Insights into the contemporary management of heart failure in specialized multidisciplinary ambulatory clinics

Abstract

Background: Heart failure (HF) clinics are associated with improved outcomes in randomized trials, however, there is substantial heterogeneity in the service models of HF clinics in practice. Our objective was to evaluate the effect of this clinic level heterogeneity on HF patient management in Ontario, Canada.

Methods: Charts were abstracted from 9 HF clinics, chosen at random from the 34 HF clinics in operation in Ontario in 2011. From each clinic, approximately 100 patient charts were randomly selected for detailed abstraction on patient demographic characteristics, comorbidities, diagnostic tests, medication use, and referrals, over a 1-year period from the first clinic visit.

Results: Significant heterogeneity was observed in patient baseline profiles, pharmacological therapies, diagnostic testing, clinic personnel, and referrals across 9 clinics. The mean age of patients was 66.1 ± 15.7 years and was significantly different between the clinics. Most patients were male (65%), and mean left ventricular ejection fraction was 33%. There was significant variation in the utilization of echocardiography (42%-94%) and coronary angiography (19%-62%). Overall, approximately 88% of patients were prescribed angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, and 85% were prescribe β-blockers. The rates of referral to cardiac rehabilitation programs were overall low at 10.4% of patients, with substantial variation (1%-28%).

Conclusions: Specialized HF clinics have wide variation in the health personnel involved and the care provided; in addition, patients treated at these HF clinics have important differences in clinical characteristics. Strategies should be considered at the appropriate level (eg, province-wide in Ontario) to standardize HF management and provide best evidence-based care to patients.