@Article{chd.12769,
AUTHOR = {Michael V. Di Maria, Cindy Barrett, Carey Rafferty, Kelly Wolfe, Sarah L. Kelly, Deborah R. Liptzin, Dania Brigham, Adel Younoszai},
TITLE = {Initiating a Fontan multidisciplinary clinic: Decreasing care variability, improving surveillance, and subsequent treatment of Fontan survivors},
JOURNAL = {Structural and Congenital Heart Disease},
VOLUME = {14},
YEAR = {2019},
NUMBER = {4},
PAGES = {590--599},
URL = {http://www.techscience.com/schd/v14n4/39288},
ISSN = {3071-1738},
ABSTRACT = {<b>Background:</b> Children with single ventricle (SV) heart disease who undergo Fontan 
operation are at risk for developing multiorgan dysfunction. Although survival has 
improved, significant comorbidities involving multiple organ systems may develop, 
requiring evaluation and management by many subspecialists. Using data from an 
internal survey, we documented high care variability for our Fontan population. We 
then developed a multidisciplinary clinic, designed and implemented a clinical care 
pathway to decrease variability of patient assessment.<br/>
<b>Methods:</b> After creating a multidisciplinary team and a clinical care pathway, we initiated a multidisciplinary clinic (MDC) where patients could see multiple subspecialists 
during a single encounter. We then monitored our effectiveness by retrospective 
chart review to determine care pathway adherence (process measure) and incidence 
of new diagnoses of end‐organ injury (outcome measure) as well interventions implemented. Adherence was analyzed using statistical process control (SPC) charts.<br/>
<b>Results:</b> Eighty‐six patients were seen in the MDC from January 2016 to September 
2017. The proportion of patients with appropriate testing increased, related to strong 
care pathway adherence. A significant amount of novel pathology was diagnosed in 
all evaluated organ systems, both Fontan‐associated comorbidities and general pediatric diagnoses. Subsequent interventions included cardiac catheterization n = 21 
(31%) with more than half of these patients undergoing intervention n = 17 (20%), and 
liver biopsy n = 9 (10%). Additionally, 58 patients (67%) were referred to a neuropsychologist based on perceived clinical need, with n = 34 (40%) undergoing a neuropsychological evaluation.<br/>
<b>Conclusions:</b> Children who have undergone Fontan palliation are at risk for developing cardiac and noncardiac comorbidities. Use and adherence to an institutional care 
pathway resulted in the diagnosis of significant novel pathology and subsequently 
provided opportunity for intervention.},
DOI = {10.1111/chd.12769}
}