‘Achieving new standards for heart failure care will require awareness-raising, investment and reform in primary care.’
This was the resounding message of the Heart Failure Policy Network’s (HFPN’s) policy webinar to launch our report From guidelines to action: opportunities for change following the 2021 ESC guidelines.
With the anniversary of the updated 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure approaching, the HFPN brought together healthcare professionals, patient advocates and policy experts to explore how to make the scientific consensus a reality. Reflecting on the long backlogs for hospital care and the changing demographics of populations affected by heart failure, community-based services are more pivotal than ever. Decision-makers, healthcare professionals and heart failure advocates can align behind this vision and close the care gap in heart failure.
The European Society of Cardiology (ESC) guidelines task force included patient representatives, recognising lived experience of heart failure, a syndrome far more complex than a single set of symptoms requiring a single specialism. ‘Fundamentally, heart failure creates a massive psychological burden on the patient,’ explained Richard Mindham, who was a patient representative on the task force and spoke at the webinar.
Dr Mar Domingo is a primary care physician with a clinical and academic specialism in heart failure who advocates for coordinated care. She highlighted that having multiple conditions is becoming the norm for people with heart failure as the population ages and more people survive cardiac events that might previously have been life-ending. Beyond cardiovascular and respiratory conditions, more people with heart failure today also live with metabolic conditions such as diabetes and chronic kidney disease than did so 20 years ago. According to Dr Domingo, the syndrome is complex from a clinical, healthcare and social perspective because it requires coordination of services and the consideration of wider needs. This complexity is receiving greater recognition in guidelines that emphasise the need for multidisciplinary care. Such care can be effectively coordinated by healthcare professionals in primary care, collaborating with community- and hospital-based teams.
The 2021 heart failure guidelines see the addition of specific recommendations for self-management strategies, as well as home- and clinic-based multidisciplinary disease management programmes – all of which can reduce the risk of avoidable hospitalisations and premature death. These strategies are particularly important when heart failure symptoms are worsening. Dr Domingo suggested promoting alternatives to hospitalisation centred around case management, taking into account the person’s holistic, multidisciplinary needs, rather than basing care on management of a single condition.
To enable ongoing management in the community and early detection of exacerbations in heart failure, telemonitoring now provides a guideline-approved approach. Ekaterini Lambrinou, a nursing professor, said: ‘One thing the pandemic has shown us is that we may use telemonitoring and telehealth effectively – actually, it was the only tool we had.’ Telehealth does not have to be futuristic: the old-fashioned telephone was one of the most important tools for remote monitoring and coordination. Mr Mindham added that the perception that technology is just for the ‘young and tech-savvy’ was also put to the test – with many older people embracing innovation.
Primary care also provides the key to care coordination following hospital discharge. The new guidelines call for follow-up appointments within two weeks, but Dr Domingo explained this is not being met by traditional service models, with waiting times of 12 weeks. The peak period for readmissions – the vulnerable phase – is the first two weeks after discharge, so this is when the appointment should be offered, ideally as a collaboration between cardiology and primary care. This alone can halve post-discharge mortality rates, as well as reducing future emergency department visits and hospitalisation, compared with no follow-up.
The case for primary care to drive the delivery of guideline-based heart failure care is strong, but the barriers are high. Even in countries with well-resourced health systems, the driving force for resource allocation is emergency care in hospitals, rather than building personal resilience in the community. A reversal of this model is needed to increase resources and time for appointments in general practice.
Reforming workforce models is one route to shifting care out of hospitals. Dr Lambrinou emphasised the ‘crucial role of nurses who always care holistically, assessing not only physical and emotional but also social, economic, educational [and] even transcultural issues’. Mr Mindham called for provision of cardiac rehab programmes that focus on patient education as well as exercise and psycho-social support to ‘help the patient regain control of their lives and become a functioning member of society’. In more financially constrained systems, such as Poland, a shortage of cardiologists creates an even stronger case for nurses and other professionals, stated cardiologist Dr Marta Kałużna-Oleksy. Specialist nurses in Poland have long been only sparsely available, mostly in university hospitals. ‘Fortunately, this situation has changed for the better recently due to the wide availability of training for heart failure nurses’, she notes.
Limited availability of, or lack of reimbursement for, recommended diagnostics and cornerstone pharmacological treatments in primary care are also barriers to implementing the guidelines. The adoption of point-of-care blood biomarker testing and handheld echocardiograms could relieve pressure on secondary care services and enable earlier diagnosis in the community, if adequate resources and reforms were in place.
To make the transition to community-led heart failure care, healthcare professionals need to develop local standards for access to care, stated Professor José Ramon González Juanatey. Long waiting times for confirmatory diagnostic tests for suspected heart failure result in delayed treatment and avoidable hospital admissions. Local health systems should establish a care pathway that allows primary care physicians to access testing, rapid post-discharge assessments, and targets for prescribing and adjusting dosage of cornerstone treatments. Professor Juanatey argued that this should be led by local healthcare professionals, while Dr Lambrinou also championed the importance of people with heart failure in shaping change as experts by experience.
The ESC guidelines also propose quality standards that can guide local pathway specification. Incorporating these quality standards into national policy and local practice is a prime example of how the latest science can be translated into action. The HFPN welcomes this step. We will follow up our report and webinar with national advocacy briefings and collaborations with our partners to make primary-care-led heart failure diagnosis and management a reality.
Thank you to the webinar speakers:
Blog post by Joe Farrington-Douglas, Network Director, Heart Failure Policy Network