Improving Diagnosis and Pathway for Heart Failure Patients-An Integrated Approach

1. Improved Diagnostics and Pathway for
Heart Failure Patients
An Integrated Approach
Professor Ken McDonald
National Clinical Lead for Heart Failure and
Clinical Director Heartbeat Trust

2. Improved Diagnostics and Pathway for
Heart Failure Patients
An Integrated Approach
Modern Heart Failure Care
Providing a Solution for all Chronic Illness?
Professor Ken McDonald
National Clinical Lead for Heart Failure
Clinical Director, Heartbeat Trust

3. 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

4. Agenda
1.The Challenge of
Chronic disease
3. Managing chronic illness
Using “reactive care” model
2. Goals of Chronic Disease
management
4.The Challenges of
Change
5. Heart Failure;
Providing Solutions

5. 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

6. Goals of Chronic Disease Management
1. Prevent / Slow the onset of Chronic Illness
o Individual responsibility
o Population health initiatives
o Personalised risk reduction in high risk cohorts
2. When developed, keep the patient well in the community
o GP-led care
o 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 outlook
o 75% of “ER candidates” can be dealt with safely in the community if………..

7. Outpatients
ED
Admission
The Acute Care Model:
Not Fit for Purpose for Chronic Disease Management
Primary Care…………………………….Interaction with…………………….Secondary Care

8. The Challenge of Change
The Resistance to Change
• Cardiology
• Procedure dominated
• Reactive
• ICS development
• Management
• “Titanic Syndrome”
• AHCP
• Pharmacists (community)
• Patient
• Individual Responsibility

9. Decision time for Chronic Disease
Same Road :
• Inevitable collapse of system
New Mode of Care
• Healthier
• More equitable
• Less costly

10. Heart Failure Management:
Clues to the Solution for Chronic Illness

11. 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

12. 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

13. Heart Failure Bed Need: a 600 bed unit occupied all year round

14. Heart Failure Bed Need: a 600 bed unit occupied all year round

15. The Problem as it now Stands

16. Heart Failure Providing Some Solutions

17. eHEALTH
Outpatients
ED
Admission
Many “medical
interactions”
don’t require the
patient!!!
Keep the limited
“real slots” for
needed patient
review

19. Virtual Consultation
Reduce Patient Referral
Reduce Patient Travel
Expedite Specialist Opinion
Knowledge Dissemination

20. 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

21. 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
Satisfaction
 Costs
Positive Public
Relation
Improve Quality
of Life

22. 200 appointments to date
50,000 km travel saved
85% no further referral
saved in travelElderly/Frail.
Multiple comorbidities.
Limited means to travel.

23. Common
Problem
Home Grown
Strategy
ProvenCost-Effective
Ready to
role
STOP-HF
A Personalised Prevention Strategy

24. 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

25. Natriuretic Peptides “personalises” Cardiovascular Risk

26. 15.5
9.9
6.2
2.7
3.8
2.7
3.8
1.4
11
5.5
0
5
10
15
20
25
30
35
40
45
Control Intervention
Numberofeventsper1,000patient
years
Stroke/TIA
PE/DVT
MI
Heart Failure
Arrhythmia
N=71 (10.5%) N=51 (7.3%)
Event Rate OR 0.54 p=0.001 vs. Control
Endpoint – MACE Event Rate

27. STOP-HF: Cost Effectiveness, n=1054
Ledwidge et al, EJHF (in press)

28. 0
500
1000
1500
2000
2500
3000
Control Intervention
Costperpatientperannum(€)
Primary Care
Secondary Care
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

29. 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

30. A New Approach to Chronic Disease
It is Great Opportunity; Don’t Miss it

31. View from STOP-HF Unit

32. 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

33. Why?

34. Heart Failure Epidemiology

35. 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

36. How Patient Groups Can Make a
Difference in Heart Failure
Professor Ken McDonald
National Clinical Lead for HF
Medical Director Heartbeat Trust

37. Virtual Consultation
Reduce Patient Referral
Reduce Patient Travel
Expedite Specialist Opinion
Knowledge Dissemination

38. 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

39. 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
Satisfaction
 Costs
Positive Public
Relation
Improve Quality
of Life

40. The STOP-HF Story
The First Personalised Approach to the Prevention of Heart
Failure

41. ~1Million ~150 million
Superior Risk Definition and Focused Use of Resources
Critical to CV Management
At Risk Population

42. Dublin South
Wicklow
Wexford
STOP-HF
Services in Ireland

43. Westmeath
Offaly
Laois
STOP HF
Midlands
Services in Ireland

45. 50,000 km
saved in travel
Elderly/Frail.
Multiple comorbidities.
Limited means to travel.

46. 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
–

47. View from STOP-HF Unit

48. STOP-HF: Cost Effectiveness, n=1054
Ledwidge et al, EJHF (in press)

49. 0
500
1000
1500
2000
2500
3000
Control Intervention
Costperpatientperannum(€)
Primary Care
Secondary Care
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