{
  "abstract": "Abstract Multidisciplinary team (MDT) meetings are essential for managing complex cardiovascular cases, enabling collaborative treatment decisions and best-practice care. We aimed to evaluate the outcomes of MDT meetings and waiting times to clinic reviews and procedures in a one- year follow-up. Among 95 patients undergoing coronary revascularization, 34.7% had PCI and 65.3% underwent CABG. Median time to PCI was shorter for inpatients (4 days) compared to outpatients (54 days). UHCW inpatients had a shorter median time to CABG (11 days) compared to QEHB (24 days), but outpatient CABG at UHCW experienced longer median time to procedure (187 vs. 108 days). TAVI was performed more frequently than aortic valve surgery (73.8% vs. 26.2%), particularly at QEHB (n: 29), with median times of 19 days for inpatients and 60 days for outpatients. UHCW’s median time to inpatient AVR was 31 days, slightly longer than QEHB’s 28.5 days. However, UHCW had significant long waiting time for outpatient AVR (252 days). Mitral valve surgeries at UHCW had a short inpatient median time of 10 days, while UHCW outpatients experienced longer median time than QEHB for mitral valve procedures (188 vs. 123.5 days). Overall mortality was 1.8% for patient waiting inpatient procedures. In summary, UHCW had longer waiting times for outpatient procedures compared to QEHB, especially for time to surgery, while QEHB demonstrated shorter overall waiting periods for both clinic review and procedures. Key factors contributing to procedural delays include inadequate MDT documentation, lack of urgent referral prioritisation, limited beds availability in specialist tertiary centers, absence of structured repatriation protocols,. delays in essential pre-operative assessments and unclear antiplatelet management further prolong waiting times.Introduction Multidisciplinary Team (MDT) meetings are vital for collaborative decision-making in complex cardiovascular conditions. However, to ensure they are truly effective at our institutes, we decided to do this audit to evaluate the outcomes of our MDT meetings, focusing on treatment decisions, referral timeliness, and waiting times for clinic reviews and cardiac procedures. Another area of focus is to identify and address any factors influencing these waiting times and outcomes to improve the standards of care for patients.Materials and Methods Data Collection and AnalysisThis first-cycle audit was conducted as a retrospective analysis of patients who were discussed during our weekly cardiology-cardiothoracic MDT meetings at Birmingham Heartlands Hospital (BHH) over a one-year period, from June 2022 to June 2023. During this time, a total of 213 patients were randomly included with a near-equal split between inpatients (108, 50.7%) and outpatients (105, 49.3%). Data was collected from various sources, including the MDT meeting register, clinic letters, and the hospital patient database (PICS system) which is a system used for patient management and documentation.Any MDT forms that did not have a definite outcome during the meetings were excluded from the analysis.Standards Data were compared to the National Cardiac Audit Programme (NCAP) which contains 11 cardiovascular audits and covers quality of care outcome measures across severe cardiovascular domains. In addition, data were audited against the National Institute for Health and Clinical Excellence (NICE) and British Cardiovascular Intervention Society (BCIS) guidelines, which have target timeline recommendations for various cardiac procedures.Results DemographicsThere is a clear predominant male referral comprising 76% compared to female which only accounts for 24%, with a male-to-female ratio of 3:1. The median age of patients is 69 years old. Caucasians formed most of the audit population at 58%, followed by an Asian population of 20%, 19% of unknown ethnicity, and smaller groups of 2% for other ethnicities and 1% black population.Table 1 shows the primary baseline characteristics of the patients for the common cardiac procedures. The Frailty score of patients who had interventional procedures (PCI and TAVI) is 3, which indicates they are managing well, while patients who underwent cardiac surgery are fitter with scores of 2 and 1 for CABG and AVR, respectively. However, there were no significant differences in other patients’ characteristics (p = 1) (table 1).Diagnoses Discussed in MDT MeetingsThe MDT meetings discussed a wide range of cardiovascular diagnoses, with valvular diseases being the most prevalent, affecting 78 patients, followed by NSTEMI in 53 patients, stable angina in 39 patients, unstable angina in 17 patients, STEMI in 13 patients, ischemic cardiomyopathy in 6 patients, infective endocarditis (IE) in 6 patients, and constrictive pericarditis in 1 patient. It is noted that the number IE patients (6 patients) is likely underestimated because a large number of patients were discussed informally by the infectious disease consultants in the MDT meetings in view of suspected IE on echocardiogram without formal MDT forms, which makes tracking their progress is challenging (figure 1, A).Agreed Outcomes During MDT MeetingsCoronary artery bypass graft (CABG) was the most agreed intervention, recommended for 68 patients, followed by percutaneous coronary intervention (PCI) in 35 patients, and transcatheter aortic valve implantation (TAVI) in 23 patients. Additionally, 23 patients were recommended for medical therapy. We also saw a range of surgical interventions, from isolated valvular surgery to combined procedures involving CABG and valve replacements. Notably, only a few patients underwent specialized procedures like balloon mitral valvuloplasty (1), aortic root replacement (1), or radical pericardiectomy (1). Out of the 213 outcomes, 156 patients successfully underwent their planned procedures, 31 patients were managed with medical therapy, 13 patients did not have the planned procedure for various reasons, and 13 patients remained on the waiting list (figure 1, B).Out of the three large tertiary centers in West Midlands, Queen Elizabeth Hospital Birmingham (QEHB) and University Hospitals Coventry & Warwickshire (UHCW) received the majority of referrals, with Stoke Hospital only receiving 2 referrals. Therefore, our comparisons will be mainly between QEHB and UHCW hospitals. QEHB received the highest number of outpatient referrals 46, compared to 38 outpatient referrals to UHCW. Conversely, UHCW handled a larger volume of inpatient referrals of 40, compared to only 31 inpatient referrals to QEHB. Notably, all PCI procedures were exclusively performed at Birmingham Heartlands Hospital (BHH).Summary of the Median Times for Surgical/Interventional ProceduresI. Coronary RevascularisationFor coronary revascularisation, a total of 33 patients (34.7%) underwent PCI, while the majority 62 patients (65.3%) discussed had CABG, wither as an isolated procedure with aortic valve replacement (AVR).Ia. PCIOf the 33 patients who underwent PCI, 23 were performed as inpatients, with a median time to the procedure of 4 days, slightly exceeding the national target of 3 days for low-risk cases and 1 day for high-risk cases. The remaining 10 patients were performed on an outpatient basis, with a median wait time of 54 days. Currently, there are no specific national targets for outpatient PCI.Ib. Isolated CABGFor isolated 57 CABG surgeries, 24 inpatient surgeries were performed at UHCW with a median time of 11 days, compared to only 9 surgeries at QEHB with a longer median time of 24 days. Both hospitals exceeded the national target for urgent inpatient CABG recommended at 7 days. All patients admitted with NSTEMI were referred for inpatient CABG as recommended. For isolated outpatient CABG, 15 surgeries were performed at UHCW compared to only 9 at QEHB. UHCW’s time to clinic review was shorter at 31 days, compared to QEHB where it took 53 days. Despite this, UHCW’s median time to surgery was significantly longer at 156 days, compared to QEHB managed it in 55 days. Both hospitals though exceeded the national target for outpatient CABG, set at 84 days (figure 2, A).Ic. CABG with AVRA total 5 patients underwent CABG with AVR, 3 of these were inpatient cases, with almost similar waiting times between UHCW and QEHB (17 days and 15.5 days, respectively. Only 2 outpatient cases were performed at QEHB, with a median time to clinic review of 66 days, followed by a significantly longer waiting time for the surgery stretching to 254.5 days (figure 2, B). II. Aortic Valve Disease (figure 2B)TAVI was the most commonly chosen procedure for 32 (72.8%) patients, while 11 (26.2%) patients underwent AVR, either as an isolated surgery or combined with mitral valve (MV) surgery. This gives a TAVI to AVR ratio of 2:1, which aligns with the national audit data.IIa. TAVIOf the total 32 TAVI patients, 13 patients had their procedures as inpatients. QEHB performed11 TAVI procedures, while UHCW and Stoke hospitals each handled only one case. Comparing the median times for inpatient TAVI, QEHB had a median time of 19 days, and UHCW’s single TAVI case also took 19 days, while Stock Hospital completed the procedure in a shorter time, at 12 daysA total of 19 patients had their procedures as outpatients. Two of these had urgent TAVI procedures within 12 days. For routine Outpatient TAVI at QEHB, 16 had their procedures scheduled with a median time to clinic review of 37 days from the referral. After the clinic review, it took around 