A national study of infective endocarditis models of care in Australia

Abstract

Background

Multidisciplinary endocarditis team (MDET) management is supported by current evidence and recommended in international society guidelines. The extent to which this recommendation has been implemented in Australian centres and the attitudes, barriers and facilitators of this model are unclear.

Aim

To describe current infective endocarditis (IE) models of care in Australian specialist referral centres and evaluate facilitators, barriers and attitudes towards MDET implementation.

Methods

Aims were addressed using two online surveys. Survey 1 audited IE models of care and was distributed to infectious disease physicians at specialist referral centres. Survey 2 assessed barriers, facilitators and attitudes towards MDETs and was distributed via societal email listings.

Results

From 56 identified cardiac surgery centres, survey 1 received 47 responses (84%). A total of 28% (13/47) of participating institutions had an existing MDET. A total of 85% (11/13) of MDETs were in public hospitals and 85% (11/13) were in high IE volume centres. Survey 2 had 109 respondents from seven specialties. Attitudes towards MDET implementation were generally favourable. Identified barriers to MDET implementation included a lack of funding, resources, expertise, time and collaboration. Facilitators included strong leadership, engagement from key stakeholders and tangible benefits.

Conclusions

Even though it is recommended in international guidelines, the MDET model is used by less than one‐third of Australian specialist referral centres. Stakeholders in IE care have generally favourable attitudes towards MDET implementation but cite a lack of resources, funding, collaboration and time as barriers to this. Dedication of financial and administrative support and leadership from key stakeholders are required to increase MDET utilisation.

Introduction

Infective endocarditis (IE) is a serious infection with high morbidity and mortality. Even in an era of advanced diagnostic and surgical techniques, along with efficacious and targeted antimicrobials, IE mortality remains around 25%. ¹ Optimal management of IE patients requires involvement of multiple hospital units, including infectious diseases (IDs), microbiology, cardiology, cardiothoracic surgery and allied health. Depending on patient care needs, additional specialties such as addiction medicine, neurology, nephrology, vascular surgery and radiology may be involved. Existing research demonstrates that diagnostic and therapeutic decisions are best made by coordination and discussion across specialties rather than a sole provider.

Multidisciplinary management has been an accepted standard in cancer care for several years. ² , ³ The concept of a multidisciplinary endocarditis team (MDET), a formalised group consisting of members from key specialties that meets regularly to provide advice and/or make management decisions, has been proposed and investigated. A quasi‐experimental study from 2009 reporting outcomes in IE patients at a single centre before and after implementation of a MDET demonstrated a 50% reduction in 1‐year mortality along with reductions in inappropriate antimicrobial prescribing and acute renal failure. ⁴ A similar pre‐ and post‐implementation trial of patients with native valve IE reported significant reductions of in‐hospital and 3‐year mortality following the institution of a MDET, as well as a decrease in cases of culture‐negative IE. ⁵ Further studies have linked MDET initiation with increased rates of early surgery and clinician satisfaction. ⁶ , ⁷ Streamlined management of IE patients by a MDET is now recommended in international society guidelines ¹ , ⁸ ; however, this recommendation is not informed by large, randomised trials.

While there is a recommendation for a team‐based management strategy for IE, it is unclear whether this has been widely implemented in Australian centres. The bulk of the literature on MDETs is from European centres, and the difficulties of applying the same model of care in a different healthcare system have been noted, leading to location‐specific recommendations for MDET implementation being developed for a North American setting. ⁹ While the Australian Therapeutic Guidelines ¹⁰ recommend multidisciplinary management for IE, citing its mortality benefit, specific guidelines for MDET implementation and function have not been developed for Australia.

This study aimed to define the current Australian models of IE care across health services nationally, including the frequency of MDETs and their structure and function, and to identify attitudes, barriers and facilitators to the implementation of MDETs.

