Referral and use of heart failure clinics: what factors are related to use?

Heart failure clinic inclusion and exclusion criteria: cross-sectional study of clinic's and referring provider's perspectives

OBJECTIVES

There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria.

DESIGN, SETTING AND PARTICIPANTS

Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada.

MEASURES

Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa).

RESULTS

Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines.

CONCLUSIONS

There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes.

Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study

BACKGROUND

Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics.

OBJECTIVE

The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic.

METHODS

An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale.

RESULTS

Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns).

CONCLUSION

Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.

Early Identification and Management of Heart Failure in Patients with Diabetes Mellitus in the United Arab Emirates: A Call to Action

Heart failure (HF) is a common and serious complication of diabetes mellitus (DM) that remains widely under-recognized. Multidisciplinary management protocols for patients with concurrent DM and HF are not widely utilized in the Middle East/Gulf region, particularly in the United Arab Emirates. Since early identification of patients with DM and HF will likely lead to initiation of therapies known to prevent adverse cardiovascular events and subsequently improve patient prognosis, we aim to highlight the importance of early recognition of HF in diabetic patients. We will also describe existing management challenges in the region, especially the lack of multidisciplinary care and emphasize the role of newer anti-diabetic therapies in preventing and treating HF. Most importantly, this call-to-action proposes a collaborative approach to the care of diabetic patients with HF involving primary care physicians, endocrinologists, and cardiologists.

Interconnected Clinical and Social Risk Factors in Breast Cancer and Heart Failure

Breast cancer and heart failure share several known clinical cardiovascular risk factors, including age, obesity, glucose dysregulation, cholesterol dysregulation, hypertension, atrial fibrillation and inflammation. However, to fully comprehend the complex interplay between risk of breast cancer and heart failure, factors attributed to both biological and social determinants of health must be explored in risk-assessment. There are several social factors that impede implementation of prevention strategies and treatment for breast cancer and heart failure prevention, including socioeconomic status, neighborhood disadvantage, food insecurity, access to healthcare, and social isolation. A comprehensive approach to prevention of both breast cancer and heart failure must include assessment for both traditional clinical risk factors and social determinants of health in patients to address root causes of lifestyle and modifiable risk factors. In this review, we examine clinical and social determinants of health in breast cancer and heart failure that are necessary to consider in the design and implementation of effective prevention strategies that altogether reduce the risk of both chronic diseases

Referral and access to heart function clinics: A realist review

RATIONALE, AIM, AND OBJECTIVES

Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics.

METHODS

Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory.

RESULTS

A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome).

CONCLUSION

Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

A 2020 Environmental Scan of Heart Failure Clinics in Ontario

Background

Multidisciplinary heart failure (HF) clinics decrease hospital admission rates and healthcare use, while improving patient outcomes. To understand the contemporary availability of HF clinics in Ontario, Canada, and the services provided, we performed an environmental scan of physician-led and nurse practitioner (NP)–led HF clinics.

Methods

Between November, 2019 and February 2020, we identified Ontario HF clinics led by physicians or NPs. Following an invitation, we conducted a semi-structured interview to evaluate the services offered and qualitatively compared our findings to the results of the 2010 Ontario provincial survey.

Results

The number of HF clinics (36 vs 34 in 2010) and physicians (157 vs 143 in 2010) have not changed since the 2010 survey. Of the 36 clinics we identified, 30 participated in our interview (22 physician-led and 8 NP-led). Twenty-five clinics (83%) were hospital-based, of which 9 (30%) were part of an academic institution. Comparisons of our findings to the 2010 study on 30 clinics show an approximately 3-fold increase (P <0.001) in both median annual and new patient visits. As previously reported, the clinics varied in services offered, but trended toward an increased availability of onsite echocardiography, exercise-stress testing, and nuclear cardiology.

Conclusions

Compared to the survey performed a decade ago, the number of HF clinics and physicians have not changed, and the services provided remain heterogenous. However, the increased number of patients served suggests a greater demand for these clinics. Improving the accessibility of these clinics and standardizing the service model are critical to improving patient outcomes.

[Modern approaches to the organization of care for patients with heart failure]

Chronic heart failure (CHF) is a wide-spread disease (from 7 to 10% in the Russian Federation) and tends to grow. Frequent, repeated hospitalizations of CHF patients are due to insufficient compliance of patients with the treatment and the absence of continuity in management of patients between the hospital and out-patient clinic. Developing a structure of specialized care could provide improvement of treatment quality, a decrease in the number of hospitalizations, and better prognosis. International experience shows that creation of specialized clinics for heart failure improves quality of medical care in CHF and decreases the frequency of re-hospitalizations and mortality. In the Russian Federation, such clinics were created in Nizhniy Novgorod, Ufa, Saint Petersburg, and several other cities. The article presents an expert consensus on the structure, functions, and equipment of departments and offices for patients with heart failure.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Comparative effectiveness of the different components of care provided in heart failure clinics-protocol for a systematic review and network meta-analysis

BACKGROUND

Heart failure (HF) is a complex chronic condition, leading to frequent hospitalization, decreased quality of life, and increased mortality. Current guidelines recommend that multidisciplinary care be provided in specialized HF clinics. A number of studies have demonstrated the effectiveness of these clinics; however, there is a wide range in the services provided across different clinics. This network meta-analysis will aim to identify the aspects of HF clinic care that are associated with the best outcomes: a reduction in mortality, hospitalization, and visits to emergency department (ED) and improvements to quality of life.

