A Global perspective on Heart Failure: What needs to change? Martin R Cowie London, United Kingdom
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
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. 3 1. 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;63:1123 1133. 2. Cowie MR et al. Improving care for patients with acute heart failure. 2014. Oxford PharmaGenesis. ISBN 978-1-903539-12-5. Available online at: http://www.oxfordhealthpolicyforum.org/reports/acute-heartfailure/improving-care-for-patients-with-acute-heart-failure 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;16:103-111.
Prevalence of HF www.escardio.org/communities/hfa/pages/global-heart-failure-awareness-programme.aspx
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)
Number and proportion of HF hospitalisations www.escardio.org/communities/hfa/pages/global-heart-failure-awareness-programme.aspx
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 (2011 12) 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
Length of stay for AHF
Trends in HF hospitalisation www.escardio.org/communities/hfa/pages/global-heart-failure-awareness-programme.aspx
High hospital readmission rates www.escardio.org/communities/hfa/pages/global-heart-failure-awareness-programme.aspx
Co-morbidity is universal http://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf
http://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf
The runaway train...?
We will have to do things differently...
National guidance & quality standards August 2010 June 2011 October 2014 Update scheduled http://www.nice.org.uk
AHA recommendations for hospital discharge: 2013 Yancy CW et al. Circulation 2013; 128: e240 327
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;33:1787 847
What is actually happening?
UK: assessing hospital adherence Six performance metrics: Data from 92% of the 150 hospitals in England & Wales >40 000 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 http://www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/hfannual12-13.pdf
Place of Care Place of care Index admission (%) Readmission (%) Cardiology ward 50 52 General medical ward 40 37 Other ward 10 11 Place of care Men (%) Women (%) Cardiology ward 55 44 General medical ward 36 46 Other ward 9 11 Place of care 16-74 (%) 75 years (%) Cardiology ward 65 43 General medical ward 29 46 Other ward 6 11
Specialist Input Specialist First admission (%) Readmission (%) Consultant cardiologist 57 61 Heart failure nurse specialist 22 20 Other consultant with interest in heart failure 6 6 Any HF specialist 78 80 Other clinician 22 20 Input from HF MDT 66 70 http://www.bsh.org.uk/resources/national-heart-failure-audit/
% 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 100 90 80 70 60 50 40 30 20 10 0 16-44 45-54 55-64 65-74 75-84 85+ Age Group ACEI and/or ARB Beta ACEI Loop diuretic MRA ARB http://www.bsh.org.uk/resources/national-heart-failure-audit/
Treatment and Specialist Input Treatment on discharge for LVSD by specialist input Medication Seen by any HF specialist (%) No specialist input (%) ACE inhibitor 75 62 ARB 18 19 ACEI and/or ARB 87 76 Beta blocker 85 69 MRA 53 32 ACEI and/or ARB, beta blocker and MRA 42 19 Loop diuretic 91 93 Thiazide diuretic 6 3 Digoxin 22 21 http://www.bsh.org.uk/resources/national-heart-failure-audit/
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 http://www.bsh.org.uk/resources/national-heart-failure-audit/ 0 5 10 15 20+ Length of stay (median) in days
Cardiology follow-up in England...poor! 70 000 survivors of HF admission. England, 2009-11. Bottle A et A al. Under et al. review In review.
Quality and Outcomes Framework in Primary Care
Compliance (%) Not all HF patients receive guideline care in the USA Wide variations in hospital performance have been reported 100 80 60 40 20 10 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
Adherence
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: 1653-59.
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 1.72 1.29-2.30 0.0002 CHF hosp in past year 1.84 1.38-2.44 <0.0001 Adherence (high vs low) 0.64 0.41-1.00 0.048 Ischaemic aetiology 1.44 1.08-1.91 0.013 Atrial fibrillation 1.34 1.01-1.78 0.045 Diabetes 1.43 1.05-1.93 0.022 Hypertension 0.70 0.53-0.93 0.012 Komajda M et al. Eur Heart J 2005; 26: 1653-59.
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
Financial Penalties
Best-practice based tariff
A community-wide approach is essential
Other approaches?
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 www.oxfordhealthpolicyforum.org /AHFreport www.escardio.org/communities/hfa/pages/ global-heart-failure-awareness-programme.aspx
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