© 2005 European Society of Cardiology
Health care professionals in a heart failure team
Department of Cardiology, University Medical Centre Groningen Groningen, The Netherlands E-mail address: t.jaarsma{at}thorax.umcg.nl
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Abstract |
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 Top Abstract 1. Introduction2. Health care providers...3. Randomised studies of...4. The pharmacist in...5. The dietician in...6. The physical therapist...7. The psychologist in...8. Other health care...9. The optimal heart...References |
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A heart failure team that treats heart failure patients often faces the challenge of managing multiple conditions requiring multiple medications and life style changes in an older patient group. A multidisciplinary team approach can optimally diagnose, carefully review and prescribe treatment, and educate and counsel patients and their families about medication use and life style changes. In this paper the possible role of the pharmacist, dietician, physical therapist, psychologist, primary care provider and social worker in heart failure management is discussed.
Key Words: Heart failure clinics • Management programs • Dietician • Pharmacist • Primary care • Physical therapist • Psychologist • Heart failure
Received May 18, 2004; Revised October 21, 2004; Accepted January 11, 2005
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1. Introduction |
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In the battle against the effects of chronic heart failure (HF) on the lives of patients and their families, much progress has been achieved in recent years. It is generally agreed that a multidisciplinary approach to treatment and care is needed to improve patient outcomes, including health care utilisation and associated costs, quality of life and mortality [1–4].
However, there is still active discussion on the optimal approach and the underlying mechanisms of success of these programs. Some authors suggest that the key elements to the success of HF programs are patient adherence to the treatment regimen and early detection and treatment of clinical deterioration [5–7]. Others stress the importance of optimal medical treatment, clinical stability, access to specialist care and the role of the nurse acting as the guardian of more expensive health care facilities [8,9]. In addition to the discussion on the mechanisms of success of HF programs, another challenge is the involvement of an optimal mix of health care professionals.
In daily practice various health care professionals are engaged in the care of HF patients and their role in a HF clinic often depends on the goodwill and enthusiasm of the individuals. In some HF programs, formal links are established between a cardiologist and HF nurse and with supporting disciplines like dieticians, physical therapists and/or social workers. However, in other programs these contacts are less formal and sometimes difficult to organize (and finance).
Without a proper description of a multidisciplinary approach it is difficult to determine its effects. The word ‘multidisciplinary— can be interpreted in several different ways. Some studies report on a ‘multidisciplinary team— if, in addition to a cardiologist, another medical specialist (e.g. internist) is involved or if a medical specialist works together with a general practitioner (GP). In some studies, a ‘multidisciplinary team— involves a cardiologist and HF nurse, while others define a ‘full (true) multidisciplinary approach—, only if other health care professionals e.g. physical therapists or dieticians are involved. In some of the other papers included in this issue of the European Journal of Heart Failure and in several other publications, the roles of the cardiologist and the specialized HF nurse are described in detail [10]. However, relatively little attention has been given to the role of ‘other— health care professionals. In this paper the role of a number of different health care providers, who can have a major contribution in multidisciplinary HF management, is discussed.
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2. Health care providers in a HF management program |
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In a survey of HF management in the Netherlands in 2003, it was found that 85 of 142 hospitals (60%) had some form of HF management program (defined as a program delivering coordinated and comprehensive treatment and care specifically targeted at heart failure patients) [11]. Most of these programs involved several health care providers (Fig. 1). In addition to the cardiologist–nurse collaboration, these HF programs also included dieticians, physical therapists, social workers, GP's, home care nurses and psychologists. Only a few programs involved a pharmacist or rehabilitation physician. This survey provides some of the first data on ‘real life— HF multidisciplinary management, however, the survey does not provide information on the structure of the involvement of the health care providers. In other words, it is not clear whether all HF patients will have a consultation with all of these health care providers or whether the health care provider will only be consulted in case of particular health care needs.
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3. Randomised studies of ‘full— multidisciplinary teams in HF clinics |
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There are several studies that address the effects of ‘multidisciplinary— HF care involving primarily a cardiologist and a specialized HF nurse [12–21]. Only a few studies evaluate the effect of more extended multidisciplinary teams caring for HF patients.
