Cardiovascular Innovations and Applications
Vol. 1 No. 1 (2015) 13–18
ISSN 2009-8618
DOI 10.15212/CVIA.2015.0005
Review
Congestive Heart Failure Clinics: How to Make
Them Work in a Community-Based Hospital
­System
Joshua Larned, MD1, Mohamad Kabach, MD1, Leonardo Tamariz, MD, MPH2 and
Kristine Raimondo, MSN, ARNP-BC1
Jim Moran Heart and Vascular Research Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA;
University of Miami Miller School of Medicine, FL, USA
2
Miller School of Medicine at the University of Miami, Veterans Affairs Medical Center, Miami, FL, USA
1
Abstract
Introduction: Congestive heart failure (CHF) accounts for over $32 billion in health care costs per year and is at the
epicenter of health care reform. CHF remains a major cause of hospitalizations. It is known and has been reported that
missed diagnosis of and missed opportunities to treat heart failure are associated with higher mortality and morbidity.
CHF disease management programs have emerged as a potential solution to the CHF epidemic. The paradox remains
that CHF disease management programs still cluster in tertiary hospital systems. The impact of heart failure specialists
and specialty teams in community health systems is less well understood. Currently there are not enough CHF-trained
teams in the community setting to address this unmet health need.
Methods: We explored the impact of CHF clinics in a community-based hospital system on readmission rates, mortality, and symptomatic relief. A total of 384 patients were enrolled in the clinic between 2012 and 2015. Data collected
included age, sex, type of heart failure, New York Heart Association class, ejection fraction, serum creatinine and brain
natriuretic peptide values, and readmission and mortality rates within 30 days, 3 months, 6 months, and 1 year. We
also compared readmission rates between patients who were followed up in the CHF clinic versus those who were not
seen in the CHF clinic.
Results: A statistically significant difference was demonstrated in readmission rates between patients who were
­followed up in the CHF clinic versus those who did not visit the CHF clinic for up to 1 year of follow-up.
Conclusion: CHF community hospital clinics that use a rapid and frequent follow-up format with CHF-trained teams
effectively reduce rehospitalization rates up to 1 year.
Keywords: congestive heart failure; community-based hospital system; clinic; multidisciplinary
Introduction
Correspondence: Joshua M. Larned, MD, FACC,
­Assistant Professor of Medicine, Medical Director, Heart
Failure Services, Holy Cross Hospital, University of
­Miami Miller School of Medicine/Holy Cross Hospital,
4725 North Federal Highway, Suite 401, Fort Lauderdale,
FL 33308, USA, Tel.: +954-772-2136, Fax: +954-772-7156,
E-mail: Joshua.Larned@holy-cross.com
© 2015 Cardiovascular Innovations and Applications
Congestive heart failure (CHF) is a complex medical syndrome that affects more than five million
people in the United States alone [1]. More than
500,000 new diagnoses are made each year in the
United States. This number is projected to increase
because of an aging population and better care of
14
J. Larned et al., Congestive Heart Failure Clinics
the ­comorbid conditions that cause CHF [2]. Despite
advances in medical therapy, half of all people who
develop CHF will die within 5 years of their initial diagnosis [1]. CHF accounts for more than $32
billion in health care costs per year and is at the
epicenter of health care reform [2]. Although this
staggeringly high figure includes hospitalizations,
outpatient medical encounters, medications, and
devices, it does not fully account for less measurable
effects such as missed days of work, missed family
days of work, and other community/biopsychosocial
impacts. Despite standardized CHF therapy and management guidelines [3], CHF remains a major cause
of hospitalizations [4]. The overall rate of CHF hospitalizations did not change significantly from 2000
to 2010 although the risk of hospitalization increases
according to increasing age [4]. As there are far more
community hospitals than tertiary hospitals, CHF
hospitalizations have disproportional consequences
in community health systems; yet community health
systems remain underequipped to address the complex needs of CHF patients. The paradox remains
that CHF disease management programs still cluster
in tertiary hospital systems. Ironically, CHF educational pathways, including fellowship programs and
board certification pathways, focus on advanced
therapies such as transplant and device therapy
rather than disease management, prevention, and
new target therapies. There are numerous factors
that complicate CHF care, including delayed diagnosis, inadequate treatment, inadequate education,
and ineffective transitions of care. It should come as
no surprise that 24% of all CHF patients are likely
to be readmitted to a hospital within 30 days [5]. A
sobering fact is that health systems have struggled to
reduce readmission rates and readmission penalties
irrespective of a patient’s socioeconomic status [6].
