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U.S. cardiac surgeons encounter complex decision-making when treating patients with injection drug use-associated infective endocarditis (IDU-IE). We evaluated surgeons’ treatment approaches for IDU-IE compared to non-IDU-IE. This is an anonymous survey of U.S. cardiac surgeons who answered hypothetical infective endocarditis (IE) clinical scenarios that varied based on patient substance use history, addiction treatment, and history of IE. Treatment approaches were classified as operative vs nonoperative. Responses were descriptively analyzed. The survey response rate was 8.7% (n = 208). Survey respondents were mostly male (85.6%) and non-Hispanic white (67.8%), but were from all regions of the United States. Surgeons reported they would operate at similar proportions for patients with native valve non-IDU-IE (63%) and IDU-IE engaged in methadone treatment (64.5%). Most surgeons reported they would operate on patients with recurrent non-IDU-IE (93.1%) compared to only 26.4% for patients with recurrent IDU-IE (P < 0.001). Most surgeons reported they would place no limits on the number of operations for patients with recurrent non-IDU-IE (73.1%), whereas 83.5% of surgeons would limit the number of surgeries for patients with recurrent IDU-IE (P < 0.001). Most respondents reported having declined to operate on patients with IDU-IE (63.5%). Cardiac surgeons are less likely to report favoring operative management for primary and recurrent infection in patients with IDU-IE, though patient engagement in methadone treatment increased the likelihood of them taking an operative approach. There is opportunity to standardize the care, including addiction treatment, of patients with IDU-IE to optimize positive short and long-term outcomes.
Cardiac surgeons are less likely to report operating on patients with primary and recurrent injection drug use-associated infective endocarditis, but patient engagement in addiction care treatment may increase likelihood of operation.
Perspective Statement
Cardiac surgeons increasingly face complex decision-making as the incidence of injection drug use-associated infective endocarditis rises amid the US opioid epidemic. We describe surgeons’ treatment approaches for endocarditis related to patient substance use history. The findings highlight the need for a multidisciplinary care approach, including addiction treatment, in these complex clinical scenarios.
INTRODUCTION
The opioid overdose epidemic in the United States has entered its second decade driven by increasing injection opioid use and a contaminated opioid drug supply.
as well as bacterial infections such as skin and soft tissue infections, and more life-threatening ones like infective endocarditis (IE). Rates of injection drug use related infective endocarditis (IDU-IE) have been increasing at exponential rates along with the proportion requiring cardiac surgery.
Rising rates of injection drug use associated infective endocarditis in Virginia with missed opportunities for addiction treatment referral: A retrospective cohort study.
Trends in infective endocarditis hospitalizations, characteristics, and valve operations in patients with opioid use disorders in the United States: 2005–2014.
Cardiac surgeons face complex medical decision-making when treating patients with IDU-IE, in part due to the increased risk of reinfection if substance use continues. For instance, recent studies have suggested that a staged operative approach for IDU-IE of the tricuspid valve: initial valvectomy and delayed valve replacement, provided abstinence from substance use–may be an appropriate approach for IDU-IE.
Most recent guidelines for surgical management of IE recommend that “normal indications for surgery (be) applied to people who use drugs (PWUD), but management must include treatment of addiction.”
Traditionally, however, treatment of addiction has not been offered to patients with IDU-IE and addiction treatment remains inaccessible in most hospital settings.
Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study.
Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study.
Several perspectives pieces proposing the need to ration care for PWUD have been published in reputable cardiac surgery journals, with titles such as “when is enough enough.”
Quantitative evidence about cardiac surgeons’ treatment approaches for patients with IDU-IE is sparse. Given the variations in outcomes based on treatment approaches, investigating treatment disparities amongst non-IDU-IE and IDU-IE is an important step in moving the field forward and improving care for patients with IDU-IE. To that end, we surveyed US cardiac surgeons about their treatment approaches for IDU-IE compared to non-IDU-IE in native and recurrent IE.