Methods

The data for this research were acquired using two separate methods. The methodology and results are reported in line with the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES). ¹¹

Part 1: National audit of the models of care for managing IE at Australian specialty referral centres

An Australia‐wide audit was undertaken of the models of care used for IE. Centres with a cardiac surgical service were selected as the focus for this audit as these are the locations where complicated IE cases most likely to require MDT input are frequent. Surgical centres were identified from the list of contributors to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database, which represents all public and most private cardiac surgical centres in Australia. ¹²

The survey‐based audit tool was electronically distributed to ID physicians and/or clinical microbiologists at Australian cardiac surgery centres. This population was selected due to their presumed involvement in the management of IE cases at their respective facilities and their anticipated familiarity with local IE care protocols. The recipients were identified through the investigators' existing professional networks. A maximum of two follow‐up email notifications were sent to optimise response rates. The survey determined demography and IE case load of the respondent's primary hospital along with key characteristics of the current model of care for IE patients at that centre, including the presence of a formal MDET and its composition and function. Scenario‐based questions were included in the survey, representing a complex IE case with surgical indications and an uncomplicated IE case with no surgical indication, to determine differences in specialty team involvement and discussion forums. Respondents provided the name of the institution for which they were answering to identify any duplication of responses, but this information was separated from their subsequent responses to maintain anonymity.

Part 2: Facilitators, barriers and attitudes towards MDET implementation among stakeholders from various specialties involved in IE management

The survey was distributed via specialised professional organisations' membership lists and the investigators' established networks, encompassing a diverse range of healthcare professionals with expertise in IE management including ID, microbiology, cardiology, cardiac surgery, addiction medicine and neurology. The primary society email listings utilised were those of the Australasian Society of Infectious Diseases (>1200 recipients), the Australian fellows of the Cardiac Society of Australia and New Zealand (>400 recipients) and the Australian fellows of the ANZSCTS (>190 recipients). Up to two reminder emails were sent. Respondents were anonymous. Demography data were collected including the respondent's area of specialty, degree of experience, volume of endocarditis patients managed and nature of their primary place of work. Based on their response to whether their primary hospital has an existing MDET or not, respondents were directed to further open‐ended and Likert‐scale questions assessing barriers, facilitators and attitudes towards the implementation and function of MDETs.

The audit tool and survey were created and distributed via the Qualtrics platform. Both were developed and piloted by the investigators. Ethics approval was obtained from Monash University Human Research Ethics Committee (approval number 37267). Participation in both surveys was voluntary, and no incentives were offered for responses. Responses were collected from May 2023 to November 2023.

Statistical analysis was performed using Stata version 18 (College Station, TX, USA). Descriptive statistics were used to present data. Categorical variables were analysed using Fisher's exact test. P values of less than 0.05 were considered significant. Free‐text responses for the survey were analysed, and consistent themes were identified and tabulated under the constructs of the Consolidated Framework for Implementation Research. ¹³ Incomplete surveys were not included in the analysis. Institutions that managed more than 30 cases of IE per year were classified as ‘high‐volume’ and institutions managing less than this ‘low‐volume’.

Results

Audit: Models of care for IE

Of 56 identified cardiac surgery centres in Australia, responses were received from 47 (84%) centres. Characteristics of the participating centres are displayed in Table 1. There were more responses from private centres (25/47, 53%) than public centres (22/47, 43%), reflecting the greater number of private centres surveyed, but public health services accounted for a far greater proportion of high‐volume centres (18/22, 82%) than private institutions (4/22, 18%). All responding centres had on‐site ID, cardiology, transoesophageal echocardiography and cardiac surgery services. A high proportion also had access to neurosurgery, neurology, microbiology, positron emission tomography scanning and outpatient parenteral antimicrobial therapy services. Addiction medicine services were only available at 48% of centres; however, 90% of public centres had access to addiction medicine, with only 8% of private facilities providing this service.

Table 1.

