Working towards optimising care for heart failure patients

Navjot Kalra

Aim:

Aims to optimise care for heart failure patients at Swansea Bay University Health Board (SBuHB) with a Value Based Healthcare approach.

Pitch:

Heart failure is estimated to account for 2% of the entire NHS budget, of which 70% is consumed by acute hospital admissions, accounting for 2% of all NHS in-patient bed days1. Patients with heart failure have a poor prognosis, worse than many cancers and is the commonest cause of acute admissions for people over 65.

Unique points of this initiative aims to reduce the number of wrongly diagnosed patients and improve the care for patients who are correctly diagnosed with heart failure (HF).

In various areas of the service, demand outweighs capacity and there is low prevalence of suspected patients on the HF register (primary care clusters range from 0.4% – 1% per population). HF admissions have a high mortality rate at the UHB (11%), doubling to 22% if patients aren’t seen by a HF specialist. A recent hospital audit found up to 15% of hospital inpatients had undiagnosed HF, while others were receiving less than optimum treatment, leading to unwarranted variation and avoidable acute admissions. The hospital audit also found that HF re-admission rate was 31% for patients not seen by a HF specialist and 19% if the patient had been seen by the HF team.

To identify areas for change we worked with multidisciplinary teams (MDT) in community, primary and secondary care, together with local informatics and finance experts, developing a plan to redesign the service, which created a MDT and improved co-production.

Aligning with national guidelines and recommendations, we identified changes to resources to maximise patient care within available means and our ability to detect where improvements can be made. We interrogated GP registers, the Welsh patient administration system, pathology laboratories and communities and therapies datasets to access relevant fields, as well as collecting patient reported outcome measures (PROMs) as recommended by ICHOM. Using a commercial system for PROM collection; we now remotely collect the four recommended HF PROM tools before every HF clinic appointment (using Kansas city12, PHQ2, PROMIS4a and EQ-5D-5L).

From April-December 2019 the health board collected 144 PROMs from 1 HF clinic. Since January 2020 collecting a further 55 PROMs across 5 HF clinics, response rate of 85%. Baseline HF measures has been identified for meaningful analysis. A data dashboard has been developed with interactive visuals, providing a single point of access for teams to view information in contexts that were previously not easily accessible. This data helps clinicians identify ways to improve patient care by using evidence-based decision making and patient prioritisation. The dashboard is being used for direct patient care, where specialist community nurses are viewing PROMs data prior to clinic appointments, to enhance patient-nurse discussions.

A plan of the system redesign has been completed, when implemented is anticipated to reduce mortality rate, acute admission rate, length of stay for admitted patients and provide earlier and better diagnosis. PROM collection will be extended and become a routine part of the patient pathway in order to directly measure a patients quality of life and involve them more in decisions about their care.

1 = NCEPOD report – Failure to Function 2018