Multidisciplinary coordinated services, drug titration plans and patient registries have been crucial to improving the quality of care for patients with chronic heart failure in Queensland. We’ve spoken to Associate Professor John Atherton, Director of Cardiology at the Royal Brisbane and Women’s Hospital about how each of these three elements have contributed to the ultimate goal of improving patient outcomes.
Evidence for multidisciplinary care
Queensland patients with heart failure are managed within a coordinated statewide service, the processes and outcomes of their care are monitored within a dedicated registry, and effective dosing of their medication is driven by formal titration plans.
Associate Professor John Atherton, Director of Cardiology at the Royal Brisbane and Women’s Hospital, says the multidisciplinary approach to care throughout the state simply aims to improve patients’ outcomes, and has evolved over more than a decade.
“We were aware of the findings from an Adelaide study from 1999, showing benefits of a multidisciplinary, home-based intervention for heart failure patients,” he told the limbic.1
During the study a cardiac nurse visited patients at home 7 to 14 days after discharge for a comprehensive review of their physical health, understanding of the disease, medication use, physical activity and social supports, arranging any necessary follow-up and further care.1
The combined primary endpoint of unplanned readmission or out-of-hospital death within 6 months was reduced by 40%.1
Australian heart failure guidelines also endorse multidisciplinary programs of care, stating that programs targeting high-risk patients after acute hospitalisation for heart failure prolong survival, improve quality of life, and are cost-effective.2
The guidelines also state that all patients hospitalised for heart failure should have post-discharge access to best-practice multidisciplinary care that is linked with health services in both acute and subacute settings.2
“Heart failure teams at the Princess Alexandra Hospital and the Royal Brisbane and Women’s Hospital worked on implementing the evidence base for comprehensive care, and showed it was feasible and effective,” Professor Atherton said.
A seamless system of care
The success of the local initiatives led to funding for a statewide program, introduced in 2006, which now includes 23 sites extending from the densely-populated south-east corner to Townsville, Cairns and Mount Isa.
The service (see https://www.health.qld.gov.au/heart_failure/ for more details) aims to improve the quality of care for patients with chronic heart failure by supporting initiatives such as clinical teams including nurses, allied health and doctors, as well as initiation and titration of evidence-based medication, not just in hospital but also in the community.
Other aims include education and counselling for patients, education programs for healthcare professionals, development and implementation of protocols for palliative care in end-stage disease, and data collection to facilitate audits and improved clinical care.
The services have specialist heart failure nurses and some also have dedicated pharmacists, physiotherapists, exercise physiologists, occupational therapists, dietitians, social workers and psychologists.
Their activities include follow-up through home visits, phone calls or clinics visits, patient and carer education, self-management strategies addressing weight, diet and exercise, medication review, and social and psychological support.
“A key step in heart failure management is the transition from inpatient to outpatient care,” Professor Atherton said.
“Careful communication with GPs and other providers is essential at this point, and it’s an important function of the service.”
The service can also accept referrals of high-risk patients direct from the community, rather than after a hospital admission.
Current European Society of Cardiology (ESC) heart failure guidelines, due to be updated this year, also stress the need for a ‘seamless’ system of care, “…embracing both the community and hospital, to ensure that the management of every patient is optimal, from the beginning to the end of their healthcare journey.”3
Up-titrating medication
Professor Atherton and his colleagues have been instrumental in developing a standardised template for titrating heart failure medication to target doses, and an associated guide to problem-solving, which is used throughout the statewide service.
The form for the Heart Failure Medication Titration Plan emphasises that titration to maximum tolerated doses of an ACE inhibitor, beta-blocker and mineralocorticoid receptor antagonist reduces mortality in left ventricular systolic heart failure.
ESC heart failure guidelines reinforce that doses of these medications should be up-titrated as far as possible before discharge, and a plan made to complete up-titration after discharge.3
The Queensland plan defines which drug should be titrated first and the schedule for dose increases of each drug. It also includes the appropriate adjustment of diuretic doses in response to fluid overload or dehydration.
“The plan nominates the person responsible for the titration, which is often the patient’s GP in the community,” Professor Atherton says.
“We want to minimise potential confusion about who is controlling the dosing, and make sure that titration actually happens.”
The problem-solving guide focuses on the best response to issues such as adverse effects, declining renal function and worsening symptoms or signs of heart failure.
A study by Professor Atherton’s group, presented at the ESC annual congress in 2015, audited medication use before and after the plans were introduced and heart failure services became eligible for incentive payments where these plans were put into practice.4
They showed increased completion of the plans throughout the study, and an increase in the use of ACE inhibitors/ARBs (from 24% to 41%, p=0.11) and beta-blockers (from 29% to 45%, p=0.036) at target doses.
“There is still room for improvement,” Professor Atherton says. “In clinical trials showing the benefits of these drug classes, target doses were usually achieved in more than 50% of patients.”
Monitoring performance: the HERO registry
Queensland State-wide Heart Failure Services have developed and implemented the Heart Failure Evaluation and Reporting of Outcomes (HERO) registry to monitor the processes and outcomes of patients within their care. It is located as a module within the broader Queensland Cardiac Outcomes Registry (QCOR), which also includes interventional cardiology, cardiac surgery, electrophysiology and cardiac rehabilitation services.
“QCOR provided us with a mechanism for developing HERO. It was established only last year and is still evolving,” Professor Atherton explained. “It captures about 3,500 new heart failure referrals a year and is linked to a death registry and readmission data.”
To his knowledge, HERO is unique in Australia. In some respects it resembles the United Kingdom National Heart Failure Audit, which has now collected over 200,000 records of heart failure-coded hospital episodes (see https://www.ucl.ac.uk/nicor/audits/heartfailure).
The UK audit aims to capture data on clinical indicators that have proven links to better outcomes, and to encourage the increased use of recommended diagnostic tools, treatments and referral pathways.
Participation in the audit has been compulsory for English NHS Trusts since 2011 and mandatory in Wales since 2012.
“Mortality rates for heart failure patients are high, with 40% of newly diagnosed patients dying within a year and 50% of patients either readmitted to hospital or dying within a year of admission to hospital,” the audit’s website states.
“Despite these poor outcomes, early diagnosis, optimal treatment and responsive management can result in significantly increased life expectancy, as well as better quality of life for heart failure patients”.
Professor Atherton said key indicators for the Queensland service, assessed within HERO, include follow-up of inpatient referrals within 2 weeks of discharge (with a target of 80%), assessment of left ventricular ejection fraction within the last two years (target 90%), the proportion of inpatients prescribed an ACEI/ARB and beta-blocker (carvedilol, metoprolol XL, bisoprolol or nebivolol) at discharge, and beta-blocker target dose achieved at 6 months.
“It’s very difficult to improve these standards of care across the service unless you can measure and analyse them,” Professor Atherton said.
References
- Stewart S et al. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999; 354: 1077-83.
- Krum H et al. 2011 update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Med J Aust 2011; 194: 405-9.
- McMurray JJ et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787-847
- Atherton JJ et al. Impact of standardised medication titration forms and incentive payments on medication titration in heart failure: should we pay for more? Eur Heart J 2015; 36 (Abstract Supplement ): 556. Abstract P3349.