Characteristics of participating centres in national audit of practice

		MDET, n = 13, n (%)	No MDET, n = 34, n (%)
Hospital type	Public	11 (85)	11 (32)
	Private	2 (15)	23 (68)
IE case volume (per year)	0–15	0 (0)	12 (35)
	16–30	2 (15)	11 (32)
	31–45	4 (31)	6 (18)
	More than 45	7 (54)	5 (15)
Percentage of IE cases transferred from other health services	0%–25%	5 (38)	19 (56)
	26%–50%	7 (54)	9 (26)
	51%–75%	1 (8)	3 (9)
	76%–100%	0 (0)	3 (9)
On‐site services	Infectious diseases	13 (100)	34 (100)
	Microbiology	12 (92)	28 (82)
	Cardiology	13 (100)	34 (100)
	Transoesophageal echocardiography	13 (100)	34 (100)
	Cardiac surgery	13 (100)	34 (100)
	Radiology	13 (100)	34 (100)
	Positron emission tomography scanning	11 (85)	26 (76)
	Addiction medicine	11 (85)	11 (32)
	Neurosurgery	10 (77)	30 (88)
	Neurology	13 (100)	33 (97)
	Outpatient parenteral antimicrobial therapy	13 (100)	33 (97)

IE, infective endocarditis; MDET, multidisciplinary endocarditis team.

Only 28% of the participating institutions had an existing formal MDET. The majority of MDETs were in public and high‐volume centres. Cardiology was the lead specialty in 46% (6/13) of endocarditis teams, with ID leading 31% (4/13) and the remaining 23% (3/13) having no lead specialty. Most MDETs met regularly rather than on an ad hoc basis, with 53% of meetings occurring at least weekly. MDETs generally discussed selected cases of suspected or proven IE rather than every IE case (85% and 15% of responses respectively). A total of 69% of MDETs had been established within the last 5 years. None of the MDETs received any dedicated funding. Further characteristics of MDETs in Australian centres are listed in Table S1.

The composition by specialty of the established MDETs was investigated (Fig. S1). Cardiology was the only unit that was always involved in MDETs. Cardiac surgery and ID were always involved in the majority of MDETs (77% and 85% respectively), while involvement of other specialties was occasional or absent.

Models of care for uncomplicated and complex IE were examined using scenario‐based questions (Table S2). In the responding centres, IDs and cardiology are involved in the care of the majority of IE cases regardless of complexity. Cardiac surgery involvement is much more likely to be sought in complicated cases with clear surgical indications, although surgical input would still be sought in >50% of uncomplicated cases in these centres. Most patients with IE are managed under the care of infectious diseases or cardiology, even in the presence of surgical indications. The most common key discussion forum reported for complex and uncomplicated IE is formal consultation/written notes. Discussion in a multidisciplinary forum, either formal MDET meeting or cardiac case conference, was more likely in complex cases compared to uncomplicated (34% vs 21%).

Survey: attitudes, barriers and facilitators to MDET implementation

A total of 109 responses were received for the survey. A similar number of responses were recorded from centres with an existing MDET and those without. Seven specialties were represented, with IDs physicians providing the highest number of responses (50/109, 46%). Respondents had varying levels of specialty experience and exposure to IE cases, and similar numbers of responses were recorded from centres with and without an existing MDET (Table S3).

The respondents' awareness of MDET research and societal guidelines regarding MDET implementation were examined (Fig. S2), with results stratified by whether the respondent's hospital had an existing MDET. Clinicians from centres with an existing MDET were significantly more likely to be aware of societal recommendations supporting MDET implementation (94% vs 71%, P = 0.003) and to agree that these recommendations were relevant to IE patients in Australian centres (96% vs 75%, P = 0.004).

Attitudes towards MDET implementation among respondents from centres without an existing MDET were generally favourable. A total of 87% agreed that formation of a MDET would be useful for managing IE patients at their centres, and 75% agreed that a MDET would be a worthy use of their time. Regarding IE outcomes and performance indicators, the majority of respondents agreed that a MDET at their centres would be useful for IE diagnosis (77%), reduce management errors (71%), reduce time to surgery (71%), improve adherence to guidelines (81%) and improve communication between teams (88%). A lower proportion agreed that mortality would be improved (56%) or that patient satisfaction would increase (42%).

