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
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
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
Virtual Consultation
Reduce Patient Referral
Reduce Patient TravelKnowledge Dissemination
Expedite Specialist Opinion
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
Virtual Consultation
Reduce Patient Referral
Reduce Patient TravelKnowledge Dissemination
Expedite Specialist Opinion
Improve Care Community Referral ER Referral
Improved Patient Satisfaction
Decreased Family Inconvenience
Improved Quality of
Life
Reduced OPD Waiting
Times
Morbidity Emergency Room Attendance Hospitalisation Effective Use of Diagnostics
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
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
Control Intervention0
500
1000
1500
2000
2500
3000
Primary Care
Secondary Care
Cost
per
pati
ent p
er an
num
(€)
STOP-HF: Cost Effectiveness, n=1054
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
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
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
Virtual Consultation
Reduce Patient Referral
Reduce Patient Travel
Expedite Specialist Opinion
Knowledge Dissemination
Virtual Consultation
Reduce Patient Referral
Reduce Patient TravelKnowledge Dissemination
Expedite Specialist Opinion
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
Virtual Consultation
Reduce Patient Referral
Reduce Patient TravelKnowledge Dissemination
Expedite Specialist Opinion
Improve Care Community Referral ER Referral
Improved Patient Satisfaction
Decreased Family Inconvenience
Improved Quality of
Life
Reduced OPD Waiting
Times
Morbidity Emergency Room Attendance Hospitalisation Effective Use of Diagnostics
Chronic Disease in Community
Public Satisfactio
n
CostsPositive Public
Relation
Improve Quality of Life
~1Million ~150 million
Superior Risk Definition and Focused Use of Resources Critical to CV Management
At Risk Population
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
–
Control Intervention0
500
1000
1500
2000
2500
3000
Primary Care
Secondary Care
Cost
per
pati
ent p
er an
num
(€)
STOP-HF: Cost Effectiveness, n=1054
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