A Heart Failure Clinic

A successful in and outpatient model in Lisbon, Portugal, has seen a 20% reduction in hospital readmissions for heart failure Heart failure (HF) is a major worldwide epidemic associated with high morbidity and mortality. The prevalence of HF is approximately 1–2% of the adult population in developed countries, rising to over 10% amongst people over the age of 65. The EPICA study, completed in 2000, estimated a 4.36% overall prevalence of chronic HF in Portugal, ranging from 1.36% in those aged 25–49, reaching 12.67% in the age range of 70–79 years and 16.14% over 80 years of age. With the aging of the population, and the increase in the survival rates of patients with coronary artery disease, the impact of the syndrome is expected to rise substantially. It is estimated that the prevalence will increase to 35% by 2035 and 30% more by 2060. Currently, HF accounts for 1–4% of all hospitalizations, being the leading cause of admission for patients over the age of 65. Nearly a quarter of these patients are re-hospitalized within a month of discharge, with each hospitalization representing a further worsening of HF, contributing to a decline in the patient’s clinical condition until death. Heart failure represents a considerable socioeconomic burden for patients, their families, and national health care systems. Worldwide, the economic burden of HF accounts for 1–3% of health budgets in the USA and Europe, being the disease with the greatest economic impact. In Portugal, a 10 M inhabitants’ country, it was estimated that in 2017 the total costs of HF (emergency department visits, hospitalizations, tests and procedures, medical appointments, and medications) were over 300 M €, and it is projected that by 2034 these numbers will increase to nearly 400 M €, with hospitalizations being the majority of these growth costs. Therefore, it is critical to optimize care for HF. In Portugal, HF is often diagnosed late, frequently at the time of the first hospitalization. There is still uncertainty among general practitioners (GPs) on how to prescribe and titrate disease-modifying drugs that are frequently prescribed too late and mostly by specialists. Communication between hospitals and GPs and hospital referral is also subject to certain constraints. Nearly half of the patients with HF are admitted to internal medicine wards and cared for by internists, and the treatment of HF patients at the time of hospital discharge varies enormously, depending on the attending physician. Furthermore, after hospital discharge there are very different and complex patient flows, frequently leading to early rehospitalization. Additionally, the implementation of HF guidelines may not be straightforward in the ambulatory care setting and only very few HF patients, mainly the ones with the most severe disease, are followed by an HF specialist. Consequently, these difficulties have resulted in unmet needs that extend beyond routine medical care. There is an urgent need to standardize the care of HF at the hospital level to improve compliance with guidelines especially during the vulnerable phase. Having identified the main shortcomings in the management of HF, we are currently implementing solutions at different levels of care that are leading to improved integration between the different specialists and care levels involved in the diagnosis, treatment and monitoring of HF patients. A consensus statement, with short-, medium-, and long-term solutions and strategies to increase awareness and improve management of HF in Portugal, was recently published. In this scenario, we have implemented at S. Francisco Xavier Hospital, Lisbon, a multidisciplinary HF management program addressing important challenges such as the patient’s journey through the health care system. The components of the HF Program are: an Acute Heart Failure (AHF) Unit, the HF Outpatient Clinic/Day Hospital, and an Advanced HF Consultation. A multidisciplinary team including a cardiologist (the coordinator), two internists, three to four residents covering different specialties such as cardiology, internal medicine and general practice, specialized nurses, pharmacists, physical therapists, nutritionists, and a social worker ensure the medical care. Other specialists, such as nephrologists, neurologists, pulmonologists, haemodynamists, electrophysiologists, and cardiovascular surgeons are involved in the decision making, as needed. All staff strictly follow diagnostic and treatment protocols according to ESC guidelines. The AHF Unit is composed of five monitored beds connected to a central monitoring station, with the multidisciplinary medical staff and a specialized nurse coordinator plus two nurses per shift (Figure1). This Unit is at the centre of the hospital, in the