Heart Failure_

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Heart Failure:

Heart failure affects around 900,000 people in the UK and is particularly
common among older people. Its prevalence is expected to rise in the next 20

Heart failure is caused by a reduction in the heart’s ability to pump blood
around the body. The prognosis is poor and survival rates are worse than, for
example, breast and prostate cancer. The condition can be extremely
debilitating and up to 40% of patients die within the first year of diagnosis.

Diagnosis of heart failure is difficult as many of the symptoms can be
confused with other similar health problems (such as chronic bronchitis).
Echocardiography is the key diagnostic test that either confirms or refutes a
diagnosis of heart failure.

There are treatments available for heart failure. Initially, this consists of ACE
inhibitors, followed by Beta blockers and other drugs depending on the
severity of symptoms. These treatments can help to reduce the symptoms of
heart failure and slow the progression of the illness.

Providing services to patients with heart failure costs the NHS £625 million a
year. Heart failure accounts for about 5% of all medical admissions to
hospital. The rates of readmission are also extremely high.

As such, effective specialist services – from diagnosis to end-of-life care – for
patients with heart failure can help to reduce avoidable hospital admissions
and have a positive impact on patients’ quality of life.

The Review:

The Heart Failure Service Review measured the performance of 303 ‘local
healthcare communities’. These comprise a primary care trust (PCT) and the
acute trusts that provide at least 10% of its activity for inpatients with heart

A detailed local assessment of each community was carried out using
2005/06 data. Four criteria were used:

    1) Diagnosis: there is effective diagnosis of patients with suspected heart
    2) Treatment and monitoring: patients are receiving high standards of
    3) Care & Support: adequate services are in place for continued care and
    4) Outcomes: there has been a positive impact on hospital admissions,
       mortality and patient experience

Created on 6/29/2007 4:25:00 PM                                                     1
Each community was ranked on these using a scale of: excellent, good, fair or
weak. An overall score was also awarded to each community.
Weak: performance that does not meet minimum requirements or the
reasonable expectations of patients and the public
Fair: performance that meets minimum requirements and the reasonable
expectations of patients and the public
Good: performance that goes beyond minimum requirements and the
reasonable expectations of patients and the public
Excellent: performance that goes well beyond minimum requirements and the
reasonable expectations of patients and the public. A leader in this aspect of

The Results:

Of the 303 communities assessed, the overall scores were: excellent (28);
good (160); fair (89); and weak (26).

Key results from the four criteria are as follows:

(1) Diagnosis:
     Excellent (52); Good (107); Fair (118); Weak (26)
     Access to, and waiting times for, the key diagnostic tests to confirm a
       diagnosis of heart failure (eg echocardiography) have improved
     As at March 31, 2006, 92.5% of patients registered on a GPs’ systems
       with a diagnosis of heart failure have had diagnosis confirmed by
     71.6% of patients waited less than three weeks for echocardiography,
       but this has risen to 88.6% as at February 28, 2007.
     Local prevalence of heart failure falls short of predicted levels in almost
       all of the communities assessed. This could mean there is a largely
       unseen demand for assessment and care. Data pertaining to
       prevalence levels was only available from 204 of the 303 primary care
       trusts involved in the review. For these PCTs, the reported prevalence
       fell short of the estimated prevalence by 139,640.
     Clinical audit data relating to heart failure is not widely available in all
       localities. This information is essential in determining whether all
       patients are gaining access to relevant care. It also helps to predict
       future need. The Healthcare Commission is funding the British Society
       for Heart Failure to develop a national heart failure audit. A pilot,
       managed by the Health and Social Care Information Centre, has
       already begun in some hospitals. The scheme will be rolled out
       nationally, providing better information on the quality of heart failure
       services offered to patients.

(2) Treatment:
     Excellent (16); Good (82); Fair (162); Weak (43)
     Nationally, 85.2% of patients registered with a diagnosis of heart failure
       are being prescribed ACE inhibitors, one of the key treatments to

Created on 6/29/2007 4:25:00 PM                                                  2
        reduce symptoms and prolong life. In 2003/04 this figure was less than
       However, at a local level, access to such medication varied significantly
        (0% to 100%) and not all patients were getting access to additional
        drugs, for example beta-blockers, proven effective for the treatment of
        heart failure.
       Heart failure is a debilitating condition, so access to a full range of
        treatments is essential.

(3) Care and Support:
     Excellent (96); Good (101); Fair (103); Weak (3)
     Most communities have established some form of specialist service for
       patients with heart failure, but some of these may be financially
       unstable. A lack of funding is also threatening many future
     Access to specialist teams for patients admitted to hospital with a
       diagnosis of heart failure is ‘extremely variable’ (0% to 74%). Despite
       86.5% of acute trusts having a lead consultant on heart failure, less
       than a quarter (22.3%) of patients were referred to them
     More attention needs to be given to meeting the needs of patients
       beyond the immediate control of symptoms
     Only 5.7% of patients were referred to rehabilitation following
       admission. Although rehabilitation has been shown to be effective for
       heart failure patients, there is very little available that is suitable for
       their needs. It is an area that therefore needs attention.
     Patients with heart failure live with a high degree of uncertainty and a
       risk of sudden death; over a third experience severe and prolonged
       depressive illness. The needs for psychology and counselling services
       therefore needs to be addressed in many areas

(4) Outcomes:
     Excellent (21); Good (69); Fair (212); Weak (1)
     Less than 20% of organisations could meet NICE (National Institute for
       Health and Clinical Excellence) and NSF (National service
       Frameworks) audit criteria
     More needs to be done to assess patients’ experiences: only 52% of
       organisations had evaluated patients’ satisfaction with heart failure
       services; just 35.6% had carried out an evaluation of patient quality of
     Effective care has been shown to reduce the level of readmissions and
       mortality for patients with heart failure. The report shows wide variation
       in these two outcomes which could potentially be reduced by a more
       rigorous application of national guidelines.

Next Steps:

The Healthcare Commission will be working closely with those ‘communities’
scoring weak.

Created on 6/29/2007 4:25:00 PM                                                      3
However, there are a number of key recommendations from the report for all
communities and relevant organisations.

The report concludes with a series of recommendations for the organisations
within a healthcare community. Primary care trusts and commissioners will
need to:

       ensure that local data on prevalence of heart failure is routinely
        compared to national trends; gaps and discrepancies must be
       ensure that all patients with suspected heart failure have access to key
        diagnostic tests
       work together with other healthcare organisation in the community to
        ensure that all patients have access to specialist advice and services

In turn, service providers in primary and secondary care have been tasked

       ensuring that all patients with confirmed heart failure have access to
        appropriate medication
       developing clinical audit programmes to evaluate the effectiveness of
        services and benefits for patients
       comparing performance with other communities and identifying areas
        for improvement

Created on 6/29/2007 4:25:00 PM                                                    4