METHODS
Study Design
In April 2019, we sent an electronic survey (Appendix 1) by e-mail to 2398 self-identified US cardiac surgeons. Email addresses were obtained by manual search of the publicly available Cardiothoracic Surgery Network database.
The survey was re-distributed again 1 week later. This is a subanalysis of survey questions specific to treatment approaches for patients with IDU-IE. Treatment approaches were presented as categorical responses to hypothetical clinical scenarios of IE where surgical management is the standard of care. Clinical scenarios were similar among patients with non-IDU-IE and IDU-IE but varied based on patient history of substance use, methadone treatment engagement, and nature of the valve infection (native vs recurrent). Surgeons classified their treatment approaches to the clinical scenario as operative vs nonoperative. Surgeons were asked to expand on their reasons for declining surgical treatments with free text answers.
Participation was voluntary and informed consent was part of the survey. This study was approved by the university institutional review board (IRB no 2000024402).
Baseline Characteristics
The survey collected cardiac surgeons’ demographic information (sex, United States region of practice) and experience (number of years in practice, number of cardiac cases per year, and number of IE cases per year).
Outcomes
The primary outcome of this study is cardiac surgeon treatment approach (surgical vs nonsurgical) in patients with IDU-IE compared to non-IDU-IE. Secondary outcomes included the types of operative approaches preferred for patients with IDU-IE compared to non-IDU-IE, and reasons why surgeons may decline to operate on patients with IDU-IE.
Data Analysis
Quantitative and qualitative results were obtained from the survey questions. Descriptive statistics were used to describe participant characteristics and treatment approaches. McNemar and Wilcoxon signed-rank tests were used to determine differences in response to scenarios. Multivariable logistic regression analysis was performed to determine factors contributing to treatment approach. Statistical tests were 2-tailed, and P < .05 was considered statistically significant.
Participants provided free-text answers giving reasons they had previously declined operating on patients with IDU-IE. Those answers were grouped into 4 applicable categories (active substance use, recurrent endocarditis with ongoing substance use, severe end-organ damage, and other), then coded and evaluated for use of stigmatizing language. Review and classification of responses was performed by 3 independent reviewers. Grouped and coded answers were subsequently compared for agreement.
RESULTS
Description of Participants
Of 2398 U.S. cardiac surgeons contacted, 208 (8.7%) responded to the survey entirely (Table 1). Most participants identified as male (178, 85.6%), 11 (5.3%) identified as female, and 19 (9.1%) did not identify their sex. Most participants were non-Hispanic white (141, 67.8%). Participant geographic location was spread across all regions of the continental U.S.: 51 (24.5%) from the Northeast, 56 (26.9%) from the South, 38 (18.3%) from the Midwest, 16 (7.7%) from the Mid-Atlantic, and 30 (14.4%) from the West Coast. Nearly half of respondents (93, 44.7%) report working in metropolitan teaching hospitals, 42 (20.2%) report working in metropolitan nonteaching hospitals, 37 (17.8%) report working in private, nonprofit hospitals, 4 (1.9%) report working in rural hospitals, 10 (4.8%) report working in government hospitals, and 8 (3.9%) report working in private, self-invest practices.
Table 1Baseline Characteristics of Cardiac Surgeon Survey Respondents
Among those who reported it, number of years in practice ranged from 0 to 50 years, mean (SD) number of cardiac cases per year was 178 (±76), and mean (SD) number of IE cases per year was 10 (±9).
With regard to patients with native valve non-IDU-IE, 131 (63%) surgeons stated they would operate, while 77 (37%) would not operate. Similarly, for patients with native valve IDU-IE and engaged in methadone treatment for opioid use disorder, 132 (64.5%) would operate and 76 (36.5%) surgeons would not operate. Importantly, there is no statistically significant difference between surgeons’ treatment approach for native non-IDU-IE and IDU-IE when patients were engaged in methadone treatment (P = 0.80).
