a global perspective on heart failure: what needs to change?...van deursen vm et al. co-morbidities...

A Global perspectiveon Heart Failure:

What needs to change?

Martin R Cowie

London, United Kingdom

Global perspective on heart failure: what needs to change?

Martin R CowieProfessor of Cardiology

National Heart & Lung Institute

Imperial College London (Royal Brompton Hospital Campus)

[email protected]

Heart failure: a worldwide burden

1. Ambrosy PA et al. The Global Health and Economic Burden of Hospitalizations for Heart Failure. Lessons Learned From Hospitalized Heart Failure Registries. J Am Coll Cardiol. 2014;63:1123–1133. 2.

Cowie MR et al. Improving care for patients with acute heart failure. 2014. Oxford PharmaGenesis. ISBN 978-1-903539-12-5. Available online at: http://www.oxfordhealthpolicyforum.org/reports/acute-heart-

failure/improving-care-for-patients-with-acute-heart-failure 3. van Deursen VM et al. Co-morbidities in patients with heart failure: an analysis of the European Heart Failure Pilot Survey. Eur J Heart Fail.

2014;16:103-111.

26 million

Number of heart failure patients worldwide.1

Health care expenditure attributed to heart failure in Europe and North America.2

1-2%

74% Heart failure patients suffering from at least 1 comorbidity: more likely to worsen the patient’s overall health status.3

http://www.oxfordhealthpolicyforum.org/reports/acute-heart-failure/improving-care-for-patients-with-acute-heart-failure

Prevalence of HF

www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx

The cost of heart failure is driven by hospitalisation

British Heart Foundation, 2002 (updated to 2014)

Total cost > GBP 1 billion (1% of annual NHS budget)

(11-13 visits per year)Outpatient investigation 6%

Outpatient care

8%

Drugs

9%

Primary Care

17%

Inpatient care

60%

Number and proportion of HF hospitalisations


Heart failure accounts for 1–3% of European hospital admissions

USA (2007)

2.9%

LOS 5.3d

Sweden (2011)

2.2%

LOS 6.4d

Norway (2008)

1.1% Netherlands (2010)

1.5%

Poland (2010)

1.9%

LOS 8d

Austria (2010)

1.0%

LOS 7.3d

Germany (2007)

2.0%

Switzerland

(2011)

1.1%

Spain

(2011)

1.8%

LOS 7.5d

England

(2011–12)

0.4%

LOS 7d

France

(2008)

1.1%

LOS 9.9d

Length of stay for AHF

Trends in HF hospitalisation


High hospital readmission rates


Co-morbidity is universal

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf

The runaway train.....?

We will have to do things differently...

National guidance & quality standards

August 2010

Update scheduled

October 2014 June 2011

http://www.nice.org.uk

AHA recommendations for hospital discharge: 2013

Yancy CW et al. Circulation 2013; 128: e240 – 327

ESC 2012 guidance

McMurray et al. Eur Heart J 2012;33:1787–847

Pre-discharge and long-term management

Plan follow-up strategy

Enrol in disease management program, educate, and initiate appropriate lifestyle adjustments

Plan to up-titrate/optimize dose of disease-modifying drugs

Ensure assessed for appropriate device therapy

Prevent early readmission

Improve symptoms, quality of life and survival

What is actually happening?

UK: assessing ‘hospital’ adherence

● Six performance metrics:

● ACEI/ARB on discharge

● Beta-blocker on discharge

● Echo during admission

● Treated on cardiac ward

● Cardiology follow-up

● HF nurse follow-up

Data from 92% of the 150 hospitals

in England & Wales

>40 000 HF admissions per year

60% of total HF admissions

http://www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/hfannual12-13.pdf

Place of Care

Place of care Index admission (%) Readmission (%)

Cardiology ward 50 52

General medical ward 40 37

Other ward 10 11

Place of care Men (%) Women (%)



Other ward 9 11

Place of care 16-74 (%) ≥75 years (%)



Other ward 6 11

Specialist Input

http://www.bsh.org.uk/resources/national-heart-failure-audit/

Specialist First admission (%) Readmission (%)

Consultant cardiologist 57 61

Heart failure nurse specialist 22 20

Other consultant with interest in heart failure 6 6

Any HF specialist 78 80

Other clinician 22 20

Input from HF MDT 66 70

Treatment


Medication

Total prescribed

(%)