In 1995, Rich and colleagues reported that a multidisciplinary intervention had beneficial effects on hospital readmission, quality of life and cost of care within 90 days of discharge among "high risk" chronic HF patients [20,21]. The multidisciplinary team consisted of a HF nurse (comprehensive education of the patient and family), a registered dietician (provision of dietary instructions), social services (post discharge care), a geriatric cardiologist (review medications, recommendations to simplify and consolidate the regimen) and home care services (intensive follow up) [21]. This extensive multidisciplinary approach resulted in a longer event-free survival (p=0.09), fewer readmissions, a better quality of life and fewer health care costs (p<0.05).
Another multidisciplinary collaboration was tested by Stewart and colleagues [22] who reported on a home-based intervention consisting of a single home visit by a nurse and pharmacist. The aim of this visit was to optimise medication management, identify early clinical deterioration, and intensify medical follow-up and caregiver vigilance as appropriate. These joint home visits resulted in a reduction of unplanned readmissions and associated days of hospitalisation (p<0.05). In later work, the authors also showed similar beneficial effects from a single home visit performed by a cardiac nurse alone [23]. The combined approach of a pharmacist and nurse specialist was also evaluated by Rainville and colleagues [24]. A pharmacist and a clinical nurse specialist identified patient issues that posed a potential risk for rehospitalisation and determined corrective action. The pharmacist then educated the patient and caregiver on medications and life style changes, resulting in a decrease in death and readmission (p<0.005) [24].
More recently, an Italian group described the effects of a multidisciplinary team consisting of a cardiologist, 4 HF nurses, 2 physical therapists, a dietician, a psychologist and a social assistant. The team members aimed at prevention and functional recovery of the consequences of disease instability and optimising treatment and care. This team approach significantly reduced mortality and morbidity of HF patients, over one year (p<0.001) [25].
Another multidisciplinary HF clinic was studied by McDonald and colleagues in Ireland [9]. In this study, the intrinsic benefit of multidisciplinary care in the setting of protocol-driven optimal medical HF management was demonstrated. Team members were the cardiology service, the HF nurse and a specialist dietician who consulted patients during the index admission [9]. This multidisciplinary approach resulted in a decrease in HF hospital readmission and/or death within 90 days (p<0.005).
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4. The pharmacist in HF care |
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In most countries patients have to visit the pharmacy to collect their medication, therefore it seems logical to include community pharmacists in multidisciplinary interventions [26]. Only a few studies have included a pharmacist in a multidisciplinary intervention to improve outcomes [23,24,27]. Other studies have focussed specifically on the individual role of the pharmacist in improving outcomes in HF [26,28–30]. Interventions by hospital pharmacists seem to focus on the role of physicians in choosing the appropriate drug regime and dosages, while studies with community pharmacist are more concerned with improving patient knowledge and compliance [31].
Patient education and goal setting by pharmacists can increase patient knowledge and the appropriateness of medications taken by patients [32]. Two studies evaluating the effect of an intensive medication counselling program by a pharmacist, showed improved compliance, functional capacity and decreased symptoms [26,30].
Clinical pharmacists also can be involved in initiating and/or titrating cardiovascular medications [27,32,33]. Involving a clinical pharmacist as a member of the multidisciplinary HF team has been shown to significantly increase the dose of ACE-inhibitors [29]. In a (non randomised) study where all patients received dietary and nursing advice, rehabilitation and social service, the additional optimisation of ACE inhibitor doses by a clinical pharmacist decreased rehospitalisation rates and lowered the cost of care [27].
Depending on the local health care system, a pharmacist can play a role in judging and evaluating treatment guidelines and initiating appropriate evidence-based therapy. In addition, pharmacists can check on possible drug interactions, treat adverse events and have a possible role in the education of patients and of physicians [24,31–36].
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5. The dietician in HF care |
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Nutritional management of the HF patient is complex because several nutritional problems can occur, including sodium and fluid retention, malnutrition and dietary management of coexisting disorders, e.g. diabetes mellitus. Although dietary advice on sodium and fluid restriction is considered essential in the management of HF patients [37], a lot of patients are not appropriately counselled about diet [38]. Although the HF guidelines stress the importance of dietary advice [37], this does not mean that in all HF teams registered dieticians are employed or consulted.
