Outpatient heart failure programs: time for a new standard

Effective ambulatory services and community heart failure care may mitigate its impact on our health care system

Heart failure imposes a significant burden on the Australian health care system. Driven by the increasing number of patients diagnosed each year, repeated hospitalisations and long inpatient stays result in substantial morbidity and costs to the health care system.1

Community-based heart failure care programs incorporate a multidisciplinary and patient-centred approach that aims to enhance self-management by the patient. This model of care directs most management of heart failure into the outpatient environment, with the goal of reducing the numbers of hospitalisations, the duration of inpatient stays, and, ultimately, morbidity and mortality. The available evidence suggests that, when properly implemented, transition-of-care heart failure management can reduce both hospitalisations and mortality.2-4 However, variability across the country in the efficacy of this care model, both between hospitals at the state level and within patient populations, may compromise its outcomes. The ability of a service to provide meaningful benefits in terms of reduced hospitalisations for heart failure and lower mortality rates is intimately dependent on the quality of implementation of the care model.5

In this issue of the Journal, Huynh and his co-authors6 describe the variability of access to post-discharge heart failure care programs across Australia and the impact of this variability on all-cause re-admission and mortality rates at 30 and 90 days. The authors performed a prospective analysis of outcomes for patients admitted for heart failure to six major heart failure centres in five Australian states according to their access to home-based disease management programs (DMPs), early post-discharge re-assessment by a cardiologist, general practitioner or heart failure nurse, and community exercise programs. They found that access to DMPs and a review within 7 days of discharge were each associated with reduced re-admission rates at 30 days (DMPs: odds ratio [OR], 0.27; 95% confidence interval [CI], 0.16–0.43; 7-day review: OR, 0.42; 95% CI, 0.28–0.65), but exercise programs were not (OR, 0.75; 95% CI, 0.41–1.38); at 90 days, a benefit was seen with all three programs (DMPs: OR, 0.50; 95% CI, 0.36–0.70; 7 day review: OR, 0.64; 95% CI, 0.46–0.88; exercise program: OR, 0.52; 0.30–0.91). Interestingly, access to the community-based management programs varied. There was also variation in service provision between the selected hospital services that appeared to influence patient outcomes.

Snapshot analyses of health care outcomes across Australia provide insights into performance at the national level. However, the non-inclusion of one state (Western Australia) and two Australian territories in the analysis by Huynh and colleagues means that their findings regarding heart failure management cannot be generalised to the entire country. Further, including only one hospital per state limits the ability to identify barriers at a jurisdictional level to implementing adequate heart failure services for specific populations. This is important because health care varies dramatically between metropolitan and regional areas. The challenges of providing adequate heart failure programs in regional areas are exacerbated by limited funding and the shortage of trained staff. The complexity of health care delivery in this context cannot be extrapolated from the analysis by Huynh and his co-authors. To instigate an evolution in clinical practice across Australia, data from more centres is required to understand the reasons for variability in different regions and how to resolve them.

Nevertheless, the authors have identified a major problem in community heart failure management. Standardisation of care and validation of efficacy across Australia is imperative to improving outcomes and reducing the costs associated with this condition. In order to promote this change, health care services must implement standardised ambulatory heart failure programs that are accessible to all patients.

The report by Huynh and colleagues further emphasises the fact that well implemented community heart failure programs provide tangible benefits. This was particularly highlighted by a reduction in re-admission rates with structured post-discharge programs and adequate patient participation, which from a patient’s perspective is clearly advantageous in the management of this chronic disease. However, the costs of medical and nursing expertise, and the substantial resources required for training and continuous quality assurance should not be underestimated. To justify ongoing investment, health care services must therefore shift towards objectively assessing the quality of their implementation, improve accessibility to community heart failure programs, and document improvements in outcomes over time.

The burden of heart failure will only increase with time, but providing efficient ambulatory services and shifting the locus of care into the community may effectively mitigate the impact of the condition on our health care system. Achieving this goal will depend on objective evaluation and benchmarking of the reach, quality, and effectiveness of local models of heart failure transition-of-care services.