High Heart Failure Rehospitalization and Mortality

Heart failure (HF) in the Middle East is a major public health problem. Recent data from Gulf Acute HF Registry (CARE) involving 7 Middle East countries have shown unacceptably high 1-year mortality.[1] In addition, postdischarge outcomes after admissions for HF have remained high. Rehospitalization and cumulative mortality at 3 and 12 months were 18%/13% and 40%/20%, respectively. These data are similar to older Western data with 30-day readmission[2] and 1-year postdischarge mortality.[3] The Trivandrum HF registry from India showed 3-year mortality at 44%.[4] Patients who survived the index hospitalization and had no additional hospital readmissions were less likely to die than participants who experienced ≥1 readmissions over time.[4] Data available from global studies conducted in higher income countries, including Global Congestive HF (CHF) Registry and Inter CHF Registry, confirm the high mortality in India.[4] Furthermore, the number of HF patients in these regions is expected to increase significantly over the coming years, through a combination of an aging population, improvements in treatment especially acute coronary syndrome and rheumatic heart disease, and the survival of patients with heart problems.[4,5] In addition to high mortality and rehospitalization, the personal burden of HF to the patient includes intolerable symptoms, functional limitation, and overall poor quality of life. CURRENT MANAGEMENT OF HEART FAILURE From the Gulf CARE study results, Oman data showed high mortality and rehospitalization.[6] Within 12-month follow-up, one in two patients was rehospitalized for acute HF. In-hospital mortality was 7.1%, which is doubled to 15.7% at 3 months and reached 26.4% at 1-year postdischarge.[6] The in-hospital mortality was acceptable compared to other Western countries suggesting satisfactory in-hospital care. However, long-term outcomes were poor. The in-hospital mortality was slightly higher in Indian registry at 8.5%.[4] There are many factors for this disturbing results with regard to HF management. In these countries, postdischarge from tertiary or secondary hospitals, HF patients are followed up by general practitioners in the regional health centers. The important causes for poor HF postdischarge outcome could be nonintegration of evidence-based treatments recommended in HF guidelines into routine clinical practice by the busy general practitioners. In addition, failure of patient's compliance to diet/medications as well as follow-up may be due to lack of proper education. This contributes to the high rates of rehospitalization, and mortality seen with HF. The current state of HF care in many countries involves a vicious cycle of acute emergency care in the emergency department (ED) with or without hospitalizations and outpatient care by a primary physician. This has not led to much change in rehospitalization or long-term mortality rates. In a study, patients discharged from ED after stabilization of decompensated HF, 61% returned to the ED or were admitted to the hospital within 3 months.[7,8] In an outpatient setting, many HF team programs have reported better morbidity outcomes (subsequent hospitalizations, length of hospital stay, quality of life, and exercise tolerance) after as little as 3 months of program implementation.[8] Data from Western countries like Get with the Guidelines – HF registry has shown improving adherence to guideline-recommended therapies when in and outpatient HF team management is implemented.[9] Numerous published studies from this program demonstrate the program's success in achieving significant patient outcome improvements. Thus, it is shown that care for patients with HF ideally integrates inpatient and outpatient health-care delivery with goals of reducing symptoms, improving health status, increasing functional capacity, decreasing the need for hospitalization, and prolonging life. There has been tremendous interest regarding “HF clinic-based” and/or “team-based” care for HF in achieving these goals. Currently, there are few HF clinic-based or team-based care approaches in these countries. ESTABLISHING A TEAM-BASED HEART FAILURE CARE Team-based HF care is important in the prevention and treatment of HF. This can be organized in the following way. In the tertiary and secondary care hospitals, a separate “HF team” has to be established along with a “HF clinic,” whereas in the primary health centers, a “care coordinator” to be identified for outpatient HF patients. HF team is the need of the hour to reduce rehospitalization and mortality in these countries. This team will be involved in the “inpatient” management of HF patients before discharge from hospital. Team may include a cardiologist and/or physician, clinical pharmacist, HF trained nurse, and a dietician. The main staff for a successful HF program often comprises a cardiologist and a HF nurse. Initially, it is better to start with small team and then expand the team members according to availability or as new recruitment. As mentioned above, the HF teams in larger hospitals can be involved in the 'inpatient' management of admitted HF patients. Instead of referring to general cardiologist, the patient can be referred to 'HF team' which can evaluate the patient and advice guideline recommended investigations/evidence-based therapies and plan for postdischarge follow-up in the HF clinic so that continuity of care is there. Team-based care for HF should have well-defined objectives and should ensure: Inpatient assessment for guideline-recommended investigations and treatment Timely follow-up of patients postdischarge from hospital with the HF clinic To liase with “care coordinator” of primary health center for further follow-up of patients. ESTABLISHING A HEART FAILURE CLINIC It is well known that there is progression of HF even when the patient remains asymptomatic with progressive deterioration in systolic or diastolic function. Drug therapies that promote reversal of ventricular remodeling or prevent its progression benefit patients by decreasing symptoms and prolonging survival. Many patients are lost to follow-up or treated inappropriately by doctors not well versed with HF management. An important aspect of disease management is the establishment of a “HF clinic” for continuity of care and more important appropriate care by HF team. A HF clinic program must have the following objectives: Confirmation of diagnosis Appropriate assessment of clinical status specifically volume status, dry weight Appropriate follow-up of investigations specifically renal function Guideline-directed medical therapy goals which must be achieved specifically with regard to medications up titration Appropriate advice on HF diet and compliance to diet and medications Comorbid conditions must be managed effectively Increase patient and family understanding of their condition and treatment options Guide patients toward supportive resources to promote adherence of the plan of care and wellness. ROLES OF DIFFERENT HEART FAILURE TEAM MEMBERS Administration Hospital administration should take important role in establishing team-based HF care. HF team requires dedicated staff and financial resources. Ideally, HF team must have an administrator who can support the program at executive levels, providing the necessary funds to establish and maintain the team.