Three studies evaluating the effects of multidisciplinary HF care, explicitly reported on the role of the dietician [9,20,27]. However, in all of these studies, the role of the dietician is poorly described (‘provision of dietary instructions— or ‘obtained detailed dietary histories and designed an individual diet for each patient)—. Only a few studies are available that focus particularly on the role of the dietician in HF management. In a small pre–post test study, a dietician developed and tested a medical nutrition therapy protocol and HF education materials. Patients' sodium and fluid intakes at 2–3 months and 6–9 months decreased compared with their baseline intakes and quality of life improved [39].
Neily and colleagues found [40] that education focusing on sodium intake by a registered dietician corrected deficiencies in the patients knowledge of dietary sodium intake. Awareness of the sodium restriction guideline increased after education by the dietician from 14% at baseline to 42% after the patient completed one or more educational sessions (mean 2.8±1.5) with the dietician (p<0.01). The proportion of patients able to read the sodium content from the Nutrition Facts label was 58% at baseline and 92% at follow-up (p<0.01). The proportion of subjects who achieved a perfect sodium knowledge score was 8% at baseline and 26% at follow-up (p<0.05) [40].
Another important aspect in dietary counselling is a healthy body weight [37], since being either overweight or underweight can be serious concerns in HF patients. Weight reduction in obese HF patients can be a complex issue, needing specialized guidance by a dietician. Recently, the prevalence and consequences of cardiac cachexia have received more attention. The ESC guideline states that in the care for patients with cardiac cachexia, the help of dieticians should be sought. The aim of treatment is to achieve an increase in non-oedematous body weight, preferably by increasing muscle mass. Dietary advice should focus on increasing energy intake [37].
Dieticians have an important role in dietary intake evaluation, formulating tailored dietary advice according to specific patient needs (e.g. combine a HF and diabetes diet), helping patients to attain or maintain an optimal nutritional status and to improve compliance with prescribed nutritional recommendations.
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6. The physical therapist in HF care |
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Patients with HF suffer from physical and psychosocial limitations caused by reduced exercise capacity and disability in different activities [41]. Patients are often unable to perform certain normal daily activities or have to decrease the rate at which they carry out their tasks. Even when patients report few symptoms during normal activities, their maximal exercise capacity is almost always reduced [42]. To increase the daily function of HF patients it is therefore important that all of the major muscle groups used in daily life are trained. Improvement in aerobic working capacity as well as in specific activities of daily life may have a great impact on the patients quality of life [43].
In several HF management programs exercise training is considered important. At the same time, HF patients are increasingly encouraged to enrol in cardiac rehabilitation programs or engage in regular exercise such as walking or cycling. Exercise training programs are encouraged in stable patients in NYHA class II–III. In order to prevent muscle de-conditioning in stable HF, patients should be advised to carry out daily physical and leisure time activities that do not induce symptoms. Strenuous or isometric exercises and competitive and tiring sport should be discouraged. If the patient is employed, the work tasks carried out must be assessed and advice given on whether they can be continued [37]. Patients seen at the HF clinic are often deconditioned by, for example, prolonged bed rest or repeated hospitalisations. Others have been inactive because of fear of increasing symptoms or fear of exertion. These patients can possibly benefit most from exercise programs, either in a cardiac rehabilitation centre, in a hospital-based exercise program or in a home-based exercise program. Early studies have demonstrated that low-intensity home walking exercise programs for patients with stable moderate HF are safe, well accepted, and effective in improving functional status and global perception of symptoms [44–47].
However, most HF management programs do not actually involve a physical therapist, exercise physiologist or rehabilitation physician who can prescribe an appropriate exercise program and give specific recommendations regarding exercise, such as the type, duration and intensity of exercise [48].
Pending on local health care systems, the option to enrol every heart failure patient into a cardiac rehabilitation program seems not realistic. In addition to enrolling a patient into a formal rehabilitation program, physical therapists can make an important contribution to the HF team, by advising the patient about reconditioning, training and also giving practical advice on energy conservation. They also can educate other professionals in the HF team.