The attitudes towards MDETs of respondents from centres with an existing MDET were also examined. A total of 92% agreed that their MDET was useful for managing IE patients, and 86% agreed that it was a worthy use of their time. Respondents generally agreed that their MDET improved IE diagnosis (82%), reduced errors (80%), improved mortality (62%), reduced time to surgery (70%), improved guideline adherence (86%) and improved communication between teams (98%). A total of 26% agreed that their MDET increased patient satisfaction, with the remainder providing neutral responses. A total of 76% of respondents were satisfied with the performance of their MDET.

The availability of resources required for MDET function was assessed (Fig. S3). The greatest difference between sites with a MDET and without was in the presence of cardiac surgery services (98% vs 64%). Other resources were similarly accessible among respondents. Administrative support was the resource most lacking across centres with a MDET and those without (52% and 42% respectively).

Perceived willingness of specialty team involvement in MDETs was investigated, and the results for core specialties in centres, both with and without a MDET, are displayed in Figure 1. Across the examined specialties, all were predominantly described as being ‘willing’ to take part in a MDET (Fig. S4). Only a small number of respondents described any of the specialties as being ‘unwilling’ to be involved. Centres without MDET reported reduced willingness for MDET involvement among core specialties, but none of these results reached significance. Proportional results were similar across centres with and without a MDET.

Figure 1.

Perceived willingness of core specialties to be involved in multidisciplinary endocarditis teams (MDETs), stratified by presence of absence of an existing MDET. () willing; () unwilling. MDET, multidisciplinary endocarditis team; ID, infectious diseases; Cardiac surg, cardiac surgery.

Barriers and facilitators to MDET implementation were assessed using free‐text responses. The themes identified from these responses are summarised in Table 2. Similar themes were identified across both domains. The perceived importance of MDET management was repeated in several responses (‘should be standard of care’, ‘should be obligatory in all hospitals treating IE patients’, ‘vital for care particularly in complex cases’). Respondents also broached the potential for longitudinal analysis of MDET outcomes (‘It would be great if there was support for prospective collection of useful data with real‐time feedback to units’) and the establishment of national guidelines surrounding IE management (‘An agreed evidence‐based national best practice model for endocarditis IE would be a major advance’).

Table 2.

Identified barriers and facilitators to multidisciplinary endocarditis team (MDET) implementation by Consolidated Framework for Implementation Research constructs, with illustrative free‐text quotes from survey responses

Barriers

Innovation

Mechanism for urgent decision‐making outside of regular meeting

Ability to match meeting frequency with case load

Outer setting

Dedicated administrative staff funding

Remuneration of clinician time

Lack of access to required specialties

Lack of expertise in endocarditis

‘The attendees need to have some expertise in endocarditis, otherwise it's either meaningless conflict or uninformed consensus’

Communication and co‐ordination of care across health

‘Would be best if we were invited to the relevant tertiary hospital MDT to present our cases’

Inner setting

Capacity of clinicians to integrate the additional workload/time commitment

‘Overworked staff with little time to spare for more meetings’

‘Multiplicity of players in some departments therefore MDT would either have very variable membership or a membership that doesn't necessarily reflect the team caring for a specific patient’

‘Our service is largely VMOs who have multiple commitments to private work reducing their availability’

Time of meeting suitable to all stakeholders

‘Unable to get everyone together at an appropriate time to make timely decisions’

Individuals

Lack of engagement from key stakeholders

Lack of consensus management approach

‘…no willingness to commit to collaborative rather than territorial decision making’

‘Some concern that emphatic communicators will dominate the discussion and drive the management as per their preference’

‘Perceived loss of autonomy for managing team/clinician’

Lack of awareness of evidence of MDET benefit

‘Potential to waste time’

‘Probably would retard administration of the correct treatment’

Implementation process

Absence of an individual or group to initiate and manage MDET

‘It may be multidisciplinary but it still needs a driver’

Lack of support from hospital administration

‘General lack of awareness, interest or support from hospital administrators’