Internal Medicine Department, close to the Day Care Unit, HF diagnosis and treatment facilities, the coronary care and intensive care units (CCU/ICU) and the emergency ward, where most patients with acute HF (HFrEF, HFmEF, or HFpEF) come from. Acute HF Unit: five monitored beds connected to a central monitoring station with a multidisciplinary staff. Despite the impact of hospital admission on the HF prognosis, hospitalization is an opportunity to optimize the treatment according to guidelines. Diagnosis and treatment protocols, according to ESC guidelines, for different hospitalization phases are followed and pre-discharge and hospital discharge are carefully prepared. In what concerns HFrEF and after the stabilization phase (intravenous diuretics, vasodilators, and inotropes as required), we certify that the initiation and titration of all disease-modifying drugs are exhaustively challenged until the maximum tolerated dosage, according to blood pressure, heart rate, estimated glomerular filtration rate (eGFR), and serum potassium levels, to ensure the patient is discharged on the best medical treatment. The discharge phase is of utmost importance to reduce the risk of early rehospitalization and death during the first 30–60 days, the so-called vulnerable phase. The discharge summary is sent to the patient’s GP who, according to the ESC guidelines, should re-evaluate the patient within 1 week. An early follow-up visit is scheduled between 7 and 14 days after discharge at the hospital outpatient clinic. The early post-discharge assessment is key, as further adjustments of the therapy will be required. The Day Hospital is a nurse-led outpatient clinic run by three specialized nurses. The structure includes five patient recliners (Figure2) with non-invasive monitoring, a chair scale and a resuscitation cart. Patients are referred to the clinic either from the AHF Unit, after an episode of decompensation, their GPs, or by other hospital departments, or even by other hospitals or clinics. In the outpatient clinic special emphasis is given to the education of the patient and caregiver initiated in the pre-discharge phase at the AHF Unit. Patients and caregivers are educated about the disease, self-care and early detection of signs and symptoms of decompensation (mainly weight control and symptoms of fluid retention), and the importance of therapeutic compliance. There is a focus on patients’ empowerment, where patients are invited to participate in the management of their treatment and disease. When stabilized and on optimized treatment, high-risk or unstable patients, patients considered for device therapy (CRT-D, CRT-P, or ICD), patients with ongoing diagnostic procedures or in need for invasive procedures are referred to the Advanced HF Consultation and the lower-risk patients are referred to their GPs. Of note, the Day Hospital is open for the return of patients whenever necessary. The Day Hospital is also an open door for the early treatment of decompensation, avoiding rehospitalization, and visits to the emergency room. All patients are provided with contact details of the nursing team. Day Hospital structure/equipment: five patient recliners with non-invasive monitoring, chair scale, and resuscitation cart. A reference protocol with primary health care physicians was established. This protocol allows the GPs to refer (i) the patient with HF decompensation to the Day Hospital, which will avoid unnecessary emergency visits and hospitalization, (ii) to the AHF Unit when hospitalization is necessary, (iii) the new cases or cases of HF suspicion, and those who need optimization of pharmacological treatment, invasive diagnostic or therapeutic procedures, such as device therapy, to the Advanced HF Consultation. This HF management program, also serves as a teaching unit for students of the NOVA Medical School, Universidade Nova de Lisboa. We also train nurses and residents from different hospitals and different specialties, in order to be able to promote and replicate patients care and the HF program in other hospitals of the country. We also invest and carry out clinical research, such as HF registries, investigator initiated trials and randomized controlled trials and participating in major randomized HF trials. Furthermore, we perform regular internal audits to evaluate our performance indicators and ensure compliance with the ESC Guidelines and best practices. The HF Management Program has already demonstrated a 20% decrease in 1-year readmissions. In conclusion, we are running a Heart Failure Management Program with a multidisciplinary team well aware of the disease, willing to improve patients’ quality of life and survival, and avoid preventable emergency visits and hospital readmissions. Conflict of interest: none declared.