Objective: To offer patients a left ventricular assist device (LVAD), programs complete a formal evaluation of the patient’s eligibility. While basic components of the evaluation are mandated by Centers for Medicare and Medicaid Services, the full process has never been systematically compared across sites.
Methods: We conducted semi-structured interviews with multiple team members at 6 diverse LVAD programs. The interviews were audio recorded, transcribed, inductively coded, and analyzed with a team-based approach.
Results: We interviewed 31 participants: 9 cardiologists, 3 surgeons, 3 nurse practitioners, 9 nurse coordinators, and 7 social workers (a total of 4-7 participants at each program). The formal LVAD evaluation process consisted of 3 main components: the medical/psychosocial evaluation to determine patient eligibility, educating the patient about the LVAD, and the multidisciplinary committee meeting to formally decide patients’ eligibility. While the basic tenants of the processes were similar across programs, 4 major differences emerged: (1) Standardization: some programs had a formal prescriptive pattern for how the process unfolded, such as order sets and timing of specific assessments, while others appeared to operate more sporadically; (2) Timing: some programs conducted patient education before the team’s decision on LVAD eligibility to assess patients’ interest in an LVAD as part of the final decision, whereas others did it after the committee meeting to prevent “false hopes” and wasted personnel time; (3) Location: programs conducted the LVAD evaluation process primarily inpatient following decompensation, or in both inpatient and outpatient settings which resulted in evaluating some patients earlier in the disease progression; (4) Personnel: some programs included certain team members’ assessments—particularly palliative care and social work—as integral in the eligibility decision, whereas other programs saw such input as peripheral. These differences affected how the medical teams and patients made decisions. The environment, attitude, speed, and personalities of the program shaped the way decisions were presented and made. Despite the variability, all programs reported similar challenges due to the complex patient population and the intricate relationships within the multidisciplinary teams. Overall, all programs expressed a universal goal of striving to implant the “appropriate patient”.
Conclusion: Despite similar medical challenges and team structure, large variability was observed across LVAD programs, affecting how medical teams and patients made decisions. Standardization of the process at a higher level and communication between programs may help identify best practices and keep programs consistent. In turn, this could lead to better internal communication and education processes and ultimately improve patient care.