Challenges and opportunities in heart failure treatment: Irish example Joe Gallagher University College Dublin Ireland
The Irish healthcare system Mixed public and private funding Primary healthcare is free through the GMS scheme until recently, only for those judged less able to pay now, for all individuals under 6 or over 70 years of age Primary care practices have high rates of EHR use (> 92%) but few disease registers, and no specific financial incentives for operating a recall system to monitor care of patients with chronic diseases such as HF Outpatient hospital treatment is free for everyone Inpatient treatment is free for those in the GMS scheme; EUR 75 per night for others Fixed cost prescriptions are available only within the GMS scheme (EUR 2.50 per item to max. of EUR 25 per family) Others pay the full costs of medicines up to a monthly limit (EUR 144 per family) EHR, electronic health record; GMS, General Medical Services; HF, heart failure. Available from: www.citizensinformation.ie. Accessed October 2015.
Waiting times! Outpatient national by specialty as of 30/07/2015 Total 0 3 months 3 6 months 6 12 months 12 24 months 24 36 months 36 48 months 48+ months Total 401,060 151,145 84,786 98,508 64,006 2,146 385 84 Otolaryngology 51,441 13,394 10,208 13,801 13,348 588 78 24 Orthopaedics 50,601 16,020 10,438 14,249 9,490 285 102 17 General surgery 35,502 20,912 6,600 5,732 2,241 16 0 1 Dermatology 31,909 12,582 6,218 7,808 5,169 131 0 1 Ophthalmology 27,752 9,683 5,778 6,997 5,258 36 0 0 Gynaecology 22,656 7,925 4,738 5,667 3,982 341 3 0 General medicine 21,845 8,371 5,208 5,527 2,635 103 0 1 Cardiology 14,796 5,807 3,805 4,028 1,092 61 3 0 Cardiology 14,796 5,807 3,805 4,028 1,092 61 3 0 Urology 20,960 6,732 4,320 5,668 4,164 58 14 4 Cardiology 14,796 5,807 3,805 4,028 1,092 61 3 0 Neurology 13,460 4,874 3,280 3,288 1,994 23 1 0 Rheumatology 12,230 4,348 2,655 2,960 2,173 58 25 11 The national treatment purchase fund Outpatient National by Specialty report. Available from: http://www.ntpf.ie/home/pdf//2015/07/nationalnumbers/out-patient/national02.pdf. Accessed October 2015.
Hospital admission crisis
The numbers of Irish people affected by HF is increasing PREVALENCE 1,2 90,071 300,000 INCIDENCE 3 (new cases of HF per year) ~ 90,000 2% 2 of the population in Ireland have HF 1 Annual inpatient ADMISSIONS and BED DAYS (any HF) 2 Primary diagnosis 5,642 Secondary diagnoses 14,544 All cases diagnoses 20,186 64,544 166,498 Total bed days ~ 231,042 10,000 **Average/mean length of stay for HF patients presenting with/without comorbidities is 11.4/11.6 days (varies from approx. 8.6 to 20.8 days) 7% of HSE bed days, 4% of inpatient admissions, 5% of ED admissions 2 ED, emergency department; HSE, health service executive. 1. Irish Heart Foundation. From crisis to control: a cohesive strategy for hospital management of heart failure in Ireland. Irish Heart Foundation Council on Heart Failure. 2002. Available from: https://www.irishheart.ie/media/pub/positionstatements/from_crisis_to_control_ihf_position_document_final.pdf. Accessed October 2015. 2. The cost of heart failure in Ireland. The social, economic and health implications of heart failure in Ireland. Data on file. 3. Department of Health and Children. Changing cardiovascular health. National Cardiovascular Health Policy 2010 2019. Dublin: Government Publications, 2010. Available from: http://www.irishheart.ie/media/pub/advocacy/changing_cardiovascular_health.pdf. Accessed October 2015.
HF: future prevalence and incidence in Ireland 200,000 Prevalence 14,000 Incidence (new cases of HF per year) 180,000 160,000 140,000 120,000 100,000 80,000 110,744 135,457 172,811 12,000 10,000 8,000 6,000 10,287 11,293 13,182 60,000 4,000 40,000 20,000 2,000 0 2020 2030 2045 0 2020 2030 2045 Year Year Adapted from: CENTRAL STATISTICS OFFICE 2013a. Population and Labour Force Projections 2016-2046. Dublin: Stationary Office. Available from: http://www.cso.ie/en/media/csoie/releasespublications/documents/population/2013/poplabfor2016_2046.pdf. Accessed October 2015.
National GP survey: barriers to diagnosis of HF Barriers Yes (%) Inadequate access to natriuretic peptide testing 63.4 (n = 227) Lack of direct access to echocardiography 81.4 (n = 226) Waiting times for outpatient appointments 89.4 (n = 222) Patient unable to attend outpatients clinic 37.5 (n = 224) Unsure of interpretation of tests 34.4 (n = 221) Other 3.1 (n = 228) GP, general practitioner. Data on file.
National GP survey: challenges to management of stable HF Challenges Yes (%) Not enough time to manage patients adequately 59.7 (n = 226) Unable to access diagnostics 87.7 (n = 228) Unable to access specialist advice easily 81.9 (n = 227) Requires further education in the management of chronic HF 76.4 (n = 220) Data on file.
