Shared care for patients with a left ventricular assist device: a scoping review

Abstract

Left ventricular assist devices (LVADs) are increasingly implanted in patients with advanced heart failure. Currently, LVAD care is predominantly concentrated at specialized tertiary care hospitals. However, the increasing workload and logistical burden for implanting centres pose significant challenges to accessing care for individual patients in remote areas. An emerging approach to LVAD patient management is the use of a shared care model (SCM), which facilitates collaboration between implanting centres and local non-implanting hospitals. This scoping review explores and synthesizes the current scientific evidence on the use of SCMs in LVAD care management. Eligible studies were identified in EMBASE, PubMed MEDLINE, Web of Science, Cochrane and Google Scholar. Findings were synthesized in accordance with PRISMA-ScR guidelines. Of the 950 records screened, five articles met the inclusion criteria. Four review articles focused on the proposed benefits and challenges of using SCMs. Main benefits included improved patient satisfaction and continuity of care. Important challenges were initial education of non-implanting centre staff and maintaining competency. One prospective study showed that absence of LVAD-specific care was associated with impaired survival and higher rates of pump thrombosis and LVAD-related infections. The use of SCMs is a promising approach in the long-term management of LVAD patients. However, sufficient evidence about the impact of SCMs on patients and the healthcare system is not currently available. Standardized protocols based on prospective studies are needed to develop safe and effective shared care for LVAD patients.

Heart failure (HF) is a lethal condition affecting 64 million people globally [1].

Graphical abstract

INTRODUCTION

Heart failure (HF) is a lethal condition affecting 64 million people globally [1]. Even with optimal medical treatment, end-stage HF patients have a poor prognosis with a one-year survival of 25% and a two-year survival of 8% [2]. Moreover, the high disease burden and loss of functional capacity often result in a poor quality of life [3]. Heart transplantation (HTx) is the preferred therapy for patients with advanced HF who no longer benefit from medical therapy. However, access to HTx is limited by donor shortage, increasing age and comorbidities [4]. To address these challenges, left ventricular assist devices (LVADs) have been introduced as an alternative treatment option. LVADs provide mechanical circulatory support and are applied as a bridge to transplantation (BTT), and increasingly as lifelong, destination therapy (DT). Today, DT has become the primary implant strategy for LVADs, providing life-saving support to a growing group of patients [5].

Despite growing confidence in the reliability and efficacy of LVADs for long-term support of patients with advanced HF, managing the device and the patients remains complex. Serious complications including driveline infections, pump thrombosis, stroke and gastrointestinal bleeding frequently ensue [6]. These complications are associated with frequent readmissions [7], prolonged hospitalization and high healthcare costs [8]. Therefore, rapid access to advanced cardiac care is a necessity. However, LVAD care is traditionally concentrated in a few specialized centres—the implanting centres. As the numbers of patients continues to grow, this may pose several challenges. Uneven geographical distribution of healthcare resources may result in a significant travel burden, particularly for patients living in remote areas. Furthermore, implanting centres may face capacity problems with growing waiting lists and further troubled accessibility. The implementation of a shared care model (SCM) partnership could help to address these challenges. Shared care is described as the joint participation of primary care physicians and specialists in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral [9, 10]. Shared care allows geographically separated care teams to facilitate seamless delivery of high quality, patient-centred care through coordinated collaboration. Compared to ‘usual care’, the use of an SCM has demonstrated success in the long-term management of patients with non-communicable chronic diseases including diabetes [11] and depression [10]. The European Society for Cardiology (ESC) has outlined principles for establishing shared care for HTx- or LVAD patients. Immediate post-operative care is managed in the tertiary centre and other phases of the care pathway, including referral and long-term follow-up care, are preferably delivered in a community-based outpatient clinic [12]. However, clear evidence underlying these principles is not yet available, and guidance for the partners involved is lacking. When focusing on LVAD management, evidence underlying these principles are not available. Furthermore, it remains unclear what impact an SCM has on the healthcare system and patient outcomes. Therefore, the purpose of this scoping review is to collate and discuss the current scientific evidence on the use of an SCM in LVAD management.

MATERIALS AND METHODS

This scoping review was conducted following a predefined protocol and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement [13]. A search strategy was developed together with a biomedical information specialist (W.B.) using the method developed by Bramer et al. [14]. The search strategy included two elements that describe ventricular assist devices or assisted circulation and shared care or inter-organizational cooperation using both controlled vocabulary and free text terms. See Supplementary Material, Appendix 1 for the full search strategy.

