International Journal of Cardiology xxx (2017) xxx–xxx IJCA-24558; No of Pages 5 Contents lists available at ScienceDirect International Journal of Cardiology j ourna l homepage: www.e lsev ie r .com/ locate / i j ca rd Short communication The Optimize Heart Failure Care Program: Initial lessons from global implementation Martin R. Cowie a,⁎,1, Yuri M. Lopatin b,1, Clara Saldarriaga c,1, Cândida Fonseca d,1, David Sim e,1, Jose Antonio Magaña f,1, Denilson Albuquerque g,1, Marcelo Trivi h,1, Gustavo Moncada i,1, Baldomero A. González Castillo j,1, Mario Osvaldo Speranza Sánchez k,1, Edward Chung l,1 a Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6HP, United Kingdom b Volgograd State Medical University, Volgograd Regional Cardiology Centre, 106, Universitetsky Prospect, Volgograd 400008, Russia c Clinica Cardio VID, University of Antioquia, Calle 78 B 75, 21, Medellín, Antioquia, Colombia d Heart Failure Unit, S. Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental and NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal e Heart Failure Programme, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore f Division ofHeart Failure andCardiac Transplantation, CardiologyHospital, NationalMedical Centre “Siglo XXI”,Mexican Institute of Social Security, 330CuauhtemocAvenue, 06720Mexico City,Mexico g School of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rua Voluntários da Pátria, 445 Suites 1401/02, Botafogo, Rio de Janeiro, RJ 22270-000, Brazil h Cardiología Clínica ICBA, Instituto Cardiovascular de Buenos Aires, Blanco Encalada 1543, 1428 Buenos Aires, Argentina i Hospital y Clínicas DIME, 2901 Ave. Ucrania, Col. Humuya, Tegucigalpa DC FM 1101, Honduras j Complejo Hospitalario Metropolitano Dr. Arnulfo Arias Madrid, University of Panama, Via Transistmica Panamá, Panama k Calle 7 #1678, Entre avenidas 16 y 18, San José, Costa Rica l Department of Medicine, University of the West Indies, Mona, Kingston 7, Jamaica ⁎ Corresponding author. E-mail addresses: m.cowie@imperial.ac.uk (M.R. Cowi (C. Saldarriaga), david.sim@nhcs.com.sq (D. Sim), antonio (J.A. Magaña), albuquerque@cardiol.br (D. Albuquerque), sacagce@ice.co.cr (M.O.S. Sánchez), eechung@cwjamaica. 1 This author takes responsibility for all aspects of the r of the data presented and their discussed interpretation. http://dx.doi.org/10.1016/j.ijcard.2017.02.033 0167-5273/© 2017 The Authors. Published by Elsevier Ire Please cite this article as: M.R. Cowie, et al., (2017), http://dx.doi.org/10.1016/j.ijcard.20 a b s t r a c t a r t i c l e i n f o Article history: Received 4 February 2017 Accepted 8 February 2017 Available online xxxx Hospitalization for heart failure (HF) places a major burden on healthcare services worldwide, and is a strong predictor of increased mortality especially in the first three months after discharge. Though undesirable, hospi- talization is an opportunity to optimize HF therapy and advise clinicians and patients about the importance of continued adherence to HF medication and regular monitoring. TheOptimizeHeart Failure Care Program (www.optimize-hf.com),which has been implemented in 45 countries, is designed to improve outcomes following HF hospitalization through inexpensive initiatives to improve prescription of appropriate drug therapies, patient education and engagement, and post-discharge planning. It includes best practice clinical protocols for local adaptation, pre- and post-discharge checklists, and ‘My HF Passport’, a printed and smart phone application to improve patient understanding of HF and encourage involve- ment in care and treatment adherence. Early experience of the Program suggests that factors leading to successful implementation include support from HF specialists or ‘local leaders’, regular educational meetings for participating healthcare professionals, multidis- ciplinary collaboration, and full integration of pre- and post-hospital discharge checklists across care services. The Program is helping to raise awareness of HF and generate useful data on current practice. It is showing how good evidence-based care can be achieved through the use of simple clinician and patient-focused tools. Preliminary results suggest that optimization of HF pharmacological therapy is achievable through the Program, with little new investment. Further data collection will lead to a greater understanding of the impact of the Program on HF care and key indicators of success. © 2017 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Heart failure Optimize Checklist