physicians’ perception of the patient care pathway for ... jantung negara, malaysia (ro) 10manila...

Original Article

ASEAN Heart Journalhttp://www.aseanheartjournal.org/

Vol. 22, no. 1, 99 – 111 (2014)ISSN: 2315-4551

Physicians’ Perception of the Patient Care Pathway for Acute Heart Failure in Asian Countries: Implications for Resource Allocation, Preventive Strategies and Clinical Trial Design

Elvira Zenaida Lansang, MD1, David Horsburgh1, Yun Ning Lee1, Adeline Sng,1 Ralph Moussalli, MSc1, KarenWai, MBBCh, MBA1, Inder Anand, MD, PhD, FRCP2, Shu Zhang, MD, PhD, FHRS3, Wataru Shimizu, MD, PhD, FJCC4, Calambur Narasimhan, MD, DM, AB5, Sang Weon Park, MD, PhD6, Cheuk-man Yu, MD, FRCP, FACC7, Tachapong Ngarmukos, MD8, Razali Omar, MBBS, M.MED, FHRS9, Eugene B. Reyes, MD, FPCP, FPCC10, Bambang Budi Siswanto, MD, PhD11, Arthur Mark Richards, MD, PhD, FRACP, FRCP, FRSNZ12, Carolyn S.P. Lam, MBBS, MRCP, MS12

1Quintiles East Asia Singapore (EZL, DH, YNL, AS, RM, KW)2VA Medical Center, Minneapolis, MN, USA (ISA)3Fuwai Hospital, China (SZ) 4National Cerebral and Cardiovascular Center and Nippon Medical School, Japan (WS)5CARE Hospital, India (CN) 6Korea University Anam Hospital, Korea (SWP)7Prince of Wales Hospital, The Chinese University of Hong Kong (CMY)8Ramathibodi Hospital, Mahidol University, Thailand (TN)9Institut Jantung Negara, Malaysia (RO)10Manila Doctors Hospital, Philippines (EBR) 11National Cardiovascular Center University Indonesia Jakarta (BBS)12Cardiovascular Research Institute, Singapore (CSL, AMR)

© The Aurthor(s) 2014. This article is published with open access by ASEAN Federation of Cardiology.

99

ABSTRACTBackground Heart failure (HF) is a growing epidemic in Asia. However, data are scarce regarding the patient care pathway of HF in Asia. We aimed to investigate the HF patient pathways in Asia using a questionnaire-based survey. Methods and ResultsSeventy physicians in 12 Asian countries were surveyed using standardized questionnaires regarding patient source, precipitating factors, clinical presentation, referral pattern, and discharge plans for patients with Acute Heart Failure (AHF). Direct self-referral was reported as the most common source of admission. Majority (70%) of patients presented at the emergency department for worsening of chronic HF, with acute coronary syndrome being the most common precipitating factor, and acute pulmonary edema the most common presentation. Patients spent an average of 10 hours in the Emergency Department and majority were admitted to Cardiology Wards. HF with reduced ejection fraction (HFrEF) were the majority of cases except in Hong Kong and Japan. Most patients were discharged home and only 13-15% were enrolled in outpatient HF programs.

ConclusionThis survey highlights the heterogeneity of AHF patient pathways in Asian countries. These fi ndings underscore the need for prospective studies to validate physicians’ reports, evaluate these differences and guide resource allocation and design of AHF clinical trials.

KEYWORDScardiovascular, emergency, congestive, referral

Correspondence to: Carolyn S.P. Lam, MBBS, MRCP, MS National University Health System Tower Block Level 9 1E Kent Ridge Road Singapore 119228 Tel: +65-6779-5555 Fax: +65-6872-2998 E-mail: [email protected]

DOI 10.7603/s40602-014-0015-z

ASEAN Heart Journal Vol. 22, no.1, 99-111 (2014) Lansang et. al.

