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Integrated tailored care: addressing heart failure comorbidities in the UK

Summary

A multi-specialty, multidisciplinary team aims to provide comprehensive, tailored care to people living with heart failure in Liverpool, UK. By addressing comorbidities in conjunction with heart failure, the initiative has the potential to improve outcomes and reduce healthcare costs. It brings together healthcare professionals with different specialties and experience in various care settings to discuss each case and provide consensus-based recommendations. This care model is expanding to other hospitals across the UK, with support from healthcare professionals and patient advocates.

The challenge

In the UK, it is estimated that heart failure affects over 920,000 people – nearly 80% of this group also lives with three or more coexisting health conditions.1 Common comorbidities are often non-cardiovascular, such as diabetes, chronic obstructive pulmonary disease, chronic kidney disease and asthma.2 3 People living with three or more comorbidities lose up to five times more life years.3 In addition to being a common cause of hospitalisation,1 4-6 comorbidities also increase healthcare costs and impact quality of life.4 7 Worse outcomes may be the result of polypharmacy, a common occurrence where a person uses five or more medications.8

The 2021 European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure state that optimal care requires a tailored and comprehensive approach.9 Multidisciplinary teams should not only manage heart failure, but all comorbidities. However, the ESC does not provide detailed guidance on the composition or organisation of such a team. Clearly defined guidelines are needed to ensure better outcomes for people living with heart failure.10

The solution

In January 2020, a new initiative was launched by Liverpool University Hospitals NHS Foundation Trust to provide tailored and comprehensive care for people with heart failure and comorbidities. This multi-specialty, multidisciplinary team is the first of its kind, integrating primary, secondary and tertiary care to manage comorbidities.11 It comprises cardiologists and nurses who specialise in heart failure and work alongside a variety of experts, including specialists in kidney disease, pharmacy and palliative care.11

The team meets virtually once a month to discuss and provide consensus-based recommendations for people who have been referred to the service. As of May 2022, 30 people have been referred by community heart failure teams, hospital-based heart failure teams (secondary and tertiary care) and other specialty teams.11 12 In preparation for the meetings, individual patients are consulted and details of each person’s case are shared with the team to discuss any preliminary questions.12

Discussions are tailored around the needs of each individual, and recommendations may involve the following:11

  • Improving heart failure treatment, including the optimisation of therapy, medication compliance and deprescription of medications to avoid the burden of polypharmacy.
  • Assessing comorbidities, such as cardiorenal metabolic status, chronic respiratory pathologies, falls risk and cognitive dysfunction.
  • Facilitating referrals to other services; for example, referring to device therapy, and transplant and dialysis assessment.
  • Advance care planning, including referral to community palliative care, hospice admission and device deactivation.

Recommendations are recorded in electronic health records, which are shared with primary care services and hospitals, and sent back to the heart failure care team that made the referral.11

What has been achieved?

The team is a tailored, cost-effective care model that addresses comorbidities in people living with heart failure, thereby improving outcomes and reducing healthcare costs.11

The initiative secured funding from the Liverpool Single Services Cardio-Respiratory Operations Group (from Liverpool Clinical Commissioning Group) by submitting a business case.12 Dr Rajiv Sankaranarayanan, Heart Failure Clinical Lead and Consultant Cardiologist at the trust, and his team used data and patient stories from a small multidisciplinary pilot to make the case for a multi-specialty, multidisciplinary team.13

An observational assessment of the initiative has shown that people who were referred to the service experienced a reduction in hospital admissions and outpatient appointments, compared with the period before introducing the multi-specialty, multidisciplinary team.11 Although further research is needed, this study showed the initiative’s potential to reduce healthcare costs, and save time and travel for participants. In addition, the initiative can address polypharmacy and reduce the number of specialist appointments that people with heart failure need to attend.11 12

During the COVID-19 pandemic, the team continued to meet virtually.14 This enabled patients to receive consensus-based recommendations without having to attend face-to-face appointments at different outpatient clinics. The team facilitates significant collaboration among a network of specialists, who are dedicated to optimising care for people living with heart failure and multiple comorbidities.11

The initiative currently comprises 25 people, and has gained national recognition from the heart failure community.12 In 2021, it was nominated for two HSJ Awards (a platform that highlights healthcare service excellence in the UK): Cardiovascular Care Initiative of the Year and Value Pilot Project of the Year.15-17

Next steps

In addition to referrals from hospitals, the team will soon allow general practitioners (GPs) to refer people with heart failure and comorbidities directly. GPs will also be able to attend the monthly meetings.12

This initiative is receiving greater recognition from other hospitals across the UK, which aim to adopt this care model.12 Although some areas in the country do not have as many specialists available, they are working on adapting the meetings to cater to local resources. The team has also engaged patient advocates, who want to ensure access to this care model in their area.12

