Multidisciplinary Care of Heart Failure: What Have We Learned and Where Can We Improve?

The last two decades have witnessed significant advances in the management of heart failure. Patients enrolled in the active arms of clinical trials of vasodilator therapy, ACE inhibitors, beta blockers, spironolactone and devices such as Automatic Implantable Cardioverter Defibrilators and biventricular pacing units have experienced significant improvements in morbidity and/or mortality [1–3]. However, translation of these benefits into the routine heart failure community remains a major problem. As a result, two distinct populations of heart failure patients have emerged: a trial population showing ever-increasing benefits of improved therapy and the much larger community population where therapy is ineffectively prescribed, patient understanding is poor and follow-up is unstructured [4]. In short, the improved understanding of the pathophysiology of heart failure has not been mirrored by the development of the necessary care structures for this problem. Over the last 5–10 years there has been increasing focus on this issue. Learning from care programs used in the management of other chronic diseases, heart failure management strategies have evolved in order to address the issues of sub-optimal therapy, poor patient understanding and lack of structured follow-up [5–10]. Almost without exception these programs have produced dramatic results, in particular in reducing re-hospitalisation and improving quality of life. Indeed the impact on re-hospitalisation has been more dramatic than that experienced with any other intervention in this syndrome. There is now an extensive literature outlining different programs structures for the management of heart failure. The differences between programs should not be surprising, given the varied health care structures that exist from country to country [5–10]. Nonetheless, there are similarities, which likely represent essential components of the overall strategy that should be incorporated wherever such a program is being put into operation. For example, there is general agreement that those who derive most benefit from this approach are the individuals recently hospitalised for heart failure [11]. These are the group most at risk for re-hospitalisation, [5,7,8,10,11] with readmission occurring in as many as 46% at 3 months. Stable community populations do not seem to derive as much benefit, most likely because they are at less risk of hospitalisation. This observation is clearly of importance as scarcity of resources demands that we focus on the group most likely to benefit. There is also universal agreement on the central role of the heart failure nurse specialist [6–10]. Along with a specialised physician, this individual is critical to the success of the programmme. He/she is the main source of contact for the patient, is responsible for patient assessment and education and in many programs has responsibility for co-ordinating drug titration. The nurse specialist is also the individual who usually deals with clinical deterioration and assesses the need for change in therapy, medical review, etc. Many programmes, through the use of agreed protocols, allow the nurse to adjust diuretic in response to weight gain or clinical deterioration. There is clear acceptance that the nursing role has been critical to the success of these programmes. Another common theme to the published programmes has been the need for structured follow-up. Moreover, this has focused on the first few weeks following discharge where the risk of developing clinical instability is highest [12]. Indeed, it is likely that the majority of patients require limited follow-up, but the benefit of applying close clinical follow-up to all in the early weeks following discharge is that it allows for the identification of more at-risk patients who would need more careful and protracted care. As the development of multidisciplinary care of heart failure proceeds several issues have arisen which need to be addressed to allow for further improvement in outcomes. To date, the majority of programmes have focused on management of patients following discharge from hospital. While the initial patient contact often occurs very soon after discharge, it seems that the failure to apply a multidisciplinary care approach while the patient is in hospital represents a lost opportunity. It is clear that the at-risk period for this patient population is in the first few days and weeks following discharge. Stewart et al. [10] have reported on a high prevalence of clinical instability in this time period. These data would suggest that problems remain with the in-hospital phase of care. There are many aspects of this phase of management that give cause for concern. These include the failure in many hospitals to bring all suitable Class IV admissions under the care of physicians with a direct interest in heart failure and indeed in a dedicated area for this management. It is reasonable and correct to expect that patients admitted with Class IV heart failure should receive the same intensive specialist care as those admitted with acute coronary syndromes, as their prognosis and outlook is similar. Providing this type of approach would result in more focused care, more complete investigation, better application of medical and other therapies and assessment of clinical stability before discharge. Work from our unit has demonstrated that this strategy