100

INTRODUCTION Heart failure (HF) is a major public health issue and a leading cause of morbidity and mortality worldwide.1,2 In 2010, an estimated 41 million people were living with HF, a 14% increase since 1990.3 It affects about 2% of Western populations, with a marked increase in prevalence with increasing age.4 In Asia, HF is becoming a similarly major health concern. Limited data suggest that HF prevalence in Asia is estimated to be in the range of 1.26% among adults5 and as high as 4.5% in the elderly.1,6 One of the potential reasons for the increase in prevalence is rapid economic growth, and the shift towards urban lifestyles. This epidemiological transition leads to rising numbers of Asians developing diabetes, metabolic syndrome, obesity and hypertension contributing to the increased incidence of cardiovascular diseases (CVD), and subsequently HF, a fi nal common pathway for multiple forms of CVD.1,7

A patient care pathway is defi ned as the referral pathway from a patient’s fi rst consult with a healthcare provider to the time that they receive the most appropriate treatment.8 In the context of hospitalized acute HF (AHF), the care pathway begins during the patient’s consult at the Emergency Department (ED) and ends once they have received appropriate treatment and are discharged. Patient registries remain an important source of real-world data to help understand the patient care pathway for AHF. Several AHF registries exist, most involving the Western population.9-17 A comparison of these registries showed that there are regional and country differences in demographics and mode of presentation of HF. The ADHERE International –

Asia Pacifi c registry demonstrated that AHF patients, particularly those from the Philippines, Malaysia and Indonesia tend to be younger, and present with more severe signs and symptoms when compared with other multicenter international registries.10 The swift increase in CVD burden, including HF in low and middle income countries such as the Philippines, Malaysia and Indonesia may be due to socio-economic changes, increase in lifespan, and acquisition of lifestyle related risk factors.18 On the other hand, the ATTEND registry, the largest study of hospitalized HF patients in Japan showed that most Japanese AHF patients with new onset HF are elderly.16 This is evidence of the heterogeneity of the Asian population, and the need to explore differences in HF presentation, etiology, and outcomes within Asian countries.

An analysis of the causes of death and re-hospitalization of HF patients in the EVEREST program involving hospitals in North America, South America, and Europe showed that despite predefi ned inclusion/ exclusion criteria, there are major regional differences in the severity, etiology, management and outcomes of AHF patients in international clinical trials.19,20 Because of the limited number of HF registries in Asia, there is a paucity of data on the clinical presentation, precipitating factors, referral pattern, length of hospital stay, and outcome of AHF. Against this background, we initiated a questionnaire-based survey

to better understand the patient care pathway for AHF in Asia. Insights into the AHF patient care pathway may have implications for resource allocation, preventive strategies and design of future HF clinical trials. METHODS

A questionnaire-based survey was designed to investigate the patient care pathway for AHF in Asia. The survey was a combination of closed and open-ended questions aimed to characterize the journey of patients with acute HF from their presentation to the hospital until the time they are discharged. The survey captured information on the: • Source of patient’s referral and the referral pattern within the hospital • Precipitating factors and overall clinical status at presentation at the ED • Discharge Plans, in-patient mortality and 30 day re-hospitalization rates

During December 2013 to February 2014, a survey (see Supplementary Data) in English was sent to physicians involved in the care and diagnosis of AHF located in 12 Asian countries – China, Hong Kong, India, Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam. The study included a broad spectrum of hospitals with different ranges of facilities for cardiology, located across Asia. The number of physicians contacted in each country was based on the number of inhabitants from that country.21 Anticipated distribution was approximately 1 physician per 8 million people, but no more than 25 and no less than 5 physicians per country. Convenience sampling was performed to identify physicians for inclusion in the survey from Quintiles’ internal database of physicians with cardiovascular clinical or clinical trial experience. All physicians were experienced in diagnosing and treating patients with AHF who are admitted to a hospital. Respondents were requested to consider the patient care pathway for their institution. The survey forms were sent by email or mailed directly to physicians at the hospitals. Appropriate telephone and email follow ups were made to encourage return of completed surveys.

Answers were based on each physician’s perception and view on how AHF patients presented at the emergency department, how they were initially diagnosed, which specialties were involved in the management, and the referral pattern. In February 2014, the responses from the completed survey forms were entered into ClickTools®, a web-based central repository. A descriptive data analysis was performed.