In addition to comprehensive searches in embase.com, Medline (Ovid), Web of Science Core Collection and Cochrane CENTRAL, an internet search was performed using Google Scholar. All scientific literature written in English and published before 3 June 2023 was considered, including quantitative, qualitative and mixed-method studies, review articles and scientific handbooks. Conference abstract and journal supplements were excluded. Identified records were imported into EndNote version 20 (Clarivate Analytics, PA, USA) and duplicates were eliminated.

Two researchers (V.D. and C.Z.) independently selected records by screening titles, abstracts, keyword fields and other relevant subject headings. Records had to cover the topic of shared care in the context of LVAD therapy to be considered for full-text screening. If screening resulted in doubt, the records were treated as eligible. Selections were compared, and disagreements were resolved by consensus. The reviewers then independently evaluated full-text records for information relevant to the study objective and then discussed their selections for final inclusion.

Data extraction was performed by one reviewer (V.D.) through a data charting process. Article characteristics (i.e. authors, year of publication, title, journal, country of origin), and study characteristics (i.e. design, purpose, main conclusions) were extracted and exported to a data-charting form. A narrative synthesis approach was used to extract, identify and group key concepts and themes within the sources of evidence. In the case of quantitative results, details of the population, study sample, intervention and comparator were extracted. The results were discussed by both reviewers and the data charts were finalized. The results were then discussed with two clinical experts (K.C. and L.C.O).

RESULTS

Our search strategy retrieved 1559 records. Of the 950 unique titles, 15 were eligible for full-text screening. Five peer-reviewed articles met the inclusion criteria. Details of the selection are presented in Fig. 1.

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) study flowchart. Adapted from Page MJ, et al. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. This work is licensed under CC BY 4.0: https://creativecommons.org/licenses/by/4.0/

Among the included articles were four reviews [15–18] and one prospective study [19]. Characteristics of each study are provided in Table 1. All articles originated from the United States and were published between 2015 and 2023. The prospective study investigated the impact of an SCM on patient outcomes including survival and the occurrence of adverse events by comparing three levels of shared care to usual LVAD care [19]. The review articles covered a variety of topics related to the use of an SCM [15–18]. Of these, three covered best practice examples of shared care programmes used in the clinical setting [15, 17, 18]. Five main themes were identified: (1) definition and goals, (2) criteria for shared care partnerships, (3) perceived benefits, (4) perceived concerns and challenges and (5) patient outcomes.

Table 1:

Literature discussing the use of a Shared Care Model in LVAD therapy

Authors, year	Title	Journal	Country	Type of study	Aim(s) of the study	Main conclusions
Estep et al., 2015 [15]	Continuous flow left ventricular assist devices: shared care goals of monitoring and treating patients	Methodist DeBakey Cardiovascular Journal	USA	Review article	To provide a rationale for the outpatient follow-up exam and surveillance testing to monitor CF-LVAD patients. To provide a protocol/algorithms for the monitoring LVAD patients. To provide a protocol for outpatient follow-up and shared care-specific responsibilities of referring healthcare providers to best manage many of patients.	The recognition and use of newer generation CF-LVADs have grown in recent years. The long-term support of this patient population requires the use of standardized outpatient follow-up including blood pressure monitoring, driveline-inspection, blood work surveillance testing, echocardiography, device review, and clinic visit documentation. Objectives and shared care responsibilities between the care teams of the implanting centre and care providers in the community should be well-defined.
Kiernan et al., 2015 [16]	Sharing the care of mechanical circulatory support; collaborative efforts of patients/caregivers, shared-care sites, and left ventricular assist device implanting centres	Circulation Heart Failure	USA	Review article	To provide a description of the collaborative efforts of LVAD implanting centres, shared- care sites, and patients/caregivers. To provide an overview of the perceived benefits and concerns of the SCM.	The growing need for ambulatory care for LVAD patients poses a strain on implanting centres and has resulted in the rise of shared care MCS providers. Successful shared care can lead to improved care access, lower travel burden, a better transition from hospital to home and better quality of life. Basic requirements for effective shared care include transparent communication between shared care partners and commitment of the implanting centre, shared care site and patient/caregiver.
Shah et al., 2021 [17]	Shared care to destination therapy left ventricular assist device site: a novel strategy to start a successful mechanical circulatory support programme	Current Cardiology Reports	USA	Review article	To provide an overview of the details of establishing successful LVAD-programme for DT-LVAD therapy.	Continuous advances in technological development are fueling the global demand for DT-LVAD sites. A model of shared care to DT-LVAD centre should be considered to manage patient volumes, maintaining patient outcomes, and keeping advanced HF programmes financially sustainable.
Sobieraj et al., 2022 [18]	Shared care left ventricular assist device site to implant centre: the next step in advanced heart failure treatment and an essential part of healthcare worldwide	International Journal of Cardiology and Cardiovascular Diseases	USA	Review article	To further elaborate on the importance, essential tools, and benefits of LVAD shared care and implant centres on improving patient outcomes, satisfaction and quality of life.	To meet the growing need for specialized care including (i.e. comprehensive selection, treatment and follow-up) in rural area patients, a shared care to DT-LVAD model is feasible. A shared care centres and can offer patients various benefits including improved access to specialized and life-prolonging treatment, increase of survival rates, reduction of time and travel investment and associated financial expenses resulting from routine care, optimized use of healthcare resources, delivery of patient-centred care. The availability of a multidisciplinary team is key for successful shared care delivery.
Yin et al., 2020 [19]	Impact of shared care in remote areas for patients with left ventricular assist devices	Journal of the American College of Cardiology: Heart Failure	USA	Prospective observational: Groups receiving LVAD-specific follow-up care at levels different in service availability and type of care were compared to the implantation centre care: • Level 1: minimal outpatient care and no inpatient care. • Level 2: care provided at level 1 and basic level of follow-up care, no inpatient care. • Level 3: care provided at level 1 and 2, advanced level of follow-up care, inpatient cardiac care unit with LVAD staff. • Implanting centre: all care provided at level 1, 2 and 3. Primary outcomes: mortality at 3 years post implantation. Secondary outcomes: adverse events at 3 years post implantation.	To evaluate the impact of an SCM on outcomes in patients supported by an LVAD and living in remote areas.	A total of 225 patients (75.9%) received shared care (Level 1: n = 56; level 2: n = 82; level 3: n = 116), and 81 patients (24.1%) received care at the implanting centre. Patients treated at levels 2, 3 and implanting centre were comparable in terms of death, and adverse events including bleeding, neurologic events, pump thrombosis and infections. Patients at level 1 had higher rates of death, pump thrombosis and infections than patients treated at the implanting centre. An SCM is effective for the delivery of LVAD care to patients living in remote areas. Absence of appropriate care for LVAD patients may lead to unfavourable clinical outcomes. Availability of LVAD-specific care is considered important for patient candidacy and should be considered during patient selection. Efforts should be made to ensure the availability of training and resources at shared-care sites.

