Post on 28-Sep-2020
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)
m.cowie@imperial.ac.uk
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
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
www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx
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
www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx
High hospital readmission rates
www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx
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 (%)
Cardiology ward 55 44
General medical ward 36 46
Other ward 9 11
Place of care 16-74 (%) ≥75 years (%)
Cardiology ward 65 43
General medical ward 29 46
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
http://www.bsh.org.uk/resources/national-heart-failure-audit/
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
http://www.bsh.org.uk/resources/national-heart-failure-audit/
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
http://www.bsh.org.uk/resources/national-heart-failure-audit/
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