Avoiding failure with heart failure

Heart failure is becoming increasingly prevalent in today’s society. Currently, there are approximately 90,000 people in Ireland living with the condition,¹ with approximately 10,000 newly diagnosed each year² – and it is projected that these numbers will continue to rise. 

This puts greater pressure on our healthcare system, which at present is moulded as a reactive structure to illness, when it needs to be re-shaped to fit a proactive preventative approach. This will demand significant structural change in the community. However, the impact of our ill-fitting approach to chronic illness is, in fact, most evident in the acute phase of a heart failure decompensation, with increasing emergency department attendances and admission rates presenting a major challenge.

In HSE hospitals, 7% of all inpatient bed days are heart failure-related³ and the European heart failure readmission rate at three months post discharge is approximately 20-30%.⁴ Such figures have shaped healthcare policy around chronic illness in the US, for example, whereby if an individual hospital’s rate of readmission with heart failure within 30 days of discharge exceeds a predicted value, a financial penalty is imposed. 

From the patient perspective, hospitalisation with acute decompensated heart failure (ADHF) is an independent predictor for worse outcomes.⁵ Therefore, change is required to work towards a community-centred chronic disease management system directed at structured prevention strategies, expedited diagnosis when symptoms appear, better patient self-care and family awareness of the illness, and more effective interaction between primary and secondary care. 

To this end, it is encouraging to see emerging concepts and strategies undergoing examination in Ireland. This article will review some of the major changes that we see as necessary to shape this new approach. 

Prevention of heart failure

The worrying epidemiological picture underlining marked growth in numbers of patients with heart failure over the coming years means attention needs to turn to an effective prevention strategy. 

The recent publication of the Ireland-based STOP-HF project⁶ and the subsequent report on its cost effectiveness⁷ has outlined an easily applied approach to heart failure prevention, which also reduces the incidence of major adverse cardiovascular events requiring hospitalisation.

Based on natriuretic peptide identification of the highest risk cohorts, this process tailors cardiovascular preventative strategies in a personalised fashion. Extrapolation of the results from the project to a national level would result in savings of approximately 5,000 cardiovascular admissions per year, or the saving of 100 beds per day.⁷

Accurate community diagnosis

Early accurate community diagnosis of new presentations of potential heart failure (HF) is essential to minimise morbidity. However, at present throughout Europe there are significant roadblocks to achieving what should be an attainable goal. 

The critical obstacles lie with access to basic diagnostics and to specialist opinion. Delay of six months in HF diagnosis increases the risk of hospitalisation by 25%, in addition to the risks of inaccurate diagnosis and incorrect therapies. The solution is not a demanding one and simply requires community access to natriuretic peptide as a rule-out test and available echocardiography for those with elevated levels of this biomarker. These two investigations are vital in making the diagnosis of HF, however, access to these for GPs throughout the country is patchy. 

A unified all-island algorithm to address this issue has been co-structured by the Irish Cardiac Society-General Practitioner working group and, if supported, would significantly improve outlook for people with heart failure. 

Specialist care in the community

As well as improved access to basic diagnostics, a greater degree of specialist support and input in the community is needed. Though GPs are often at the forefront of HF management, it is prudent to bear in mind the vast array of conditions GPs are confronted with and expected to treat on a daily basis. As such, it is a responsibility of specialists to ensure GPs are well supported in the management of such a complex condition as heart failure. 

However, one of the major challenges in modern day HF management is to construct a community-centred model of care where specialist access can be made readily available. One such emerging solution is the use of virtual consultations. This involves a live video-linked discussion between GPs and HF specialists, providing a forum for GPs to discuss and gain advice regarding certain patients. This allows GPs to not only advance their knowledge and confidence in the management of heart failure by discussing their own patients, but also garner experience through observing how others’ patients are managed. 

This concept of the virtual consultation has been in operation in the Dublin-South, Wicklow and north Wexford areas for approximately two years through the St Vincent’s University Hospital/St Michael’s Hospital Heart Failure Unit (HFU) and has recently been expanded to the Carlow-Kilkenny region. The initial review of this process in the St Vincent’s/St Michael’s HFU has shown a dramatic improvement in the speed of care delivery, marked reduction in the need for formal outpatient appointments (with consequent significant impact on the waiting times), reduction in patient and family travel, and a noted increase in the level of comfort of GPs in managing heart failure – further reducing referral numbers to routine outpatient clinics.