My HF Passport Hospitalization e), clarais@une.net.co .maganas@imss.gob.mx mstrivi@icba.com.ar (M. Trivi), com (E. Chung). eliability and freedom from bias land Ltd. This is an open access articl The Optimize Heart Failure C 17.02.033 1. Introduction Heart failure (HF) is the leading cause of hospitalization in the US and Europe, accounting for 1–2% of all admissions [1], and approximate- ly 30% of these patients require rehospitalizationwithin 60–90 days [2]. A recent nine-country analysis carried out in Asia showed that HF accounted for 2.2–19% of all admissions, with 30-day readmission rates of 3–15% [3]. Such findings demonstrate the global burden that HF hospitalization places on healthcare providers. e under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). are Program: Initial lessons from global implementation, Int J Cardiol http://www.optimize-hf.com http://creativecommons.org/licenses/by-nc-nd/4.0/ http://dx.doi.org/10.1016/j.ijcard.2017.02.033 mailto:eechung@cwjamaica.com Journal logo http://dx.doi.org/10.1016/j.ijcard.2017.02.033 http://creativecommons.org/licenses/by-nc-nd/4.0/ http://www.sciencedirect.com/science/journal/01675273 www.elsevier.com/locate/ijcard http://dx.doi.org/10.1016/j.ijcard.2017.02.033 2 M.R. Cowie et al. / International Journal of Cardiology xxx (2017) xxx–xxx While treatment advances have improved the prognosis for many HF patients over recent decades, hospitalization is one of the strongest predictors of increased mortality [2]. Mortality is particularly high in the first month after discharge [4]. Data from the most recently published National Heart Failure Audit of nearly 57,000 HF admissions in England andWales in 2014–15 showed in-hospitalmortality of 9.6%, 30-daymortality of nearly 20% andmortal- ity at one year of 30% [5]. These rates were unchanged from those in the previous six years [5]. Post-discharge mortality at one year, and out to six years, was related to access to specialist HF care and to use of key disease-modifying drugs for HF with reduced ejection fraction [5]. The greatest benefit was seen in patients leaving hospital on angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta blockers (BBs) and mineralocorticoid receptor antagonists (MRAs) [5]. A recent analysis has suggested that ivabradine should be consid- ered in HF patients with elevated heart rate during the ‘vulnerable’ phase after hospitalization to prevent early readmission [6]. Hospitalization, though in itself undesirable, is an opportunity to op- timize HF therapy and to provide appropriate discharge information for both clinicians and patients about the importance of adherence to HF medication and regular monitoring. During HF hospitalization, the use of a simple checklist to remind physicians about medications and dose uptitration, relevant counseling, and follow-up instructions at discharge has been shown to improve quality of care and reduce readmissions [7]. ‘GetWith the Guidelines-Heart Failure’ is an in-hospital program for im- proving care by promoting consistent adherence to treatment guide- lines. It has been shown to reduce 30-day readmission for HF [8], but recent analyses suggest that there is continuing room for improvement [9]. International guidelines suggest that improving ‘transition’ arrange- ments for patients leaving hospital and returning to care in the commu- nity are key to success [10]. In this paper, we describe the Optimize Heart Failure Care Program, which includes inexpensive initiatives to improve prescription of appropriate guidelines-recommended drug therapies, patient educa- tion and engagement, and post-discharge planning. We also review key learnings about the implementation of this Program and prelimi- nary findings concerning its impact on clinical practice. 2. The Optimize Heart Failure Care Program The Optimize Heart Failure Care Program (www.optimize-hf.com) was initiated in 2013 and includes both clinician- and patient-focused tools for improving outcomes for patientswho are hospitalizedwithHF. Hospitals that express an interest in the Program are provided with examples of best practice protocols developed for optimizing HF management drawn up by other hospitals involved in the Program. These protocols are based on latest recommendations from the European Society of Cardiology guidelines [10], and include optimiza- tion of pharmacological therapy and pre-discharge assessment and planning for patients returning to the community. Centres are encour- aged to adapt these protocols to local