With regard to patients with recurrent non-IDU-IE, 175 (93.1%) surgeons would operate, while 13 (6.9%) surgeons would not operate. In contrast, for patients with recurrent IDU-IE, only 55 (26.4%) surgeons would operate while 153 (73.6%) surgeons would not operate (P <0.001). All surgeons who would operate on patients with recurrent IDU-IE would also operate in recurrent non-IDU-IE. Conversely, most (139, 71.6%) surgeons who would operate on patients with recurrent non-IDU-IE would not operate on patients with recurrent IDU-IE (P< 0.001).
With regard to patients with non-IDU-IE, 152 (73.1%) surgeons stated they would not limit the number of valve repairs or replacements done in the event of IE recurrence, while for patients with IDU-IE, 83.5% of surgeons stated they would place limits on the number of valve repairs or replacements they would perform (P < 0.001). Most would limit the number of operations among patients with IDU-IE to 1 (83, 40.3%), 2 (79, 38.4%), or 3 (10, 4.9%) compared to limits of 1 (13, 6.3%), 2 (30, 14.5%) or 3 (13, 6.3%) among patients with non-IDU-IE. Wilcoxon rank-sum test showed a statistically significant difference in the operative limitations placed on recurrence for non-IDU-IE vs recurrent IDU-IE. (P < 0.001).
We performed multivariable logistic regressions with surgical vs nonsurgical management as the dependent variable to determine if surgeon characteristics such as sex, region, type of hospital, number of years in practice (categorical), and number of IE cases per year effected treatment approach (Table 2). Compared to surgeons who have been in practice between 0 and 10 years, those who have been in practice between 10 and 20 years were less likely to report choosing surgical management in the case of patients with active IDU and recurrent IE (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09–0.85, P = 0.03). Similarly, compared to surgeons who have been in practice between 0 and 10 years, those who have been in practice for 30 to 40 years have lower odds of reporting choosing surgical management for patients with IDU-IE with ongoing methadone treatment (OR 0.39, 95% CI 0.12–0.98, P = 0.05), as well as lower odds of reporting choosing surgical management of native non-IDU-IE (OR 0.26, 95% CI 0.09–0.73, P = 0.001).
Table 2Multivariable Logistic Regressions Identifying Associations Between Treatment Approach and Respondents’ Characteristics
Dependent Variable: Surgical Approach vs Non-surgical
Recurrent IE with active IDU
Native IE, History of IDU, and methadone Treatment
The survey also assessed surgical approaches to tricuspid valve IE management comparing patients with native valve non-IDU-IE, native valve IDU-IE, and prosthetic valve IDU-IE (Figure 2). Valve excision without replacement was rarely recommended for patients with non-IDU-IE. Valve excision without replacement was also rarely recommended for patients with IDU-IE who were engaged in methadone treatment. These results contrast with the surgical approach for patients with recurrent tricuspid valve IDU-IE where over half of respondents (30, 54.6%) would elect to perform a valve excision without replacement, while the remaining 25 (45.4%) would perform a valve replacement. There was no statistically significant association between the type of surgical approach and the number of years in practice (P = 0.92).
Figure 1Cardiac surgeons’ approaches (operative vs non-operative management) in native & recurrent IDU-IE vs non-IDU-IE.
Most respondents report having declined operating for patients with IDU-IE (132, 63.5%) and fewer than half (60, 45.5%, n = 132) report referring the patients to another surgeon or center.
Qualitative responses from 86 surgeons illustrate that the most common reasons for nonsurgical management was active substance use (71, 82.6%), and recurrent IE (50, 58.1%). Severe end-organ damage was less of a reason for surgical denial (9, 10.5%). Furthermore, our coding of word choice reveals the use of stigmatizing and criminalizing language (“recalcitrant,” “recidivism,” and “contract violation”) in over a third of responses (36, 41.9%). One surgeon commented that “the addiction is stronger than the will to live” suggesting addiction is a matter of intrinsic will. There was a general lack of explicit acknowledgement that addiction is a complex chronic illness with highly effective treatment options.
