Heart failure is a public health problem affecting 1% to 2% of the adult

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1 The care continuum: post discharge assessment and follow-up management of outpatients with heart failure The tools provided by the Optimize Program are designed for use by any health care professional, regardless of training level. Most heart failure patients worldwide are assessed throughout hospitalization and discharged by heterogeneous personnel who are not cardiologists, including family physicians, internal medicine specialists, and emergency specialists. This project may be implemented in all hospitals to achieve a successful transition from hospitalization to discharge. OF THE HEART FAILURE PATIENT S J O U R N E Y by C. I. Saldarriaga Giraldo, Colombia Clara Inés SALDARRIAGA GIRALDO, MD Head of the Heart Failure Clinic CardioVID, Medellín, COLOMBIA and Associate Professor, University of Antioquia, Medellín, Antioquia COLOMBIA and Director of the Cardiology Program Pontificia Bolivariana University Medellín, Antioquia, COLOMBIA and Past President of the Colombia Heart Failure Chapter Colombian Society of Cardiology COLOMBIA Address for correspondence: Dr Clara Inés Saldarriaga Giraldo, 78b Street #75-21, Medellín, Antioquia, Colombia ( clarais@une.net.co) Heart failure is a public health problem affecting 1% to 2% of the adult population. Most of this disease s treatment costs are due to readmissions, which occur in 44% of patients within 30 days of discharge. These events are potentially preventable if a strategic transition process is implemented from hospitalization to the outpatient setting. Ideally, all patients should be followed-up after discharge in a multidisciplinary care program. However, the reports in the literature show that only a minority receive follow-up. The Optimize Program emerged in response to this problem as a simple, easy to implement strategy requiring few resources. The Optimize Program is aligned with the 2016 European Society of Cardiology guidelines and highlights the importance of planning outpatient care beginning at discharge, including nonpharmacological methods and medication initiation and titration. Implementation of this program has shown improved use of pharmacological treatment and fewer readmissions. The ideal answer to the problem of a successful transition to outpatient follow-up of patients with heart failure should focus on the implementation of the Optimize Program in all hospitals, regardless of their level of specialization, followed by referral of high-risk patients to multidisciplinary care programs, as this strategy has been shown to decrease mortality, recurrent hospitalizations, and the cost of disease treatment. Medicographia. 2018;40:20-25 The care continuum: post discharge assesment and follow-up management of outpatients with heart failure Heart failure is a public health problem affecting 1% to 2% of the adult population. 1 Once the disease is diagnosed, mortality at 12 months is 17% for patients who have been hospitalized for acute decompensation, and the risk of readmission during the same time period is 44%. 2 The rate of recurrent hospitalizations explains 70% of health system costs. These events may be preventable if a strategic transition program is implemented from hospitalization to the outpatient setting. 3,4 The prognosis of the chronic phase of the disease has improved in the past few years. 5,6 However, the increased mortality after an acute decompensation continues to be unacceptably high and is explained by factors such as insufficient treatment of the congestion, delay in beginning medications to modify the course of the disease, lack of patient education, and lack of an adequate connection with a team that guarantees outpatient follow-up. 7,8 Therefore, the goal at discharge should al- 20 MEDICOGRAPHIA, Vol 40, No. 1, 2018 Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo

2 OF THE HEART FAILURE PATIENT S JOURNEY ways be to provide a quality transition. Ideally, patients should be enrolled in a heart failure program that is multidisciplinary in nature. However, only a minority of patients have access to such a resource. Reports from the United Kingdom indicate that only 34% of patients at discharge are evaluated by a cardiologist during the following 2 weeks; in France, only 24% access specialized follow-up in the 3 months after discharge, and reports from Colombia show that 29% of patients do not receive any follow-up at 30 days. 9,10 The 2016 European guidelines introduced the innovative concept of initiating and titrating all treatments for altering the course of the disease during the hospital stay 11 and, in addition, of developing a follow-up plan, which includes the following: Scheduling a check-up for the 7 to 10 days after discharge; Identifying who is going to follow-up with the patient and when this will occur; Titrating medications and assessing the need for devices; Enrolling the patient in a multidisciplinary follow-up program; Educating the patient and family; Avoiding readmissions and improving quality of life. These recommendations are clearly established. However, one of the barriers to implementation is the heterogeneity of the health care personnel caring for the patient after discharge. The Optimize Program emerged as a response to this problem: the program is a simple strategy requiring few financial resources and is easy to implement at all levels in the health care system. Its objective is to improve health care and provide a successful transition from hospitalization to outpatient care. In this way, the Optimize Program is aligned with the 2016 guidelines of the European Society of Cardiology. 