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Hassanein M, Tageldien A, Badran H, Samir H, Elshafey WE, Hassan M, Magdy M, Louis O, Abdel‐Hameed T, Abdelhamid M. Current status of outpatient heart failure management in Egypt and recommendations for the future. ESC Heart Fail 2023; 10:2788-2796. [PMID: 37559352 PMCID: PMC10567665 DOI: 10.1002/ehf2.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 05/27/2023] [Accepted: 07/17/2023] [Indexed: 08/11/2023] Open
Abstract
Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6 min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.
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Fowokan A, Frankfurter C, Dobrow MJ, Abrahamyan L, Mcdonald M, Virani S, Harkness K, Lee DS, Pakosh M, Ross H, Grace SL. Referral and access to heart function clinics: A realist review. J Eval Clin Pract 2021; 27:949-964. [PMID: 33020996 DOI: 10.1111/jep.13489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVES Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics. METHODS Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory. RESULTS A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome). CONCLUSION Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.
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Affiliation(s)
| | | | - Mark J Dobrow
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- St. Paul's Hospital, University of British Columbia, and Cardiac Services BC, Vancouver, British Columbia, Canada
| | - Karen Harkness
- CorHealth Ontario, Toronto, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Douglas S Lee
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- University Health Network, Toronto, Ontario, Canada
| | - Sherry L Grace
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Faculty of Health, York University, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting. RECENT FINDINGS Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada.
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Abrahamyan L, Sahakyan Y, Wijeysundera HC, Krahn M, Rac VE. Gender Differences in Utilization of Specialized Heart Failure Clinics. J Womens Health (Larchmt) 2018; 27:623-629. [PMID: 29319404 DOI: 10.1089/jwh.2017.6461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although heart failure (HF) prevalence is equally high among men and women, observed differences in the provision of care are still not fully understood. We sought to evaluate gender differences in patient profiles, diagnostic testing, medication prescription, and referrals in specialized multidisciplinary ambulatory HF clinics in Ontario. MATERIALS AND METHODS Medical chart abstraction was conducted first by randomly selecting 9 (out of 34) HF clinics in Ontario, and then by randomly selecting 100 patient records in each clinic. Data on patient demographics, comorbidities, diagnostic tests, medication use, and referrals were abstracted, covering a period from the first clinic visit up to 1 year. Descriptive statistics and regression analysis were used to assess gender differences. RESULTS Of the 884 patients, only 314 were women (35.5%). At the first clinic visit, women were older, had better systolic function but worse functional status, and had a lower prevalence of hyperlipidemia, diabetes, and smoking than men. There were more women with non-ischemic HF etiology than men (63.9% vs. 43.3%, p < 0.001). Adjusted analysis did not reveal gender differences in the average number of echocardiographic assessments and in the prescription rates of evidence-based medications. Men were twice more likely to be referred to electrophysiology studies than women (18.6% vs. 7.8%, p < 0.001). The rates of dietary counseling and cardiac rehabilitation referrals were similarly low in both groups. CONCLUSIONS More men than women are treated in specialized ambulatory HF clinics. Although women differ from men in selected clinical characteristics, no major differences were observed in patient management. The reasons for low enrollment rates of women into the HF ambulatory clinics need further investigation.
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Affiliation(s)
- Lusine Abrahamyan
- 1 Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto , Toronto, Canada .,2 Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada
| | - Yeva Sahakyan
- 2 Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada
| | - Harindra C Wijeysundera
- 2 Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada .,3 Department of Medicine, University of Toronto , Toronto, Canada .,4 Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre , Toronto, Canada .,5 Institute for Clinical Evaluative Sciences (ICES) , Toronto, Canada
| | - Murray Krahn
- 1 Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto , Toronto, Canada .,2 Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada .,3 Department of Medicine, University of Toronto , Toronto, Canada .,5 Institute for Clinical Evaluative Sciences (ICES) , Toronto, Canada
| | - Valeria E Rac
- 1 Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto , Toronto, Canada .,2 Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada .,6 Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, University Health Network , Toronto, Canada
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Ducharme A. Do Heart Failure Clinics Have to Reinvent Themselves to Remain Germane? Can J Cardiol 2017; 33:1212-1214. [DOI: 10.1016/j.cjca.2017.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 07/11/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022] Open
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Aspromonte N, Gulizia MM, Di Lenarda A, Mortara A, Battistoni I, De Maria R, Gabriele M, Iacoviello M, Navazio A, Pini D, Di Tano G, Marini M, Ricci RP, Alunni G, Radini D, Metra M, Romeo F. ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care. Eur Heart J Suppl 2017; 19:D89-D101. [PMID: 28751837 PMCID: PMC5520754 DOI: 10.1093/eurheartj/sux009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.
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Affiliation(s)
- Nadia Aspromonte
- CCU-Cardiology Department, Presidio Ospedaliero San Filippo Neri, Via G. Martinotti, 20, 00135 Rome, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Andrea Mortara
- Clinical Cardiology and Heart Failure Unit, Policlinico di Monza, Monza, Italy
| | - Ilaria Battistoni
- CCU-Cardiology Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Renata De Maria
- Institute of Clinical Physiology of the CNR, ASST Grande Ospedale Metropolitano Niguarda, ilano, Italy
| | - Michele Gabriele
- Cardiology Department, Ospedale Ajello c/o Ospedale Vittorio Emanuele I, Castelvetrano (TP), Italy
| | | | | | - Daniela Pini
- Clinical Cardiology Unit, Istituto Clinico Humanitas, Rozzano (MI), Italy
| | | | - Marco Marini
- CCU-Cardiology Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Renato Pietro Ricci
- CCU-Cardiology Department, Presidio Ospedaliero San Filippo Neri, Via G. Martinotti, 20, 00135 Rome, Italy
| | - Gianfranco Alunni
- Integrated Heart Failure Unit, Ospedale di Assisi, Assisi (PG), Italy
| | - Donatella Radini
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Marco Metra
- Cardiology Unit, Spedali Civili, Brescia, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Policlinico "Tor Vergata", Roma, Italy
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Henri C, O’Meara E, De Denus S, Elzir L, Tardif JC. Ivabradine for the treatment of chronic heart failure. Expert Rev Cardiovasc Ther 2016; 14:553-61. [DOI: 10.1586/14779072.2016.1165092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Howlett JG. Specialist Heart Failure Clinics Must Evolve to Stay Relevant. Can J Cardiol 2014; 30:276-80. [DOI: 10.1016/j.cjca.2013.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/20/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022] Open
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Jaarsma T, Strömberg A. Heart failure clinics are still useful (more than ever?). Can J Cardiol 2014; 30:272-5. [PMID: 24468418 DOI: 10.1016/j.cjca.2013.09.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 09/20/2013] [Accepted: 09/22/2013] [Indexed: 11/16/2022] Open
Abstract
Heart failure (HF) clinics have had an important role in optimal HF management and the effectiveness of these clinics has been studied intensively. A HF clinic is one of the various ways to organize a HF disease management program. There is good evidence that HF disease management can improve outcomes in HF patients, but it is not clear what the optimal components of these programs are and what the relative effectiveness of a HF clinic is compared with other forms of HF management. After initial positive reports on the effect of HF clinics, these clinics were implemented in many countries, although in different formats and of varying quality. In this article we describe the initial need for HF clinics, reflect on their development over time, and discuss the role of HF clinics in context of the current need for HF disease management.
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Affiliation(s)
- Tiny Jaarsma
- Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
| | - Anna Strömberg
- Department of Medicine and Health Sciences, Division of Nursing, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Cardiology UHL, County Council of Östergötland, Linköping, Sweden
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