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

The scale of Heart Failure in Ireland ~ 300,000 people with ‘LV Dysfunction’; more than 100,000 with HF 2 IHF 2001

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 The population in Ireland affected by heart failure can be drawn into three major groups: 1. There are an estimated 12,000 people forming the most severe category, the “sick HF” group; because of frequent and costly admissions to hospitals consume the majority of resources of HF care. Currently, there is no widely implemented, co-ordinated care strategy for the management of these people. 2. The second category have milder disease, are being treated in general practice but have not yet entered the cycle of admission and readmission for HF. There is no co-ordinated care strategy here and other difficulties in managing this group of people include high rates of mis-diagnosis and under-treatment. 3. The third group have left ventricular systolic dysfunction or impending heart failure without symptoms. These are frequently not treated, or even recognised. The estimated annual numbers moving from stages 3 to 2 to 1 are shown. 3

Heart Failure: Problems and Solutions Life Cycle Ideal : 85 yrs 40 yrs Life Cycle with Heart Failure: At Risk First Diagnosis Hospitalisations 75 yrs 40 yrs Prevention Community Mx Hospital

Heart Failure Solution Life Cycle of Heart Failure in 2011: Hospitalisations 40 yrs 75 yrs Life Cycle with Heart Failure Programme: 76 yrs 40 yrs

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

ECG, BNP, Bloods, QoL Measures Week 3 Week 4 Week 5 Week 6 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 Education – review of medications Week 7 Week 8 Week 9 Week 10 Week 11 Tel Week 12 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 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*

42.3% less emergency GP visits in the intervention arm Adherence Outcome Follow up Courtney 2009 RCT (blinded) Intervention n=58 Control n= 64 Mean 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 months Access 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=112 SC=55 CR= 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 = 25 C=35 P<0.00001 Cardiovascular 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 = 1159 UC=1172 36 supervised exercise sessions Hospitalizations I=2297 UC=2332 LOS I= 13.6days UC=15 days Total medical cost I=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 MLWHF EQ-5D P<0.0001* P<0.01* 5 years P<0.001* P=0.12* Bellardinelli (1999) 15months 19 months

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?