Outpatient heart failure (HF) clinics that provide patient education on ways to manage heart failure and risk factors, prescribe home-based exercises, and monitor therapy compliance have been shown to reduce morbidity, mortality, and health care costs. A new study published in the current issue of the Canadian Journal of Cardiology finds that despite guidelines that encourage physicians to recommend heart failure clinics, very few patients recently hospitalized with HF 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, York University, University Health Network, and Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
The investigators recruited 474 HF inpatients from 11 hospitals across Ontario. The patients completed a survey that evaluated environmental and individual factors affecting HF clinic use. Environmental factors included hospital type, whether the hospital had an onsite HF 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 sociodemographic 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 and reported whether they had been referred to an HF clinic, and if they had attended. 270 patients completed the follow-up survey and were included in the analysis.
Results showed that 15% of study participants were referred to, and 13% reported using an HF clinic. Patients with higher education were five times more likely to use an outpatient HF clinic compared to those with lower education. Lower stress levels and more serious health conditions were also associated with HF use. Patients who received a referral to another DMP were nearly five times more likely to use an HF clinic. The most important factor in determining whether a patient used an HF clinic was the presence of an established program at the patient's original hospital. "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," says Dr. Gravely.
In a related study published in the same issue, Dr. Gravely and colleagues examined more broadly the use of DMPs by patients with cardiovascular disease (CVD). 1,803 hospitalized patients completed a survey about factors that influenced DMP use and a follow-up study a year later that assessed whether they had used any DMPs: cardiac rehabilitation, outpatient diabetes education, an HF clinic, stroke rehabilitation, or a smoking cessation program.
Overall, roughly 40% of patients did not access any post-acute DMPs. Fifty percent accessed one program, and 10% attended more than one. Among participants with a comorbid indication (diabetes, stroke, heart failure, or smokers), 21% 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% reported participating in cardiac rehabilitation, and among participants with a comorbid illness or risk, 41% of diabetics reported attending a diabetes education center, 26% of stroke patients attended stroke rehabilitation, 13% of patients with a heart failure diagnosis used a heart failure clinic, and 12% of smokers attended a smoking cessation program. Among all study participants these findings suggest a gross underuse of DMP services, particularly stroke rehabilitation, HF clinics, and most notably, smoking cessation programs.
"What is one of the most concerning findings is that only 12% of current smokers reported taking part in a smoking cessation program," notes Dr. Gravely. "Participation in smoking cessation programs results in significantly higher cessation rates when compared with standard care."
Dr. 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," she concludes.
More information: "Referral and Use of Heart Failure Clinics: What Factors Are Related to Use?" by Shannon Gravely, PhD, Liane Ginsberg, PhD, Donna E. Stewart, MD, FRCPC, Susanna Mak, MD, PhD, FRCPC, Sherry L. Grace, PhD on behalf of the Cardiac Rehabilitation Care Continuity Through Automatic Referral Evaluation (CRCARE) Investigators (DOI 10.1016/j.cjca.2011.11.020)
"A Prospective Examination of Disease Management Program Use by Complex Cardiac Outpatients," by Shannon Gravely, PhD, Robert D. Reid, PhD, MBA, Paul Oh, MD, FRCPC, Heather Ross, MD, FRCPC, Donna E. Stewart, MD, FRCPC, Sherry L. Grace, PhD on behalf of the Cardiac Rehabilitation Care Continuity Through Automatic Referral Evaluation (CRCARE) Investigators (DOI 10.1016/j.cjca.2012.01.004)
They appear in Canadian Journal of Cardiology, Volume 28, Issue 4 (July/August 2012)