CHF disease management programs have emerged
as a potential solution to the CHF epidemic [7].
There are some data that demonstrate that specialized heart failure clinics result in better management
of patient behavior and medication adherence, with
fewer hospitalizations [7–10]. Meta-analyses of
CHF disease management programs, however, have
demonstrated variable impact on CHF populations
[11]. This heterogeneity may be explained by a lack
of a standardized multidisciplinary process and variable levels of provider training and care delivery [12,
13]. It is known and has been reported that missed
diagnosis of and missed opportunities to treat CHF
are associated with higher mortality and morbidity
[14, 15]. The transition from inpatient to outpatient
care can be an especially vulnerable period because
of the progressive nature of the disease state, complex medical regimens, the large number of comorbid conditions, and the multiple clinicians who may
be involved [16–20]. The impact of CHF specialists
and specialty teams in community health systems is
less well understood. Currently there are not enough
CHF-trained providers to address this unmet health
need.
Methods
Our institution set out to examine the impact of a
CHF disease management program at Holy Cross
Hospital, Fort Lauderdale, Florida. Holy Cross
Hospital is a 570-bed nontransplant/nonimplant
community hospital in metropolitan Fort Lauderdale. Our program infrastructure uses a trained
advanced registered nurse practitioner (ARNP) to
identify all CHF hospitalized patients and standardize adherence to national guidelines. Additionally, the ARNP facilitates provider follow-up v­ isits
after hospital discharge and encourages 1-week
follow-up in an ARNP-maintained CHF clinic on
our hospital campus. Patients who are referred to
the CHF clinic are seen within 1 week to 10 days
of discharge by the ARNP team and on a weekly/
as-needed basis until congestion-free stability is
achieved. At appropriate intervals, evidence-based
treatment is recommended or initiated and titrated
according to protocols. Quality-of-life scores are
obtained at the index visit and 6-min-walk testing
is performed on able patients. The Seattle Heart
Failure Risk Assessment is used, when appropriate,
to communicate risk with referring providers and
drive therapy changes. When mild decompensation episodes occur, patients may receive intravenous diuretics and may be monitored in the clinic.
Patients receive additional services such as dietary
education or follow-up phone calls (if needed).
Family members or support persons are encouraged to accompany patients to the clinic. Patients
are seen for up to 1 year, when possible, and discharged from the clinic after 1 year if they maintain
continued stability. A CHF fellowship-trained and
J. Larned et al., Congestive Heart Failure Clinics
b­oard-certified specialist provides program oversight. Patents who exhibit progressive features are
referred to the CHF specialist for further management. If appropriate, high-risk patients undergo cardiopulmonary exercise testing and right-sided heart
catheterization, and are referred to tertiary systems
for potential stage D therapies such as transplant
or left ventricular assist device (LVAD) therapy. If
appropriate, patients are referred for palliative care
by the CHF clinic. As a means of tracking our outcomes, we created a CHF clinic disease management registry where individual data were entered
on a recurring-visit basis. We used this r­egistry
to conduct our analysis. Our hypothesis was that
management in our CHF clinic would result in a
primary end point of fewer hospitalizations compared with all patients discharged with CHF at our
community-based ­
­
institution. We also used our
registry to review mortality and appropriate use of
evidence-based medicines with systolic CHF.
A total of 384 patients were seen in the CHF clinic
and entered into the CHF registry between 2012 and
2015. A detailed medical record review of patients
with a diagnosis of heart failure based on International Classification of Diseases, Ninth Revision
(ICD-9) coding during the 3-year timeframe was
done. Data regarding age, sex, type of heart failure,
New York Heart Association (NYHA) class, ejection fraction, serum creatinine and brain natriuretic
peptide values, and readmission and mortality rates
within 30 days, 3 months, 6 months, and 1 year were
collected. Fifty-nine patients were lost to follow-up
and were not included in our analysis. The registry
data were analyzed with Pearson’s chi-square test
and Fischer’s exact test, and independent samples
t tests were used to compare the baseline characteristics. All analyses were performed with SPSS for
Windows version 16.0.
