Practices of Referring Patients to Advanced Heart Failure Centers

doi:10.1016/j.cardfail.2021.05.024

Journal of Cardiac Failure

Volume 27, Issue 11, November 2021, Pages 1251-1259

https://doi.org/10.1016/j.cardfail.2021.05.024 Get rights and content

Highlights

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Most referrals for advanced heart failure (AHF) therapies originate from heart failure (HF) cardiologists.
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Worsening HF, inotrope dependence, hospitalization, and shock often prompt referral.
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Many patients are too ill or have psychosocial limitations precluding AHF therapies.
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Patients referred by HF cardiologists were more likely to receive AHF therapy.

ABSTRACT

Background

Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers.

Methods

We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients’ demographics, referring providers’ characteristics, referral circumstances, and evaluation outcomes were collected.

Results

The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1–3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%–45.1%) or for psychosocial reasons (20.3%–28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice.

Conclusions

In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.

Section snippets

Methods

We performed a retrospective review of patients referred for evaluation for AHF therapies (ie, LVAD and/or OHT) at 9 AHF centers across the United States. Centers provided data concerning their most recent 50--100 completed evaluations prior to July 1, 2018. Eligible patients were adults (>18 years) with AHF who were referred and subsequently completed evaluation for AHF therapies. Participating sites included California Pacific Medical Center (CA), Cleveland Clinic (OH), MedStar Washington

Results

A total of 515 patient referrals were collected across 9 sites. The population was predominantly male (73.4%) and Caucasian (55.7%), and the median age was 58 years. The most common causes of HF were nonischemic (55.9%) and ischemic (33.2%) cardiomyopathies, with other causes constituting small proportions of the total population (Table 1). Patients were advanced in their disease states at the time of referral, with 51.5% having an LVEF <20% and 74.5% dependent on inotropic support or temporary

Discussion

Our analysis is the first in the era of contemporary HF and MCS therapies to examine advanced HF referral patterns across the United States by pooling data from 9 advanced HF therapies programs. Our participating programs represent a broad distribution of size, geographic location and range in annual volume from 30 to 100 VADs and 20–80 heart transplants. This multicenter study has several important findings that help to enhance understanding of this topic.

In this cohort, a large percentage of

Conclusions

Our findings indicate that patients referred for AHF therapies tend to be male and advanced in the disease state and are often declined because of psychosocial factors. Solutions may include improved identification of AHF in females, earlier referral to AHF teams to allow for timely evaluation of AHF therapies, and addressing psychosocial concern issues before they become an obstacle to effective therapeutic decision making. These findings highlight the need for continual education and specific

Bullet Points

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Understanding how and why heart failure patients are referred to advanced heart failure centers is an important aspect of ensuring access to these lifesaving therapies.
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Recognize many patients with heart failure continue to be referred late in their disease, limiting their therapeutic options. Educational opportunities to promote earlier referral remain important to ensure access to therapeutics when appropriate.
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Patients are often cited as unable to be offered advanced therapies due to

Lay Summary

Patients with heart failure are increasing in number and even in its most advanced state have access to lifesaving medical and surgical treatments that can increase survival and quality of life. Access to these advanced therapies such as heart transplantation and mechanical circulatory support requires timely referral to centers providing these treatments. Our study examines how and why patients are referred to these centers. We found that many patients are referred late and are too sick to

Authors’ Disclosures

JJH has received research grants and has served as a speaker and consultant for Abbott Laboratories; MZT has received speaker honoraria and consulting fees for Abiomed and Abbott Laboratories; FS has received consulting fees and research support from Pfizer, consulting fees and research support from Alnylam, consulting fees from Eidos, consulting fees from Akcea, speaker honoraria and research support from Abbott Laboratories; AR has received speaker honoraria from Abbott Laboratories and