METHODS

Relevant electronic databases will be systematically searched to identify eligible studies. Controlled trials and observational cohort studies of adult (≥ 18 years of age) patients will be eligible for inclusion if they evaluate at least one component of guideline-based HF clinic care and report all-cause or HF-related mortality, hospitalizations, or ED visits or health-related quality of life assessed after a minimum follow-up of 30 days. Both controlled trials and observational studies will be included to allow us to compare the efficacy of the interventions in an ideal context versus their effectiveness in the real world. Two reviewers will independently perform both title and abstract full-text screenings and data abstraction. Study quality will be assessed through a modified Cochrane risk of bias tool for randomized controlled trials (RCTs) or the ROBINS-I tool for observational studies. The strength of evidence will be assessed using a modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. Network meta-analysis methods will be applied to synthesize the evidence across included studies. To contrast findings between study designs, data from RCTs will be analyzed separately from non-randomized controlled trials and cohort studies. We will estimate both the probability that a particular component of care is the most effective and treatment effects for specified combinations of care.

DISCUSSION

To our knowledge, this will be the first study to evaluate the comparative effectiveness of the different components of care offered in HF clinics. The findings from this systematic review will provide valuable insight about which components of HF clinic care are associated with improved outcomes, potentially informing clinical guidelines as well as the design of future care interventions in dedicated HF clinics.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058003.

Improving care for patients with acute heart failure: before, during and after hospitalization

Acute heart failure (AHF) is a common and serious condition that contributes to about 5% of all emergency hospital admissions in Europe and the USA. Here, we present the recommendations from structured discussions among an author group of AHF experts in 2013. The epidemiology of AHF and current practices in diagnosis, treatment, and long-term care for patients with AHF in Europe and the USA are examined. Available evidence indicates variation in the quality of care across hospitals and regions. Challenges include the need for rapid diagnosis and treatment, the heterogeneity of precipitating factors, and the typical repeated episodes of decompensation requiring admission to hospital for stabilization. In hospital, care should involve input from an expert in AHF and auditing to ensure that guidelines and protocols for treatment are implemented for all patients. A smooth transition to follow-up care is vital. Patient education programmes could have a dramatic effect on improving outcomes. Information technology should allow, where appropriate, patient telemonitoring and sharing of medical records. Where needed, access to end-of-life care and support for all patients, families, and caregivers should form part of a high-quality service. Eight evidence-based consensus policy recommendations are identified by the author group: optimize patient care transitions, improve patient education and support, provide equity of care for all patients, appoint experts to lead AHF care across disciplines, stimulate research into new therapies, develop and implement better measures of care quality, improve end-of-life care, and promote heart failure prevention.

Heart failure clinics are still useful (more than ever?)

Heart failure (HF) clinics have had an important role in optimal HF management and the effectiveness of these clinics has been studied intensively. A HF clinic is one of the various ways to organize a HF disease management program. There is good evidence that HF disease management can improve outcomes in HF patients, but it is not clear what the optimal components of these programs are and what the relative effectiveness of a HF clinic is compared with other forms of HF management. After initial positive reports on the effect of HF clinics, these clinics were implemented in many countries, although in different formats and of varying quality. In this article we describe the initial need for HF clinics, reflect on their development over time, and discuss the role of HF clinics in context of the current need for HF disease management.

A prospective examination of disease management program use by complex cardiac outpatients

BACKGROUND

The use of disease management programs (DMPs) by patients with cardiovascular disease (CVD) is associated with improved outcomes. Although rates of cardiac rehabilitation (CR) use are well established, less is known about other DMPs. The objectives of this study were to describe the degree of DMP utilization by CVD outpatients, and examine factors related to use.

METHODS

This study represents a secondary analysis of a larger prospective cohort study. In hospital, 2635 CVD inpatients from 11 hospitals in Ontario Canada completed a survey that assessed factors affecting DMP utilization. One year later, 1803 participants completed a mailed survey that assessed DMP utilization.

RESULTS

One thousand seventy-three (59.5%) participants reported using at least 1 DMP. Overall, 951 (52.7%) reported participating in cardiac rehabilitation, and among participants with a comorbid indication, 212 (41.2%) reported attending a diabetes education centre, 28 (25.9%) attended stroke rehabilitation, 35 (12.9%) used a heart failure clinic, and 13 (11.7%) attended a smoking cessation program. A multinomial logistic regression analysis showed that compared with no DMP use, participants that attended 1 or multiple programs were younger, married, diagnosed with a myocardial infarction, less likely to have had a percutaneous coronary intervention and had higher perceptions of personal control over their heart condition. There were few differences between participants that used 1 vs multiple DMPs, however, having diabetes or comorbid stroke significantly increased the likelihood of multiple DMP use.

CONCLUSIONS

Approximately 40% of CVD outpatients do not access DMPs. An integrated approach to vascular disease management appears warranted.