Definition and goals

Shared care for LVAD patient management has been described as the collaboration between an LVAD implanting centre and local (non-implanting) shared care sites in the continued care for patients [16]. After initial device implantation at the implanting centre, patients can receive a substantial part of the outpatient care from a referring advanced HF specialist at a regional hospital or clinic [15, 17, 18]. According to Kiernan et al. [16], the common goal of shared care partners is to improve patient satisfaction and quality of life while preserving LVAD-related clinical outcomes. Shah et al. [17] stated that the purpose is to transfer as much outpatient care, such as echocardiograms, anticoagulation regime, dressing change and office visits, to the non-implanting site, and allow local management of non-device-related admissions (e.g. gastrointestinal bleeding, stroke and HF), and non-device related inpatient issues. All sources described the introduction of shared care as a response to the growing HF population and the simultaneously increasing demand for continuous, long-term LVAD-care [15–18]. In terms of model types, we identified a ‘shared care LVAD centre model’ and a ‘shared care to destination therapy model’ [17, 18]. Furthermore, this scoping review revealed concepts that can be relevant to the field, including ‘satellite MSC programme’ and ‘satellite partnerships’. The term ‘satellite’ is used by Kiernan et al. [16] to refer to the shared care centre, which operates independently in the local area of the patient, while receiving remote support from the implanting centre. In such collaborations, the scope of shared care partnerships extends beyond post-operative LVAD care. In addition to long-term follow-up care, an SCM also allows for optimal timing of referral of patients with advanced HF, co-management of acutely ill patients with cardiogenic shock, post-transplant care (HTx), and establishing regional extracorporeal membrane oxygenation (ECMO) programmes.

Criteria for shared care partnerships

One study [16] identified three main categories of potential criteria for shared care partnerships: general (staff, equipment, communication), education (initial and ongoing training) and maintenance (protocol use, written policies for device-related complications, quality assessment of patients) (Table 2).

Table 2:

Potential criteria for shared-care partnerships, adapted from Kiernan et al. [16]