12 History of the Optimize Program This is a global project that began in 2013 and has been implemented in 45 countries around the world. It includes European patient populations, as well as populations from other regions that had been poorly represented in the worldwide heart failure scene, such as Latin America, Africa, and Asia-Pacific. Now, 4 years later, clinical information has been gathered regarding the program s impact on the care of this population: the data show a greater than 90% use of angiotensinconverting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) and b-blockers, a 25% use of ivabradine, and a 1% incidence of hospitalizations at 30 days and 17% at 3 months. These data support the importance of implementing the project as a simple solution to the complexity of transitioning from the hospital setting to the outpatient setting. 10,13 Optimize Program elements The program includes the use of a checklist for reminding health care personnel at discharge regardless of their level of training of the following elements, which are key for improving the quality of care and which need to be evaluated before discharge and throughout the early post discharge follow-up. u Clinical assessment u Weight Establishing the dry weight of patients is key for determining whether adequate control of congestive signs has been achieved. Population registers show that patients who are congested at discharge are rapidly readmitted for acute decompensation. In addition, daily weighing is a self-monitoring tool that patients can carry out at home, thereby detecting warning signs such as rapid weight gain greater than 3 kilos in 3 days. 14 u Heart rate An elevated heart rate at discharge is an adverse prognostic factor for patients with reduced function and who are in sinus rhythm. This is why it is part of the various scales for heart failure risk assessment, such as those from ADHERE (Acute Decompensated Heart Failure National Registry), GWTG-HF (Get With The Guidelines Heart Failure program), and the Optimize Program In addition, it predicts the risk of readmissions and mortality at 1 year. Therefore, keeping the heart rate below 70 beats per minute (bpm) beginning before discharge is a reasonable goal. The ETHIC-AHF study (Early THerapy with Ivabradine in patients with Congestive Heart Failure) tested the hypothesis of a benefit from simultaneously beginning ivabradine and b-blockers on a titration schedule before discharge, and the findings showed that 28 days after discharge, the goal of decreasing the heart rate was achieved more rapidly. In addition, a significant improvement was seen in the ejection fraction and in levels (decreased) of natriuretic peptides at 4 months. 18 SELECTED ABBREVIATIONS AND ACRONYMS ACE ADHERE ARB ARNI bpm ETHIC GWTG-HF ICONS MHFP NYHA angiotensin-converting enzyme Acute Decompensated HEart failure national registry angiotensin II receptor blocker angiotensin II receptor neprilysin inhibitor beats per minute Early THerapy with Ivabradine in patients with Congestive Heart Failure Get With The Guidelines Heart Failure [program] Improving Cardiovascular Outcomes in Nova Scotia [registry] multidisciplinary heart failure program New York Heart Association Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo MEDICOGRAPHIA, Vol 40, No. 1,

3 OF THE HEART FAILURE PATIENT S J O U R N E Y Figure 1. Schematic depicting pre discharge assessment. Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; ARNI, angiotensin II receptor neprilysin inhibitor; BB, b-blocker; MRA, mineralocorticoid-receptor antagonist. u Arterial pressure The assessment of arterial pressure is part of monitoring the patient s hemodynamic status and helps the treating physician determine when he/she should continue with the increased dose titration of the medications. u New York Heart Association functional class and ejection fraction These two elements are essential for considering the indications for pharmacological treatment and devices in patients with heart failure. They are also useful parameters for guiding follow-up and decision making. u Creatinine and potassium Verification of the stability of kidney function for at least 24 hours is a discharge assessment criterion, according to the 2016 European Society of Cardiology guidelines. In addition, potassium-level monitoring is necessary in patients receiving treatments such as aldosterone antagonists and ACE inhibitors/arbs. 11 u Patient and caregiver education Hospitalization is the key time to begin the educational process. The Optimize Program checklist recalls the importance of instruction in diet, regular exercise, daily weighing, and detecting symptoms of disease worsening. In addition, there are two tools directed to patients: (i) My Heart Failure (MyHF) passport: a book where patients can record their vital signs and which reminds them of the importance of monitoring warning signs; and (ii) MyHF App: an application that has been designed for use on smart phones, which reminds patients of the need to monitor warning signs and to take their medications. u Optimization of pharmacological treatment Therapeutic inertia is a common behavior in medical visits, where modifications to doses or medications are avoided in spite of a clear recommendation and benefit for changing treatment. The Optimize Program checklist reminds physicians of the importance of verifying that the patients are receiving the pharmacological groups that modify the disease course. In the event that they are not receiving them, the reason (intolerance vs contraindication) must be recorded in order to verify their initiation at the next appointment. This tool facilitates patient follow-up in the event that this is carried out by different physicians during and after hospitalization and improves adherence to the guideline recommendations. The medications included in this checklist are: ACE inhibitor/arb, angiotensin