Authors (including presenting author) :
Kam KH (1), Chan CP (1), Geri Wong (1), Leo Lai (1), Mak HL (1), Fung KY (1), Chan WC (1), Kent So(1), Cheung LL (1), Chan YS (1), Lee PW (1)(2), Bryan Yan (1)(2)
Affiliation :
(1) Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital
(2) Department of Medicine and Therapeutics, the Chinese University of Hong Kong
Introduction :
Heart failure (HF) is a pervasive and serious cardiovascular condition that has been a significant global health concern. According to Hospital Authority statistics, the prevalence of HF has been on rising trend with 19% increase within 10-year time. There are approximately 11,000 newly diagnosed heart failure cases annually with more than 90% requiring acute hospitalization. The risk of heart failure rehospitalization is high globally as well as locally, the 30-day HF readmission could be up to 32% according to a local study in 2016. As a result, there is an unmet need to establish an efficient service model to better manage the growing demand.
Objectives :
(1)Primary outcome is all-cause mortality, heart failure hospitalization and urgent A&E visit due to HF in REDUCE-HF group (active arm) and historical cohort group (control arm). (2) Secondary outcome will be comparison of clinical and functional status at baseline and 3-month on follow up in active intervention cohort.
Methodology :
The Reduction of Decompensation and Unnecessary Cardiac failure Emergency admissions: ambulatory Heart Failure service model (REDUCE-HF) is a single-centre, non-randomized pragmatic study (CREC ref no: 2022.240) prospectively evaluates the clinical outcomes of symptomatic patients who have been hospitalized with primary diagnosis of heart failure in Prince of Wales Hospital. Before HF discharge, eligible patients were recruited into our ambulatory day care service program irrespective of left ventricular ejection fraction. They were subsequently seen in our ambulatory care centre within two weeks, where intensive up-titration of guideline directed medical therapy (GDMT), personalized care planning and patient-centred education would be proceeded. Our ambulatory care team including cardiologists, dedicated nurses and pharmacists would closely monitor their clinical status, laboratory values, and provided protocol-driven GDMT titration. After stabilization, HF patients would be discharged to general cardiology clinic in 3-6months.
The aim of the study is to assess the efficacy of this brand-new ambulatory service model in reducing all-cause mortality, heart failure hospitalization (HHF), improving clinical as well as functional outcomes of our post-discharge patients with Heart Failure. The data of our service model will be compared with our 5-year historical cohort which were propensity score matched.
Result & Outcome :
Between October 2022, and December 2023, 245 patients were successfully recruited into our REDUCE-HF service model. Historical cohort of 6867 patients (not recruited into REDUCE-HF, code: acute heart failure, admitted to Prince of Wales Hospital) will serve as usual care control group and their data were extracted from Clinical Data Analysis and Reporting System (CDARS) from year 2019 to 2023. Mean age was 67.8+/-12.2 and 72.2% patients were male. Their heart failure cateogories are as follow: heart failure of reduced EF (HFrEF) 60%, heart failure of mildly reduced EF (HFmrEF) 11% and heart Failure of preserved EF (HFpEF) 29%. Their risk profile were as follow: ischemic heart disease 27.8%, diabetes 33.1% and hypertension 58.4%. The mean follow up period was 3 months. At 90 days, REDUCE-HF cohort group has shown much lower all-cause mortality compared with usual care group (2.5% vs 9.3%, p< 0.001). There was a much lower incidence of heart failure hospitalization and urgent A&E visit due to HF in REDUCE-HF group as compared to usual care group (8.6% vs 13.1%, p< 0.01). In secondary outcome, there was significant reduction of NT-ProBNP of 45.2% (from 4229pg/ml at baseline to 2319pg/ml at 3 month, p< 0.001), tremendous increment of 6-minute walk test (from 211.5m at baseline to 250m at 3 month, p< 0.001) and remarkable improvement of Kanas City Cardiomyopathy Questionaires (KCCQ) score from 55.1 at baseline to 86.7 at 3 month (63% enhancement, p< 0.001). The overall ejection fraction (EF) was significantly increased from 39% at baseline to 44% at 3 month (p< 0.05). The average length of stay for HF hospitalization was 7.69 days (first index HF admission) reduced to 5.46days (second HHF), p< 0.05. We attributed the positive outcomes to good adherence to GDMT: ACEi/ARB or ARNI 91%, Beta-blocker 90.3%, Mineralocorticoid receptor antagonist 72.4% and Sodium-Glucose co-transporter-2 inhibitor (SGLT2i) 95.5%.
The REDUCE-HF ambulatory service model has been proven effective in reducing mortality, decompensation and preventing unnecessary emergency admissions in this prospective cohort study. By intervening proactively, this model not only enhances the quality of care but also hold promise in alleviating the burden of in-patient services on heart failure, and potentially cost-saving.