infrastructure and needs. The Program also provides pre- and post-hospital discharge check- lists of relevant clinical parameters for assessment, evidence-based pharmacologic and non-pharmacologic therapeutic measures and edu- cational initiatives (Fig. 1). These are completed prior to discharge and copies given to patients and sent to their community-based clinicians, so that results can be updated at follow-up consultations. This aspect of the Program aims to ensure that measures instituted during hospital- ization are continued post-discharge in order to optimize outcomes, especially during the first weeks and months when patients are partic- ularly vulnerable to further potentially fatal events. Used as a hand-held tool duringpatient review, the checklist rapidly upskills both thepatient and the healthcare professional about the key features of symptoms, clinical examination, drug therapy, and blood testing, that are required to optimize care. In most parts of the world such clinical review is not Please cite this article as: M.R. Cowie, et al., The Optimize Heart Failure C (2017), http://dx.doi.org/10.1016/j.ijcard.2017.02.033 necessarily undertaken by a healthcare professional who is an expert in heart failure, so such an aid can be crucial for ensuring that care is up-to-date and tailored to the individual. The patient education element of the Program, called ‘My HF Pass- port’, is designed to improve patient understanding of HF and encour- age involvement in care and adherence to treatment. It also gives patients the opportunity to collect serial data on weight, blood pressure (BP) and heart rate (HR), tiredness and breathlessness, to aid subse- quent clinical decision making. It is available in both printed form and as a smartphone application (MyHF application). All elements of the Optimize Heart Failure Care Program have been translated and customized for participating hospitals. 3. How is the Program being used and what have we learned? The Optimize Heart Failure Care Program is being used by clinicians and patients in 45 countries. Some hospitals have implemented the complete Program, while others are delivering either the clinician or patient-based elements (Fig. 2). During review of the Program with each of the centres involved, a number of factors have been identified which are likely to lead to successful implementation, irrespective of the geographical location of the centres or the relative wealth of the country: • Involvement of a national or local HF group and/or a ‘local leader’ to generate interest in the Program and drive diffusion of implementa- tion across multiple hospitals • Regular educational meetings of healthcare professionals involved in the Program to raise awareness of the impact of HF interventions on hospitalization and mortality and to share goals, experience and results of the Program in raising standards of care • Multidisciplinary collaboration on Program implementation, includ- ing specialist nurses • Full integration of pre- and post-hospital discharge checklists across inpatient, outpatient and community-based services to facilitate con- sistent use of evidence-based interventions across the healthcare community • Simple-to-use tools, customized to local needs and languages The main obstacles to implementation have been identified as: • Lack of awareness of the importance of optimization of HF drug therapy • Insufficient number of HF specialists, resulting in patients seeing doctors with different levels of training • Difficulty in providing early follow-up visits during the vulnerable weeks after hospitalization • Poor communication between inpatient and post-discharge services and a lack of consistency in HF care • Failure of patients to attend for outpatient follow-up visits after hospital discharge due to lack of facilities, long waiting lists, or large geographi- cal distances from the patient's home to the clinic or hospital 4. Impact on clinical practice Data are being collected on the impact of the Program across the world. Introduction of the Program has been a trigger for establishing appropriate collection of data on both process and outcome measures, particularly where no HF register or practice audit has previously been in place. More complete datawill be available in due course, but prelim- inary data describing the impact of Optimize on the prescription of pharmacological therapy and early post-discharge outcomes have been reported from two regions: in several Russian-speaking countries, and in Colombia, South