Policy tips for heart failure advocates

  • Address a local problem: use local data on heart failure to identify a problem in your heart failure service and find approaches to address it. Start with a low-resource pilot and collect data on effectiveness and patient stories to build a business case to secure funding.
  • Leverage your network: engage colleagues across non-cardiovascular specialties to show the benefits of the initiative for people with heart failure and the health system. Garner further support by presenting and actively promoting your initiative to professional societies and hospitals to spur interest and replication.
  • Engage patients throughout the initiative: gathering feedback from people with heart failure at early stages can help to ensure that the initiative appropriately addresses the problem. Once you can prove the benefits, engage patient organisations and advocates to drive advocacy efforts and increase access to the care model.
  • Carry out pragmatic evaluations: decision-makers require evidence of cost-effectiveness. Assess the benefit of your initiative using data on hospitalisations, outpatient visits and cost savings before and after the intervention, or by using a control group that does not receive the intervention if possible.
  • Adapt to local resources: as the initiative expands to other regions, it is important to take the local context into consideration. Healthcare professionals can adapt the initiative to address local needs using the specialists and resources that are available in the area.

Contact

Dr Rajiv Sankaranarayanan (Heart Failure Clinical Lead and Consultant Cardiologist, Liverpool University Hospitals NHS Foundation Trust): Rajiv.Sankaranarayanan@liverpoolft.nhs.uk

  1. Conrad N, Judge A, Tran J, et al. 2018. Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals. The Lancet 391(10120): 572-80
  2. National Institute for Cardiovascular Outcomes Research. 2021. National Heart Failure Audit: 2021 summary report (2019/2020 data). London: NICOR
  3. Drozd M, Relton SD, Walker AMN, et al. 2021. Association of heart failure and its comorbidities with loss of life expectancy. Heart 107(17): 1417
  4. Hollingworth W, Biswas M, Maishman RL, et al. 2016. The healthcare costs of heart failure during the last five years of life: A retrospective cohort study. International Journal of Cardiology 224: 132-38
  5. Dunlay SM, Redfield MM, Weston SA, et al. 2009. Hospitalizations After Heart Failure Diagnosis: A Community Perspective. Journal of the American College of Cardiology 54(18): 1695-702
  6. Madelaire C, Gustafsson F, Kristensen SL, et al. 2019. Burden and Causes of Hospital Admissions in Heart Failure During the Last Year of Life. JACC: Heart Failure 7(7): 561-70
  7. Streng KW, Nauta JF, Hillege HL, et al. 2018. Non-cardiac comorbidities in heart failure with reduced, mid-range and preserved ejection fraction. Int J Cardiol 271: 132-39
  8. Beezer J, Al Hatrushi M, Husband A, et al. 2022. Polypharmacy definition and prevalence in heart failure: a systematic review. Heart failure reviews 27(2): 465-92
  9. McDonagh TA, Metra M, Adamo M, et al. 2021. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 42(36): 3599-726
  10. Jaarsma T, van der Wal MHL, Lesman-Leegte I, et al. 2008. Effect of Moderate or Intensive Disease Management Program on Outcome in Patients With Heart Failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Archives of internal medicine 168(3): 316-24
  11. Essa H, Walker L, Mohee K, et al. 2022. Multispecialty multidisciplinary input into comorbidities in heart failure reduces hospitalisation and clinic attendance. medRxiv: 10.1101/2022.01.31.22270113: 2022.01.31.22270113
  12. Sankaranarayanan R. 2022. Interview with Karolay Lorenty and Kirsten Budig at The Health Policy Partnership [teleconference]. 22/03/22
  13. Sankaranarayanan R, Douglas H, Wong C. 2020. Cardio-nephrology MDT meetings play an important role in the management of cardiorenal syndrome. The British Journal of Cardiology 27(3): 1-3
  14. Essa H, Oguguo E, Douglas H, et al. 2021. One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings. European Heart Journal 42(Supplement_1): ehab724.0971
  15. HSJ Awards. 2021. Cardiovascular Care Initiative of the Year. Available from: https://value.hsj.co.uk/cardiovascular-care-initiative-year-0 [Accessed 16/03/22]
  16. HSJ Awards. 2021. Value Pilot Project of the Year. Available from: https://value.hsj.co.uk/hsj-value-pilot-project-year-1 [Accessed 16/03/22]
  17. HSJ Awards. 2022. HSJ Partnership Awards 2022. Available from: https://partnership.hsj.co.uk/ [Accessed 16/03/22]
The Heart Failure Policy Network is an independent, multidisciplinary platform made possible with financial support from AstraZeneca, CSL Vifor, Boehringer Ingelheim and Roche Diagnostics. The content produced by the Network is not biased toward any specific treatment or therapy. All outputs are guided and endorsed by the Network’s members. All members provide their time for free. The Network is hosted by The Health Policy Partnership .