The role of internist in heart failure management bridging the quality gaps Mohammad AlQahtani.MD,FACP Associate professor and head of internal medicine, KSAU-HS/KAMC Consultant internal medicine/hf Deputy head REPS,KAIMRC
Heart failure epidemiology While the prevalence of heart diseases begin to taper off In Western and European nations, the prevalence in developing nations is strikingly increasing, accounting for more than 80% of the cause of death in these nations In Saudi Arabia alone, the recent epidemiologic studies highlighted the worsening prevalence of diabetes mellitus, hypertension and coronary artery disease in KSA as compared only to the previous decade
Heart failure is an epidemic, incidence and prevalence is increasing worldwide. Recent epidemiologic studies observed a declining trend in heart failure hospitalizations in US, but not in European nations such as England and Wales indicating discrepancies in trends and management even in developed nations.
epidemiologic data in Saudi Arabia and the Middle East and North Africa are limited and little has been mentioned as to the adherence of Saudi HF patients to current management guidelines.
LOCAL DATA
Who is treating heart failure patients? Advanced Heart Failure + transplant specialist Cardiology + Heart Failure Specialist General Internists Family Physicians
Advanced Heart Failure and Transplant Cardiology: Subspecialty was born (ABMS,sept 2008) :majority of mild to moderate stable HF patients can managed and followed by IM and PC physicians? 1. The huge number of heart failure patients (epidemic) 2. Insufficient number of heart failure specialists and cardiologists interested to manage and follow heart failure patients 3. Opportunity to debulk stable heart failure patients to decrease the load on heart failure programs
4. Availability of excellent and clear heart failure guidelines (ACC/AHA, HFSA, ACP) that can provide internist with road maps of care partially for mild to moderate cases of heart failure. 5. Most of the decompensated HF patients are admitted to general Internal medicine wards.
Different obstacles?
Who is treating heart failure patients? Advanced Heart Failure + treatment specialist Cardiology + Heart Failure Specialist General Internists Adherence To Guidelines Outcome (mortality and morbidity) Family Physicians
HF Program (No + resources) limited Management outcome IM/FM < HF program? HF admissions Cardiac wards < IM wards Rapid Access Echo limited
HF PROGRAMS MISSED PATIENTS UNDERTREATED PATIENTS
HOW WE CAN ACHIEVE THIS Heart Failure Problem of everyone!! Administration EP Internists Heart Failure Specialist Cardiac Surgeon Heart Failure Family Medicine Social Dietician Cardiac Rehab Nursing
CREATE SMOOTH/ CLEAR CHANNELS OF COMMUNICATION AND EDUCATION HF Program Internal Medicine Family Medicine Continuous Education
CONTINOUS EDUCATION Regular meetings Lectures/workshops Pathway / guidelines Criteria for referrals
Cardiology Heart Failure Internal Medicine Family Medicine
Where is the role of Internist in Heart Failure Patient Management? 1 2 3 Clinics (OPD) During Admission (Inpatients) Before discharge (pre-discharge) Early Identification Early Initiation of RX F/U stable mild to moderate HF cases Early referral when indicated Adequate management of decomposition + identify + RX precipitating factors Maximiz Rx Education Measures to low 30 days rehospitalization
Our small experience in KAMC Department of medicine
IM division statistics Average daily Inpatient census from 160 to 200. Average daily admissions 15 (range 10 25). (Total 4,193 admissions in 2013) Average LOS, 11 days (90% department of medicine, 30% all hospital) Average 9,000 + outpatients per year. Total 25 clinics
2013 Internal Medicine Inpatients 450 400 350 300 250 311 348 392 319 367 258 284 331 359 358 416 450 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total number of inpatients = 4193
TOTAL NUMBER OF INPATIENTS YEAR 2011 and 2012 2011 47% 2012 53% 2012 = 3650 inpatients 2013 = 4193 inpatients
Aim of the study: 1. clinical characteristics of heart failure patients 2. to evaluate the adherence to guidelines (AHA/ACC) in managing heart failure patients.
Study Design & Subjects : Retrospective chart review study done at KAMC from 2002-2008 total of 500 patients charts admitted to IM wards secondary to heart failure [defined as systolic heart failure (ejection fraction < 55%) and/or heart failure with preserved ejection fraction diagnosed either clinically and/or by echocardiogram and/or cardiac catheterization
Inclusion criteria Exclusion Criteria Patients with heart failure and reduced ejection fraction Patients with heart failure and preserved ejection fraction Congenital heart disease ESRD on Hemodialysis Patients above 90 years of age
A total of 392 CHF cases included
General Characteristics of Patients N 392 Males 208 (53.1) Age (years)# 67.8 (12.8) NYHA Class# 2.73 (0.9) NYHA 1 53 (13.6) NYHA 2 67 (17.1) NYHA 3 203 (51.9) NYHA 4 68 (17.4) Mortality 205 (52.3) Hypertension 333 (84.9) Smokers 60 (15.3) Hyperlipidemia 233 (59.4) Diabetes Mellitus Type 2 (DMT2) 242 (61.7) Left Ventricular Dysfunction (EF < 55%) 289 (73.7) Normal Ejection Fraction (EF 55%) 103 (26.3) Valvular Disease 45 (11.5) Ischemic Cardiomyopathy 268 (68.5) Chronic Atrial Fibrillation 103 (26.3) PTCA/CABG 91 (23.2) Stroke/TIA 89 (22.7) Note: Data presented as N (%); # presented as mean (SD).
Adherence to Guidelines EF < 55% EF 55% P-value Hypertension 245 88 0.51 Diabetes Mellitus 173 69 0.11 Coronary Artery Disease 230 59 < 0.001 Atrial Fibrillation 67 24 0.54 Stroke/TIA 64 25 0.38 Dyslipidemia 175 88 0.26 Mortality 143 44 0.14 ACE I 147 28 < 0.001 β-blockers 223 46 < 0.001 Digitalis 240 94 0.001 Spironoloctone 79 9 < 0.001 Diuretics 219 79 0.4 ARB 102 33 0.35
How to improve the care? 1. inpatients (decompensated HF) 2.out patients(acc) 3.pre discharge Cardiology => understanding + cooperation
Ministry of National Guard Health Af fairs Department of Medicine Division of Internal Medicine Riyadh, Kingdom of Saudi Arabia
وزارة الحرس الوطني-للشئون الصحية قسم الباطنة وحدة االمراض الباطنية الرياض المملكة العربية السعودية
In summary: Heart failure is a huge problem in KSA There are clear gaps in the current quality of care for heart failure patients Current heart failure programs recourses in not enough to take care of this huge burden Internal medicine and PC should be part of any heart failure programs. Different obstacles can be solved through serious Channels of communication and education
IM/Dr. Qahtani 2014
IM/Dr. Qahtani 2014