Results
The baseline characteristics of CHF clinic enrollees
are given in Table 1. Most of our patients had NHYA
class II heart failure symptoms (72%); 28% had
NYHA class III-IV heart failure symptoms. Patients
were likelier to receive standard medical therapy if
they were enrolled in the CHF clinic. Our usage
rate of beta-blocker and ­
angiotensin-converting
15
Table 1 Baseline Characteristics of Congestive Heart
­Failure Clinic Enrollees.
Number of enrolled patients
Age, years
Median
IQR
Female, %
Systolic heart failure, %
Ejection fraction
Median
IQR
NYHA class III–IV, %
Serum creatinine, mg/dL
Median
IQR
NT-BNP, pg/mL
Median
IQR
384
76
63–85
40
77
35
25–55
28
1.18
0.92–1.69
3365
1546–6847
IQR, interquartile range; NT-BNP, N-terminal brain
­natriuretic peptide, NYHA, New York Heart Association.
enzyme inhibitor/angiotensin-receptor blocker therapy in patients with systolic heart failure is illustrated in Table 2. Readmission and mortality rates
for patients enrolled in the CHF clinic is shown in
Table 3. As shown in Table 4, the effect of evidenceTable 2 Medication Use in Systolic Congestive Heart
­Failure.
Medications
Use (%)
ACEI/ARB
Evidence-based beta-blockers
Aldosterone antagonist
ACEI/ARB at the maximum target
Beta-blocker at the maximum target
92
98
30
44
38
ARB, angiotensin-receptor blocker; ACEI, angiotensin-­
converting enzyme inhibitor.
Table 3 Readmission and Mortality Rates for Patients
­Enrolled in the Congestive Heart Failure Clinic.
Period
Readmission (%)
Mortality (%)
30 days
3 months
6 months
1 year
7
12
16
19
2
4
9
15
16
J. Larned et al., Congestive Heart Failure Clinics
Table 4 Effect of Evidence-Based Medications at Maximum
Target Dosages on Readmission and Mortality Rates.
Use of medications
at maximum dosages
Readmission
(%)
Mortality
(%)
Yes
No
P
5
9
0.29
2
2
0.60
based medications at maximum target dosages on
readmission and mortality rates was not statistically
significant. However, we were able to demonstrate
a statistically significant difference in readmission
rates between patients who were followed up in the
CHF clinic versus those who were not seen in the
CHF clinic (Figure 1).
Discussion
Our CHF clinic has been able to demonstrate a consistent favorable impact on readmission rates versus readmission rates for CHF patients who were
not referred to a community-based CHF clinic, as
illustrated in Figure 1. Over the 1-year course of
longitudinal follow-up in the CHF clinic, the readmission risk increased in all groups, thereby reflecting the risk of CHF progression. Recurrent CHF
hospitalizations indicate a higher risk prognosis
across multiple CHF clinical trials, which supports
why our center tries to maintain longitudinal care
for 1 year, when possible [21, 22].
One explanation for our favorable readmission
data may lie in our follow-up protocols. Our followup regimen is rigorous, encouraging patients to be
followed up in the CHF clinic on a weekly basis,
until they are deemed clinically stable, then on a
1–3-month recurring basis for 1 year after hospitalization. Urgent visits are encouraged, and mild
to moderate CHF decompensations are treated
with intravenous diuretics, as needed, in the clinic.
Patients are encouraged to call the CHF clinic if
there is a change in their clinical status, and recommendations may be made to patients accordingly via the telephone. Nutritional services and
social support services are provided to all patients
enrolled in the CHF clinic. If indicated, home health
and cardiac rehabilitation is provided to appropriate
patients. Monthly educational group sessions are
held for enrolled patients though our Heart Failure
University to promote CHF self-management. This
medical home approach seems to provide an infrastructure that allows more mechanisms to intervene
on CHF patients and across the spectrum of their
illness. Our follow-up protocol may be a more costeffective alternative in the context of the cost of a
CHF admission along with readmission penalties.