23 days for the procedure, making a total of 60 days from referral to procedure, which is nearly half the BCIS target of 125 days. Notably, many TAVI patients undergoing outpatient procedures had their tests and protocols done on the same day as their clinic visit, which significantly reduced the overall waiting time. In contrast, Stoke Hospital completed one outpatient TAVI case after 160 days.IIb. Isolated AVRA total of 9 patients underwent isolated AVR surgery. Of these, UHCW has performed 3 inpatient surgeries with a median time to surgery of 31 days, while QEHB handled inpatient 2 surgeries achieving a slightly shorter median time of 28.5 days. However, both hospitals exceeded the NICE target of 2 weeks from diagnosis to surgery for inpatient AVR.For outpatient isolated AVR surgeries, UHCW managed 4 cases with a median time to clinic review of 40 days, and a significantly longer median time to surgery of 252 days, exceeding the NICE target of 18 weeks (126 days) from diagnosis to outpatient AVR.IIc. AVR with MV SurgeryThere are only 3 patients who underwent combined AVR and MV surgery. UHCW managed one inpatient surgery, which involved a re-do AVR and MVR IE, with a time to surgery of 48 days. UHCW has performed one outpatient surgery with a median time to clinic review of 223 days and to surgery of 678 days, highlighting significant delay. While still delayed, QEHB had performed one outpatient surgery with shorter waiting times of 67 days to clinic review and to surgery of 390 days compared to UHCW.II. Mitral Valve DiseaseMitral valve repair was the most common treatment, accounting for 5 cases (55.6%), followed by mitral valve replacement (MVR) in 3 cases (33.3%), and percutaneous balloon mitral valvuloplasty (PBMV) in 1 case (11.1%). At UHCW, 3 inpatient cases were treated (1 MVR, 2 MV repairs) with a median time to surgery of 10 days, while QEHB handled 1 inpatient PBMV case with a median time of 17 days. For outpatient cases, UHCW managed 3 (1 MVR, 2 MV repairs) with a median clinic review time of 53 days and a median surgery time of 188 days. QEHB treated 2 outpatients (1 MVR, 1 MV repair) with a median clinic review time of 60 days and a shorter median surgery time of 123.5 days.Unplanned ProceduresThere are 28 unplanned outcomes different from the originally agreed outcome during the MDT meeting. The primary reason was a change in the treatment plan after further clinical review, accounting for 17 cases (60.7%). This suggests that alternative management strategies were deemed more appropriate for these patients. Mortality of 1.8% of patients was the second most common reason, with only 4 cases (14.3%) who died while waiting for their urgent procedures such as severe distal LM disease and severe symptomatic aortic stenosis. Additionally, 3 cases (10.7%) were associated with new clinical incidents, such as complications of a stroke in an infective endocarditis patient, which rendered the original procedure unsuitable. Two patients (7.1%) lost follow-up because they refused to engage in our services anymore and self-discharged.Awaiting ProceduresA total of 13 patients were awaiting their procedures. The majority (6 patients) were on the waiting list for coronary artery bypass grafting (CABG), followed by 3 patients awaiting MV repair, 3 for TAVI, 1 for MV replacement, and 1 for PCI. The reasons for delays were as follows: 7 patients remained on the waiting list, 2 had their treatment plans altered after clinic review, 2 were awaiting the completion of further investigations, and only 1 had a missed referral because of not completing a referral letter to the responsible team on discharge from hospital.Conclusions Key factors contributing the delayed waiting times for procedures and referral to specialist centres are multifactorial, and often resulting in prolonged hospital stays, increased patient morbidity and mortality, and inefficient resource utilisation. Through our quality improvement analysis, we have identified several key factors contributing to these delays:Lack of documentation of MDT decisions. Patients discussed in MDT meetings may not have their management plans documented and tracked effectively, leading to delays in implementing necessary investigations or referrals.Absence of a prioritisation framework for urgent referrals.Limited bed availability at specialist tertiary centers often results in delays in inpatient hospital transfers, and the lack of a structured repatriation protocol further exacerbates the waiting time for necessary interventions.Lack of standardised pre-operative investigation protocols:Essential pre-operative assessments (e.g., carotid ultrasound, pulmonary function tests) may not be performed in advance, leading to further delays when patients