Sources of Funding

None

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Disparities in Practice Patterns by Sex, Race, and Ethnicity in Patients Referred for Advanced Heart Failure Therapies
2022, American Journal of Cardiology
Citation Excerpt :
Scientific advancements in both medical and surgical therapies, such as left ventricular assist devices (LVADs) and heart transplantation (HT), dramatically improve clinical outcomes in patients with advanced HF.3 Despite these advances, sex-based, racial-based, and ethnic-based disparities in HF care exist,4–9 with often complex and multifactorial reasons underpinning these discrepant outcomes.10 Black and Hispanic patients have the highest burden of HF and worse clinical outcomes than White patients,2 and racial and ethnic minorities often undergo advanced therapies in states of greater illness severity and acuity.11,12
Advanced heart failure (HF) therapies improve survival in patients with stage D HF. We sought to evaluate differences by race/ethnicity and sex in advanced HF therapy referrals and decision-making across a multicenter survey. We performed a retrospective analysis of patients referred for evaluation for advanced HF therapies at 9 centers (n = 515) across the United States. The median age was 58 years, and 73% were male. White patients comprised 55.7% of referrals, whereas non-White patients comprised 44.3%. Non-ischemic etiology was more common in non-White patients (66.6% vs 47.4% p = 0.0005), and ischemic etiology was more common in men (37.8% vs 20.4% p = 0.0005). The primary reason for referral differed by race/ethnicity but not sex, with ventricular arrhythmias (7.6% vs 3%, p = 0.024) and pulmonary hypertension (3.4% vs 0.4% p = 0.018) being more common in White patients, whereas worsening HF was less common (25.4% vs 35.9%; p = 0.009). White patients were offered left ventricular assist devices (LVADs) (60.3% vs 54.7 p = 0.039) and heart transplants (51.8% vs 33.1% p = 0.0007) more often than non-White patients. The preference not to pursue LVAD therapy was more common in non-White patients (17.6% vs 9.6%; p = 0.049). Men were more often declined for a heart transplant because of psychosocial contraindications (34% vs 15%, p = 0.005). In conclusion, in this multicenter analysis of referrals for advanced HF therapies, we observed significant differences by race, ethnicity, and sex in both referral characteristics and evaluation outcomes. Further investigation is warranted to better understand why rates of LVAD and transplantation may be lower in non-White patients who are referred for advanced therapies.
Taking Small Steps To Achieve Health Equity in Advanced Heart Failure
2022, Journal of Cardiac Failure
Can Machines Find the Sweet Spot in End-Stage Heart Failure?
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Augmented Intelligence to Identify Patients With Advanced Heart Failure in an Integrated Health System
2022, JACC: Advances
Timely referral for specialist evaluation in patients with advanced heart failure (HF) is a Class 1 recommendation. However, the transition from stage C HF to advanced or stage D HF often goes undetected in routine care, resulting in delayed referral and higher mortality rates.
The authors sought to develop an augmented intelligence-enabled workflow using machine learning to identify patients with stage D HF and streamline referral.
We extracted data on HF patients with encounters from January 1, 2007, to November 30, 2020, from a HF registry within a regional, integrated health system. We created an ensemble machine learning model to predict stage C or stage D HF and integrated the results within the electronic health record.
In a retrospective data set of 14,846 patients, the model had a good positive predictive value (60%) and low sensitivity (25%) for identifying stage D HF in a 100-person, physician-reviewed, holdout test set. During prospective implementation of the workflow from April 1, 2021, to February 15, 2022, 416 patients were reviewed by a clinical coordinator, with agreement between the model and the coordinator in 50.3% of stage D predictions. Twenty-four patients have been scheduled for evaluation in a HF clinic, 4 patients started an evaluation for advanced therapies, and 1 patient received a left ventricular assist device.
An augmented intelligence-enabled workflow was integrated into clinical operations to identify patients with advanced HF. Endeavors such as this require a multidisciplinary team with experience in design thinking, informatics, quality improvement, operations, and health information technology, as well as dedicated resources to monitor and improve performance over time.

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Practices of Referring Patients to Advanced Heart Failure Centers

Highlights

ABSTRACT

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Bullet Points

Lay Summary

Authors’ Disclosures

Sources of Funding

J Am Coll Cardiol

J Card Fail

JACC Heart Fail

J Card Fail

J Am Coll Cardiol

J Heart Lung Transplant

J Heart Lung Transplant

J Heart Lung Transplant

J Heart Lung Transplant