ACE inhibitor 73

ARB 18

ACEI and/or ARB 85

Beta blocker 82

MRA 49

ACEI and/or ARB, beta blocker and MRA 39

Loop duiretic 91

Thiazide diuretic 5

Digoxin 22

Treatment on discharge for LVSD

100

90

80

70

60

50

40

30

20

10

0

16-44 45-54 55-64 65-74 75-84 85+

Age Group

% P

res

cri

pti

on

ACEI and/or ARB

Beta

ACEI

Loop diuretic

MRA

ARB

Prescription of secondary prevention medication

by age

Treatment and Specialist Input


Medication

Seen by any HF

specialist (%) No specialist input (%)

ACE inhibitor 75 62

ARB 18 19

ACEI and/or ARB 87 76

Beta blocker 85 69

MRA 53 32

ACEI and/or ARB, beta blocker and

MRA42 19

Loop diuretic 91 93

Thiazide diuretic 6 3

Digoxin 22 21

Treatment on discharge for LVSD by specialist input

Discharge Planning


Follow-up appointment Total (%)

Follow-up appointment with MDT scheduled 56

Appointment scheduled within two weeks of discharge 34

0 5 10 15 20+

Ho

sp

itals

Length of stay (median) in days

Median length of stay by hospital

Cardiology follow-up in England....poor!70 000 survivors of HF admission. England, 2009-11.

Bottle A et al. Under review Bottle A et al. In review.

Quality and Outcomes Framework in Primary Care

Not all HF patients receive guideline care in the USA

● Wide variations in hospital performance have been reported

0

20

40

60

80

100

Com

plia

nce (

%)

25th percentile50th percentile75th percentile90th percentile

10th percentile

Discharge

instructions

Smoking

counselling

Medication at

discharge

LV function

assessed

Adherence

Adherence by physiciansMAHLER Study in 6 European countries

Komajda M et al. Eur Heart J 2005; 26: 1653-59.

Adherence = physician following ESC guidelines

for use of ACE inhibitors, β-blockers & spironolactone

NB suppressed zero

Adherence by physiciansMAHLER Study in 6 European countries

Predictors of time to CV hospitalization on multivariable Cox model

Komajda M et al. Eur Heart J 2005; 26: 1653-59.

Factor Hazard Ratio 95% CI P value

NYHA III vs II 1.72 1.29-2.30 0.0002

CHF hosp in past year 1.84 1.38-2.44 <0.0001

Adherence (high vs low) 0.64 0.41-1.00 0.048

Ischaemic aetiology 1.44 1.08-1.91 0.013

Atrial fibrillation 1.34 1.01-1.78 0.045

Diabetes 1.43 1.05-1.93 0.022

Hypertension 0.70 0.53-0.93 0.012

North AmericaCanada

South AmericaEcuador

Eastern EuropeHungary RomaniaBelarus PolandLithuania SlovakiaAustria Russia

Ukraine

AsiaBruneiChinaKoreaMalaysiaThailand

Middle EastBahrain JordanKuwait

KazakhstanOman TurkeyQatar LebanonUAE Egypt

CaucasusArmeniaGeorgiaAzerbaijanAfricaMorocco

Australia

EuropeIreland Germany

Portugal Denmark

Spain GreeceFrance

547 centers in 36 countries

Enrolled between August 2012 and December 2014

Financial Penalties

“Best-practice” based tariff

A community-wide approach is essential

Other approaches?

Policy-makers urged to act

on eight recommendations

Optimize care transitions

Improve patient education

and support

Provide equity of care

for all patients

Appoint experts to lead heart failure across

disciplines

Stimulate research into

new therapies

Develop and implement better measures of care

quality

Improve end-of-life care

Promote acute heart failure prevention

www.oxfordhealthpolicyforum.org

/AHFreport

www.escardio.org/communities/HFA/Pages/

global-heart-failure-awareness-programme.aspx

Conclusions

● HF is a global burden

● Policy makers are paying close attention to HF care

● Peformance metrics are increasingly in use

● Rapid access for all patients to timely diagnosis and

treatment is a challenge for ALL healthcare systems

● The age and level of co-morbidity is rising rapidly

● New approaches are needed to face current and future

challenges

a global perspective on heart failure: what needs to change?...van deursen vm et al. co-morbidities...

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