Letter to the editor Heart Team Decision-making in Spain: Is There Room for Improvement? Response

To the Editor,

We truly appreciate the interest shown by Lozano et al in our article¹ and we would like to make some remarks about their comments.

Despite the inherent limitations of the concept of a heart team,¹ collective decision making in cardiology is of central importance. This decision-making is influenced by the specific characteristics and preferences of each patient and by the availability of resources. The decision-making can be modified both by the internal heart-team dynamics and by oversight of outcomes by the health authorities.

One of the most noteworthy care models is that of New York State in the United States.² There, the health authority audits and assesses the care processes based on standard and mandatory reporting derived from individual patient data. The results are available in the public domain and posted yearly. They contain data on percutaneous coronary intervention, heart surgery, and pediatric heart surgery and are adjusted by clinical risk factors. Publication of outcomes has led to homogenization of cardiovascular disease management and heart team actions in New York State. This has all contributed to a substantial reduction in mortality.

We agree with Lozano et al¹ that the difficulty in referring patients to other centers, the lack of transparency in the waiting lists, audits based on administrative data, and the progressive loss of influence of clinical cardiologists in decision making are aspects that could be improved in the Spanish health system.

However, our previous criticism of the limitations of the heart team would remain purely a mental exercise if the assessment of a given decision-making system was not backed up by hard data.¹ This is why the initiatives to assess the health outcomes for cardiovascular disease, such as INCARDIO,³ are very important for determining whether the actions of a given group are in line with the required quality objectives for care.

In view of the above, in addition to practical clinical guidelines for the treatment of specific diseases, scientific societies should draft action protocols for heart teams. Centers should attach the minutes of heart-team meetings to the patient documentation, and the health authorities should then assess the centers according to adherence these protocols.

In conclusion, standardization and protocolization of the actions of heart teams and subsequent assessment of their outcomes are essential for clinical decision-making in Spain.