Point/Counterpoint
Specialist Heart Failure Clinics Must Evolve to Stay Relevant

https://doi.org/10.1016/j.cjca.2013.12.022Get rights and content

Abstract

The widespread acceptance of heart-failure (HF) clinics is based on studies with poor and poorly-described care. This led to HF-clinic proliferation, often with access for a small percentage of younger, healthier and generally affluent patients. This system fails to provide the essential timely access to specialist-team consultation following hospital-discharge. Recent well-conducted randomized trials of HF-clinic care found no benefit over usual care. To provide optimal value, HF-clinics must evolve to devote resources to timely assessment/reassessment and close follow-up of selected high-risk/advanced HF patients, along with timely support of the primary-care team that will assure the bulk of routine HF care.

Résumé

L’acceptation généralisée des cliniques d’insuffisance cardiaque (IC) repose sur des études montrant des soins médiocres ou décrits comme étant médiocres. Cela a mené à la prolifération des cliniques d’IC, souvent accessibles à un pourcentage restreint de patients plus jeunes, en meilleure santé et habituellement mieux nantis. Ce système n’a pas offert l’accès en temps opportun à la consultation essentielle de l’équipe de spécialistes à la suite du congé de l’hôpital. Les récents essais aléatoires menés avec rigueur sur les soins offerts par les cliniques d’IC n’ont montré aucun avantage par rapport aux soins habituels. Pour offrir une valeur optimale, les cliniques d’IC devront consacrer leurs ressources à l’évaluation et à la réévaluation en temps opportun et offrir un suivi étroit aux patients ayant une IC avancée et étant exposés à un risque élevé, parallèlement à un soutien plus opportun de l’équipe de soins primaires qui assurera la majeure partie des soins courants aux patients atteints d’IC.

Section snippets

Evidence Supporting HF Clinics: Significant Deficiencies

Previous authors8 have taken issue with existing meta-analyses of HF clinics and have identified several drawbacks, such as small number of included studies, disproportionate representation from 1 large study, poorly described and heterogeneous interventions, poor descriptions of the patient populations (especially with respect to patient diversity), varying time horizon of assessment (as little as 3 months of follow-up), and virtually no description of usual care. All of these shortcomings

Heterogeneity of HF Clinic Models and Patient Populations

I will focus on 2 of these criticisms—the heterogenous nature of the HF clinic intervention, and the lack of description of usual care. In terms of the intervention, most studies described the personnel involved in a HF clinic (usually including an HF specialist physician and nurse, clerical support, occasionally pharmacists), planned visit frequency, and a list of general topics to cover during visits. No other methods were provided. The result was that each clinic developed its own version of

How Should We Compare With Usual Care Considering Changing Outcomes?

In addition, only the Trans-European Network-Home-Care Management System (TEN-HMS) study13 delineated baseline care intensity and type for the patients who were enrolled, although this was only by way of the number of visits to primary care (urgent or nonurgent) in a table. Only 1 other study reported primary care visits (Cleland, 2005)13 or described the goals or rationale of care in the usual care group. As a result, we only know that patients in the active treatment group received some type

HF Clinics Fail in Recent Studies

Not all studies have reported a positive outcome, and some of these were the largest ever performed. Many of these were reported after the previously mentioned analyses.23, 24, 25, 26, 27, 28 The TEN-HMS study, an evaluation of telemonitoring, nurse phone support, or usual care for patients with ambulatory HF, actually showed a large and statistically significant increase in total days in hospital over the first 240 days of follow-up (813 days in 69 usual care patients, 2514 in 170 nurse

The Need for Primary Care and Its Evolution

Patients with HF also suffer from other noncardiac conditions. Braunstein et al. reported results from a cohort of more than 120,000 US Medicare beneficiaries.34 More than 80% of patients in this cohort suffered from more than 5 concomitant conditions. In this report, more than 50% of reviewed hospitalizations were judged to be potentially preventable with half due to HF and the other half due to infection/chronic obstructive pulmonary disease exacerbation.34 Because specialist-led HF clinics

