MDM referrals- the solution to turf wars?

[Raygun77]

---

Members do not see this ad.

Hey guys,

Everyone knows there are massive turf wars when it comes to not only specific procedures (e.g. carotid stenting- cards vs vasc vs neurosurg) but what procedure patients should be offered (e.g. stents vs. CAGS). In terms of the latter example, cardiothoracics has pretty much been squashed because of cardiologists being the 2nd line 'gatekeepers' and thus offering their patients stents before they even get a CTS opinion. CAGS seems relegated to triple vessel disease or left main etc. based on largely outdated data...newer series w arterial grafts, off pump etc show dramatic improvements. People with single vessel disease may benefit from these procedures more than a stent. Still we only see 3xCAGS or up.

What has always struck me as a good solution to the gatekeeper bias is PCPs referring to multidisciplinary teams, where the surgeons and docs can duke it out with data and take into account the anatomy in choosing what to do. It works so well for oncology- for example, limited prostate CA where the data shows equal efficacy between EBRT/seeds/prostatectomy, all cases get discussed and a plan agreed on.

So getting to my question- why don't all patients get put into an MDM meeting between cards and cardiothoracics after their angio? Should cardiologists be allowed to stent then and there- do you think there is improved outcome by this or by waiting 1wk or however many days til the meeting and deciding on what to definitively do? Or do you think this is wasteful (patient is on the table with PCI in and cardiologist doesn't stent, only to stent the next week or whatever).

Interested to hear opinions on whether MDMs could work outside of oncology to diffuse turf wars

 

[Winged Scapula]

So getting to my question- why don't all patients get put into an MDM meeting between cards and cardiothoracics after their angio? Should cardiologists be allowed to stent then and there- do you think there is improved outcome by this or by waiting 1wk or however many days til the meeting and deciding on what to definitively do? Or do you think this is wasteful (patient is on the table with PCI in and cardiologist doesn't stent, only to stent the next week or whatever).

Interested to hear opinions on whether MDMs could work outside of oncology to diffuse turf wars

You're thinking like someone who is training in an academic program (nothing wrong with that, most of us had that bias). Most care in this country is not rendered in such places but rather in the community.

So here are the issues (that we face all the time):

1) when do you have the MDM? Who's time schedule are you going to accomodate? I can tell you that the 1200 time for Tumor Board at 1 hospital is not conducive to surgeon schedules and the 0700 at another, while great for me, is not popular with Med and Rad Onc.

2) where are you having it? Which hospital? Many community surgeons are on staff at multiple hospitals.

3) how are you going to get everyone there at the same time, the same place, and who takes charge of organizing it, etc.

The above are not insurmountable. Its done everyday in the community. But the real logistical problem is that you cannot and will not have all Cardiologists and all CT surgeons attend the same MDM, all the time, present all patients, etc.

I love MDM, really and think they work well. We had them frequently in residency and fellowship. But they are difficult at best to carry out in the community when people are spread around time and have different schedules. There are other issues as well (ie, that people are not as altruistic as we would like them to be, so you cannot expect that Cardiologists will even bring their patients to MDM - why should they? There's good data to support CABG in many patients over stenting.) that I'll let the CT people here delve into.

Finally, when did CABG become CAGS? Or is that a regional thing?

 

[Raygun77]

You're thinking like someone who is training in an academic program (nothing wrong with that, most of us had that bias). Most care in this country is not rendered in such places but rather in the community.

So here are the issues (that we face all the time):

1) when do you have the MDM? Who's time schedule are you going to accomodate? I can tell you that the 1200 time for Tumor Board at 1 hospital is not conducive to surgeon schedules and the 0700 at another, while great for me, is not popular with Med and Rad Onc.

2) where are you having it? Which hospital? Many community surgeons are on staff at multiple hospitals.

3) how are you going to get everyone there at the same time, the same place, and who takes charge of organizing it, etc.

The above are not insurmountable. Its done everyday in the community. But the real logistical problem is that you cannot and will not have all Cardiologists and all CT surgeons attend the same MDM, all the time, present all patients, etc.

I love MDM, really and think they work well. We had them frequently in residency and fellowship. But they are difficult at best to carry out in the community when people are spread around time and have different schedules. There are other issues as well (ie, that people are not as altruistic as we would like them to be, so you cannot expect that Cardiologists will even bring their patients to MDM - why should they? There's good data to support CABG in many patients over stenting.) that I'll let the CT people here delve into.

Finally, when did CABG become CAGS? Or is that a regional thing?

