Elsevier

Journal of Cardiac Failure

Volume 14, Issue 10, December 2008, Pages 801-815
Journal of Cardiac Failure

Consenus
The Heart Failure Clinic: A Consensus Statement of the Heart Failure Society of America

https://doi.org/10.1016/j.cardfail.2008.10.005Get rights and content

Abstract

Background

Outpatient care accounts for a significant proportion of total heart failure (HF) expenditures. This observation, plus an expanding list of treatment options, has led to the development of the disease-specific HF clinic.

Methods and Results

The goals of the HF clinic are to reduce mortality and rehospitalization rates and improve quality of life for patients with HF through individualized patient care. A variety of staffing configurations can serve to meet these goals. Successful HF clinics require an ongoing commitment of resources, the application of established clinical practice guidelines, an appropriate infrastructure, and a culture of quality assessment.

Conclusions

This consensus statement will identify the components of HF clinics, focusing on systems and procedures most likely to contribute to the consistent application of guidelines and, consequently, optimal patient care. The domains addressed are: disease management, functional assessment, quality of life assessment, medical therapy and drug evaluation, device evaluation, nutritional assessment, follow-up, advance planning, communication, provider education, and quality assessment.

Section snippets

Methods

Members of the Quality of Care Committee of the HFSA performed an extensive review of the literature and collaboratively developed a family of 11 domains of care that apply to the HF Clinic (Table 1). These domains are based on the presupposition that the patient has been correctly identified as having HF. The HF clinic was not viewed as a mechanism through which patient populations can be screened for the presence of left ventricular dysfunction or clinical HF.

To ensure both consensus and

Description

Disease management has been defined as “a comprehensive, integrated system for managing patients across the health care continuum by using best practices, clinical practice improvement, information technology, and other resources and tools to reduce overall costs and improve measurable outcomes in the quality of care.”14 Disease management is most commonly applied in the outpatient setting to patients with chronic disease or risk states, often with particular concentration on those who are at

Description

The functional assessment of ambulatory HF patients in the outpatient setting is an important component of the initial and follow-up evaluations. Three methods to assess functional status have been subject to extensive research and clinical use: evaluation of New York Heart Association (NYHA) class; the 6-minute walk test (6MWT); and cardiopulmonary exercise stress (CPX) testing.29, 30, 31, 32, 33 BNP testing may be useful in certain clinical settings, but its value for guiding therapy requires

Description

Two important goals of HF treatment are to increase quality of life and improve health status, terms often used interchangeably. In this document, health status refers to the sum of a patient's symptoms, functional status, and health-related quality of life. Quality of life is by definition patient-centered and may include not only the patient's view of his or her own level of functioning, but how that functioning differs from expectations.

Most instruments combine components of quality of life

Description

Evidence-based practice guidelines for the pharmacotherapy of HF have been established by HFSA and other professional organizations.9, 13 Compliance with these guidelines, however, varies considerably by region, hospital, and prescribing physician. HF clinics should include features that will promote optimal medication prescribing practices, including an effective drug therapy evaluation process.

Rationale

Despite the fact that the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors and

Description

Implantable cardioverter defibrillators (ICDs) and biventricular pacing (CRT-P and CRT-D) are being used increasingly in patients with LV dysfunction and HF.80 The role of the HF clinic in this aspect of care is evolving. At a minimum, HF clinic physicians should be able to identify patients who may be candidates for devices and should have some knowledge of device evaluation and management,81, 82 including a reporting process when programming issues or device recalls arise.

Rationale

The option of

Components Relevant to Patients Without an Implantable Cardiac Device

  • 1.

    A system of screening that facilitates the identification of patients who might benefit from device therapy.

  • 2.

    Documented discussion of therapeutic options, including potential benefits and risks, with each patient being considered for device therapy.

Components Relevant to Patients With a Preexisting Implantable Cardiac Device

  • 1.

    A site registry, updated and reviewed regularly, of all patients in whom cardiac devices have been implanted.

  • 2.

    A clear and consistent system for device evaluation, including documentation in the medical record, and a mechanism to monitor patients with a frequency established by a protocol.

  • 3.

    Coordination of care with electrophysiologists to avoid duplication of services and conflicting interventions.

  • 4.

    A system to respond to alerts or recalls produced by regulatory agencies or device manufacturers.

Description

Nutritional screening, assessment, and guidance are essential components of patient management in the HF clinic. Special attention should be given to sodium and fluid restriction. In particular, tailored nutritional assessment and management is recommended for patients with comorbid conditions such as diabetes, hyperlipidemia, renal disease, alcoholism, cardiac cachexia, and obesity. The process should begin when a patient is first diagnosed or admitted with HF; outpatient follow-up is

Description

HF is a chronic disease that cannot be adequately addressed by treating acute episodic exacerbations. Continuity of care is a hallmark of HF care, and the HF clinic is uniquely positioned to provide focused evaluation and management, thereby limiting potential complications, such as early rehospitalization.

A major contributor to early rehospitalization is inadequate discharge planning.89 Patients should be told how to recognize and respond to a return of symptoms.92 Providers should establish a

Description

Seriously ill patients or those with a chronic illness with a risk of mortality should be approached by the provider in an empathic and thoughtful manner to discuss care preferences before the disease has progressed to its near-terminal stage.96 The process of mapping out the types of medical and nonmedical care a patient would like to receive, before the clinical condition makes it difficult for the patient to express these wishes, is known as advance care planning. This type of planning is an

Rationale

With advance care planning, physicians can improve patient satisfaction and provide compassionate care at the end of life that is in accordance with the patient's wishes. However, because the patient remains autonomous, the type and intensity of care designated in advance care planning comes into effect only if the patient can no longer express his or her intentions.

Description

Effective communication is associated with improved patient satisfaction and is ethically required so that patients and families can participate as much as desired in care decisions. Shared decision-making goes beyond informed consent by making the ends of care, as well as the means of care, a matter of negotiation. Shared decision-making is the best way to assure that patients and families receive care that is consistent with their own goals.103

The barriers to effective communication are

Description

The Institute of Medicine recognizes that professional education is an integral component in the quality of HF care,111 a fact confirmed in many studies.112, 113, 114 It is also recognized by clinicians, as reflected in a national survey of clerkship directors in internal medicine in which HF was ranked 4th of a possible 60 disease targets.115 Provider education in the HF clinic encompasses a full range of initiatives designed to ensure provider competence. Competence includes the knowledge of

Description

Quality of HF care can be divided into outcome, process, and structural components.127 The degree to which the HF clinic can evaluate quality using measures that reflect these components varies, depending on many factors, such as payer mix and clinic commitment.

Outcome Measures

Outcome measures, such as survival and quality of life, are the most important quality measures from both the patient's and society's perspective. They are influenced by patient factors128 and thus require substantial clinical data to

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    Disclosures are on file with the Heart Failure Society of America as a condition of participation on the Quality of Care Committee. The disclosures are updated annually.

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