II receptor neprilysin inhibitor (ARNI), b-blockers, aldosterone antagonists, and ivabradine. It is important to emphasize that hospitalization is the key moment for beginning and titrating treatments for modifying the course of the disease because vital signs, as well as adverse effects, such as hypotension and kidney function deterioration, can be monitored (Figure 1). Optimize Program target population The tools provided by the Optimize Program are designed for use by any health care professional, regardless of training level. Most heart failure patients worldwide are assessed throughout hospitalization and discharged by heterogeneous personnel who are not cardiologists, including family physicians, internal medicine specialists, and emergency specialists. This project may be implemented in all hospitals, regardless of their level of complexity, to achieve a successful transition from hospitalization to discharge. All information on the Optimize Program may be consulted on the website This site describes the tools used for the program s implementation and the extent of its use in various countries around the world. 19 Multidisciplinary heart failure programs In 1995, Rich et al 20 published the first study showing that hospital readmissions after an acute decompensation episode were preventable if a multidisciplinary follow-up program was implemented. This study s population included elderly patients with heart failure; after 90 days of follow-up, the study showed a 56.2% reduction in hospitalizations due to heart failure and a 28% reduction in admissions due to other causes MEDICOGRAPHIA, Vol 40, No. 1, 2018 Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo

4 OF THE HEART FAILURE PATIENT S JOURNEY Cline et al 21 carried out a study in a Swedish patient population with heart failure and a New York Heart Association (NYHA) functional class III. It included patient and family education, follow-up by nursing, self-titration of the diuretic, and early reporting of warning signs of decompensation; it showed a significant reduction in hospitalizations due to heart failure, with a relative risk [RR] of 0.69 ( ). 21 Later, Jaarsma et al 22 evaluated the impact of an intervention that was begun before discharging patients hospitalized for decompensated heart failure. The intervention included a check-up in the 7 to 10 days after discharge and frequent appointments with the patients and their families after this. They found a tendency toward a decrease in hospitalizations due to heart failure. 22 The results of these studies were replicated in other countries such as the United States, Canada, Holland, Sweden, and Australia including multidisciplinary care and follow-up by nursing as common elements, and similar results were achieved Gwadry-Sridhar et al 27 carried out a meta-analysis of eight clinical studies and found that in order to decrease one hospitalization due to heart failure, nine patients must be treated (ie, number needed to treat [NNT]=9). It is important to note that few cardiology interventions have managed to show this effectiveness. 27 The ICONS registry (Improving Cardiovascular Outcomes in Nova Scotia), in turn, collected follow-up information on all Canadian patients with a heart failure diagnosis who were being followed-up by multidisciplinary clinics, showing a 13% reduction in mortality at 1 year. 28 Selection of patients who are candidates for follow-up in heart failure programs The greatest benefit of follow-up in disease management programs is seen in patients who meet criteria for a high risk of recurrent hospitalizations or death. Therefore, it is ideal in the vulnerable phase after hospital discharge. In addition, patients who meet the following criteria also benefit from multidisciplinary follow-up: (i) persistent functional class III-IV; (ii) newonset heart failure; and (iii) criteria suggestive of disease progression, such as persistent kidney function deterioration, anemia, elevated natriuretic peptides, functional class deterioration according to the NYHA classification, and cardiac cachexia. Intervention in this group of patients includes patient and family education; assessment and treatment of comorbidities, such as depression, anemia, and iron deficiency; inclusion in a cardiac rehabilitation program; medication titration; and evaluation of the need for high-voltage devices, or referral for heart transplant, mechanical ventricular assistance, or palliative care, when needed. 32,33 Optimization of pharmacological treatment in multidisciplinary programs Rapid titration of medication dosages recommended for treating heart failure with reduced function is one of the treatment objectives in multidisciplinary programs. This process may be carried out by the cardiologist or nurse; therefore, easily followed protocols are needed. Follow-up in specialized heart failure programs also facilitates patients receiving all the pharmacological treatment recommended by the guidelines, 11 which improves the patients ejection fraction and functional class. 21,22 In addition, it allows the adequate selection of patients who could benefit from implantation of devices such as implantable cardiac defibrillators and resynchronizers, guaranteeing follow-up of their adequate functioning and improving treatment response rates. 29 The European Society of Cardiology establishes that the key elements a multidisciplinary program should include are a cardiologist and nursing staff with training in heart failure. In addition, the program should have the ability to carry out outpatient follow-up, the tools for disease diagnosis, and the ability to link with staff at the basic health care level. 30 The multidisciplinary nature of heart failure programs is fundamental to success and is based on recognition that in the paradigm of chronic diseases, the patients should have an active role in their treatment. Therefore, patient education, follow-up, and detection of barriers to adherence to pharmacological and nonpharmacological measures are necessary. 31 Figure 2. Schematic depicting optimization of therapy in the multidisciplinary heart failure program. Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; ARNI, angiotensin II receptor neprilysin inhibitor; BB, β-blocker; bpm, beats per minute; HFrEF, heart failure with reduced ejection fraction; HR, heart rate; MRA, mineralocorticoid-receptor antagonist; NYHA, New York Heart Association [functional class]. Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo MEDICOGRAPHIA, Vol 40, No. 1,