Thanks for the reply WS

You're absolutely right, I am thinking from the perspective of an academic or public hospital. I'm from Australia, where a lot of care is provided by the 'public system', but even here there are big turf issues. But out in the community i can totally understand why MDMs are impractical.

I guess ideally i was thinking it would be nice, in the community and at academic centres, if PCPs could refer their patients with angina/ACS to a 'cardiovascular team/clinic' rather than a cardiologist- they'd have a shared clinic with a meeting in the morning (say 7:30-9) running through who should see each patient and agreeing on a treatment plan.

I also can't understand why CT surgeons aren't able to do angios 'on table' after the patient's grafting surgery. It's like a general surgeon not being able to do cholangiography or a Cscope, for example. Incredibly inefficient imo!

 

[Winged Scapula]

Thanks for the reply WS

You're absolutely right, I am thinking from the perspective of an academic or public hospital. I'm from Australia, where a lot of care is provided by the 'public system', but even here there are big turf issues. But out in the community i can totally understand why MDMs are impractical.

I guess ideally i was thinking it would be nice, in the community and at academic centres, if PCPs could refer their patients with angina/ACS to a 'cardiovascular team/clinic' rather than a cardiologist- they'd have a shared clinic with a meeting in the morning (say 7:30-9) running through who should see each patient and agreeing on a treatment plan.

I agree - in theory its a great idea. But in practice in the US community, its hard to implement. For one, the ORs typically start at 0730, so you aren't going to find a lot of surgeons giving up the prized first start time to attend a MDM unless it were on their clinic day.

Secondly, again in the community, you still face the problem of where to have the meeting. Surgeons are *generally* not employed by a hospital in the US, thus, they may have admitting/operating privileges at multiple facilities.

Thirdly, a MD team cannot possibly include everyone in the community. Therefore, some PCPs may not want to refer patients because their favorite cardiologist/CT surgeon isn't on the team. We faced this recently with a hospital based Breast Center (well, let's call it that - it ended up being a radiology facility). The hospital did not want to commit to hiring a Med Onc group because they would lose referrals from PCPs who perhaps preferred another group or individual practitioner.

I also can't understand why CT surgeons aren't able to do angios 'on table' after the patient's grafting surgery. It's like a general surgeon not being able to do cholangiography or a Cscope, for example. Incredibly inefficient imo!

I can't speak about Australia, but there's no reason why CT surgeons in the US cannot do an on-table angio to check for graft patency if they really felt the need to. There's no rules against it.

 

[Socrates25]

Hey guys,What has always struck me as a good solution to the gatekeeper bias is PCPs referring to multidisciplinary teams, where the surgeons and docs can duke it out with data and take into account the anatomy in choosing what to do. It works so well for oncology- for example, limited prostate CA where the data shows equal efficacy between EBRT/seeds/prostatectomy, all cases get discussed and a plan agreed on.

Are you going to pay the guys on the MDM board for their time in considering the case? If you are, then you are increasing healthcare costs because now you are paying 2-3 doctors compared to just 1 doctor previously.

If the MDM people do NOT get paid for their "consultation" on the board, then I think you'll have a hard time getting people to join it.

 

[Winged Scapula]

Are you going to pay the guys on the MDM board for their time in considering the case? If you are, then you are increasing healthcare costs because now you are paying 2-3 doctors compared to just 1 doctor previously.

If the MDM people do NOT get paid for their "consultation" on the board, then I think you'll have a hard time getting people to join it.

Payment would have to come from private sources. You cannot bill insurance for multiple consultations in the same day for the same diagnosis code. MDM that I am involved in get around it one of two ways:

1) no billing; free service - if patient chooses one of the providers in the group, then they will make something later
2) rotate billing (ie, one day specialist X will bill for consult and the next time, it will be someone else); this means that someone is always working for free

I disagree that you have to pay people to be involved in these. BUT it is a consideration for many in private practice.

 

[ESU_MD]

Mdm for heart disease is a nice concept frequently discussed. Indications for cabg are well described though, so i doubt that these discussions are needed. Complex cases are usually discussed in informal mdm anyway.

On table angio in cabg?? They write these papers up now and then, but it seems like a waste of time. Getting a C-arm in the or is no fun and nobody wants to do routine cases in a hybrid suite. Grafts are checked by injecting some cardioplegia at completion and you can tell the runoff by how hard it is to inject, plus you can see the wholecourse to see it isnt kinked, unlike a fempop which is tunneled