Access to Timely HF Care: A Major Barrier

At present there are between 400,000 and 500,000 patients with HF in Canada.19, 35, 36 It is estimated that less than 15% of HF patients have access to HF clinics, which is a generous assessment.36, 37, 38 In 1 cohort study of access to HF clinics in a large urban area (where HF clinic access is enhanced), only 13% reported attendance in a HF clinic within 1 year of admission to a hospital for HF.12 Even if HF clinics were universally effective, it would be impossible to fund all of the HF

What Value Can HF Clinics Offer?

So what can the specialty HF clinic offer to this? Much (Table 1). For instance, newly diagnosed HF patients face an enlarging array of potential treatments and investigative strategies, some of which are not accessible to primary care providers. Determination of volume status for many patients with HF can be challenging and comorbid conditions frequently affect the ability to deliver optimal dosages of evidence-based therapy. Newer treatments need to be evaluated. Implantable monitors and

A Sea Change in HF Clinic Focus and Operation

The scenario outlined represents a sea change in how HF clinics would work in Canada. Over the course of many years I have noted admission and referral patterns for more than 10 HF clinics. Most clinics will allocate between 80% and 90% of visit slots for returning patients with the balance allocated for new referrals. This observation is in keeping with data from the Canadian Heart Failure Network, in which most HF clinics allocate >90% of visit capacity for repeat visits of existing patients.

Disclosures

The author is President of the Canadian Heart Failure Society and has authored Heart Failure Guidelines, which support specialist HF clinics for treatment of HF.

References (43)

  • S.D. Anker et al.

    Telemedicine and remote management of patients with heart failure

    Lancet

    (2011)
  • J.B. Braunstein et al.

    Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure

    J Am Coll Cardiol

    (2003)
  • H. Ross et al.

    Treating the right patient at the right time: access to heart failure care

    Can J Cardiol

    (2006)
  • D.E. Feldman et al.

    Access to heart failure care post emergency department visit: do we meet established benchmarks and does it matter?

    Am Heart J

    (2013)
  • J. Howlett

    I have heart failure - what happens now, Doc?

    Can J Cardiol

    (2009)
  • J.G. Howlett et al.

    The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

    Can J Cardiol

    (2010)
  • M.W. Rich et al.

    A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure

    N Engl J Med

    (1995)
  • M.W. Rich et al.

    Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study

    J Gen Int Med

    (1993)
  • J. Gonseth et al.

    The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports

    Eur Heart J

    (2004)
  • R.A. Clark et al.

    Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis

    BMJ

    (2007)
  • R. Holland et al.

    Systematic review of multidisciplinary interventions in heart failure

    Heart

    (2005)
  • Cited by (12)

    • The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey

      2020, CJC Open
      Citation Excerpt :

      A key finding of our survey is a lack of consistency in identifying the group of patients deemed to be most appropriate for HFC services. This phenomenon has been recently described in the Canadian context17 and relates to the following factors: A mismatch between HFC entry criteria and a given patient’s clinical risk profile.

    • The Need for Heart Failure Advocacy in Canada

      2017, Canadian Journal of Cardiology
    • Team-Based Care for Outpatients with Heart Failure

      2015, Heart Failure Clinics
      Citation Excerpt :

      The earliest description of specialized HF clinics was in 1983.25 However, greater development did not take significant shape until a landmark pilot study by Rich and colleagues26,27 in 1993 when they demonstrated fewer hospital readmissions and a decreased number of hospital days in the HF multidisciplinary intervention group.28 Later studies implementing team-based HF clinic interventions also reported improved functional status, quality of life, and HF medication optimization, and reduction in hospital readmissions, length of hospital stay, and health care costs.29–37

    View all citing articles on Scopus

    See article by Jaarsma and Strömberg, pages 272-275 of this issue.

    See page 279 for disclosure information.

    View full text