Heart Failure: Accelerating change to alleviate the burden on healthcare systems

I have always been acutely aware of how important, and often how stretched, our healthcare resources are. But having worked as a front-line ICU doctor during the COVID-19 pandemic, in one of the heaviest hit parts of London, I was reminded once again of how rapid and optimal service reconfiguration needs to be, to address shifting clinical needs.

I’ve seen first-hand how people living with cardiovascular diseases, such as heart failure, are disproportionately vulnerable to the severe complications of COVID-19 infection.[1] This has required exploration of how we can keep vulnerable, at-risk heart failure patients well managed and out of the clinical setting. But even on a broader level, beyond the pandemic, heart failure is an often overlooked condition[2] – a fact that has significant implications for patient outcomes and healthcare systems as a whole[3]. Today, heart failure affects almost one million people in the UK[4] - it has been linked to around 86,500 hospitalisations in 2018/2019, and is on the rise.[5] It is also a condition where hospital admissions can last for around 10 days, double the average for all diagnoses.[6] This can lead to both physical and mental distress for the patient, and significant burden on health services. [5],[6] Inpatient care can comprise up to 91% of the costs associated with heart failure throughout the last five years of life - this represents a significant proportion of the estimated £625m that the NHS spends annually to tackle the disease.[3],[7]

Compounding this burden is a lack of public awareness of heart failure. Recent World Heart Federation global research commissioned by AstraZeneca has shown that 55% of respondents from the general public were unable to identify a correct description of heart failure.[2] This can also impact recognition of symptoms, which, due to their non-specific and progressive nature, may lead to significant delays in diagnosis. In fact, most cases are often diagnosed too late, with 80% of people diagnosed in secondary care and emergency services, despite more than 40% of these having shown symptoms at primary care consultations as far back as five years prior to diagnosis.[8] Furthermore, we know that heart failure diagnosed in the emergency department or hospital is associated with a two-fold increased risk of death within one year, a significantly higher mortality risk compared with those diagnosed in community care.[9]

It is clear, then, that the burden heart failure places on healthcare services urgently needs addressing, by working to both reduce heart failure hospitalisations and by raising awareness of the condition among patients and the healthcare system. This has been raised as a priority for quality care and outcomes improvement under the NHS Long Term Plan.[10]

So how do we go about doing this? Firstly, it is essential that we investigate and deliver optimal service models to ensure symptoms are recognised to enable earlier detection and commencement of evidence-based interventions for people living with undiagnosed heart failure.

There is also a need to focus resources on more effective management of the interrelated conditions that can affect heart failure. There are several cardiovascular, renal, and metabolic diseases that play into how heart failure can affect an individual, and each can have a knock-on effect on the other. Take diabetes, for example: men and women with diabetes have their risk of developing heart failure increased up to two- and five-fold respectively, compared to non-diabetics.[11] Chronic kidney disease can also increase the risk of heart failure, and those with an eGFR of under 60 mL/min/1.73 m² are two to three times more likely to have heart failure than those with normal eGFR.[12]

I believe that improving understanding of how these diseases are connected can help guide management and prevention, particularly when it comes to the lifestyle changes that can help prevent the onset of these diseases, or facilitating earlier diagnosis of heart failure. Similarly, this understanding can be used to guide multidisciplinary teams working and collaborating across primary and secondary care. People living with heart failure will see a team of healthcare professionals across primary and secondary care, and cross-specialty collaboration is therefore essential.

This is linked to better patient outcomes[13], in part because it enables clinicians to choose interventions that are beneficial across multiple comorbidities and risk factors at once, rather than focusing on a single, isolated condition to treat. It can also facilitate opportunistic screening and diagnostic testing. Therefore, comprehensive care planning that has a holistic and multidisciplinary focus must be central to efforts to make better use of healthcare resources and alleviate the burden on our systems.

COVID-19 has shown us just how quickly and substantially health systems can respond to pressing challenges, such as the rapid implementation of digital solutions which have been embedded into healthcare service delivery during the pandemic. Although it doesn’t represent the same, all-encompassing threat of COVID-19, heart failure is nonetheless another major healthcare challenge where coordinated action can make a major difference to the health of millions in the years to come. There is a lot of work to be done to achieve this, but through strong service models, increased awareness, embracing strong multidisciplinary team working, and a more holistic approach to an individual’s overall health, we can help achieve improved outcomes for people living with heart failure.

[1] British Heart Foundation. Coronavirus: what it means for you if you have heart or circulatory disease. Available at: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/coronavirus-and-your-health Last accessed September 2020.

[2] AstraZeneca, World Heart Federation. Accelerate change together: heart failure gap review. Available at: https://www.world-heart-federation.org/resources/accelerate-change-together-heart-failure-gap-review/ Last accessed September 2020.

[3] Sutherland K. Bridging the quality gap: heart failure. London: Health Foundation, 2010. Available at: https://www.health.org.uk/sites/default/files/BridgingTheQualityGapHeartFailure_0.pdf Last accessed September 2020.

[4] British Heart Foundation. UK Factsheet. Available at: https://d1qotm6w854ck0.cloudfront.net/Uploads/a/f/a/bhfcvdstatisticsukfactsheet1_343908.pdf. Last accessed October 2020.

[5] British Heart Foundation. Heart failure hospital admissions rise by a third in five years. Available at: https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2019/november/heart-failure-hospital-admissions-rise-by-a-third-in-five-years Last accessed September 2020.

[6] Gustafsson F, Arnold JM. Heart failure clinics and outpatient management: review of the evidence and call for quality assurance. Eur Heart J. 2004;25:1596–1604.

[7] Hollingworth W, et al. The healthcare costs of heart failure during the last five years of life: a retrospective cohort study. Int J Cardiol. 2016;224:132-138.

[8] Bottle A, et al. Routes to diagnosis of heart failure in England: observational study using linked data in England. Heart. 2018;104:600–605.

[9] Lawson CA, et al. 20-year trends in cause-specific heart failure outcomes by sex, socioeconomic status, and place of diagnosis: a population-based study. Lancet Public Health. 2019;4:e406-420.

[10] NHS. The NHS Long Term Plan. January 2019. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf Last accessed September 2020.

[11] Kenny HC and Abel ED. 2019. Heart failure in type 2 diabetes mellitus: impact of glucose-lowering agents, heart failure therapies, and novel therapeutic strategies. Circ Res. 2019;123:121-141.

[12] Kottgen A, et al. Reduced kidney function as a risk factor for incident heart failure: the Atherosclerosis Risk in Communities (ARIC) Study. J Am Soc Nephrol. 2007;18:1307-1315.

[13] Holland R, et al. Systematic review of multidisciplinary interventions in heart failure. Heart. 2005;91:899-906.