting-edge translational research. At the American College of Cardiology’s 2013 conference, the Institute had one of these educational symposia, bringing together representation from all disciplines, addressing a multitude of problems, inclusive of atrial fibrillation, pulmonary embolism, peripheral vascular disease, stroke, and preventative strategies. At Heart Rhythm in May 2013, we will be hosting an educational symposium highlighting multi-disciplinary care of the atrial fibrillation patient, intersection of cardiovascular genetics with rhythm disturbances, and cross-disciplinary modes of treating heart failure patients with implanted devices. The vision of the Institute is to stage these educational symposia regionally, nationally and internationally, to help disseminate knowledge of the continually evolving state-of-the-art treatment strategies.
Tell us more about how the Institute will be involved in addressing critical issues of national health policy and reform.
The evolving landscape of healthcare reform and the changing demands from the patients, insurance companies, and government funding bodies is going to require innovative thinking. The adopted narrative that there is nothing wrong with us doesn’t work any longer, and we are being asked to continually morph with the times and provide the most cost-effective care with the best clinical outcomes in the most efficient manner. We are fortunate to have many of the members and leaders of our Institute on boards of major societies and associations. The Institute is in step with the changes coming through as a consequence of the Affordable Care Act, and is focused on delivering the finest value-based care. Using case examples and data from the experience gained through the adaptive process of providing integrative care, the leaders from within the Institute have and will continue to play a significant role in the development of national guidelines and policy changes.
What technological innovations are included in the new Institute?
I think it is important to recognize that high technology is meaningful, only if accompanied by a well-thought-out strategic vision. The Institute has done a phenomenal job in prioritizing and investing resources toward the different technological innovations, and I could certainly go on for hours highlighting each one of them. Generically speaking, there is great progress being made in the stem cell arena, structural heart (i.e. percutaneous valves) end of things, and we are also in the process of starting early investigative work on the renal denervation front. There is futuristic work in the arena of regenerative medicine, inclusive of attempts to reconstruct the human heart.
From the electrophysiology aspect, much is happening on the device front as well as on the ablation front. Our group has investigative work going on with left atrial pressure sensors, vagal nerve stimulators, non-fluoroscopic approaches to procedures, atrial appendage occlusion strategies, as well as a host of new catheter technology for atrial fibrillation ablation.
In the August 2012 issue of EP Lab Digest®, we spoke with the MGH Multidisciplinary CRT Clinic about clinical outcomes in CRT patients. The clinic opened in 2005; was it the first to offer the integrated care approach at MGH?
MGH has a long tradition for multidisciplinary teams, but in the past most of this had been largely directed to disciplines such as oncology. As far as our cardiovascular departments, I am pretty sure the first integrated program was the Thoracic Aorta program, which in fact preceded the cardiac resynchronization therapy program by a few years. The ‘Aorta’ program was a pioneer on the multidisciplinary front, and brought together cardiology, cardiothoracic surgery, vascular medicine, and surgery under the same umbrella. We now have 19 programs at different stages of evolution. It is a very exciting time to be part of the Institute, as we continue to morph and adapt to the changing healthcare landscape.
How will integrated care change the future of health care delivery? Due to this model, do you expect to see overall better outcomes in cardiovascular care?
I think we all agree that there are sweeping changes taking place in the healthcare arena, right from access to healthcare providers, reimbursement rates, and payment structures. We are more and more going to be held accountable for our outcomes, be it for heart failure re-admissions, post-ablation atrial fibrillation recurrence, or readmissions for inappropriate ICD shocks, etc.
In regards to whether we expect better outcomes, we’ve already seen some initial results showing that multidisciplinary care works. Again, using the ‘resynchronization therapy patients cohort’ as a case example, we published the MGH experience last year in the European Heart Journal. Briefly, our study examined the clinical outcome in 254 patients receiving multidisciplinary care compared to 173 patients who received conventional care. The multidisciplinary group was followed prospectively in the MGH integrated program setting by a team of subspecialists from the heart failure, electrophysiology, and echocardiography service at 1, 3 and 6 months post-implant. There was a 38% relative risk reduction for heart failure hospitalization, transplant, and/or mortality over a two-year follow-up in the group receiving multidisciplinary care versus conventional care. I think a similar impact on clinical outcomes can and will be replicated by a similar team-based approach amongst the other integrated programs within the Institute.
Is there anything else you’d like to add?
I think these are incredibly interesting times, where we are in the midst of a disruption of our conventional clinical and financial systems. Within these rapidly changing dynamics, we have to quickly adapt, step out of our silos, collaborate, and provide ‘holistic’ integrated care to our patients. The MGH Institute of Heart, Vascular and Stroke Care has already set out on this path, and it is a privilege to be a part of this undertaking.