Outpatient heart failure clinics, which provide patient education on risk factor and ways to manage the condition, prescribe home-based exercises and monitor therapy compliance, have shown they reduce morbidity, mortality and health care costs, a new study has found.
Published in the current issue of the Canadian Journal of Cardiology, the study reports that despite guidelines encouraging physicians to recommend heart failure clinics, few patients recently hospitalized with heart failure receive referrals or use one.
“Given the demonstrated benefits of these services, the rates of referral and enrollment in our study are discouragingly low,” says lead investigator Shannon Gravely (PhD ’11) of York University, the University Health Network and the Toronto Rehabilitation Institute. York Professor Sherry Grace and Professor Liane Ginsburg both of York’s Faculty of Health were also involved with the study.
The investigators recruited 474 heart failure inpatients from 11 hospitals across Ontario. The patients completed a survey that evaluated environmental and individual factors affecting heart failure clinic use. Environmental factors included hospital type, whether the hospital had an onsite heart failure clinic and whether the patient had been referred to other outpatient disease management programs (DMP), such as smoking cessation clinics or diabetes education. Individual factors included socio-demographic information, whether the patient lived in a rural area, marital status, perceived stress and depressive symptoms. Clinical indicators of the need for rehabilitative services were gathered from patient charts.
A year after the first survey, the patients received a second survey. The 270 patients who completed the follow-up survey reported on whether they had been referred to a heart failure clinic and if they had attended.
Results showed that 15 per cent of study participants were referred to a heart failure clinic and 13 per cent reported using one. Patients with higher education were five times more likely to use an outpatient heart failure clinic compared to those with lower education. Lower stress levels and more serious health conditions were also associated with heart failure clinic use. Patients who received a referral to another DMP were nearly five times more likely to use a heart failure clinic. The most important factor in determining whether a patient used a heart failure clinic was the presence of an established program at the patient’s original hospital.
“It’s likely that having an HR clinic on-site is related to greater awareness of the benefits of such services by physicians providing care,” says Gravely. “However, broader referral mechanisms are needed to ensure that all patients, regardless of where they receive care, have equitable access to heart failure clinics.”
In a related study published in the same issue, Gravely and colleagues examined more broadly the use of DMPs by patients with cardiovascular disease (CVD). The survey looked at factors that influenced DMP use and was completed by 1,803 hospitalized patients, along with a follow-up study a year later which assessed whether they had used any DMPs, such as cardiac rehabilitation, outpatient diabetes education, a heart failure clinic, stroke rehabilitation or a smoking cessation program.
Overall, roughly 40 per cent of patients did not access any post-acute DMPs, 50 per cent accessed one program and 10 per cent attended more than one. Among participants with a comorbid indication (diabetes, stroke, heart failure or smokers), 21 per cent of these participants reported that they used multiple programs. DMP participants were younger, more likely to be married and more highly educated than those who did not attend DMPs.
Overall, 53 per cent reported participating in cardiac rehabilitation, and among participants with a comorbid illness or risk, 41per cent of diabetics reported attending a diabetes education center, 26 per cent of stroke patients attended stroke rehabilitation, 13 per cent of patients with a heart failure diagnosis used a heart failure clinic and 12 per cent of smokers attended a smoking cessation program. Among all study participants these findings suggest a gross underuse of DMP services, particularly stroke rehabilitation, heart failure clinics, and most notably, smoking cessation programs.
“What is one of the most concerning findings is that only 12 per cent of current smokers reported taking part in a smoking cessation program,” says Gravely. “Participation in smoking cessation programs results in significantly higher cessation rates when compared with standard care.”
Gravely notes that future research is needed to explore not only patient-related factors, but also health-system factors, such as awareness and capacity that may be at play. “The appropriateness and cost repercussions of multiple DMP use should be investigated, as an integrated approach to vascular disease management may be warranted.”