DISCUSSION
In this study, we surveyed cardiac surgeons’ treatment approaches for IE, differences in treatment approaches between IDU-IE and non-IDU-IE, and potential reasons behind these clinical decisions. Our data highlight a disparity in reported treatment approaches for IDU-IE compared to non-IDU-IE, as well as deviation from guidelines for surgical IE when it comes to IDU-IE. Treatment approaches vary based on substance use history, and surgeons are less likely to report favoring operative management for primary and recurrent IDU-IE compared to non-IDU-IE. Engagement in methadone treatment for opioid use disorder appears to be a protective factor against this disparity. In terms of types of surgery that surgeons would elect to perform for IE, they are more likely to offer tricuspid valvectomy without replacement to patients with recurrent tricuspid IDU-IE. Among those who report having declined operating for IDU-IE, most did not refer to a different surgeon or center, and active substance use and recurrence of IE are the leading reasons for the nonoperative approach. While surgeons who have entered practice most recently are more likely to choose surgical management, free-text answers provided suggest a level of stigma and lack of knowledge about addiction and addiction treatments contributing to their treatment approaches.
Many participants report not referring patients to other surgeons or centers if they opt in favor of a non-operative approach. While they may land on the non-operative approach by weighing the benefits and risks of a surgery, the irreversible nature of this decision, if surgery would otherwise be indicated notwithstanding a patient's substance use history, arguably warrants additional input from colleagues including other surgeons and addiction specialists if available especially in light of evidence that medications for opioid use disorder are highly effective and can help prevent return to substance use in patients with IDU-IE.
Ethicists argue in favor of some level of oversight via procedural mechanism such as ethics consultations, rather than unilateral decision-making by individual clinicians.
Ultimately, however, we recognize that other factors may also contribute to the complex decision making around the surgical management of IDU-IE including but not limited to hospital resources, lack of addiction medicine resources both in the hospital and outside the hospital, and access to long term antibiotic management. This highlights the need for guidelines, support, and team-based decision-making to optimize treatment for IDU-IE and complex decisions around surgical treatment.
Concerns with reinfection and recurrence of IE and associated cost considerations may explain the disparity in surgical approaches. This might also explain the penchant in favor of tricuspid valvectomy without valve replacement for IDU-IE. Prior studies and case reports have suggested this as a viable option to prevent recurrence of endocarditis,
given that most patients with IDU-IE are younger than those with non-IDU-IE, and at a lesser risk of congestive heart failure from tricuspid regurgitation in the short term.
Furthermore, a recent, large study of patients who underwent cardiac surgery for tricuspid IDU-IE showed that compared to valve repair or replacement, those undergoing valvectomy had nearly 4-times higher risk of operative mortality.
The observed disparities in reported treatment approaches between IDU-IE and non-IDU-IE may also reflect stigma against PWUD and lack of education on addiction. The leading reason for declining to operate was active substance use and a third of free-text answers used stigmatizing language. Prognosis and surgeons’ judgment of patients’ ability to receive appropriate postdischarge and long-term care may also contribute to surgeons’ treatment approach. PWUD often deal with homelessness and are of lower socioeconomic position, which may impact their ability to undergo cardiac rehabilitation and continuity of care.
The finding that engagement in addiction treatment influences surgeons’ treatment approach supports the hypothesis that prognosis and concerns for recurrence of IE contribute to surgeons’ decision-making. However, many patients with IDU-IE may present having never received treatment for addiction, and may not receive first-line addiction treatments, as shown by prior studies.
In fact, receiving addiction care alongside surgical management would likely improve outcomes, hence the recommendation by most recent guidelines, that patients receive addiction care along surgical management if indicated. While recent health policy changes such as the expansion of Medicaid with the passing of the Affordable Care Act have led to an increase in the uptake of medication for opioid use disorder and reduction in opioid overdoses,
addiction care remains limited, particularly in the hospital setting. Methadone treatment of OUD is highly regulated in the outpatient setting and is not integrated with primary care,
In addition, stigma against PWUD among healthcare providers can be a barrier to patients receiving addiction treatment, particularly in the hospital setting.
