Exploring optimal heart team protocol to improve decision-making stability for complex coronary artery disease: a sequential explanatory mixed method study
Authors: Ma H P , Lin S , Li X , Dou K F , Yang W X , Feng W , Liu S , Wu Y , Zheng Z 
Published: October 2021

Abstract

Background
Although heart team was recommended by guideline for decision-making in patients with complex coronary artery disease (CAD), the decision-making stability was lack of evaluation and optimal protocol remained unknown.

Purpose
We aimed to assess inter-team agreement for revascularization decision-making and related influencing factors, so as to provide recommendations for optimal protocol.

Methods
A sequential, explanatory mixed method study was conducted, including (1) a cross-sectional study retrospectively enrolling patients with complex CAD and four heart teams to assess the inter-team decision-making agreement and (2) a qualitative study that semi-structurally interviewed all heart team members to analyze the potential factors associated with decision-making discrepancy. Primary outcome was kappa value of inter-team decision-making agreement. Inductive thematic analysis was used to generate themes and subthemes attributing to decision-making discrepancy. Integrating qualitative and quantitative data, we explained how each subtheme affected decision-making agreement and provided corresponding recommendations based on these explanations. Finally, we provided a detailed heart team protocol by integrating our recommendations, published experience and guideline. Patient sample size was precalculated and interviewee sample size was identified by theoretical saturation.

Results
A total of 101 patients with complex CAD were randomly enrolled from a consecutive angiography registry. Sixteen specialists were invited and randomly established four heart teams to make decisions for enrolled patients. Inter-team decision-making agreement was moderate (kappa 0.582) (Table 1). Decision-making may be influenced at three themes (specialist quality; team composition; meeting process) and ten subthemes (decision thought; understanding of disease and evidence; understanding of other discipline; personality; learning curve; personnel quality; number of team members; discipline selection; ratio of different disciplines and meeting form). Recommendations at five levels were provided, including (1) specialist selection, (2) specialist training, (3) team composition, (4) team training and (5) meeting process. A detailed implementation protocol to establish and deploy a qualified heart team was generated.

Conclusions
Agreement between heart teams for revascularization decision-making in patients with complex CAD was moderate. Five recommendations to improve heart team modality were provided based on factors associated with decision-making discrepancy. A detailed heart team implementation protocol came into being. Randomized controlled trial was warranted to further confirm the protocol.

Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the national key research and development program;Beijing municipal commission of science and technology project Table 1. Inter-team agreement of decision making