Facilitators

Innovation

Efficiency of meeting

Anecdotal and data‐driven evidence of improved outcomes

‘The tangible benefits on patient outcomes are rewarding and motivating’

Clinician satisfaction with MDET model

Outer setting

Access to high‐quality cardiac imaging

Expertise in endocarditis management

Virtual/video conference meetings to improve attendance

Inner setting

Established and agreed pathways of clinical care

Cardiac care co‐ordinator involvement

Volume and complexity of endocarditis cases

‘Delayed presentations and remoteness of some of the patients means that all clinicians find value in discussing cases jointly’

Individuals

Strong senior medical attendance at meetings

Enthusiasm and collaboration from primary stakeholders

‘Willingness to peer review/get differing opinions among each specialty and have frank conversations’

Implementation process

Initiation by lead clinicians in key specialties

‘Senior consultant champions in the primary clinical specialties are a key facilitator’

Discussion

This is the first study examining IE models of care and establishing the frequency of MDET management at a national level, to the best of our knowledge. We could not find any published data describing the degree to which the MDET model has been instituted in other parts of the world.

Despite evidence for the benefit of multidisciplinary management of endocarditis and its recommendation in international guidelines, less than one‐third of Australian cardiac surgery centres have an established MDET. This may be due to existing endocarditis team literature lacking relevance to Australian healthcare structures and models of care and, therefore, uncertainty in Australian clinicians about the relevance of these findings in local practice. High‐volume, public centres account for the majority of existing MDETs, and many of these have been established within the past 5 years. While it is encouraging that these centres have MDETs, it may be the smaller, low‐volume centres, in which there is less frequent exposure to complex IE cases, where multidisciplinary input would be of most benefit.

We found that willingness to participate in a MDET among key stakeholders was generally high. As with the findings of El‐Dalati et al., we also demonstrated that practitioners in centres with a MDET had overwhelmingly favourable perceptions of the MDET's performance and impact on communication, diagnosis and reduction of errors. ⁷ Also in accordance with El‐Dalati et al. were the more tempered responses regarding patient outcomes such as mortality. ⁷ It is interesting that, while perceived willingness for MDET involvement was high across specialties, a lack of motivation or collaboration was often cited as a barrier for MDET implementation. This perhaps reflects the disconnect between the attractive concept of the MDET model and the reality of implementing it into a complex and busy healthcare system.

Our data show that the lack of a MDET in cardiac surgery centres does not appear to be driven by a lack of any specific on‐site specialty service. Indeed, the survey of barriers and facilitators to MDET implementation identified that there are a wide range of material and non‐material barriers, including administrative resources, funding, timing within busy schedules, willingness to collaborate and engagement/leadership from key specialties. These barriers mirror those that have been identified in MDTs for other conditions including cancer and diabetes. ¹⁴ , ¹⁵

The demonstrable benefits of MDETs would suggest that efforts to overcome these barriers are warranted. These interventions require engagement and collaboration at a local healthcare level, forming consensus protocols and securing administrative support, but also at a national level, designing guidelines and synchronising data collection. Once established in cardiac surgery centres, these MDETs should act as referral points for discussion of patients admitted at local and regional healthcare facilities. This model is already present in one state of Australia, in which an endocarditis advisory team based at a cardiac surgery centre accepts referrals from smaller hospitals and provides guidance on investigation, management and need for transfer. ¹⁶ In Table 3 we offer several proposals for optimising MDET implementation in Australia and identify the relevant knowledge gaps that should be addressed to achieve this, based upon responses received in this study.

Table 3.