General	Staff	Designated multidisciplinary team [16] • Dedicated heart failure specialist in the role of local leader and supervisor [16, 18] • Advanced practice nurse coordinator in the role of frontline contact for patients [16] • Additional team members: LVAD surgical director, LVAD medical director, medical critical care director, social workers [18]
	Resources	LVAD-specific equipment [16] • Device specific: system monitor, batteries, controller and power cable [16] • Driveline management: dressing supplies [16]
Education	Training	LVAD-specific training about the principles of device and patient monitoring • Training personnel on role-based the principles of managing LVAD patients similar knowledge skillset and training standard, independent of the location of care [16, 18] • On-site and online training, provided by the LVAD vendor [16]
	Competency maintenance	Ensure competency maintenance [16] • Annual educational meetings [16] • Visiting conferences about LVAD management [16] • Visits to the implanting centre, seminars [16] • Temporary co-staffing to learn from external care practice [16]
Maintenance	Standardization	Follow-up protocol [15, 16] • Well-defined objectives and care responsibilities between shared care partners [15] • Follow-up visits include blood-pressure monitoring, driveline-exit site inspection, outpatient LVAD-alarm trouble shooting, surveillance bloodwork and echocardiography [15] • Regularly scheduled conference calls to ensure both teams are updated about the patient’s status [16]
	Coordination	Coordinated effort to prevent fragmentation of care [16] • Commitment of all involved parties: the patient, implanting centre and shared care site [16]
	Communication	Regular and bidirectional communication structure between partnering centres [16] • Transparent communication to identify potential barriers to care [16]

In general, shared care requires a commitment of a designated, multidisciplinary team [16–19]. It is suggested that shared care teams are supervised by a dedicated LVAD advanced HF cardiologist and coordinated and supported by an advanced practice nurse, who serves as frontline contact for patients [16, 18]. Training in the basic principles of LVAD care is essential for acquiring knowledge and role-based skillsets comparative to the implanting centre team [16, 18, 19]. One study identified the level of LVAD-specific care available and regular training as critical factors in the screening of LVAD patients [19]. LVAD vendors could support shared care sites by organizing initial training on the use of the purchased equipment needed for LVAD care delivery. Furthermore, once shared care partnerships are established, maintaining competencies is needed to guarantee the delivery of safe and high-quality care [16]. Partnering centres could organize conferences, educational meetings and preceptorships on both locations to learn from each other’s local processes. Furthermore, continuous commitment from both shared care partners is needed to maintain competencies for delivering safe, high-quality care [16, 19].

Essential for effective shared care partnerships are standardization, coordination and communication. Follow-up protocols can provide both teams with a clear description of shared care goals, and responsibilities in the care for their patients. Estep et al. [15] published a physician partnership follow-up protocol used in The Houston Methodist Hospital (TX, USA), including an overview with general patient- and device-related details, a clinical evaluation checklist and a schedule indicating alternation of follow-up visits of the implantation centre and the shared care site, and their care responsibilities. It is suggested that standard routine visits should include measurement of blood pressure, driveline exit site inspection, laboratory testing, LVAD alarm troubleshooting and echocardiography surveillance [15, 16]. Furthermore, shared care require a well-designed communication structure between the implanting centre and the shared care site, structured coordination and commitment of all involved parties [16].

Potential benefits

Numerous potential benefits of using an SCM were identified (Table 3). At the patient level, perceived benefits were linked to access to care, finances, traveling and patient outcomes. Shared care can improve access to advanced HF care, especially to those living in remote areas. This allows patients to receive specialized care from local care team members, with whom they already have an established relationship [15–18]. Easy access to appropriate specialized care might also reduce anxiety and offer reassurance to patients and their caregivers [15–17], and improve compliance with routine follow-up visits [15]. Importantly, shared care can make LVAD treatment available to those patients to whom traveling can form a barrier [17]. Furthermore, from a financial perspective, patients and their caregivers might save on travel-related expenses [15, 16, 18], and reduce missed working hours and associated wages due to lower time investment [16]. Shorter travel distances allow patients and their caregivers to receive continuous care with the convenience of staying in their community [16, 17]. Patients could regain some travel-related and social independence from their caregivers [16, 18]. Ultimately, having local experts available can save patients and caregivers travel-related time investment and commitment [18]. After initial implementation, shared care sites can build patient communities, which could offer patients a platform to share experiences, and offer support to those who face treatment decisions [16]. Overall, it is considered that shared care can directly or indirectly contribute to improved patient outcomes including quality of life [16–18], patient satisfaction [17, 18] and reduction of stress [16].

Table 3:

Perceived benefits and potential challenges of LVAD shared care partnerships

	Potential benefits	Perceived concerns
Patient (and caregiver)	Access to care: • Allows for continuity of care [15, 16, 18] • Permits to maintain existing relationships with the referring healthcare provider [15–18] • Reduces anxiety, resulting from direct access to local specialized care [16] • Makes outpatient visits easier for patients and caregivers [15] • Improved access may increase compliance with recommended follow-up [15] • Can reach patients who may not be inclined to commit to the travel burden associated with long-term or lifelong treatment [17] Financially • Reduces travel-related costs linked to follow-up appointments [15, 16, 18] • Reduces missed work hours and associated wage-loss [16] Travel-related • Allows for continuous care, close(r) to home [16, 17] • Decreases the social care burden placed on patients and caregivers [16, 18] • Saves travel time and -commitment that was required before the adoption of an SCM [18] Treatment-related: • Improvement of quality of life [16–18] • Increased satisfaction [17, 18] • Improved patient outcomes [18] • Reduction of stress [16] • Improved confidence of patients and caregivers in the transition to home post-implantation [16] • Receiving support from patient communities, which can help patients with difficult treatment decisions [16]	Treatment-related: • Initial separation anxiety from implanting LVAD team at time of discharge [16] • Requires building of trust and confidence in care coordination among multiple providers [16]
Implanting centre	Access to care: • Allows for delivery of quality care beyond the walls of the implanting centre [16] • Early joint evaluation of advanced HF patients can optimize timing of referral to an advanced heart failure centre [16] Financial impact: • Hiring additional staff for the management of the growing LVAD patient population can be avoided [17] Staff and resources: • Improves recourse allocation by transfer of follow-up care to referring partners [16, 17] • Offload the work linked to laborious long-term management of patient [18] • Increases capacity and flexibility for managing new evaluations and recent implantations [16, 18] Institutional outcomes: • Can reduce of hospital length of stay post-implantation, given local resources for early monitoring and continued patient education [16] • Lower readmission rates and improved performance resulting from outsourcing local evaluation [16] • Increased referral from shared-care sites [16] • Shared care can help non-implanting centres to become implanting centres [17] Quality of care: • Improving the quality of short-term and long-term care for LVAD patients [16] • Tailored delivery of care offers convenience to patients and caregiver [16] • Training provides knowledge to local partners about patient selection, timing of referral, and pretransfer management preferences of the acutely ill patient [16] • Offers insight in capabilities and care processes of both partnering centres [16]	Financial impact: • Decreased revenue from shifting ambulatory to the shared-care site [16] • Increased costs from shifting complex hospitalizations from the shared care centre to the implantation centre [16] Institutional outcomes: • Transfer of care to a less-experienced centre may negatively impact institutional outcomes [16] Professional experience: • Transfer of patients to less experienced centres may lead to worries about safety and negative patient outcomes [16]
Shared care site	Access to care: • Rehabilitation, evaluation and patient training can continue locally [16] • Improved access to care may lead to more willingness to accept MSC therapy [17] Financial impact: • Increased referral from regional cardiologists as a provider of advanced HF therapies [16] • Additional revenue from increased ambulatory visits and potential hospitalizations [16, 17] • Additional revenue from non-LVAD related hospitalizations [16] Professional experience: • Gaining a position as the main provider for emergent community care services that may be needed in patients supported by CF-LVAD [15] • Remaining intimately involved with their patients [16] • Becoming resident experts in the management of patients with LVADs [16] • Empowers staff in delivery of reliable long-term care in accordance to established care practices as defined by the implanting centre [15] • Experiencing higher professional satisfaction as a result of training and care delivery [16] Quality of care: • Offering continuous patient care [16] • Delivering high quality patient care [17] • Gaining a knowledge and skills to address urgent/emergent inpatient issues [15] • Offering local support to LVAD patients with non-LVAD related complaints [16] • Low patient-to-physician-ratios allow for personalized, patient-centred delivery of care [18]. Treatment outcomes: • Improved patient satisfaction [17]	Financial impact: • Hiring and training additional staff (e.g. nurse coordinator) [16] • Providing continuous medical education and in-service training [16] • Purchase of LVAD-specific equipment and peripheral supplies [16] Professional experience: • Perceived liability about practicing outside of scope of expertise for inpatient personnel beyond the core LVAD team [16] • Visiting nursing staff may lack knowledge and skills regarding LVAD-care delivery [16] Quality of care: • Lack of routine care may result in knowledge attrition, which could impact patient safety [16].

At the healthcare level, the improved access to LVAD-specific care is a major benefit for partnering centres. Shared care allows for extending the delivery of continuous, high quality and patient-tailored care beyond the confines of the implanting centre. It also promotes the multidisciplinary evaluation of advanced HF patients, possibly enhancing timely referral from the region of the shared care centre [16, 17]. Furthermore, rehabilitation, evaluation and training can be delivered locally [16]. By offering local expertise, therapy compliance might even improve among HF patients [17]. Shared care may also result in optimized recourse allocation. Transfer of laborious routine follow-up care can offload the work from the implanting centre, allowing for more evaluations for LVAD therapy and inpatient care [16, 17]. Physician-to-patient ratios can be kept low, allowing for the delivery of more personalized care [16, 18]. In addition, an SCM can potentially improve the quality of care, e.g. by knowledge exchange about procedures, patient selection, timing of referral and pretransfer management of the acutely ill patient, and provides awareness about local ways of working [16]. This can equip the shared care team with the appropriate clinical tools to handle urgent issues [15]. From a professional perspective, an SCM can help local teams to profile as resident experts in the delivery of LVAD-specific care [16], and empower them to deliver long-term follow-up care according to care practices that are defined by the implanting centre. In addition, training and care delivery may also increase professional satisfaction among local experts [15].