[10] Emergency department Although HF is a chronic outpatient condition, most of patients will get admitted with acute decompensation of chronic HF or present first time as de novo acute HF. During working hours, emergency medicine physicians should initiate appropriate therapy and should be aware of HF team and must refer to the team for opinion before stabilizing the patient and discharging home. If patient needs admission, HF team will be consulted and taken opinion appropriately. After-hour ED visits involves solely the ED physician who must be aware of presence of HF team/clinic in the hospital and give appropriate follow-up to HF clinic if patient being discharged from ED or if needed, should admit after involving on-call cardiology or physician teams. Admitted patients can be seen by inpatient HF team next day. In addition, in some countries, ED personnel may be the sole care providers for urgent HF care and hence must be included in the team and trained.[10] Cardiologist or physician Cardiologists who are specialized in HF management typically lead the HF management program. In hospitals where cardiologists are not available, physicians trained in HF can do this job. Many studies have demonstrated that HF outcomes are better when patients are admitted under cardiologist.[11,12] During this initial admission, it is very important for the diagnosis to be confirmed, precipitating factors addressed, evidence-based therapies initiated, comorbidities investigated and treated. Post discharge appropriate appointment in HF clinics within 2 weeks must be given as recommended by many guidelines. According to the European Society of Cardiology HF Association Standards for delivering HF care, it was suggested that all tertiary hospital referral centers should have among their cardiology staff/faculty an individual with a specific interest and expertise in HF.[13] Being the team leader, the cardiologist is having the following roles: Provides medical knowledge and experience in the management of HF and evaluates for underlying causes, initiation and interpretation of diagnostic tests, and selection of appropriate treatment with appropriate dose/device Drafts and/or approves protocols developed for the HF program and updates the protocol often Ensures that other caregivers apply the protocol and evidence-based therapies in the management of HF Physicians/doctors/nurses education who are involved in HF care Initiates quality assurance or performance improvement initiatives. Nurses Nursing role is equally important in the care of the patients hospitalized with HF: Medication administration Patient education Assess worsening or improvement in clinical status or symptoms. In a cardiologist- or physician-lead clinic, nurses assist with patient management. In a nurse-lead care, an initial management is made by cardiologists. Subsequently, advanced practice nurses have primary responsibility for the management of patients and may see patients independently or in collaboration with cardiologists.[14] In a randomized trial of postdischarge education provided by knowledgeable cardiac nurses, 1-year readmission rates decreased by 39% and combined 1-year hospitalization or death also decreased significantly (risk reduction: 31%, P = 0.01).[15] Pharmacist Clinical pharmacists have an important role in educating the patient about the evidence-based medications, its usefulness, side effects, laboratory monitoring when needed and ensure medication adherence through education during an inpatient stay and in the HF clinic. Several randomized controlled studies performed in multiple continents found that integrating clinical pharmacists in the care of patients with HF results in reduced hospitalizations, which has led to the recommendation that clinical pharmacists be part of the team caring for patients with HF by the HF Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network.[16] Dietician Dietician should ensure patient understand what is low-sodium diet, fluid restriction, dry weight, and weight measurement at home. They should give written instructions to patient. In addition, they may be required to perform complex nutritional assessments because of other comorbidities, such as diabetes and hyperlipidemia. PHYSICAL AND OCCUPATIONAL THERAPISTS HF patients have decreased mobility due to fatigue, reduced exercise capacity, reduced flexibility, and conditioning due to lengthy hospitalization. Inpatient and HF clinic patient assessment and education about activity recommendations and strategies with or without aids for dealing with activities of daily living will help patient in mobilization.[10] SOCIAL WORKER/CASE MANAGER It has been observed that 30-day rehospitalization rates are not only related to underlying cause of HF and its manifestations but also dependent on nonmedical, socioeconomic, and environmental factors which can be identified by social workers or case managers.[10,17] Social workers are known to have sound knowledge of local community resources and may help patients secure additional services, such as transportation or in-home nursing after discharge, meals-on-wheels, which have shown to improve clinical outcomes.[10,17] CARE COORDINATOR CONCEPT IN PRIMARY HEALTH CENTERS Chronic care models using multidisciplinary health-care professionals have been effective in other chronic disease models as reported in many centers.[18,19] In the outpatient setting, each HF patient must be managed by a “care coordinator” so that continuity of care is maintained. A meta-analysis of 47 randomized studies of care coordination showed marked reduction in readmissions and some trend in reducing mortality.[20] In addition, AHA recommends that care coordination is very much required for patients with HF being discharged from the hospital after acute decompensated HF admission.[21] The care coordinator, may be a doctor or nurse or physician assistant who will be aware of medical and social condition of patient with HF and he/she will be the direct contact for that patient during patient visit to clinic. Recently, services such as telehealth must be available to monitor patients with HF at home which has been shown to reduce mortality in patients with HF.[22] Recent data from Gulf countries and India suggest high rehospitalization rates and 1-year mortality in patient admitted with HF. This may be due to lack of dedicated HF team-based care management which has proved to improve long-term outcomes in other countries. Hence, there is an urgent need for establishing HF team-based care approach with starting of HF team and HF clinics all over Gulf countries/India and identifying care coordinators in primary health centers.