Monday, 10 March 2014

Heart failure: what works?

Heart failure is the end result of most heart diseases, especially ischemic coronary disease. This is a highly prevalent chronic condition among older people (6-10% in those over 65 years), which provides a great disease burden to the healthcare system.

Both for its origin, which is none other than the long-term failure of acute cardiac pathology, as well as for its diagnosis, the cardiologists, and not the family physicians are the ones leading the management of some clinical processes that are almost always torpid and uncertain and which require a lot of action in the community and a lot of coordination between the hospital and primary care; as you can see, it’s not an easy business.

Heart failure, unlike diabetes, is a chronic process that, as I have already mentioned, slips away from the hands of the family doctor. To begin with at the time of diagnosing, because the clinical diagnosis is only presumptive and sending the patient to the hospital for an echocardiogram confirmation is required. It now appears, however, that it has been shown that the "NT-proBNP*" test (Verdú 2012), detectable in both blood and urine testing is sufficiently cost-effective to be able to expect that primary care units could begin to autonomously solve the diagnosis.
(*NT-proBNP. Natriuretic peptides are hormones with diuretic and vasodilator effects, segregated mainly in the left ventricle as a compensatory mechanism for a pressure overload).

What are the programs that work?

A review published in the Health Affairs journal (Sochalski 2009) and a recent Cochrane review (Takeda 2012) give us an idea about which programs are giving better results.

Despite the methodological difficulties of a logical program evaluation of clinical practice, the authors of this work funded by The Commonwealth Fund, after reviewing 10 randomized clinical trials with 2,028 patients, concluded that the programs that are provided with multidisciplinary teams of community clinic action and the practice of “in-person" contact between a trained professional and the patient (we call this ‘nurse case manager’), both significantly reduce readmissions and hospital stays (25% and 30% respectively).

Clinical service organisation following hospital discharge for adults with chronic heart failure.
Takeda A, Taylor SJC, Taylor RS, Khan F, Krum H, Underwood M. Published Online: September 12, 2012.

"Chronic heart failure (CHF) is a serious condition, mainly affecting elderly patients. It is becoming increasingly common as the population ages, and carries high risks of emergency hospitalisation and death. This is an update of an earlier review, including clinical trials published since the previous version".

The Cochrane group reviewed 25 clinical trials involving nearly 6,000 patients and reached the same conclusions as the review published three years earlier in Health Affairs, (nurse case management and community care by a multidisciplinary team are effective actions to reduce hospitalizations), with the addition that the Cochrane review also measures mortality, and concludes that variable case management conducted by a nurse also reduces the mortality of these patients.

And in the meanwhile, what are the English doing?

Given the reform difficulties, the Nuffield Trust initiated a project to explore the role of purchasing services (commissioning) in the integration of clinical teams and care levels. For this post, I have chosen a case of commissioning of an integrated cardiovascular service from the Knowsley area (a post-industrial area between Manchester and Liverpool). In this area, health indicators were below the national average and manifest difficulties of access to health care, particularly in cardiology, which was referred to 4 different hospitals with all kinds of variables that this implies, were observed.

Local authorities designed a new model of cardiovascular -based service:
  1. Single administration for the whole area (one phone, one counter)
  2. Drastically reduce waiting lists for cardiologist visits
  3. Sending cardiologists to the community
  4. Involvement of community nurses in case management
  5. Rehabilitation services, both in community centres and in sports centres
The NHS brought this service to into competition for the period 2009-2013 and the winner was Liverpool Heart and Chest Hospital Trust, which had to take a specification of results which promised 20% of the turnover in the second year and up to 40% the third year. While waiting for the results of the contracted period, a preliminary assessment suggests that the urgency of the known cardiovascular patients has been reduced by 10% and hospitalizations by 12%.

In summary

Heart failure is a chronic condition associated with age, occurring in patients who already are familiar with the ways of the hospital emergency waiting rooms and cardiologists. For this reason, the model that is working so well in Spanish primary care for the management of diabetics doesn’t shape up for the management of patients with heart failures.

As seen in the evidence presented in this post, the intensive monitoring programs that address these patients at community level, both by multidisciplinary teams as well as by case managers (surely cheaper), are proving to be successful in the reduction of hospitalizations, placement and even death, in addition to the seemingly non measurable improvements in the confidence and comfort of the patient. One should also note as usual, that in the absence of cost-effectiveness studies, it’s believed that the expected reduction in hospitalizations should offer a margin big enough to provide for the new community action teams.

Finally, the courage of the English shouldn’t go unnoticed, which in the case of Knowsley, specify in the contract the expected outcomes that, far from fee-for-service, are directed to improvements in clinical outcomes and reductions in unnecessary health consumption. Meanwhile, I think the primary care teams should be repositioned on the evidence that in certain caseloads as in heart failure, specialized activities in the community are quite helpful.


Verdú JM, Comín-Colet J, Domingo M, et al. Punto de corte óptimo de NT-proBNP para el diagnóstico de insuficiencia cardíaca mediante un test de determinaciones rápida en atención primaria. RevEsp Cardiol 2012; 65 (7) :613-9.

Jordi Varela


No comments:

Post a Comment