The Heart Failure Clinical Programme and its impact on Cardiac Rehabilitation Karen Cradock, B. Physio, MSc. Therapy Lead.

The Heart Failure Clinical Programme and it’s impact on Cardiac Rehabilitation

Karen Cradock, B. Physio, MSc.Therapy Lead

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IHF 2001

The scale of Heart Failure in Ireland ~ 300,000 people with ‘LV Dysfunction’; more than 100,000 with HF

The Heart Failure Pyramid

HF patients with a history of admission

Symptomatic HF in the community

Asymptomatic Ventricular dysfunction

15,000 – Sick HF

85,000 – Stable HF

250,000 – Impending HF

Heart Failure: Problems and Solutions

Life Cycle Ideal :

Life Cycle with Heart Failure:

40 yrs85 yrs

HospitalisationsFirst

Diagnosis

75 yrs40 yrs

At Risk

Prevention Community Mx Hospital

Heart Failure Solution

Life Cycle of Heart Failure in 2011:

75 yrs40 yrs

Hospitalisations

40 yrs 76 yrs

Life Cycle with Heart Failure Programme:

OVERARCHING AIM

TO IMPROVE QUALITY OF LIFE FOR PATIENTS WITH HEART FAILURE

IN IRELAND

Objectives

Access – Every patient with symptoms of heart failure is diagnosed

correctly and without delay Quality – Every patient with heart failure is managed within a

structured programme – Implement targeted programme to prevent heart failure Cost – Reduce recurrent admissions by 1,000 with

additional impact on de novo admissions – Reduce length of stay saving 20,000 hospital days per year

IMPLEMENTATION OF PROGRAMME

• Heart Failure Clinical Lead• 2 WTE Heart Failure Nurses in hospitals accepting

acute admissions (1.5 WTE HFN in hospitals with mainly non acute admissions and providing out patient services)

• Administrative support available • Adequate clinical space to see patients available • Structures in place for timely access to BNP and

echocardiography • Access to therapy services

Inpatient 2-3 visits Self care management

Week 1

Week 2 Clinic visit ECG, BNP, Bloods, QoL Measures

Week 3

Week 4

Week 5

Week 6 Clinic visit Education – review of medications

Week 7

Week 8

Week 9

Week 10

Week 11 Tel

Week 12 Clinic visit ECHO, bloods, HADs, enrolled in rehabilitation programme

Note: Access to Monday to Friday 5 day per week clinic for unscheduled visit

Active National Programmes

• St. Vincent’s University Hospital• Tallaght Hospital • St. James Hospital • Mater Hospital • Beaumont Hospital • Our Lady of Lourdes Hospital, Drogheda• Wexford General Hospital • Galway University Hospital • Portiuncula Hospital, Ballinasloe

Key performance indicators Key performance indicator Target

2012 Metric August

2012 Rate of readmission for heart failure within 3 months following discharge from hospital

≤ 27% 6.3%

Median Length of Stay for patients admitted with a principal diagnosis of ADHF

≤ 7.0 days

8.0 days

Percentage of patients with ADHF who are seen by the Heart Failure Clinical Lead during their hospital stay

>65% 92.3%

N = 427*

Intervention Adherence Outcome Follow up

Courtney 2009 RCT (blinded)Intervention n=58Control n= 64Mean age 78.8±6.8 years

Muscle strengthening, balance training, walking, muscle stretching. Assessed by PT.HV by Nurse 48 hours post DC weekly follow up calls X 4 weeks, monthly telephone follow up X 5 months

53% of intervention arm training at 6 months

24% less admissions to ED in the intervention arm

42.3% less emergency GP visits in the

intervention arm

21 readmissions in the intervention with 49 in the control

7 months

Wierzchowlecki 2006

RCT Intervention n=80 Control n =80

HFU visit day 14, and at 1,3,6 and 12 monthsAccess to cardiologist, HF CNS, Psychologist , Physio Control; Primary physician

Reduced hospital admissions by 37%

Reduced hospital readmissions with HF by 48% Mean duration of hospitalisation I= 9.3 days C=12.5days

1 year

Austin 2008 n=112SC=55CR= 57

Cardiac rehabilitation (twice weekly) 8 week MDT programme. This was followed by a 16 week community based exercise class V standard HF follow up

Number of inpatient days was 50% lower in CR group I=4.1days C=8.4days

Survival was 32 months in CR group V 23 months in SC group.

5 years

Davidson 2010 n=105 RCT 12 week once per week tailored MDT programme

All cause hospitalisation; I = 25C=35 P<0.00001Cardiovascular events;I=24%C=55%Mortality: 79% alive in the usual care V 93% in the intervention arm

5 year follow up

Reed 2010 HF Action

I = 1159UC=1172

36 supervised exercise sessions

Hospitalizations I=2297UC=2332LOS I= 13.6days UC=15 days Total medical costI=50,857 dollars UC=56,177 dollars Cost of intervention 1000

2.5 years

Cochrane Review- Exercise based Rehabilitation for Heart Failure

Follow up HRQoL Significance

HF- ACTION (2009) 30 months KCCQ P<0.001

Austin (2005) 6 months MLWHFEQ-5D

P<0.0001*P<0.01*

5 years MLWHFEQ-5D

P<0.001*P=0.12*

Bellardinelli (1999) 15months 19 months

MLWHF P<0.001P<0.001

Model A Heart Failure team manage the service

Model B Integration of cardiac rehabilitation and heart failure services

Training

Heart Failure Nursing Professional Certificate UCD

On-going course – intake 18-20 annually (FETAC level 9)

Advanced Skills Training for Physiotherapists in Heart Failure

Commenced in September 2012 – 6 months training (Aspiring to FETAC level 9 )

Pharmacy Training Programme Undergoing development

Foundation Course In the discussion phase (Possibly e-learning)

Units planning for implementation of the National Heart Failure Programme (Sept 2012)

• Connolly Hospital • Cavan/Monaghan Hospital Group • Mid Western Regional Hospital, Limerick • Sligo General Hospital

Impact of Programme on Cardiac Rehabilitation

• All current programme sites have cardiac rehabilitation programmes- likely to be referred- will they be included in the group sessions?

• Can cardiac rehabilitation become integral part of this care structure?