Evidence has shown that outpatient heart failure (HF) clinics reduce morbidity, mortality and health care costs. However, a new study in the current issue of the Canadian Journal of Cardiology shows that very few recently hospitalized patients with HF either receive or use a referral to such clinic despite guidelines that encourage physicians to recommend these clinics.
Outpatient heart failure clinics provide patient education on how to manage heart failure and risk factors, monitor therapy compliance and prescribe home-based exercises.
Leading researcher Shannon Gravely, PhD from York University’s Health Network, and Toronto Rehabilitation Institute in Toronto, Canada notes: “Given the demonstrated benefits of these services, the rates of referral and enrollment in our study are discouragingly low.”
The study involved a total of 474 HF inpatients from 11 Ontario hospitals in Canada, who were surveyed twice with a yearly interval to evaluate what impact environmental and individual factors had on HF clinic use. Environmental factors were defined as hospital type, whether they were referred to other outpatient disease management programs (DMP), like diabetes education or smoking cessation programs and whether the hospital included an onsite HF clinic, whilst individual factors included marital status, depressive symptoms, sociodemographic information and whether the patient lived in a rural area.
The researchers obtained clinical indicators for required rehabilitative programs from patient charts. The second survey, conducted 12 months after the first survey, asked patients whether they had received a referral to an HF clinic and whether they had attended. From 474 participants, 270 patients completed the follow up survey.
The findings demonstrated that 15% of patients received a referral and that 13% used an HF clinic. The researchers observed that the likelihood of using a HF clinic was five times higher in participants who enjoyed a higher education compared with those of a lower education level. The team noted that lower levels of stress and more serious health conditions were also linked to using a HF clinic. Furthermore, they noted that patients who received a referral to another DMP were almost 5 times more likely of using a HF clinic.
Whether or not the patient’s original hospital had an HF clinic or an established program turned out to be the most important factor in establishing whether they would use such clinic or program. Dr. Gravely comments:
“It’s likely that having an HF clinic on-site is related to greater awareness of the benefits of such services by physicians providing care. However, broader referral mechanisms are needed to ensure that all patients, regardless of where they receive care, have equitable access to HF clinics.”
Dr. Gravely and her team performed a related study featured in the same issue of the Canadian Journal of Cardiology, which examined the use of DMPs by patients suffering from cardiovascular disease (CVD) more broadly. In this study, the team surveyed 1,803 hospital patients regarding influencing factors for using DMPs. A follow-up survey conducted 12 months after the first survey was able to establish the proportion of patients who used outpatient diabetes education, cardiac rehabilitation, an HF clinic, smoking cessation program or stroke rehabilitation.
The study revealed that around 40% of patients did not access any post-acute DMPs, whilst 50% made use of one program. From the 10% of patients who attended more than one program, 21% suffered from diabetes, stroke, heart failure or smoked. The team observed that DMP participants tended to be younger with a high education and were more likely to be married compared with those who did not attend DMPs. Of those who attended DMPs, 53% participated in cardiac rehabilitation, whilst the proportion of patients in the comorbid illness or risk group showed that 41% of those with diabetes attended a diabetes education center, 26% of stroke victims went to stroke rehabilitation and 12% of those who smoked took part in a smoking cessation program.
The findings reveal that DMP services amongst all study participants were extremely underused, especially those offering stroke rehabilitation, HF clinics, and most significantly programs that help to stop smoking.
Dr. Gravely said:
“What is one of the most concerning findings is that only 12% of current smokers reported taking part in a smoking cessation program. Participation in smoking cessation programs results in significantly higher cessation rates when compared with standard care.
The appropriateness and cost repercussions of multiple DMP use should be investigated, as an integrated approach to vascular disease management may be warranted.”
Written by Petra Rattue