America [11–12]. Lopatin et al. reported results over a three-month period from 317 patients in sinus rhythm hospitalized due to worsening HF at hospitals in Russia, Armenia, Belorussia, Georgia, Ukraine, Uzbekistan and are Program: Initial lessons from global implementation, Int J Cardiol http://www.optimize-hf.com http://dx.doi.org/10.1016/j.ijcard.2017.02.033 Pre- and Early Post-discharge Follow-up Patient’s name: Gender: Male Female Age: PRE-DISCHARGE VISIT Hospital specialist: Date of discharge: / / 20 EARLY POST-DISCHARGE VISIT 1 Doctor/Nurse: Date of visit: / / 20 EARLY POST-DISCHARGE VISIT 2 Doctor/Nurse: Date of visit: / / 20 CLINICAL ASSESSMENT Weight kg kg kg Resting heart rate bpm Rhythm: sinus atrial fibrillation not available bpm Rhythm: sinus atrial fibrillation not available bpm Rhythm: sinus atrial fibrillation not available Blood pressure Systolic/diastolic: / mm Hg Systolic/diastolic: / mm Hg Systolic/diastolic: / mm Hg Clinical symptoms of volume overload Signs of congestions: pulmonary rales, jugular venous congestion, hepatomegaly, peripheral edema Breathlessness Orthopnea Signs of congestions: pulmonary rales, jugular venous congestion, hepatomegaly, peripheral edema Breathlessness Orthopnea Signs of congestions: pulmonary rales, jugular venous congestion, hepatomegaly, peripheral edema Breathlessness Orthopnea NYHA class Class I Class II Class III Class IV Class I Class II Class III Class IV Class I Class II Class III Class IV Other measurements LV ejection fraction % Serum creatinine Potassium mmol/L LV ejection fraction % Serum creatinine Potassium mmol/L LV ejection fraction % Serum creatinine Potassium mmol/L PATIENT EDUCATION Nonpharmacological measurement Diet Exercise Weight monitoring Detection of worsening symptoms Diet Exercise Weight monitoring Detection of worsening symptoms Diet Exercise Weight monitoring Detection of worsening symptoms OPTIMIZATION OF MEDICAL THERAPY ACEIs or ARBs or ARNI Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) Beta-blockers Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (patient refused) MRAs Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Ivabradine Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Prescribed Not prescribed (CI or intolerance) Not prescribed (not indicated) Not prescribed (patient refused) Fig. 1. Optimize checklist for pre- and post-discharge follow-up. 3M.R. Cowie et al. / International Journal of Cardiology xxx (2017) xxx–xxx Kazakhstan which are using the Optimize Program [11]. At discharge of Program participants, the prescription rates of key guideline-based HF treatment with ACE inhibitors/ARBs, BBs, MRAs and ivabradine were 92.4%, 82.6%, 90.5% and 25.5%, respectively. Diuretics and digoxin were prescribed in 98.8% and 17.7% respectively. At three-month follow-up, 17.6% of patients had required rehospitalization. This is the Please cite this article as: M.R. Cowie, et al., The Optimize Heart Failure C (2017), http://dx.doi.org/10.1016/j.ijcard.2017.02.033 first time that such data have been collected in this region, but they compare very favourablywith regional data fromother countries [5,13]. Saldarriaga et al. reported data on 250 HF patients hospitalized in nine hospitals in Colombia, which suggested that the use of a pre- discharge checklist and educational material for patients may help to improve the use of recommended therapies [12]. At discharge, 95% of are Program: Initial lessons from global implementation, Int J Cardiol http://dx.doi.org/10.1016/j.ijcard.2017.02.033 Fig. 2. Global implementation of the Optimize Heart Failure Care Program. 4 M.R. Cowie et al. / International Journal of Cardiology xxx (2017) xxx–xxx patients had been prescribed BBs, 85% ACE inhibitors/ARBs, 74% MRAs, and 36% ivabradine. The mean heart rate at discharge was 77 bpm and more than 50% of patients were discharged with a heart rate above 70 bpm. Seventy-one per cent of patients attended a follow-up visit within 30 days after discharge, and 67% of these patients had a heart rate below 70 bpm. The rate of rehospitalization and decompensation at 30 days was 7% overall. For those in sinus rhythm with tighter heart rate control with BBs and ivabradine, the rate of rehospitalization and decompensation was 1% at 30 days. 5. Conclusions The Optimize Heart Failure Care Program is achieving encouraging levels of implementation, especially where there is support from HF specialists or ‘champions’, regular educational meetings for participat- ing healthcare professionals,multidisciplinary