There are at least 5.7 million adults living with heart failure in the United States with 550,000 new cases each year (CDC, 2016). The annual healthcare costs are estimated to be in the billions. Evidence-based approaches, such as the frequency of touch points with health care providers and optimization of evidence-based guidelines have shown to decrease mortality and improve outcomes in patients with heart failure (Yancy et al., 2013). However, it is not known to what extent individuals with heart failure actually receive these interventions in the primary care setting.
Previous studies have described variations in care for individuals who are diagnosed with heart failure who are being followed up in the outpatient cardiology setting. In fact, the IMPROVE HF prospective cohort study conducted by Fonarow and colleagues (2008) used a registry to track baseline evidence-based heart failure therapies of 40,000 patients in a single cardiology or multispecialty outpatient practice settings in the United States. Only 27% of patients (median) received all the guideline recommended therapies that they were eligible for during the time of the review (Fonarow et al., 2008). Nonetheless, less is known about the current evidence-based practices for heart failure patients in primary care settings. The purpose of this literature review is to summarize the current state of heart failure management in primary care settings. The goal of this review is to identify areas of knowledge as well as gaps that exist in this field.
Methods
The literature review was conducted using relevant search engines and electronic databases, including, PubMed, CINAHL Plus, and Web of Science, to locate appropriate articles for “primary care management of heart failure patients” or “heart failure management in the primary care practice setting.” Search filters were set for publication dates within 5 years, research related to humans, and the English language. However, based on references, older articles and landmark studies were included. The search criteria yielded over 1000 articles, in which the following keywords were used to narrow down the search: heart failure, primary care, ambulatory care, guideline adherence, medication adherence, and disease management. From the initial 52 articles, seven were selected and highlighted in this review based on relevance to the topic.
Results
Heart failure management programs have been studied widely across different care settings. However, despite the advances in medical knowledge and care delivery models, heart failure continues to be a major burden to the healthcare system due to high rates of morbidity, mortality and cost. Some of the factors that decrease mortality and hospital readmissions include greater use of evidence-based guideline recommended therapy, protocol-driven education and its assessment, effective self-management support programs, interdisciplinary approach to management, and continuity of care (Oyanguren et al., 2016). In addition, programs outside of the United Sates demonstrate better outcomes (Oyanguren et al., 2016).
In Spain, Comín-Colet et al. (2016) conducted a natural experiment to study the effects of a hospital-primary care program for heart failure management between 2005 to 2011. From the total of 56,742 patients, 2083 (3.7%) were enrolled in the program and 54,659 (96.3%) were used as a comparison group. The program was described as a multidisciplinary model using a specialized heart failure nurse who acted as a case manager to coordinate care for the patient in the outpatient setting. Primary care physicians were included in the communication and collaborative efforts. The study results indicate that patients who were enrolled in the program had a lower risk of death (HR: 0.92, 95% CI: 0.86 to 0.97, p=0.005) and lower risk of hospital readmissions related to heart failure (HR: 0.86, 95% CI: 0.80 to 0.94, p<0.001). However, cardiologist were the primary providers involved in the management of these patients and not the primary care (Comín-Colet et al., 2016).
In the Netherlands, Luttik et al. (2014) randomized 189 patients with heart failure into either primary care (n=97) or heart failure clinic (n=92) cohorts and tracked the outcomes over 12 months. The goal of this study was to determine if long-term follow-up in the primary care setting can be as effective as follow-up with a specialized heart failure clinic. The model that was used for the primary care setting is a home-based management with a general practitioner (i.e. PCP). In contrast, the heart failure clinic was a hospital-based management with a cardiologist. However, both cohorts were initially managed for optimal medication titration by the hospital-based heart failure clinic. Results from the study indicate that long-term management by the primary care providers are similar in terms of adherence to guideline recommended therapy as well as patient adherence to medications. In addition, outcomes in mortality and hospital readmissions were similar in both cohorts expect the primary care group had a higher non-cardiovascular related hospital readmission (p=0.05). The researchers recommend that patients can be managed long-term by primary care after the initial management in a specialized heart failure clinic (Luttik et al., 2014).
In the United Kingdom, Tierney, Kislov and Deaton (2014) conducted a qualitative study to describe the process of facilitating evidence-based practice in the primary care setting. In the program, nurse facilitators were used from specialty areas to educate and implement evidence-based recommendations for managing heart failure patients in 45 primary care practice settings. The semi-structured interviews were conducted with nurse facilitators (n=9) and primary care providers (n=7). The main theme from the study is about the importance of the work environment as well as context in facilitating knowledge transfer and practice change. For example, even when physicians had good intentions, they would miss addressing care gaps due to system related issues (e.g., lack of decision support or having limited time with patients during the clinic visit). In summary, the facilitators needed a range of skills to effectively facilitate knowledge transfer and get buy in from primary care providers (Tierney, Kislov, & Deaton, 2014).
In Uzbekistan, Ahmedov et al. (2013) interviewed 15 physicians and 30 patients to understand the challenges in primary care settings in managing heart failure patients. Prior to the study, investment was made to educate and train primary care physicians on evidence-based guideline recommended therapies for heart failure. However, the results of this qualitative study show that physicians were recommending interventions to patients that were not evidenced-based, such as outdated medications and getting admitted to the hospital for monitoring even when it could be managed as an outpatient. In addition, physicians were relying on pharmaceutical companies for information about medications and therapies. As a result, the authors recommend system-level changes that will help provide up-to-date information to providers and create a process of accountability with evidence-based guideline recommended therapies (Ahmedov et al., 2013).
Discussion
This literature review has highlighted articles related to heart failure management in the primary care setting. Two of the articles discussed quantitative methods in comparing outcomes in mortality and hospital readmission with the heart failure patients. Results show positive outcomes in the management of heart failure patients by primary care providers in the outpatient setting. The qualitative studies explored barriers faced by primary care providers in managing heart failure patients. Recommendations include using comprehensive multidisciplinary programs to improve outcomes by provide self-management support for heart failure patients.
Conclusion
As the number of heart failure cases increases with the aging population, primary care practices are left with majority of the responsibility of managing and coordinating care for these patients. Understanding the current evidence-based approaches in primary care settings can improve management and outcomes for patients with heart failure.
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