Our findings contribute to an ongoing discussion among cardiac surgeons and other providers who care for patients with IDU-IE. Hayden and Moore's 2019 qualitative study showed that implicit and explicit bias were pervasive among surgeons interviewed, and futility and rationing of care were the lead reasons behind their surgical decision making.
this is the first study that quantitatively describes cardiac surgeons’ treatment approaches between patients with IDU-IE vs patients with non-IDU-IE.
Given disparity from current guidelines for surgical IDU-IE and existing literature on stigma against substance use disorders, PWUD and barriers faced by patients with IDU-IE, this suggests there is need for medical education for health care professionals about addiction and its treatments. Management and support from a hospital-based multidisciplinary team with addiction medicine consultation and initiation of medications for opioid use disorder may be 1 approach to better address the complex decision making and treatment needs of patients with IDU-E.
LIMITATIONS
Our findings represent the result of a voluntary survey and may not reflect approaches of all cardiac surgeons, particularly outside of the United States where practice patterns may differ and rates of IDU-IE may also differ. The surgical scenarios presented in the survey were simple, and did not provide respondents with as many details as may be necessary to make complex clinical decisions such as patient age and comorbidities, thus this may have affected the treatment approach. Even though, our response rate was approximately 10%, respondents were distributed across all regions of the continental U.S., ranges of years in practice, a wide range of number of cardiac cases and IE cases per year, and practiced in a variety of hospitals.
CONCLUSION
Cardiac surgeons’ treatment approaches for native and recurrent IE differ, based on patient substance use disorder history. Although engagement in addiction treatment appears protective against this disparity, the significance of the disparities remains noteworthy, as most patients with IDU-IE do not receive first-line addiction treatment. At least one of the reasons behind this disparity may be stigma against PWUD. These findings underline the need for education on addiction among health care professionals, broader adoption of addiction treatment for patients with IDU-IE and offer an opportunity for the profession to formulate protocols to approach peri-operative care of patients with IDU-IE. Treatment of IDU-IE that includes a multidisciplinary approach including cardiac surgery, addiction medicine, and infectious disease may address the concerns surgeons have when caring for this complex patient population and ultimately improve outcomes.
Acknowledgment
The authors would like to thank Raymond Jean, MD, MHS and Benjamin Oldfield, MD, MHS for their contribution to and guidance at initial conception of this project.
Rising rates of injection drug use associated infective endocarditis in Virginia with missed opportunities for addiction treatment referral: A retrospective cohort study.
Trends in infective endocarditis hospitalizations, characteristics, and valve operations in patients with opioid use disorders in the United States: 2005–2014.
Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study.
Opioid drug use continues unabated and may have been accentuated by the concurrent COVID-19 pandemic.1 Drug overdose and bacterial endocarditis (BE) are dramatic interactions of patients who use intravenous drugs (PWUID) with our health care system and represent potential opportunities to treat the underlying root problem of addiction and opioid use disorder (OUD). In our clinical practice, intravenous drug use associated BE (IVDU-BE) doubled over the past 3 decades and is now the dominant cause of valve surgery for BE surpassing 60%, an experienced shared by other referral centers.
The United States Department of Health and Human Services (HHS) declared the national opioid crisis a public health emergency in 2019 amidst an ongoing rise in opioid-related drug overdoses.1 One of the many consequences of increased intravenous drug use (IVDU) includes the concurrent rise in the incidence of infective endocarditis (IE) and subsequent need for surgical intervention.2 Unfortunately, recurrence is common among patients with a history of continued IVDU,3 raising the concern for prosthetic valve endocarditis (PVE).
P-value ≤ 0.05.
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