collaboration, and full in- tegration of pre- and post-hospital discharge checklists across care services. The Program is helping to raise awareness of HF and generate useful data on current practice and how good evidence-based care can be achieved through the use of simple clinician and patient-focused tools. Preliminary results suggest that optimization of HF pharmacolog- ical therapy is achievable through the Program, with little new invest- ment. Additional data will be made available in a fuller report in due Please cite this article as: M.R. Cowie, et al., The Optimize Heart Failure C (2017), http://dx.doi.org/10.1016/j.ijcard.2017.02.033 course, leading to a greater understanding of the impact of the Program on HF care, hospitalization and other key indicators of success. Conflict of interest Martin R Cowie has received speaker fees and has provided consul- tancy advice to Servier. Yuri M Lopatin has received speaker fees and has provided consul- tancy advice to Servier. Clara Saldarriaga has been a speaker for Servier, Novartis, Sanofi and Abbot and consultant for Medtronic. Cândida Fonseca has received consulting and speaker fees from Servier, Novartis, OMPharma, Bayer, Daiichi Sankyo and Orion. David Sim none reported. Jose Antonio Magaña has been an advisor, speaker and researcher for Abbvie, Novartis, Servier and Sanofi, all with modest honoraria. DenilsonAlbuquerquehas received speaker fees and provided consul- tancy advice to Servier. Marcelo Trivi has no conflict of interest about this publication. Gustavo Moncada has no conflict of interest. Baldomero A. González Castillohas been a clinical trial investigator for Sanofi, Lilly, Astra Zeneca and Novartis, and participant in Advisory Boards for Stendhal, MSD and Sanofi. Speaker for Servier, Novartis, Sanofi, MSD, Astra Zeneca, Bayer, Pfizer, Menarini, Abbott. are Program: Initial lessons from global implementation, Int J Cardiol http://dx.doi.org/10.1016/j.ijcard.2017.02.033 5M.R. Cowie et al. / International Journal of Cardiology xxx (2017) xxx–xxx Mario Osvaldo Speranza Sánchez has no conflict of interest. Edward Chung has provided consultancy advice to Servier and has received speaker fees from Pfizer. Acknowledgements Writing assistance was provided by Jenny Bryan and funded by Servier. National Coordinators of the Optimize Program: Prof Marcelo Trivi, Argentina; Prof H Sisakyan, Prof H Hayrapetyan, Armenia; Prof Adil Bakhshaliyev, Prof Gulnaz Dadasheva, Azerbaijan; Ass. Prof. Elena Kurlianskaya, Belarus; Prof Denilson Albuquerque, Brazil; Prof Yotov, Bulgaria; Dr. Mario Speranza, Dr. Gustavo Moncada, Dr. Baldomero Gonzalez, Central America; Dr. Clara Saldarriaga, Dr. Solón Navarrete, Colombia; Dr. Jiří Šťastný, Czech Republic; Prof Mahmoud Hassanin, Egypt; Prof Pagava, Prof Kipiani, Georgia; Prof Nooshine Bazargani, Prof Fahad Baslaib, Prof Wael AlMahmeed, Prof Amrish Agrawal, Prof Adel AbdAlla, Prof Amr Badr, Prof Fouad Abd ElKader, Prof Kadhim Jaffar, Prof Mousa Akbar, Prof Rajaa Dashti, Gulf countries; Dr. Nyolczas Noémi, Hungary; Dr. Isman Firdaus, Dr. Rarsari Soetikno, Indonesia; Prof Volterrani, Italy; Dr. Berkimbaev, Dr. Rakisheva, Kazakhstan; Dr. Azmee Mohd Ghazi, Malaysia; Dr. Antonio Magaña, Mexico; Eugenio B. Reyes, Philippines; Prof Cândida Fonseca, Portugal; Assoc. Prof Ovidiu Chioncel, Prof Dan Dobreanu, Dr. G. Tatu Chitoiu, Prof CezarMacarie, Romania; Prof Yuri Lopatin, Prof A Chesnikova, Prof N Koziolova, Prof M Glezer, Prof E Tarlovskaya, Dr. T Chernyavskaya, Russia; Dr. David Sim, Singapore; Dr. Eva Goncalvesová, Slovakia; Phrommintikul Arintaya, Thailand; Prof L Voronkov, Prof V Tselujko, Ukraine; Prof Martin Cowie, UK; Prof Abdullaev, Uzbekistan; Dr. Vu Quynh Nga, Vietnam; Dr. Edward Chung, West Indies. References [1] A.P. Ambrosy, G.C. Fonarow, J. Butler, et al., The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries, J. Am. Coll. Cardiol. 63 (12) (Apr 1 2014) 1123–1133. Please cite this article as: M.R. Cowie, et al., The Optimize Heart Failure C (2017), http://dx.doi.org/10.1016/j.ijcard.2017.02.033 [2] M. Gheorghiade, M. Vaduganathan, G.C. Fonarow, R.O. Bonow, Rehospitalization for heart failure: problems and perspectives, J. Am. Coll. Cardiol. 61 (4) (Jan 29 2013) 391–403. [3] E.B. Reyes, J.W. Ha, I. 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Introduction 2. The Optimize Heart Failure Care Program 3. How is the Program being used and what have we learned? 4. Impact on clinical practice 5. Conclusions Conflict of interest Acknowledgements References