5 OF THE HEART FAILURE PATIENT S J O U R N E Y The heart rate should be the goal during the medication titration process, always aiming for levels under 70 bpm in patients with a sinus rhythm, 34,35 and the early use of ivabradine is considered in order to achieve this goal. It is not clear whether patients with atrial fibrillation are benefitted by strict heart rate control, and achieving a heart rate under 110 bpm is reasonable. 36,37 In medication titration, the dose of one pharmacological group at a time should be increased, at 1- to 2-week intervals, watching for hypotension, hyperkalemia, and kidney function deterioration (Figure 2, page 23). Optimize and multidisciplinary care programs: the ideal strategy for changing the story of heart failure In spite of the proven efficacy of multidisciplinary program implementation for long-term follow-up of heart failure patients, the number of programs continues to be insufficient for the follow-up needs of the growing number of cases. 9 Data taken from the ROCI registry, a registry of the population of patients discharged after an acute decompensation in Colombia, show that only a third of patients received follow-up at discharge with a specialized program. Therefore, the Optimize Program should be implemented in all hospitals, regardless of their level of specialization, in order to achieve a successful transition; and patients with a persistent NYHA functional class III-IV, new-onset heart failure, or criteria suggestive of disease progression should be referred to multidisciplinary care programs to continue follow-up (Figure 3). Recently, the data from the Optimize Colombia project showed the results of implementation of the Optimize Program in the composite outcome of decompensation plus hospitalizations 30 days after hospital discharge in hospitals with and without multidisciplinary heart failure programs (MHFPs). The Optimize Colombia project included 436 patients, 44% (N=192) from hospitals with an MHFP and 56% (n= 244) from hospitals without these programs. Of the patients from hospitals with an MHFP, 20.3% were treated with ivabradine, compared with 59.83% of the patients from hospitals without an MHFP. Only 61.4% of the patients were followed-up in an outpatient department. Thirty days after hospital discharge, the percentage of the composite outcome of decompensations plus hospitalizations was 2.2% vs 3.3% (P=0.530) in hospitals with and without an MHFP, respectively. This is the first experience showing how the implementation of the Optimize Program in hospitals without an MHFP improves the short-term prognosis of patients, with a rate of the composite outcome of decompensations plus hospitalizations at 30 days similar to that observed in hospitals with an MHFP. The implementation of this program and the early use of ivabradine in the vulnerable phase, beginning at hospital discharge, is a good strategy to standardize health care in all types of hospitals as part of a quality improvement initiative. 38 Figure 3. Schematic depicting Optimize and heart failure programs, the ideal strategy in heart failure. Abbreviations: d, days. On the basis of this evidence, our next challenge must be to expand the scope of the population involved in the Optimize Program. Heart failure patients are not only seen by cardiologists or heart failure specialists; internal medicine and primary care doctors must be our next target in order to have a successful transition between the hospital and outpatient follow-up, including the vulnerable phase of the disease. Conclusion The successful transition from hospitalization to outpatient follow-up is a challenge and must be carried out systematically in order to avoid new hospitalizations and worsening of the disease. The Optimize Program emerged as an answer to this problem, and its implementation simplifies and standardizes patient care at discharge and throughout early post discharge follow-up. It recalls the importance of nonpharmacological measures and the initiation and titration of medications for altering the course of the disease, such as b-blockers, ACE inhibitors/arbs, ARNI, aldosterone antagonists, and the early initiation of ivabradine in patients with an indication for its use. Patients presenting high-risk criteria should also be referred for follow-up to multidisciplinary care programs, due to their proven benefit in decreasing mortality and recurrent hospitalizations, improving functional class and quality of life, and decreasing costs related to disease treatment. n 24 MEDICOGRAPHIA, Vol 40, No. 1, 2018 Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo

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Improving heart failure care in hospitals with and without a multidisciplinary heart failure program: results from Optimize Colombia Project. Eur J Heart Fail. 2017;19(suppl S1): Keywords: follow-up; heart failure; multidisciplinary heart failure program; Optimize Program; post discharge Optimize transition from discharge to outpatient follow-up in heart failure Saldarriaga Giraldo MEDICOGRAPHIA, Vol 40, No. 1,