David Landers, MD, is an interventional cardiologist with Hackensack Meridian Health.

David Landers, MD

David Landers, MD | Image Credit: Hackensack Meridian Health

Multidisciplinary care is an increasingly common topic of conversation across all healthcare specialties. Having a small group of highly specialized clinicians operating as a group to better provide care is an ideal situation, and one that has been proven time and again to be effective.

, the importance of multidisciplinary care has long been a focus. In 2022, the American College of Cardiology, American Heart Association, and 

 Society of America released guidelines for heart failure recommending a multidisciplinary team (MDT).

Additionally, previous research has indicated the effectiveness of multidisciplinary work in aortic disease, peripheral artery disease, and bicuspid aortic valve disease. A system of shared decision-making has been encouraged repeatedly, as it better determines optimal medical, endovascular, and potentially open surgical therapies.

For additional insight into the inner workings of an MDT in cardiology, the editorial team at 

 spoke with Landers in the following Q&A:

: How would you define the role of an MDT in modern cardiovascular care, particularly for complex cases?

 I believe an MDT is essential for implementing proper methodologies and treatment options to provide to the patient. The question is, how do you do that? How do you bring together the appropriate team members, organize the presentations, and determine what's optimal? But I think it's critically important.


: What does a high-functioning MDT look like in practice? Who needs to be at the table for structural heart or advanced coronary intervention programs to succeed?

 You need participants from structural heart disease, from surgery, from interventional cardiology. In virtually all such cases, there will be overlap and contribution from each sub-specialist, which is important both in most structural heart cases and most coronary cases. The involvement of all 3 of those team members is important.

Additionally, electrophysiologists oftentimes have additions and comments to make regarding pacing strategies, whether they be in structural heart disease or heart failure, as both have implications in the best treatment options for patients. We have heart failure specialists involved to be certain that the pre-interventional strategies have been met, so that we can optimize the likelihood of a successful outcome. Heart failure participants are necessary.

Indeed, for many of the patients, the long-term likelihood of LV and RV recovery is important to understand from the heart failure specialist. So those are the key members in our MDT. We have participation virtually from all those service lines in each of our case discussions.


: How has using an MDT changed your center’s outcomes, particularly in metrics like readmissions or length of stay?

: Well, we'd like to think that it was impactful. It's hard to tease out the MDT with regard to those metrics. I think that the length of stay would be sort of self-evident in that, if you get early on in the patient's admission, all the participants participating in decision making, then the optimum sequence of care and interventions is more likely to be obtained than if it were a singular specialty. Just 1 clinician treating the patient, having an outcome that then requires subsequent consultation, and then perhaps another consultation, all of which delays care and lengthens the patient's hospital stay.

The logic is clear with regard to readmissions. Readmissions are reduced when all the variables of care have been addressed. And if you have an MDT, part of that is not only the strategy for what to do with the case initially, but also options for additional therapies and when they are best applied or sought. So, one would hope and anticipate that readmissions are reduced, although those two data points are buried in lots of other analytics and processes within the hospital.


: Some critics have argued that MDTs may add cost and administrative burden to clinics. How would you address these concerns?

: I don't think it adds it either; no one in the MDT receives additional compensation for their participation in the MDT, so there's no cost basis there. The time of the clinicians is not altered, as it would be an exercise that they would normally go through anyway. Having the MDT participants all operate on a routine basis may, in fact, allocate their time more efficiently, rather than having to seek each other out individually.

I don't think there can be any issue concerning cost or administrative time if the individuals are regularly convening at 7 o'clock in the morning, Monday, Wednesday, and Friday, and discussions will take place. Follow-up discussions, should they be necessary, can also be presented at that very same meeting, so it doesn't add cost, and it makes administrative time, in my view, more efficient.


: What role can tele-MDTs play in supporting smaller community hospitals or rural programs?

: So that's an interesting concept. And what we do is we publish, we make available our MDTs to our network of participating hospitals. So we do have participation. Many of the physicians who are participating in our MDTs are not actually presenters, but just signing on to understand and learn. There are lots of physiology, lots of nuance, lots of technological advances, and research also discussed at the MDT, so it serves as an educational forum.

We also invite doctors who may have referred a case but don't regularly participate in our MDTs. They very well may be at another institution to hear their case presented and then asked to participate in the clinical analysis and judgments as to what should be done next. It is an opportunity for those institutions that may have very sick patients, but all the modalities to make the analysis of their patients and development of treatment options much more efficient aren’t available to them. Otherwise, they would have to seek out the individual practitioners.

An individual practitioner will always have the bias of their specialty at the forefront of their mind. The idea that outside hospitals with less generally available expertise might have the full options available to their patients is a very efficient way for them to manage their time as well.


: Looking forward, how do you see the MDT model evolving to incorporate AI decision support or computed physiology?

: Well, I think artificial intelligence will certainly play an increasingly important role in medical care in general. I don't know that artificial intelligence will undermine the activities of the MDT, but it may better inform the participants in the MDT as to what subjects, what needs, and what elements of care they need to discuss in their presentations. But I think artificial intelligence is quite good, if not spectacular, in some regards of providing information to decision makers.

I'm less convinced at this point in its ability to make decisions, but to provide relevant, updated, and comprehensive information to decision makers. It’s something that, at this point, artificial intelligence is quite capable of doing, and I think we'll continue to see that become part of the way clinicians inform themselves and make decisions. But at the moment, these are very complex decisions beyond the scope of AI algorithms.

Editor’s note: Landers reports no relevant disclosures.

Sokos G, Kido K, Panjrath G, et al. Multidisciplinary Care in Heart Failure Services. J Card Fail. 2023;29(6):943-958. 

Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334-e482. 

Articles

Multidisciplinary care is crucial in managing complex cardiovascular diseases, with guidelines recommending a team-based approach for heart failure. This model involves specialists from various fields, such as structural heart disease, surgery, and interventional cardiology, to optimize patient outcomes. The use of multidisciplinary teams (MDTs) can potentially reduce readmissions and hospital stays by ensuring comprehensive care. While some argue MDTs may increase costs, they can enhance efficiency and education, especially with tele-MDTs supporting smaller hospitals. Artificial intelligence may further inform MDTs, though its decision-making capabilities remain limited.

Landers discusses the importance of including multiple specialized professionals and sharing the decision-making process in cardiovascular care.