Financially, implanting centres may benefit as expenditures for hiring additional staff to manage growing patient population can be eliminated [17]. At the same time, revenue at shared care sites may increase resulting from increased ambulatory visits, potential hospitalizations and other, non-LVAD related care [16, 17].

Linked to institutional performance, adding a level of LVAD-specific support may help patients to return home earlier after discharge, therefore potentially shorten their length of hospital stay at the implanting centre. Continuous alignment between partners may also improve timely identification of advanced HF patients, potentially preventing unnecessary complications and hospitalizations due to referral delay [16]. Lastly, the use of an SCM can be the first step for non-implanting centres towards becoming an LVAD implanting centre or DT-LVAD centre [17, 18].

Perceived concerns and challenges

Several perceived concerns related to the use of an SCM were reported by Kiernan et al. [16] These are included in Table 3. For patients, transitioning to a shared care site for follow-up may trigger feelings of anxiety, especially upon discharge post-implantation. Collaborating centres may have to focus on building trust to enable a smooth transition. At the same time, the implanting centre may feel hesitant to transfer their patients to a centre that is less experienced in LVAD management, as this might result in negative institutional and patient outcomes.

Financially, implantation centres could see revenue decrease by the transferring routine clinical visits to the shared care site. Furthermore, they could be challenged with hospitalizations transfers of complex and critically ill patients from the shared care facility, resulting in high hospitalization costs and lower institutional performance. Financial challenges for the shared care site include the purchase of LVAD-specific equipment, hiring and initial training of additional staff. Furthermore, regular competence maintenance education is required to stay up to date with the latest clinical insights. This requires continued investment of time and resources from both partners.

Patient outcomes

A study by Yin et al. [19] investigated the impact of shared care on survival and adverse events in LVAD patients living in remote areas. The authors reported a prospective design, with mortality and device-related adverse events at 3 years after LVAD implantation. The study population concerned patients with LVAD implantation for BTT or DT between 2007 and 2018. On LVAD evaluation, patients were prospectively allocated to one of four different levels of care, each differing in available follow-up care and used training and recourses: Level 1 offered shared care at an outreach centre without LVAD-specific care; level 2 offered all care provided at level 1, and LVAD-specific outpatient care; level 3 offered all care provided at levels 1 and 2, and LVAD-specific outpatient and inpatient care; the implanting centre offered all care provided by levels 1, 2, and 3 including multidisciplinary advanced HF care (Supplementary Material, Appendix 2). All shared care patients received follow-up at the implanting centre at least annually. Participating shared care facilities were provided with standardized LVAD-specific protocols. Furthermore, regular training on LVAD-specific care was delivered at levels 2 and 3 facilities to primary care physicians, general cardiologists, emergency medical services/fire station staff and sonographers. A total of 336 included patients received an LVAD at the implantation centre, of which 255 patients (75.9%) received follow-up care in shared care facilities, and 81 patients (24.1%) received follow-up from the implanting centre. At baseline, groups were comparable in psycho-social characteristics, educational level, household income, care-giver quality, and distance from patient home to IC. The median follow-up was 810 days (IQR: 321–1096) and the overall mortality rate was 78 (23.2%). When comparing shared care groups to patients followed up at the implanting centre, mortality rates were similar for level 2 and 3 patients, but significantly higher in Level 1 patients. When comparing the groups to patients followed at the implanting centre, rates of death, LVAD-related infections and pump thrombosis were significantly higher among level 1 patients than in level 2 and 3 patients. The time to therapy range (TTR) was similar for patients followed up at the implanting centre (median TTR: 51.3% [IQR: 34.9–64.1]) and patients followed up at level 1 (median TTR: 54.1% [IQR: 39.6–64.4]; P = 0.80) [19]. The translational outlook of this study suggests that an SCM can lower the burden of care delivery at specialty care centre while patients benefit from the care delivered in their communities in an accessible and consistent manner. However, the quality of care at the local level should be a major concern and should be at a safe level of assurance with regular training on LVAD specific care.

