Structural components for the development of a heart failure network

Abstract

Diagnosis and treatment of heart failure (HF) is challenging, and development of specialized HF networks is mandatory to warrant broad access to guideline directed therapies for patients. Numerous national cardiovascular societies recommend a three-level association of health care providers. This comprises tertiary academic centres, specialized HF clinics and specialized general cardiologists to cover the large spectrum of HF severity and entities. Although this idea of a multi-level care is widely accepted, optimal approach to build and implement a HF network service needs further definition. The core principle is that of network healthcare facilities that also consider regional peculiarities and that implements academic standards, quality indicators (QIs), interdisciplinarity and reimbursement strategies. These determinants of trans-sectoral healthcare need to be embedded in a network that provides sustainability and that incorporates QIs to objectify the efficacy of specific measures. The basis of a HF-network should be a certification system of the respective national HF association to warrant guideline standards and to prevent development of regional hierarchies or dependencies between members. This nationwide framework needs to be complemented by a federal system of regional networks, which also takes local demands into account. These regional units should incorporate digital communication and interaction pathways, structured educational programmes, certified telehealth concepts and follow-up algorithms to meet the requirements of sustainability and efficacy. We here summarize different components of HF networks and introduce the structure and development philosophy of the RUHR-HF-network that constitutes the first certified HF-clinics-network in the Ruhr area-the largest metropolitan area in Germany.

Keywords: Digital; Heart failure; Networks; Telehealth.

Figure 1

Quality of care aspects throughout the spectrum of heart failure. Single interventions like structural interventions in heart failure (HF) patients, ventricular assist device (VAD) implantation, heart transplant (HTX), mechanical circulatory support (MCS)/extracorporeal membrane oxygenation (ECMO) or device implantation and advanced ablation therapies (EP) are often applied to objectify the capacity of institutions and/or networks. These benchmark procedures are often limited to HF patients in advanced disease stages or cardiogenic shock whereas most patients are presenting with chronic HF where quality indicators for benchmarking (like proportion of patients having correct diagnosis, proportion of patients on guideline directed medical therapy (GDMT)) still need to be implemented. Likewise, process and outcome measures need to be considered when assessing the impact of network activities on the burden of HF. QoL, quality of life; FU, follow‐up; HF‐MPs, HF management programmes. Images are created with Biorender.com.

Figure 2

Landmarks of network development and implementation of quality indicators (QIs). The Working Group for Heart Failure Quality Indicators in collaboration with the Heart Failure Association of the European Society of Cardiology developed quality indicators for the care and outcomes of adults with heart failure (HF) that cover the whole trajectory of a HF patient. QIs were selected across five domains of care for the management of HF: (1) structural framework, (2) patient assessment, (3) initial treatment, (4) therapy optimization, and (5) assessment of patient health‐related quality of life. These QIs need to be taken into consideration during HF network development because they represent evidence based tools for the assessment of quality of care. Clinical episodes like first presentation, diagnosis or discharge management are practical landmarks in the disease trajectory of a patient with heart failure to implement QIs objectify process quality. HRQoL, health related quality of life.

Figure 3

Structural components of a supra regional heart failure network—development scheme of the RUHR‐HF network. The conceptual framework of a heart failure (HF) network needs to cover all dimensions of health care. According to the Donabedian model, these are structure (Certified HF infrastructure—solid black lines, Local Network Competencies—dotted grey lines), process (Interaction & Communication—solid blue lines), and outcomes (Benchmark System—dotted red lines). The overall aim of network building should be a sustainable and measurable reduction of the burden of HF—to objectify theses aims, an independent benchmark system using validated quality indicators (QIs) should be installed. The well‐established model of a three‐staged association of health care providers comprising tertiary academic centres, specialized HF clinics and specialized general cardiologists (HF GC) constitutes the basis of the structure. According to the fact that general practitioners (GP) are often involved in both first diagnosis as well as follow‐up of HF and HF patients this cohort needs to be considered in the establishment of a comprehensive HF management programme. Infrastructural demands need to be specified, controlled, and certified by national cardiac societies to prevent hierarchies between network members. This nationwide certificate structure needs to be further adopted by incorporating regional and local competency maps to adopt algorithms and to individualize protocols between the institutions. The development plan of the RUHR‐HF network incorporates a more granular breakup of the dimensions and highlights the need for contract‐based interaction, recurring network communication and digital communication pathways. MCS, mechanical circulatory support, ECMO, extracorporeal membrane oxygenation, EP, electrophysiology.