Referral for Specialist Follow-up and Its Association With Post-discharge Mortality Among Patients With Systolic Heart Failure (from the National Heart Failure Audit for England and Wales)

Abstract

For patients admitted with worsening heart failure (HF), early follow-up after discharge is recommended. Whether outcomes can be improved when follow-up is done by cardiologists is uncertain. We aimed to determine the association between cardiology follow-up and risk of death for patients with HF discharged from hospital. Using data from the National Heart Failure Audit (England and Wales), we investigated the effect of referral to cardiology follow-up on 30-day and 1-year mortality in 68,772 patients with HF and a reduced left ventricular ejection fraction discharged from 185 hospitals from 2007 to 2013. The primary analyses used instrumental variable analysis complemented by hierarchical logistic and propensity-matched models. At the hospital level, rates of referral to cardiologists varied from 6% to 96%. The median odds ratio (OR) for referral to cardiologist was 2.3 (95% confidence interval [CI] 2.1 to 2.5), suggesting that, on average, the odds of a patient being referred for cardiologist follow-up after discharge differed ∼2.3 times from one randomly selected hospital to another one. Based on the proportion of patients (per region) referred for cardiology follow-up, referral for cardiology follow-up was associated with lower 30-day (OR 0.70; 95% CI 0.55 to 0.89) and 1-year mortality (OR 0.81; 95% CI 0.68 to 0.95) compared with no plans for cardiology follow-up (i.e., standard follow-up done by family doctors). Results from hierarchical logistic models and propensity-matched models were consistent (30-day mortality OR 0.66; 95% CI 0.61 to 0.72 and 0.66; 95% CI 0.58 to 0.76 for hierarchical and propensity matched models, respectively). For patients with HF and a reduced left ventricular ejection fraction admitted to hospital with worsening symptoms, referral to cardiology services for follow-up after discharge is strongly associated with reduced mortality, both early and late.

Management of Acute Decompensated Heart Failure in the Cardiac Intensive Care Unit: The Importance of Co-management With a Heart Failure Specialist

“…Access to timely follow-up in a multidisciplinary HF clinic has been shown to reduce hospital readmissions at 6 months and subsequent visits to the emergency department, as well as an improvement in quality of life. 20,21 Although multiple studies have shown reduced mortality in patients discharged from hospital with ADHF with follow-up with a cardiologist compared with a noncardiologist (ie, family practice), 6,7 there are no studies examining whether mortality rates differ among cardiac specialties (ie, HF specialist vs general cardiologist). Further investigations are needed to examine this particular clinical question.…”

“…Multiple studies have shown the benefit of general cardiologists' involvement in the management of these patients. [4][5][6][7][8][9] In one study, cardiology service discharge summaries were more likely to have details, which include reassessment of left ventricular ejection fraction (LVEF), inpatient study results (ie, laboratory work, imaging results), discharge weight and vital signs, and a discharge physical examination. Furthermore, multiple studies have shown that patients followed in a HF clinic at the time of hospital discharge had higher use of guideline-directed medical therapy (GDMT) and a reduction in hospitalizations and mortality.…”

“…Furthermore, multiple studies have shown that patients followed in a HF clinic at the time of hospital discharge had higher use of guideline-directed medical therapy (GDMT) and a reduction in hospitalizations and mortality. [4][5][6][7][8] Despite these benefits, a Canadian population-based study found that a cardiologist saw only 54.9% of patients with an index HF diagnosis in the subsequent 2.5 to 3.5 years. 9 Despite the evidence that close cardiology follow-up improves clinical outcomes, there is currently no data examining the role of a dedicated HF specialist consultation alongside the cardiac intensive care unit (CICU) team.…”

Advanced heart failure with reduced ejection fraction

“…The researchers found that 30-day mortality (odds ratio 0.7; 95% CI 0.55-0.89) and 1-year mortality (odds ratio 0.81; 95% CI 0.68-0.95) were significantly lower for patients who were referred to a cardiologist after discharge compared to those who were not. 52 A reduced ejection fraction <40% should stimulate consideration for referral. Functional limitations with activity and a lack of terminal comorbidities often warrant referral to an advanced heart failure specialist (Table 1) Or Hospitalization for heart failure Implantable defibrillator shocks (if defibrillator present) Arrythmias (e.g., ventricular tachycardia, atrial fibrillation) Increasing diuretic dosing -Furosemide !160 mg/day -Torsemide !80 mg/day -Bumetanide !4 mg/day Worsening renal function -Creatinine !1.6 mg/dL -Blood urea nitrogen !45 mg/dL Hyponatremia: Sodium <135 mEq/L Unexplained weight loss (cardiac cachexia) Desire for assistance and advice on long-term management à There is no consensus on exact criteria, and cutoffs for the values cited vary from center to center.…”

Neighborhood Socioeconomic Status and Adverse Outcomes in Patients With Cardiovascular Disease

“…At the individual level, perhaps a history of heart failure or MI is "protective" in low nSES patients. Previous studies have shown that low nSES individuals generally receive secondary preventive medications and/or procedural intervention less than high nSES individuals; 19 however, individuals with high-risk cardiovascular histories are more likely to follow-up with providers 20 and be prescribed secondary preventive medication. 21 It is possible that higher healthcare surveillance or treatment in patients with heart failure or prior MI offsets the lower rates of evidence-based care that low nSES patients typically receive.…”