As described above, our experience demonstrates
that most of our CHF clinic patients had NHYA
class II symptoms. This may be attributable to
careful management and follow-up of our patient
population. Even when medical therapy could not
be achieved to target doses, patients still had fewer
hospital events and fewer CHF symptoms. Despite
18
HF clinic patients
16
Non-clinic patients
14
12
10
8
6
4
2
0
2012 (P-value 0.002)
2013 (P-value 0.0003)
2014 (P-value 0.012)
2015 (P-value 0.04)
Figure 1 Readmission Rates of Congestive Heart Failure (HF) Clinic Patients versus Nonclinic Patients (2012–2015).
J. Larned et al., Congestive Heart Failure Clinics
their mean ejection fraction and baseline N
­ -terminal
brain natriuretic peptide levels, only 28% of our
population had severe CHF symptoms as defined
by NHYA class III or greater.
Across the NYHA classes we report 15% mortality at 1 year for CHF clinic enrollees. This statistic was not significantly related to achieving target
therapy, according to our data. Yet, our mortality
rates at 1 year were lower than rates reported by
other investigators [23–25].
With regard to a comparison group, we do not
have complete mortality data on those CHF patients
who were discharged from our hospital but were not
followed up in the CHF clinic.
We were able to achieve a high usage rate of betablocker and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker therapy in patients
with systolic heart failure. Accordingly, we report a
lower usage rate of aldosterone antagonist therapy
in systolic heart failure patients. Our aldosterone
antagonist use may reflect the fact that, although
aldosterone antagonists are integrated into the current guidelines for use in systolic heart failure of
NYHA class II or greater, they tend to be used less
in patients with NYHA class II CHF [26, 27]. This
may also reflect the challenges of aldosterone antagonists and their side effects in an elderly population.
In our experience, our specialty team consisting
of a CHF-trained ARNP and CHF-trained cardiologist may have impacted our CHF clinic outcomes.
CHF community hospital programs represent opportunities to identify patients who may be “CHF rapid
progressors.” Early identification of the highest-risk
CHF patients facilitates early evaluation and referrals for stage D therapies such as LVAD therapy,
transplant, inotropes, palliative care, or hospice care.
Study Limitations
Our sample size is small and likely reflects our
referral patterns within our hospital system. Our
experience demonstrates the challenges in treating
CHF within a nontransplant/nonimplant community
hospital setting. Our hospital system is not unique
in that it is an “open” system where both hospitalemployed and non–hospital employed physicians
may treat CHF patients when they are admitted to
the hospital. Hospitalized heart failure patients are
17
likelier to be referred to the CHF clinic if they are
admitted to the hospitalist service or a hospital medical group service versus a nonemployed provider.
Therefore, the bulk of our analysis is limited to those
patients who were ultimately referred to the CHF
clinic. Secondly, during our CHF clinic’s early existence, our impact was lessened by the fact that we
were confined initially to making recommendations
rather than directly changing therapy. We were able
to shift from an advisory role to a more active role
within the first year, but it stands to reason that this
initial limitation may have affected our outcomes.
Our data do not account for decompensation episodes within the CHF clinic population. In fact,
decompensation episodes did occur in our clinic
population but in many circumstances could be
managed in an outpatient setting by either administration of intravenous diuretics in the clinic or
through increase of oral diuretic therapy followed
by rapid follow-up in the clinic.
Conclusion and Take-Home Message
We conclude that CHF community hospital clinics
that use a rapid and frequent follow-up format with
an ARNP with CHF specialist oversight effectively
reduce rehospitalization rates at 1 year. We demonstrate that CHF-trained teams are likelier to place
emphasis on evidence-based therapy and achieve
greater symptom relief. Having a CHF-trained team
in a community hospital setting may create an extra
edge that allows earlier recognition of high-risk
CHF and facilitate appropriate referrals for LVAD
therapy, transplant, or palliative care. This construct
presents potential opportunities to reduce medical
costs at it pertains to the CHF epidemic. Future
directions in CHF management should focus on
improving and standardizing the delivery of heart
failure care in a community setting.
Conflict of Interest
The authors declare no conflict of interest.
Funding
This research received no specific grant from any
funding agency in the public, commercial or notfor-profit sectors.
18
J. Larned et al., Congestive Heart Failure Clinics
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