ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

Abstract

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

Keywords: Chronic care model; Clinical competence; Disease networks; Heart failure; Outpatient clinics.

Figure 1

Care referral pathways within the HF network based on patients’ clinical profiles. Stable patients at low-to-moderate risk of cardiovascular events, as well as frail elderly subjects with multiple comorbidities, should be managed in the community (green circle), with a focus on clinical monitoring and patient education. Patients with acute exacerbations or de novo gradual—onset symptoms should be referred to the geographically nearest (proximity) cardiology using shared protocols based on validated biomarkers. Proximity cardiology units (yellow circles) should admit to hospital patients with acute HF syndromes or outpatients from the community to perform appropriate diagnostic tests, to start or optimize drug therapy and to draft a tailored follow-up plan. Proximity cardiology units should share with network hubs the follow-up care of patients with advanced HF who are candidates to or have received heart transplantation or mechanical circulatory support. Network hubs, based on geographic location, are tertiary referral cardiology units (red circles) that should offer advanced treatment options to unstable patients at high risk of events. All network nodes should entertain close relationships with palliative network nodes for shared care of end-stage HF patients. CRT, cardiac resynchronization therapy; HF, heart failure; HTx, heart transplantation; ICD, implantable cardioverter defibrillator; LVAD, left ventricular assist device; Tx, transplantation.