Inpatient care to be specialist-delivered

A proportion of patients admitted to hospital with ADHF continue to be referred to and admitted under general medical teams. However, it has been well established that specialist-led inpatient management not only improves outcomes, but also reduces the risk of readmission post discharge.⁸ This is a basic aspect of HF inpatient care and is a must in modern management of the condition. 

Furthermore, as part of this specialist-driven management, the role of multidisciplinary care is essential, particularly during the patient’s complicated transition from inpatient to outpatient. The administration of education about symptoms to look out for, medications being prescribed and monitoring of weight is a key step during this transition and highlights the importance of multidisciplinary staff, especially the clinical nurse specialist.

Structured care post-discharge

The first three months post discharge following an admission with ADHF is a critical time for patients, when the risk of readmission is at its highest. This vulnerability underscores the need to have a structured care plan in place post discharge. Here, the benefits of specialist-led inpatient care also extends into the outpatient setting and, again, there is a proven and crucial role for multidisciplinary input. This can have different structures, but is usually primarily nurse-led and involves patient education and self-care sessions (following on from those administered during the inpatient phase) as well as telephone follow-up. It has been shown to be effective in reducing rates of readmission compared to optimal medical care and close clinic follow-up alone ⁹ and has been outlined as an essential facet of HF services in the European Heart Failure Association’s Standards for delivering heart failure care.¹⁰

A caveat to this, however, is the need for hospital-based cardiology departments to have the capabilities to accommodate this type of service. Currently, there are only 12 hospitals in Ireland that receive HSE funding to resource this level of support and multidisciplinary care. Yet to truly move towards a community-centred approach to disease management, this is something that needs to be remedied. 

Looking at the investment, organisation and staff resources (particularly in relation to multidisciplinary staff) involved in hospital-based diabetes services around the country, dedicated specialist HF centres fail to compare. Though the benefit is obvious, the investment is still lacking.

Patient education

There is a lack of awareness of the common symptoms of ADHF among the general public, with only approximately 7% of the European population actually aware of these symptoms.³ The knock-on effect of this is later presentation to the medical professional and, thus, later implementation of appropriate treatment, resulting in worse outcomes. 

However, this isn’t exclusive to patients with a new diagnosis of heart failure, as the majority of patients (with both new and known heart failure) tend to have quite a prolonged duration of symptoms before presenting to a doctor with symptoms of ADHF. In relation to patients with a known history of heart failure, there is generally good adherence to regular weight monitoring. However, it is well reported that weight gain is a specific but not sensitive marker of clinical deterioration.¹¹ Therefore, a prolonged symptom duration among patients suggests that there is both an over-reliance on identifying weight gain and an under-recognition of other identifiers of HF decompensation. 

Patient education, though pertaining only to those who already have a diagnosis of heart failure, is an important aspect of HF management and should be provided during both the inpatient and outpatient phases as mentioned above. However, a patient’s main carer also plays a vital role in the outpatient management of this chronic condition. Education about heart failure should acknowledge this responsibility and be equally aimed at a patient’s primary carer, be it a family member, home carer or nursing staff in a long-term care facility. 

Worrying trends and ways to tackle them

Worrying trends in the epidemiology of heart failure are presenting major challenges to our healthcare system. However, there are emerging ideas to tackle these and improve the efficiency of how we deliver healthcare as well as reduce costs and pressure on hospitals. 

Essential to this is switching to a community-based system of care delivery focused on preventative strategies as well as early diagnosis and treatment when symptoms develop. However, there are several changes that need to be implemented for this to become a reality: improved access to necessary investigations; more effective interaction between primary healthcare providers and HF specialists; implementing and investing in a multidisciplinary-based approach to community patient care; and better patient/carer education and awareness of the features of heart failure. 

Though there is some cause for optimism, there is still some way to go before there is a system in place that can truly meet the demands heart failure is putting on the healthcare service in Ireland.

References on request