Bridging Gaps in Heart Valve Disease Care: Opportunities for Quality Improvement

Background
The Society of Cardiovascular and Angiography Interventions (SCAI) and Avalere Health (“Avalere”) sought to develop a heart valve-focused initiative seeking to advance the identification and management of patients with heart valve disease (HVD). A formal environmental scan was conducted to 1) identify existing gaps that affect detection and management of HVD; 2) determine what work in this area has already been done; 3) where there were opportunities to build of what been done; and 4) identify who the key stakeholders are working towards improving the quality of care for patients with HVD.

Methods
SCAI and Avalere performed a targeted white and grey literature search. Specifically, we searched PubMed and Google Scholar to identify guidelines and clinical consensus documents focused on the identification and management of heart valve in the community, primary care, outpatient, pre-admission, or non-acute settings of care. Additionally, the team interviewed 5 experts between February and May 2018 (cardiologists, interventional cardiologists, patient advocacy groups, and a primary care clinician) to gain insight of diagnosis and treatment that may not be reflected through publicly available information.

Results
Overall, the results of the environmental scan showed a lack of a standardized approach to detection and management of HVD in ambulatory settings. This gap presented a clear opportunity to improve identification and management of patients with HVD through various vehicles, including but not limited to, increased provider education, raised awareness of the disease, shared decision making and quality measurement. The primary discussion in published literature around HVD focused on valve replacement options and symptom management. The clinical guidance documents reviewed did not provide specific recommendations on early identification of patients with HVD. Furthermore, there are few published studies that focused on examining adequate early diagnosis of HVD during routine doctor visits. Despite the demonstrated gaps along the patient journey, several key stakeholders have developed tools and educational resources to assist patients in symptom identification and a better understanding of treatment options. However, there are no existing performance measures and/or validated shared decision-making tools that address patients with HVD.

Conclusions
Results from the scan highlight opportunities to increase awareness about HVD and the quality of care delivered to patients, specifically in the ambulatory setting. Approximately 4.2% to 10.7% of the population ages 65 and older has moderate or severe aortic stenosis and 5.1% of the population ages 65 and older has mitral valve disease. Yet, as of 2016, researchers found that 30% of older adults are unaware of heart valve disease. Furthermore, 40% of heart murmurs, which often serve as a primary diagnosis for HVD, are often missed by primary care clinicians. Lastly, evidence shows that approximately 56% of patients with symptomatic aortic stenosis referred to a surgeon were not operated on. These findings illustrate many opportunities to improve the care continuum for patients with HVD from routine assessment to management of disease. Implications for Policy or Practice: Based on this preliminary scan, there are no major national or regional quality improvement initiatives targeting HVD patients. These findings indicate clear gaps to manage this population and that there are opportunities to develop tools and materials to assist providers in actively and appropriately identifying patients, even when symptoms are mild. Based on these recommendations, there is an opportunity to create an initiative focused on the identification and management of asymptomatic and symptomatic patients with HVD through increased provider education, quality measurement, and the development and implementation of tools targeted towards this specific patient population.