Self-care in the Irish population is low Daily weighing Regular exercise Weight gain contact doctor Fatigue contact doctor Limit fluids Short of breath contact doctor Low salt diet Rest daily Swollen feet contact doctor Flu injection Short of breath take it easy Medication as prescribed 14 27 38 42 41 55 n = 98 61 63 65 77 79 94 0 10 20 30 40 50 60 70 80 90 100 Self-care behaviour (%) Tully N, et al. RCSI Psychology Reports. 2009. Available from: http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1026&context=psycholrep. Accessed October 2015.
A study of hospital-based rehabilitation programmes All focus-group participants had completed time-limited rehabilitation programmes Some felt adrift once they had completed the programme Participants felt that GPs played a minor part in managing HF Regarding hospital care, participants expressed frustration at the lack of continuity of personnel during treatment Tully N, et al. RCSI Psychology Reports. 2009. Available from: http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1026&context=psycholrep. Accessed October 2015.
Cost of HF: summary Total cost of HF was approx. EUR 660m direct cost to the HSE was EUR 158m (1.2% of 2012 healthcare budget) HF-related admissions account for 4% of inpatient admissions and 7% of all HSE inpatient bed days in 2012 < 1% of patients are referred for cardiac rehabilitative services Informal care is estimated at EUR 364.2m and represents the largest component of HF costs Clear evidence of national disparity in the provision, activity, and planning of cardiac and outpatient follow-up services between counties not related to differences in need The cost of heart failure in Ireland. The social, economic and health implications of heart failure in Ireland. Data on file.
Cost of HF in Ireland Prevalence-based analysis Description Primary costs (EUR) HF costs Total expenditure (%) Direct cost (%) Related costs (EUR) HF-related costs Total expenditure (%) Direct cost (%) Direct cost GP 40,093,486 6.1 25.4 40,093,486 5 14 Hospital costs Hospitalization 42,943,087 6.5 27.2 132,146,669 17 47 Ambulance 876,817 0.1 0.6 2,852,761 0 1 OPD 12,638,660 1.9 8.0 27,420,852 4 10 Heart-transplantation procedure 2,925,583 0.4 1.9 2,925,583 0 1 Specialist assessment 3,275,023 0.5 2.1 3,275,023 0 1 Cardiac rehabilitation 29,722 0.005 0.02 29,722 0 0 Diagnostics 11,161,663 1.7 7.1 11,161,663 1 4 Nursing home care 17,925,376 2.7 11.3 34,334,770 4 12 Drug cost 26,137,255 4.0 16.5 26,137,255 3 9 Indirect cost Informal care 364,188,083 55.5 NA 364,188,083 47 NA Economic cost LYL 134,041,499 20.4 NA 134,041,499 17 NA LYL, life years lost; NA, not applicable; OPD, outpatient department. The cost of heart failure in Ireland. The social, economic and health implications of heart failure in Ireland. Data on file.
HF costs are comparable or higher to type 2 diabetes costs Disease area Fall and fracture 1 Stroke and TIA 2 Type 2 diabetes 3 HF 4 Total cost EUR 402m EUR 489m 805m EUR 377m 580.2m 660m 1. Gannon B, et al. Ir Med J. 2008;101:170-3. 2. Economic Social and Research Institute. Cost of stroke in Ireland: estimating the annual economic cost of stroke and TIA in Ireland. Dublin: The Irish Heart Foundation, 2010. 3. Nolan JJ, et al. Ir Med J. 2006;99:307-10. 4. The cost of heart failure in Ireland. The social, economic and health implications of heart failure in Ireland. Data on file.
Management of HF in Ireland: summary Reactive system Structured care in (some) hospitals Unstructured primary care High societal burden Lack of continuity (we aren t joined up!) High economic costs
Are there opportunities?
Virtual consult Move the data, not the patient! Use the technology you have in your pocket!
262 cases reviewed by VC May 2014 Oct 2015 VC, virtual consult.
82% do not require referral to outpatients clinic
50,000 km saved in travel Elderly/frail Multiple comorbidities Limited means to travel
Enhance access to diagnostics in the community Of patients referred to HF diagnostic clinics, only 30 40% actually have HF at the end of the diagnostic process Can giving primary care physicians access to diagnostics reduce referral while maintaining quality?
Gorey project: access to diagnostics GPs were given access to BNP testing and echocardiography in the community reduced need for echocardiography by 25% reduced need for specialist review by 62% BNP, brain natriuretic peptide.
Quality of care I m much happier in the practice than the hospital. They had time and I didn t feel rushed. My trouble is the travelling. I have a 5-inch plate in my leg and a new knee and I find it hard to go on the bus. I used to go on the bus and that was ok, but I can t use it now. It saves a big rigmarole with traffic and you know the people who are treating you. It s a great help really, I don t drive a great deal either.
Summary Challenges exist Current situation is not sustainable Opportunities exist
Challenges and opportunities in heart failure: unmet clinical needs, economic burden, and impact on society 7 November 2015 Milan, Italy