In two reviews [17, 18], authors described the implementation of an SCM to DT-LVAD centre in the Deborah Heart and Lung Center, a regional specialty heart centre located in a rural catchment area in South Jersey (US). Both reviews report that gaining institutional expertise in LVAD-specific care can enable the process of establishing a shared care site, transitioning to implanting centre and subsequently to DT-LVAD centre. Their results reflect that a model of shared care to a DT-LVAD centre can significantly benefit patients, the implanting centre, and the non-implanting site. Shah et al. [17] reported observational data from two groups: patients receiving an LVAD as part of an SCM between April 2017 and April 2020 (n = 20), and patients receiving an LVAD after the transition to DT-LVAD centre between February 2019 and December 2020 (n = 32). Sobieraj et al. [18] reported observational data of patients receiving an LVAD after the hospital changed status to LVAD-implantation centre (N = 50), and those after the centre transitioned to DT-LVAD centre (N = 17). In both reviews, study method, statistical analyses and interpretation of data, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles, discharge rates and complications were not provided in detail.

DISCUSSION

The purpose of this scoping review was to collate and discuss the literature on the use of an SCM in LVAD patient management. To our knowledge, this is the first systematic scoping review on this topic. The need for long-term management of a rapidly growing patient population has triggered the discussion of expanding LVAD care beyond implantation centres as capacity will be exceeded. Furthermore, shorter travel distances for patients to their primary care team may improve their quality of life. Our findings indicate that using an SCM is a novel approach in LVAD management that does not appear to be widely considered, but the benefits of this model are recognized.

Despite employing a broad scope of this review, we only were able to retrieve limited empirical work to substantiate the impact of using an SCM, which we consider a call to action. One single study by Yin et al. [19] investigated the impact of using an SCM on patient outcomes for survival and adverse events. According to this study, shared care can be effectively delivered to LVAD patients in remote areas without compromising clinical outcomes. However, this depends on the level of availability of LVAD-specific care and the provision of frequent training to local care teams. These should be considered when evaluating patients for LVAD candidacy. There have only been a few other attempts to study the impact of shared care regarding the safety and feasibility of an SCM. Lotan et al. [20] retrospectively reviewed the data from shared care LVAD patients (n = 30) to assess LVAD-related adverse events without a control group. They concluded that adverse events were within the expected rates and suggested that an SCM is a feasible and effective model for the management of LVAD patients. In contrast, Gajanan et al. [21] conducted a comparative study with historic patient data. They compared shared care patients who were followed up by their primary HF cardiologists (n = 27) with non-shared care patients who were followed exclusively care at the implanting centre (n = 34). The groups showed comparable health outcomes in terms of survival and adverse events, including stroke, driveline infection, gastrointestinal bleeding and rehospitalization. In addition, Meehan et al. [22] studied an international shared care programme involving an implanting centre in the United States and two shared care sites in the Middle East. The programme resulted in 109 patient referrals, of which 7 patients received an LVAD and were successfully co-managed. The authors stated that LVAD care programmes can be established between different countries. Notably, these studies were retrospective in nature, included small study cohorts, and lacked replicable methodology, as they were published as journal supplements or as an abstracts [20–22]. These limitations make it difficult to gain a comprehensive understanding of the evidence-based foundations of effective shared care in the management of LVAD patients.

The findings from this scoping review predominantly concern the possible beneficial aspects of an SCM at the healthcare level, including offloading the implanting centre and delivering high-quality, patient-centred care. By contrast, concerns and challenges were reported less frequently. Statistical data on the use of an SCM should help implanting centres, non-implanting centres and local policymakers in their decision to initiate shared care partnerships. Similarly, at the patient level, findings were also more skewed towards possible benefits, compared to perceived concerns and challenges. Despite some suggested patient benefits, empirical evidence on the experiences of LVAD patients was lacking. For example, patient-reported outcomes (PROs) such as quality of life and satisfaction were not included. Previous research has highlighted the importance of including PROs for the optimization of LVAD-care [23]. Qualitative research among shared care partners and patients may provide insights about how to optimize shared care pathways for LVAD patients.

At present, standardized protocols and detailed society guidelines for establishing shared care LVAD partnerships are still missing. The ESC has recommended the use of existing hub-and-spoke networks for establishing shared care partnerships. Hub-and-spoke networks are composed of a central tertiary hub centre, referral centres, and general care providers and provide infrastructures for continuous advanced HF care [12]. However, according to the ESC, partners should establish their own shared care pathway with a focus on clear communication, coordination and patient involvement. This underlines that there is no blueprint for setting up partnerships. Evidence-based guidelines may help hospitals and clinics in the initial implementation and maintenance of an SCM.

Although benefits of an SCM seem evident in terms of travel reduction for patients living far from the implanting centre, evidence on patient safety and prognosis is still missing. From a clinical perspective, travel distance to an LVAD-centre may be considered as a critical factor for timely diagnosis, evaluation and intervention. Yet, the optimal density is of shared care network for patient outcomes and cost-effectiveness remains unknown. Ravichandran et al. [24] investigated the impact of patient distance to implanting centre on survival and incident event rates. Survival was similar in LVAD patients residing > 90 miles to the implanting centre compared to those living $\le$ 90 miles away. Remarkably, their findings also demonstrated that incidence rates of adverse events were generally higher among patients living closer to the implanting centre. It remains unclear which threshold distance should be considered for offering LVAD patients access to shared care follow-up at local non-implanting centre.