arrive to the specialist tertiary center.Unclear protocols on antiplatelet management. The absence of standardised protocols regarding the duration of stopping antiplatelet therapy pre-operatively can lead to inconsistent decision-making and procedural delays.Recommendations MDT forms should be completed for all patients discussed in MDT meetings to ensure progress tracking and timely intervention.A structured prioritisation system should be established to identify and expedite urgent cases requiring specialist tertiary referrals.Reviewing internal referral pathways and processes to mitigate the causes of the delays, and this includes:Ensure prompt completion of inpatient hospital transfer (IHT) forms immediately after MDT meetings to facilitate timely transfers.Regional protocols should be established for conducting essential pre-operative investigations (e.g., carotid ultrasound, pulmonary function tests) before referring patients for surgical procedures.Develop standardized protocols for the appropriate duration of stopping antiplatelets pre-operatively to prevent procedural delays.Implement repatriation or patient transfer protocols between the referring hospitals and specialist tertiary centers to reduce delays caused by bed availability constraints.A second cycle is planned to assess the impact of implementing these changes on the standards of care for the patients in West Midlands.Limitations MDT forms frequently document only the final decision, with limited documentation of the MDT discussions.This audit reflects our practice only on the formally documented MDT forms.The audit included a small number of certain surgical procedures, e.g. mitral surgeries.Abstract 2-011 Figure 1(A, B) Summary of diseases and outcomes discussed in MDT meetingsAbstract 2-011 Figure 2(A, B) Median waiting times for surgical CABG with or without AVR in west midlandsAbstract 2-011 Table 1Patients characteristics Characteristics PCI CABG TAVI AVR Median Age (IQR) 70 (60 – 77)65.5 (59 – 75)76.5 (73 – 82.5)62 (53 – 65) Rock Wood Frailty Score Managing well(Score 3)Fit(Score 2)Managing well(Score 3)Very fit(score 1) Smoker 22.9%22%15.6%27.7% HTN 60%60.2%41.1%72.2% DM 45.71%38.2%29.4%22.2% CKD 34.29%14.7%32.3%0% IHD 65.71%55.8%50%11.1% Old CVA 2.86%5.8%5.8%5.5%Abstract 2-011 Table 2Summary of median waiting times of inpatient and outpatient procedures in west midlands compared to the national standards* Procedures Location Hospital Median Time to Referral Letter Median Time to Clinic Review Median Time to Procedure National Standards (Days) CABG +/- AVR Isolated CABG InpatientUHCW--117QEHB--24OutpatientUHCW43118784QEHB553108 CABG + AVR InpatientUHCW--177QEHB--15.5OutpatientQEHB566245.584 Treatment of Aortic Valve Diseases TAVI InpatientUHCW--19-QEHB--19Stoke--12OutpatientQEHB53760125Stoke--160 Isolated AVR InpatientUHCW--3114QEHB--28.5OutpatientUHCW340252125 AVR + MV Surgery InpatientUHCW--48-OutpatientUHCW32223678-QEHB-67390 Treatment of Mitral Valve Diseases MV Surgery InpatientUHCW--10-OutpatientUHCW1053188-QEHB560123.5 Percutaneous Balloon Mitral Valvuloplasty (PBMV ) InpatientQEHB--17-* Median Time if Expressed in Days.Acknowledgement We wish to record our thanks to the cardiology team, including consultants and resident doctors, at Birmingham Heartlands Hospital in their help for completing this audit.Conflict of Interest The authors have no competing interests and did not receive funding for this study.",
  "authors": [
    {
      "affiliations": [
        "Department of Cardiology, University Hospital Coventry and Warwickshire, Clifford Bridge Rd, Coventry CV2 2DX"
      ],
      "name": "Ahmed Elsherif"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Ahmet Suleyman"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Jannatual Mita"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Farah Al-Ali"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Tahmidul Islam"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Balasooriya Maleesha"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Bahaeddin Ben Hamida"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Nwabor Godswill"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Shaza Meqdad"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Fizza Mobasher"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Yahya Altalib"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Gurbir Bhatia"
    },
    {
      "affiliations": [
        "Department of Cardiology, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK"
      ],
      "name": "Jerome Ment"
    }
  ],
  "title": "2-011 Evaluation of outcomes for patients discussed at joint cardiology- cardiothoracic MDT meetings in west midlands",
  "uid": "ced91d85-af70-5661-9dff-de132ca152d3"
}