The Epidemic of Heart Failure: Who is Certified to Care for these Patients?

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1 The Epidemic of Heart Failure: Who is Certified to Care for these Patients? Mariell Jessup MD, FAHA, FACC, FESC Professor of Medicine University of Pennsylvania President, American Heart Association

2 Disclosure: Mariell Jessup MD Speakers Bureau: none Advisory Board: none Organizations: Chair, ABIM Advanced Heart Failure and Transplant Cardiology test committee. Chair, ACCF COCATS writing committee, HF task force

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4 Hospitalization rates are decreasing somewhat.

5 Even if one-year mortality rates are not..

6 Months from diagnosis Heart Failure is deadly and costly.

7 In 1941, the subspecialty of Cardiovascular Disease was one of the first four subspecialties of Internal Medicine in which an examination was administered and certificates awarded. The other three subspecialties were in Allergy, Gastroenterology, and Tuberculosis; Nearly 50 years passed before certification in the cardiovascular secondary subspecialty of Clinical Cardiac Electrophysiology (CCEP) began in Seven years later the secondary subspecialty of Interventional Cardiology (IC) was formed in witnessed the approval of the 3 rd secondary subspecialty in Cardiology..

8 The ACGME has now accredited the first set of training programs for the secondary subspecialty of Advanced Heart Failure and Transplant Cardiology.

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12 Faculty Resources Eligibility of the Fellows Educational program

13 Procedural Competencies Formal instruction, clinical experience & demonstrated proficiency : Patients: Evaluated for transplant or LVADs ( 30) Undergone transplant ( 30; 5 init. hosp.) On assist devices ( 10; 2 peri-op) Evaluated for ICDs ( 50) Evaluated for CRT ( 50) Device interrogation and interpretation in ICD or CRT pts ( 100) Endomyocardial biopsies ( 30)

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17 Clinician Skill Set Heart failure differential diagnosis determine etiology evidence-based Tx disease management assess inc. severity end of life issues advanced therapies Transplant listing process sensitized pts. immunosuppress post-op issues long-term care recognize rejection recognize PTLD GDMT for HF VADs assess RV assess pulm HT post-op issues long-term care: infection GI bleeding suck-down AI, HTN GDMT for HF

18 *Sent to the members of all 3 organizations who had identified themselves as interested in HF, heart transplant, or both. *Between March 12, 2009, and May 12, Results The response rate to the 1,823 surveys was 23%. 257 unique practices in the United States (81% of total sites) 58 international sites (19%);

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21 Yet more skills are needed

22 How Many Patients, How Many Staff? In this snapshot of the heart failure scene: More sites performing MCS than transplant Additional staffing needed for VAD programs, 3.25 FTE 6-7 clinicians to deliver care to 1,641 HF outpatients 140 patients/month <1 new heart transplant recipient/month

23 Heart Failure Program Resources Access to state of the art imaging echocardiography, CT scans, MRI, PET and nuclear imaging Cardiopulmonary Exercise Laboratory Dedicated hemodynamic/endomyocardial biopsy laboratory Electronic Medical Record with patient and referring physician portals Penn Heart and Vascular Diagnostic Center

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26 UNOS determines ancillary services, and credentialing, in addition to maintenance of list

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29 Who and how we will take care of the heart failure patients? 2007 HF hospital discharges: 990, HF office visits: 3,434,000 83% hospitalized once 43% hospitalized at least 4 times 2010 internists, and generalists: 50, Physicians and surgeons: 293, cardiologists: 20,000

30 Who Manages Heart Failure? FP/GP 29% IM 43% Other 11% CARD 17%

31 Stages of CHF ACC/AHA Guidelines 2005 Ammar et al. Circulation 2007; 115:1563 D Refractory 0.2% Olmsted County survey 11.8% C Prior, current symptoms 22% B Structural heart disease LVH, MI, low LVEF, dilatation, valvular disease A High-risk patients 34% Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs

32 Stages of CHF ACC/AHA Guidelines 2005 Ammar et al. Circulation 2007; 115:1563 D 0.2% 11.8% Refractory C Prior, current symptoms B Structural heart disease LVH, MI, low LVEF, dilatation, valvular disease 34% 22% A High-risk patients Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs

33 Prevalence and prognostic significance of HF Stages Survival (years) Ammar et al. Circulation 2007; 115:1563

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35 World Health Organization Heart failure as a model of chronic care.

36 Coordinating Care for Patients With I IIa IIb III Chronic HF Effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization. I IIa IIb III I IIa IIb III Every patient with HF should have a clear, detailed and evidencebased plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with Secondary Prevention Guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient s healthcare team. Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life.

37 Where is the patient in this picture? Family Medicine Electrophysiology Heart Transplant Heart Failure Research Internal Medicine Familial Cardiomyopathy Heart Failure Program VAD Program Pharmacies Hospice Pulmonary Hypertension Valve Program Skilled Nursing Cardiac Surgery Home Care

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40 Where is the patient in this picture? Family Medicine Familial Cardiomyopathy Electrophysiology Heart Transplant Heart Failure Research LOCAL HOSPITALS Internal Medicine Pharmacies Skilled Nursing Pulmonary Hypertension Heart Failure Program Cardiac Surgery Valve Program VAD Program Home Care Hospice

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42 Annals of Internal Medicine 2008; volume 148.

43 The Epidemic of Heart Failure: Who is Certified to Care for these Patients? Certification may not be as important as collaboration Certified personnel are too few to deal with this HF epidemic. Finding ways to put the patient back in the middle of care and share in the responsibility is of paramount importance!

44 Thank You.