Reorganization of heart failure management and improved outcome – the 4D HF Project

Abstract

Objectives. Heart failure (HF) management is suboptimal in Sweden despite available evidence-based guidelines. To improve HF treatment, a comprehensive HF management program (4D project) was implemented in the Stockholm County (>2.1 million inhabitants). Design. A standardized care program centralized at five hospital-based HF clinics was implemented in 2014-2017. We registered from 2012 to 2017: (1) numbers of referrals and visits to HF clinics, (2) numbers of hospital admitted patients per million inhabitants, (3) dispensed HF medications after admission, and (4) covariate-adjusted 1-year allcause mortality or HF readmission. Results. Yearly visits to the five HF outpatient clinics increased 3.4 times from 3,372 to 11,527. Dispensed HF drug prescriptions increased, in particular, for readmitted patients, compared to 2012 (p<.0001). Total number of hospital admitted HF patients as well as newonset or readmitted HF patients decreased by 16, 13, and 20%, respectively (p < .0001). The combined 1year mortality or HF readmission over the period was 48% (n ¼ 17,124/35,880) and improved per year (HR 0.98 [0.97-0.99], p < .001) from 2012. Conclusion. A comprehensive standardized care HF management program including expanded HF clinics was associated with improved evidence-based medication, reduced HF hospitalization, and improvement of the combined outcome of 1-year mortality or HF readmission in Stockholm.

Baseline characteristics of 547 new onset heart failure patients in the PREFERS heart failure study

“…These findings underline the importance of HF awareness and a structured diagnostic and therapeutic approach. 7 Our previous results indicate that HF medication prescription increase and need for HF hospitalizations decline when such a process is implemented in a larger population. 7,25 Although we only could perform cMRI in 50 patients, we found no signs of diffuse fibrosis or in remote native T1 or ECV between the HF groups regardless of the cut-off values for LVEF.…”

“…7 Our previous results indicate that HF medication prescription increase and need for HF hospitalizations decline when such a process is implemented in a larger population. 7,25 Although we only could perform cMRI in 50 patients, we found no signs of diffuse fibrosis or in remote native T1 or ECV between the HF groups regardless of the cut-off values for LVEF. However, this absence does not preclude that fibrosis was present.…”

“…The patients were treated according to a structured regional guideline 2,7 . All clinical assessments and data entry were made by an HF physician and an HF nurse on the average 2–4 weeks after a de novo HF hospital admission or at the first outpatient visit for new onset HF in the HF outpatient clinics.…”

Navigating between Scylla and Charybdis: challenges and strategies for implementing guideline‐directed medical therapy in heart failure with reduced ejection fraction

“…2 Of note, interventions aimed at providing standardised management protocols and institutional accreditation have proven effective in boosting prescription rates and adherence to evidence-based therapies. 46,47 a project of Quality-of-Care Centres (QCC), defined as healthcare institutions offering multidisciplinary HF management (from primary to tertiary levels) in accordance with the academic accreditation protocols from ESC/HFA. 48 These centres will be embedded into the existing healthcare systems across ESC member countries.…”

“…A post‐discharge plan including a schedule for up‐titration visits and guidance about how to monitor and manage drug intolerance and side‐effects can also help in overcoming clinical inertia in optimising GDMT 2 . Of note, interventions aimed at providing standardised management protocols and institutional accreditation have proven effective in boosting prescription rates and adherence to evidence‐based therapies 46,47 . To meet this goal, ESC/HFA initiated a project of Quality‐of‐Care Centres (QCC), defined as healthcare institutions offering multidisciplinary HF management (from primary to tertiary levels) in accordance with the academic accreditation protocols from ESC/HFA 48 .…”