Finally, our findings demonstrate that an SCM can be used to promote a care continuum for LVAD patients by involving multiple healthcare providers in the community. This may however increase the level of care fragmentation and negatively impact healthcare outcomes. Kim et al. [25] mapped the networks of physicians involved in the care for LVAD patients and demonstrated that a greater level of care fragmentation is associated with higher infection rates and indirectly results in higher healthcare costs. Raising awareness among teams about the impact of care fragmentation and optimizing care networks may be important to consider when setting up shared care partnerships. Fragmentation can also potentially be reduced by using eHealth technologies, such as telemedicine and mobile health applications. These tools can enable collaboration and communication between shared care partners and patients, as well as remote patient monitoring and timely intervention when needed. In this way, patient care could be streamlined, regardless of geographic barriers. Further research into eHealth technologies may provide insights into the optimization of shared care pathways, the enhancement of shared care collaborations and the improvement health outcomes in the management of patients with an LVAD.

Limitations

Despite adhering closely to the PRISMA guidelines for Scoping Reviews [13], certain elements in this study may have introduced potential limitations. A major limitation is the significant lack of evidence-based literature. Also, by not addressing non-English literature, this study may have missed valuable findings that could contribute to the overall understanding of this emerging model. Furthermore, the included reports were heterogeneous in terms of methodology, making it difficult to compare study findings. In addition, a possible overrepresentation of positive results and proposed benefits of the SCM may have impacted the validity of this scoping review. Although the articles included emphasized the benefits of an SCM for LVAD patients living in remote areas, supportive clinical evidence is urgently needed.

CONCLUSION

As the number of LVAD-patients continues to rise, shared care collaborations are needed to keep LVAD care accessible. Although the literature is limited, shared care might contribute to improved care access, continuity of care and satisfaction in LVAD patients. The delivery of successful, patient-centred shared care requires effective communication, coordination, scheduling training and competence maintenance are important criteria for shared care partnerships. Furthermore, standardized protocols and society guidelines for implementing and maintaining LVAD shared care programmes have not yet been developed and are considered a basic requirement for successful collaborations and care delivery. Future research should focus on prospectively investigating the impact and intricacies of implementing at the level of the LVAD patient and caregiver, implanting centre and shared care site.

Glossary

ABBREVIATIONS

BTT

Bridge to transplantation therapy

CF

Continuous flow

DT

Destination therapy

ESC

European Society of Cardiology

HF

Heart failure

HTx

Heart transplantation

INTERMACS

Interagency Registry for Mechanically Assisted Circulatory Support

LVAD

Left ventricular assist device

MCS

Mechanical circulatory support

SCM

Shared care model

SUPPLEMENTARY MATERIAL

Supplementary material is available at EJCTS online.

FUNDING

This work was supported by Abbott Medical Netherlands from which V.C.E.D. received an unrestricted educational grant [E-APC 2023-HF-79], and the Wassink Hesp Foundation, Netherlands. Funders had no role in any phase of the creation of this manuscript.

Conflict of interest: R.A.d.B. has received research grants and/or fees from AstraZeneca, Abbott, Boehringer Ingelheim, Cardior Pharmaceuticals GmbH, Novo Nordisk, and Roche and (in the last 36 months) has had speaker engagements with and/or received fees from Abbott, AstraZeneca, Bristol Myers Squibb, Cardior Pharmaceuticals GmbH, Novo Nordisk, and Roche. All other authors have reported that they have no conflict of interest to declare.

DATA AVAILABILITY

All relevant data are within the manuscript and its Supporting Information files.

THIRD-PARTY CONTENT

Supplementary Material, Appendix 2, Table S2. Studied levels of care based on available services and type of care, Yin and colleagues, Impact of Shared Care in Remote Areas for Patients With Left Ventricular Assist Devices, 2020, by permission of Elsevier (License Number: 5720890287306).

Author contributions

Valérie C.E. Drost: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing. Luuk C. Otterspoor: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing. Casper F. Zijderhand: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Validation; Visualization; Writing—original draft; Writing—review and editing. Jelena Sjatskig: Writing—review and editing. Jolanda Kluin: Writing—review and editing. Rudolf A. De Boer: Resources; Writing—review and editing. Kadir Caliskan: Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing.

Reviewer information

European Journal of Cardio-Thoracic Surgery thanks Rakesh Christopher Arora, Bart Josephus Johannes Velders and Branislav Bezak for their contribution to the peer review process of this article.