Prof Ken Mc Donald , Associate Clinical Professor UCD/ St Vincent's

Improved Diagnostics and Pathway for Heart Failure Patients

An Integrated ApproachProfessor Ken McDonald

National Clinical Lead for Heart Failure and Clinical Director Heartbeat Trust

Improved Diagnostics and Pathway for Heart Failure Patients

An Integrated ApproachModern Heart Failure Care

Providing a Solution for all Chronic Illness?Professor Ken McDonald

National Clinical Lead for Heart Failure Clinical Director, Heartbeat Trust

Two Messages from this Talk

1. Chronic Disease poses a risk to our healthcare system greater than anything experienced before

And

2. Solutions are with us but we need to apply them

Agenda

1.The Challenge of Chronic disease

3. Managing chronic illnessUsing “reactive care” model

2. Goals of Chronic Diseasemanagement

4.The Challenges of Change

5. Heart Failure;Providing Solutions

Chronic Illness in Ireland

• 38% of those >50yrs have at least 1 Chronic Illness

• 11% have 2 or more Chronic Illnesses

• Account for 80% of GP visits

• 40% of hospitalisations

• 75% of hospital bed days

• Will grow by 20% by 2020

• Driven by age, survival, obesity and DM and…..

The Challenge of Chronic Disease

Goals of Chronic Disease Management

1. Prevent / Slow the onset of Chronic Illnesso Individual responsibilityo Population health initiativeso Personalised risk reduction in high risk cohorts

2. When developed, keep the patient well in the community o GP-led careo Ease of access to specialist opinion/ investigations

3. Minimize need for ER referral and hospitalization o Will always be a need but…..o Each hospitalisation directly impacts on outlooko 75% of “ER candidates” can be dealt with safely in the community if………..

Outpatients

ED

Admission

The Acute Care Model:Not Fit for Purpose for Chronic Disease Management

Primary Care…………………………….Interaction with…………………….Secondary Care

The Challenge of Change

The Resistance to Change

• Cardiology • Procedure dominated• Reactive • ICS development

• Management• “Titanic Syndrome”

• AHCP• Pharmacists (community)

• Patient• Individual Responsibility

Decision time for Chronic Disease

Same Road :

• Inevitable collapse of system

New Mode of Care

• Healthier• More equitable• Less costly

Heart Failure Management: Clues to the Solution for Chronic Illness

What is Heart Failure?

A complex chronic illness characterized by reduction in physical

capacity occurring as a result of heart damage

Results in reduced QoL, shortened life expectancy

Significant burden on hospital care with present management structure

2% of National Health Care Budgets • >30 billion $ in the USA (Cost of running Ireland

for 6 mths)

To escalate by >100% over the next 15 years• 70 billion in US

Now

2030

Water Tax in Ireland • 160 Euro per year (maybe)

Heart Failure Tax in 2030• 250 Euro per year

Heart Failure Numbers

Heart Failure Bed Need: a 600 bed unit occupied all year round

Heart Failure Bed Need: a 600 bed unit occupied all year round

The Problem as it now Stands

Heart Failure Providing Some Solutions

eHEALTH

Outpatients

ED

Admission

Many “medical interactions”

don’t require the patient!!!

Keep the limited “real slots” for needed patient

review

Virtual Consultation

Reduce Patient Referral

Reduce Patient Travel

Expedite Specialist Opinion

Knowledge Dissemination



Reduce Patient TravelKnowledge Dissemination


Reduced OPD Waiting

Times

Improved Quality of

Life

Morbidity Emergency Room Attendance Hospitalisation Effective Use of Diagnostics

Decreased Family Inconvenience

Improved Patient Satisfaction

Improve Care Community Referral ER Referral








Improved Quality of

Life

Reduced OPD Waiting

Times


Chronic Disease in Community

Public Satisfactio

n

CostsPositive Public

Relation

Improve Quality of Life

200 appointments to date

50,000 km travel saved

85% no further referral saved in travelElderly/Frail.