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7. The psychologist in HF care |
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Psychosocial factors have been demonstrated to be independently predictive of morbidity and mortality in HF patients [49]. Specifically anxiety, depression, social support and quality of life are related–independent of medical risk factors–to morbidity and mortality in patients with cardiac disease in general and also specifically in HF [50,51].
In a substudy of the Studies of Left Ventricular Dysfunction (SOLVD) trial in 5025 patients with left ventricular dysfunction, Kostam et al. [52] showed that mortality and HF hospitalizations were predicted by two quality of life dimensions, HF symptoms and the patients assessment of general health. In addition, social isolation is associated with increased risk of rehospitalization and death [53,54].
It is also known that HF patients have higher levels of depression and anxiety than other cardiac patients [55]. Depression is often overlooked in HF patients due to overlapping signs and symptoms such as apathy or fatigue [56]. In some studies depression has been associated with poorer outcomes, including decline in functional status, rehospitalization, death, and nonfatal MI in HF and in cardiac patients with low ejection fractions [57,58]. Depression is also known to be related to non-compliance and therefore can have an indirect effect on clinical outcomes.
Psychologists can play an important role in HF care, by helping patients and relatives to cope with the effects of HF and help cardiologists and HF nurses to specifically look for and identify subtle symptoms of depression in patients with HF at an early stage [59]. In a recent review, Moser critically discussed the potential reasons for infrequent assessment and treatment of psychosocial factors in HF patients by current health care providers [49]. Moser identified the following reasons: (1) inadequate dissemination of research about the link between psychosocial factors and outcomes; (2) insufficient training in heart–mind interactions that precludes clinicians from taking advantage of what is known; (3) perceived problems with interventions or with the science of heart–mind interactions that interfere with the acceptance of what is known; (4) concerns about how to measure psychosocial factors in clinical practice; and (5) lack of curiosity from clinicians about the role of psychosocial factors in their patients [49]. Increased interdisciplinary collaboration may improve acceptance of the notion of the influence of psychosocial aspects on cardiac outcomes and vice versa.
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8. Other health care providers |
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Primary care providers are key players in HF management at all stages of the disease. Patients with HF diagnosed and treated by a cardiologist in most countries represent only the tip of the iceberg, however, most of these patients will visit their GP frequently [60]. After the initial diagnosis, the primary care providers play a crucial role in the implementation of evidence based treatment and subsequent follow up [61]. Independent of the model of the HF management program, a close cooperation between primary care and the hospital team should be established.
Depending on the health care system, national/local job descriptions and responsibilities of social services, several roles can be envisioned for the social worker in a HF management program. In the study of Rich and colleagues, social services arranged appropriate post-discharge care [20,21]. Social services are often involved in identifying the various needs of the patients during the course of their chronic illness. Some HF patients also need advice on optimizing financial benefits, arranging home help, assessing what aids are needed. Supporting caregivers in their practical and emotional help of the HF patient may also be an essential role of social services.
In the complex and varied world of health care, one can image that multidisciplinary HF teams include other health care professionals. For example, when working with a pre-heart transplant population, close collaboration with transplant coordinators is quite obvious. When working with a chronic and elderly population, some HF teams involve palliative care providers, while other health care systems integrate palliative care into their home care services. Regular consultations between palliative care and the HF clinic on a patient to patient basis seem very efficient.
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9. The optimal heart failure team |
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It seems obvious that a HF management program needs to be tailored to the individual patient situation and that there is no ‘one-size-fits-all— model. Therefore, it is sometimes difficult for the health care provider in daily practice to find the optimal evidence-based model of care delivery to suit a particular patient. The decision about who should be involved in a HF management program should be driven by patient outcomes and criteria for optimal care. Table 1 presents the recommended components of a heart failure management program. Each HF clinic should establish which health care provider will be the obvious person for the specific component. Acknowledgment of professional boundaries and critical evaluation of professional and personal expertise are prerequisites for a flexible HF management structure. In the meantime more research is needed on the underlying mechanisms of a HF clinic and the multidisciplinary team (how much is really needed?) enabling us to make rational and informed choices in the future about which components of a HF management program should be expanded and which components can be removed.
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