A Global perspective on Heart Failure: What needs to change? Martin R Cowie London, United Kingdom

Transcription

1 A Global perspective on Heart Failure: What needs to change? Martin R Cowie London, United Kingdom

2 Global perspective on heart failure: what needs to change? Martin R Cowie Professor of Cardiology National Heart & Lung Institute Imperial College London (Royal Brompton Hospital Campus) m.cowie@imperial.ac.uk

3 Heart failure: a worldwide burden 26 million 1-2% Number of heart failure patients worldwide. 1 Health care expenditure attributed to heart failure in Europe and North America. 2 74% Heart failure patients suffering from at least 1 comorbidity: more likely to worsen the patient s overall health status Ambrosy PA et al. The Global Health and Economic Burden of Hospitalizations for Heart Failure. Lessons Learned From Hospitalized Heart Failure Registries. J Am Coll Cardiol. 2014;63: Cowie MR et al. Improving care for patients with acute heart failure Oxford PharmaGenesis. ISBN Available online at: 3. van Deursen VM et al. Co-morbidities in patients with heart failure: an analysis of the European Heart Failure Pilot Survey. Eur J Heart Fail. 2014;16:

4 Prevalence of HF

5 The cost of heart failure is driven by hospitalisation Outpatient investigation 6% Outpatient care 8% Drugs 9% Primary Care 17% (11-13 visits per year) Inpatient care 60% Total cost > GBP 1 billion (1% of annual NHS budget) British Heart Foundation, 2002 (updated to 2014)

6 Number and proportion of HF hospitalisations

7 Heart failure accounts for 1 3% of European hospital admissions USA (2007) 2.9% LOS 5.3d Norway (2008) 1.1% Sweden (2011) 2.2% LOS 6.4d Netherlands (2010) 1.5% Poland (2010) 1.9% LOS 8d England ( ) 0.4% LOS 7d Germany (2007) 2.0% France (2008) 1.1% LOS 9.9d Spain (2011) 1.8% LOS 7.5d Switzerland (2011) 1.1% Austria (2010) 1.0% LOS 7.3d

8 Length of stay for AHF

9 Trends in HF hospitalisation

10 High hospital readmission rates

11 Co-morbidity is universal

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14 The runaway train...?

15 We will have to do things differently...

16 National guidance & quality standards August 2010 June 2011 October 2014 Update scheduled

17 AHA recommendations for hospital discharge: 2013 Yancy CW et al. Circulation 2013; 128: e

18 ESC 2012 guidance Pre-discharge and long-term management Plan follow-up strategy Enrol in disease management program, educate, and initiate appropriate lifestyle adjustments Plan to up-titrate/optimize dose of disease-modifying drugs Ensure assessed for appropriate device therapy Prevent early readmission Improve symptoms, quality of life and survival McMurray et al. Eur Heart J 2012;33:

19 What is actually happening?

20 UK: assessing hospital adherence Six performance metrics: Data from 92% of the 150 hospitals in England & Wales > HF admissions per year 60% of total HF admissions ACEI/ARB on discharge Beta-blocker on discharge Echo during admission Treated on cardiac ward Cardiology follow-up HF nurse follow-up

21 Place of Care Place of care Index admission (%) Readmission (%) Cardiology ward General medical ward Other ward Place of care Men (%) Women (%) Cardiology ward General medical ward Other ward 9 11 Place of care (%) 75 years (%) Cardiology ward General medical ward Other ward 6 11

22 Specialist Input Specialist First admission (%) Readmission (%) Consultant cardiologist Heart failure nurse specialist Other consultant with interest in heart failure 6 6 Any HF specialist Other clinician Input from HF MDT

23 % Prescription Treatment Treatment on discharge for LVSD Medication ACE inhibitor 73 ARB 18 ACEI and/or ARB 85 Beta blocker 82 MRA 49 ACEI and/or ARB, beta blocker and MRA 39 Loop duiretic 91 Thiazide diuretic 5 Digoxin 22 Total prescribed (%) Prescription of secondary prevention medication by age Age Group ACEI and/or ARB Beta ACEI Loop diuretic MRA ARB

24 Treatment and Specialist Input Treatment on discharge for LVSD by specialist input Medication Seen by any HF specialist (%) No specialist input (%) ACE inhibitor ARB ACEI and/or ARB Beta blocker MRA ACEI and/or ARB, beta blocker and MRA Loop diuretic Thiazide diuretic 6 3 Digoxin

25 Hospitals Discharge Planning Follow-up appointment Total (%) Follow-up appointment with MDT scheduled 56 Appointment scheduled within two weeks of discharge 34 Median length of stay by hospital Length of stay (median) in days

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27 Cardiology follow-up in England...poor! survivors of HF admission. England, Bottle A et A al. Under et al. review In review.

28 Quality and Outcomes Framework in Primary Care

29 Compliance (%) Not all HF patients receive guideline care in the USA Wide variations in hospital performance have been reported th percentile 25 th percentile 50 th percentile 75 th percentile 90 th percentile 0 Discharge instructions Smoking counselling Medication at discharge LV function assessed

30 Adherence

31 Adherence by physicians MAHLER Study in 6 European countries Adherence = physician following ESC guidelines for use of ACE inhibitors, β-blockers & spironolactone NB suppressed zero Komajda M et al. Eur Heart J 2005; 26:

32 Adherence by physicians MAHLER Study in 6 European countries Predictors of time to CV hospitalization on multivariable Cox model Factor Hazard Ratio 95% CI P value NYHA III vs II CHF hosp in past year < Adherence (high vs low) Ischaemic aetiology Atrial fibrillation Diabetes Hypertension Komajda M et al. Eur Heart J 2005; 26:

33 North America Canada 547 centers in 36 countries Europe Ireland Portugal Spain France Germany Denmark Greece Eastern Europe Hungary Belarus Lithuania Austria Romania Poland Slovakia Russia Ukraine South America Ecuador Enrolled between August 2012 and December 2014 Asia Brunei China Korea Malaysia Thailand Middle East Bahrain Kuwait n Oman Qatar UAE Caucasus Jordan Armenia Kazakhsta Georgia Azerbaijan Turkey Lebanon Africa Egypt Morocco Australia

34 Financial Penalties

35 Best-practice based tariff

36 A community-wide approach is essential

37 Other approaches?

38 Policy-makers urged to act on eight recommendations Promote acute heart failure prevention Optimize care transitions Improve end-of-life care Provide equity of care for all patients Appoint experts to lead heart failure across disciplines Develop and implement better measures of care quality Improve patient education and support Stimulate research into new therapies /AHFreport global-heart-failure-awareness-programme.aspx

39 Conclusions HF is a global burden Policy makers are paying close attention to HF care Peformance metrics are increasingly in use Rapid access for all patients to timely diagnosis and treatment is a challenge for ALL healthcare systems The age and level of co-morbidity is rising rapidly New approaches are needed to face current and future challenges