Multiple comorbidities. Limited means to travel.

Common Problem

Home Grown

Strategy

Proven Cost-Effective

Ready to role

STOP-HF A Personalised Prevention Strategy

STOP-HF Hypothesis

NP-driven screening and targeted collaborative care in the general at-risk population will decrease the prevalence of LVD and HF

39 collaborating primary care practices, intervention provided in a single referral center

STOP-HF,JAMA, 2013

Natriuretic Peptides “personalises” Cardiovascular Risk

Control Intervention0

5

10

15

20

25

30

35

40

45

15.59.9

6.2

2.7

3.8

2.7

3.8

1.4

11

5.5

Stroke/TIAPE/DVTMIHeart FailureArrhythmia

Num

ber o

f eve

nts p

er 1

,000

pati

ent

year

s

N=71 (10.5%) N=51 (7.3%)

Event Rate OR 0.54 p=0.001 vs. Control

Endpoint – MACE Event Rate

STOP-HF: Cost Effectiveness, n=1054

Ledwidge et al, EJHF (in press)


500

1000

1500

2000

2500

3000

Primary Care

Secondary Care

Cost

per

pati

ent p

er an

num

(€)


MACE reduction associated with a shift in costs from secondary to primary care

17,000 MACE hospitalisations in Ireland

Equivalent to 380 bed capacity in system

Two Messages from this Talk

1. Chronic Disease poses a risk to our healthcare system greater than anything experienced before

And

2. Solutions are with us but we need to apply them

A New Approach to Chronic Disease It is Great Opportunity; Don’t Miss it

View from STOP-HF Unit

Where / Who should care for HF?

Care should be based in the community and be GP-led

Complex illness needs time-sensitive access to specialist tests/advice at certain critical stages

Not available in Ireland or Western world Delay to diagnosis Delay to Rx Increased Hospital utilization Compromised outcome

Why?

Heart Failure Epidemiology

2% of National Health Care Budgets • Approx 700million in Ireland• >30 billion $ in the USA (Cost of running Ireland

for 6 mths)

To escalate by >100% over the next 15 years• Approximatley 1.5billion in Irelnad• 70 billion in US

Now

2030

Water Tax in Ireland • 160 Euro per year (maybe)

Heart Failure Tax in 2030• 250 Euro per year

Heart Failure Numbers

How Patient Groups Can Make a Difference in Heart Failure

Professor Ken McDonald National Clinical Lead for HF

Medical Director Heartbeat Trust



Reduce Patient Travel


Knowledge Dissemination





Reduced OPD Waiting

Times

Improved Quality of

Life












Improved Quality of

Life

Reduced OPD Waiting

Times


Chronic Disease in Community

Public Satisfactio

n

CostsPositive Public

Relation

Improve Quality of Life

The STOP-HF Story

The First Personalised Approach to the Prevention of Heart Failure

~1Million ~150 million

Superior Risk Definition and Focused Use of Resources Critical to CV Management

At Risk Population

Dublin South

Wicklow

Wexford

STOP-HF

Services in Ireland

Westmeath

Offaly

Laois

STOP HFMidlands

Services in Ireland

50,000 km saved in travel

Elderly/Frail. Multiple comorbidities. Limited means to travel.

Need• Thank you to staff slide • Serendipity • Need Irish slides• Where we cam from –HFUN in 2004—follow on from serepndipity • NP and tracking risk • More Mayo data• Need to menion that this is off label use of NP• Echo concept and STOP

– Risk of Normal Echo and Np

–

View from STOP-HF Unit


Ledwidge et al, EJHF (in press)


500

1000

1500

2000

2500

3000

Primary Care

Secondary Care

Cost

per

pati

ent p

er an

num

(€)


MACE reduction associated with a shift in costs from secondary to primary care

17,000 MACE hospitalisations in Ireland

Equivalent to 380 bed capacity in system

Prof Ken Mc Donald , Associate Clinical Professor UCD/ St Vincent's

Healthcare