Recommendations for optimising multidisciplinary endocarditis team (MDET) implementation in Australia

I. Identify principal referral centres to act as dedicated MDET referral sites for local/regional hospitals

Potential benefits: provision of timely specialist advice to smaller healthcare facilities, clear referral pathways

Current challenges: clinician desire for autonomy in patient management, low frequency of MDETs in cardiac surgery centres

Knowledge gaps: feasibility and efficacy of a MDET referral model, ideal fashion in which to provide MDET expertise to smaller healthcare facilities

II. Compose Australian IE guidelines including recommendations for MDET management and optimal structure/function

Potential benefits: a clearer recommendation for MDET in Australian guidelines would provide a framework for implementation and enable resource acquisition from health services

Knowledge gaps: local evidence to guide optimal MDET structure/function for Australian setting

III. Ensure consumer engagement in the maturation of MDET recommendations/model in Australia

Potential benefits: development of an acceptable and accessible model that caters to consumer priorities

Current challenges: heterogeneous patient population including people who inject drugs, regional and remote communities, Aboriginal and Torres Strait Islanders, ethnic diversity

Knowledge gaps: consumer priorities in endocarditis care

IV. Provide resources to support clinician time in MDET

Potential benefits: maximise clinician engagement

Current challenges: limited healthcare budget, different funding models across public and private systems, inadequacy of remuneration structure to appropriately define and remunerate MDET involvement

Knowledge gaps: level of resourcing required

V. Provide dedicated funding for adequate resourcing of MDET (i.e. nursing/co‐ordinator support, data collection and maintenance, IT/systems support)

Potential benefits: streamline MDET function, provide accessibility for remote/regional sites

Current challenges: lack of perceived importance of MDET in healthcare systems by clinical and non‐clinical staff, determining funding model for MDET servicing multiple health networks

VI. Increase education and support for MDETs through professional societies

Potential benefits: increased clinician motivation to implement ideal model of care, utilisation of MDETs for continuing professional development

VII. Develop consensus local protocols for IE management and identify MDET leaders in key specialties

Potential benefits: reduced disagreement regarding patient management, clear escalation pathways, provide rationale for adequate resourcing

Current challenges: timely process that requires engagement of key units and agreement on care pathways

VIII. Collect longitudinal IE/MDET data and develop a national IE registry

Potential benefits: allows auditing and quality improvement, facilitates local research activity, describe the local epidemiology of IE to increase understanding and expertise, provide guidance for resource allocation in different health settings, address existing data gaps

Current challenges: synchronisation of data collection between health systems for a complex condition, lack of dedicated funding, data storage and linkage issues, lack of well‐established targets for IE outcomes

This study has several strengths, including the broad coverage of the model of care audit, with 84% of Australian cardiac surgery centres included. We received a diverse range of respondents to the implementation survey in which multiple specialties were represented from facilities both with and without an existing MDET. The anonymous nature of the surveys promoted candid responses.

There are several limitations to this study, such as the potential that individuals with more familiarity or favourable views towards MDETs may be more inclined to participate. Indeed, almost half of the responses to the implementation survey were from centres with an existing MDET, when we know that this represents only a small proportion of hospitals in Australia. The online nature of the survey limited the depth of responses that could be provided, and duplicate responses to the implementation survey were possible given there was no IP/cookie tracking performed. The overall response rate to the implementation survey was low despite its electronic distribution through the major professional societies of IE stakeholders and attempts to maximise responses. The low response rate and disparity in responses between specialties may further reflect the perceived lack of import of a MDET model or that responsibility for its implementation lies with another specialty group. Another potential factor may be that, while IE represents a condition frequently encountered by many ID physicians, cardiologists whose primary practice pertains to interventional procedures or electrophysiology may have limited or no exposure to IE cases.

The MDET model has not been widely put into practice in Australian cardiac surgery centres. We have described several material and non‐material barriers and facilitators to the implementation of MDETs. We have also provided recommendations for optimising the uptake of this model and identified knowledge gaps that should be addressed in future to further refine and enhance IE care in Australia.

Supporting information

Table S1 Characteristics of MDETs in Australian centres.

Table S2. Management pathways for uncomplicated vs complicated IE.

Table S3. Characteristics of respondents to MDET attitudes survey.

Figure S1. Composition by specialty of MDETs in Australian centres.

Figure S2. Awareness and support for MDET societal guidelines and research (by percentage).

Figure S3. MDET resource availability (by percentage).

Figure S4. Perceived willingness of teams to be involved in MDETs.