Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams?

Abstract

Objective: To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons Design: Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa.Results: Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively) Conclusion: In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel.

Determinants of variations in coronary revascularization practices

“…18 In New York State, Hannan and colleagues observed that many pa tients who had indications for CABG surgery (according to the American College of Cardiology / American Heart Association guidelines) at the time of angiography received multivessel PCI and never saw a cardiac surgeon. 19 Although previous studies have shown that interventional cardiologists are more likely to recommend PCI and cardiac surgeons are more likely to recommend CABG surgery for patients with similar indications, 20,21 we found substantial variation among cardiology specialists across different hospitals in terms of their revascularization practices.…”

2018 ESC/EACTS Guidelines on myocardial revascularization

“…Multidisciplinary decision-making in a Heart Team can minimize specialty bias and prevent self-referral from interfering with optimal patient care. 49 Several reports from different centres have established that the treatment recommendations made in multidisciplinary Heart Team discussions are reproducible and implemented in the vast majority of cases (93-95%). 50,51 Interdisciplinary institutional protocols should be developed for common case scenarios to avoid the need for systematic caseby-case review of all diagnostic angiograms.…”

Exploring Current Evidence on the Past, the Present, and the Future of the Heart Team: A Narrative Review

“…Moreover, Heart Team seems to be an "ideal platform for recruitment into trials of PCI vs CABG" as SYNTAX teams proved to be [51]. In addition, not all the hospitals detain on-site cardiac surgery, which makes the decisions biased toward PCI [52] (a situation almost similar to the contrary situation, as surgeons show a slight bias toward CABG) [53,54].…”