has a dramatic effect on early readmission, even without the addition of other components of multidisciplinary care [12]. Moreover, it is likely that this approach will be more efficient and result in reduced length of stay. In addition to more structured medical input there is also an opportunity for the nurse specialist to become involved from early during the index admission. Two to three meetings with the patient and family members can help ease patient's concerns regarding the diagnosis, complex medication regimens and also provide important tips for the patient to aid in self-management [12]. Analysis from our unit demonstrates that patients usually receive just under 2 h one-on-one education with our nurse specialists during the in-hospital stay without extending length of stay [13]. In addition to the potential benefit on early readmission, feedback from our patients is very positive on this aspect of our multidisciplinary care programme. Initiating in-patient programmes also allows for education from the nutritionist, physiotherapist, pharmacist and other allied health care professionals. All in all the above approach would likely produce a patient at discharge who has been more thoroughly investigated, is on more effective therapy, has achieved clinical stability and has received important foundation education from other relevant members of the multidisciplinary team. Our opinion is that this leads to a more straightforward immediate post discharge course as evidenced by the elimination of 1-month readmission in our unit [12]. Heart failure with preserved systolic function comprises a significant minority of the heart failure population. However, little is known about effective medical strategies for this population, predominantly because this population has not been studied in the same detail as that with heart failure and reduced systolic function [1]. Similarly, there has been a tendency to exclude these individuals from heart failure programmes. There is no good reason for this. In fact one could make the contrary argument more effectively. Certainly these patients tend to be older and, therefore, possibly more prone to readmission [14]. Analysis of data from our unit demonstrates quite clearly that patients with preserved systolic function are as likely to be readmitted with heart failure and more likely to have unscheduled contacts with the heart failure service [15]. These data would suggest that this subset of the heart failure population would likely derive as much benefit from heart failure programmes as those with reduced systolic function. As mentioned above there have been significant differences between the type of service provided in published data. Some structure follow-up around home visits by the specialist nurse [7,8], some on visits to a hospital heart failure clinic [5,9,10] and there is an emerging interest in telemonitoring. Whereas individuals may view one structure as superior to another, it is more likely that the optimal service would include facets of each approach, with the choice based on the individual patient, the social circumstances of the patient and the medical needs. For example, a patient demonstrating ongoing signs of clinical instability may benefit more from review at a hospital clinic where a physician can assess the patient. Indeed, more and more hospital based clinics may use their facilities to treat these patients with parenteral therapy, such as intravenous diuretic or even short course of inotropes or inodilators. A patient who finds difficulty in returning to the hospital may be best served by home visits, which also give the opportunity to review the patient in his/her home environment, thereby potentially providing clues to potential problems that may not be obvious from clinic visits. Telemonitoring may develop a niche role for patients living in remote areas where either of the first two approaches would not be practical. This represents the most significant challenge over the next few years. At present, the majority of patients with heart failure do not receive the benefit of this intervention. That such an effective approach is available only on a restricted basis requires urgent attention. Funding restrictions may pose the major impediment to this task. However, strong arguments can be made to the contrary since this approach has shown substantial cost-savings from the perspective of the healthcare provider [13]. Training of specialist nurses also needs attention in order to meet the growing demands of this approach to heart failure care. Finally, physicians need to apply the same specialist attention to heart failure that they do to acute coronary syndrome and help cultivate the multidisciplinary approach outlined above to maintain clinical stability of this population in the community. The development of multidisciplinary care in the management of heart failure has been the most significant development in this area over the last number of years. The role of the nurse has and will continue to be critical to effective programmes. In order to maximise the effectiveness of this approach, more attention needs to be focused on the in-hospital phase of care and providing several post-discharge follow-up strategies tailored to the patient, including those with preserved systolic function. With more widespread application of multidisciplinary care of heart failure we may have an opportunity of meaningfully reducing morbidity of this growing epidemic.