AbbreviationsHF – Heart Failure; AHF – Acute Heart Failure; HFrEF – Heart Failure reduced Ejection Fraction; CVD – Cardiovascular Diseases; ED – Emergency Department; GP – General Practitioner; ACS – Acute Coronary Syndrome; LVEF – Left Ventricular Ejection Fraction; HFpEF - Heart Failure preserved Ejection Fraction; N=Number


101

RESULTS

Two hundred physicians were sent surveys across 12 Asian countries. Thirty-fi ve percent (70/200) returned the surveys. Responders and non-responders were similar in terms of type of specialty and affi liation to academic versus non-academic institutions. All responders were located in urban areas. Majority of the physicians who participated in the survey identifi ed themselves as cardiologists or cardiologist with a special interest in HF (Table 1A and 1B).

Source of patients

The survey sought clarifi cation on where patients with HF come from. Direct self-referral was the most common source of admission. Only 35% of patients admitted were directly referred from other hospitals or General Practitioners (GP). Other sources were referrals from other departments or specialist outpatient clinics (Figure1).

Clinical presentation and precipitating factors

The majority (70%) of patients presented at the ED due to worsening of an existing condition (acute on chronic HF). Thirty percent (30%) had new-onset HF. Acute coronary syndrome (ACS) was the most commonly cited precipitating factor in patients with HF at presentation. AHF patients were most likely to present at the ED with acute pulmonary edema. (Figure 2A and 2B).

Patient journey

Overall, patients with AHF were estimated to spend an average of 10 hours in the ED before being admitted to hospital. Signifi cant variability was seen among countries, with those in Japan and India staying for only 2 hours, while those in China and Taiwan extending for as long as 18-25 hours. 38% of patients were discharged directly from the ED. Of those who were admitted, the most common in-hospital location was the cardiology ward (38%) followed by the coronary care unit (28%) and the intensive care unit (15%). The average estimated length of stay was 10 days and the estimated in-hospital death rate was 8%. The vast majority of patients (75%) were discharged to their homes, with only 13-15% enrolled in a dedicated outpatient HF program and only 3-5% transferred to a rehabilitation center.

HF with preserved versus reduced ejection fraction (HFpEF versus HFrEF)

Figure3A shows that the cut-off values for classifying HF as preserved or reduced EF varies across and within countries. Across Asia, majority (44%) of physicians use LVEF > 50% to distinguish between the two. Furthermore, a higher percentage of patients with Heart Failure Reduced Ejection Fraction (HFrEF = 70%) at the ER are admitted, as opposed to only half of those with Heart Failure Preserved Ejection Fraction (HFpEF). Physicians were also asked to estimate the percentage of patients that have HFpEF versus HFrEF.

Median estimates are displayed in Figure 3B. Except for Hong Kong and Japan, majority of patients had HFrEF.

Generally, there were similar trends observed in the length of stay and hospital course of HFpEF and HFrEF. A higher percentage of patients with HFrEF spent time in coronary care units and intensive care units. (Figure 4).

For HFpEF and HFrEF, general cardiologists made the initial diagnosis for most patients (Figure 5A). Furthermore, the majority of patients for both types of HF were treated by the same physician, even if symptoms remain uncontrolled (HFpEF = 62%, HFrEF = 55%). At discharge, the overall proportions of patients sent home, transferred to another hospital or rehabilitation center or entered into an outpatient HF program were similar for HFpEF and HFrEF, except for a slightly greater estimated proportion of HFrEF being enrolled in an outpatient HF program (Figure 5B). Inter-country differences exist, with more than 25% of patients discharged from Singapore, South Korea and Thailand enrolled into a HF program. In-patient mortality and 30 day re-hospitalization rates were estimated to be slightly higher for HFrEF than HFpEF (Figure 5C). DISCUSSION

This is the fi rst multi-national questionnaire-based survey regarding AHF patient care pathways in Asia. Previous HF registries did not include information on the source of referral of AHF patients presenting to the ED. Asian physicians reported that almost a third of AHF presentations at the ED were direct self-referrals/ “walk-in” consults, with 70% due to worsening of pre-existing HF (acute on chronic HF). The rapid onset of signs and symptoms in acute pulmonary edema, availability of direct access to EDs and relative lack of outpatient HF program management may be explanations for the high proportion of direct self-referrals to the ED in Asia.22

ACS and myocardial ischemia were reported as the most common precipitating factors of AHF in Asia. Similar results from the OPTIMIZE-HF registry in the United States showed that myocardial ischemia was among the most frequent precipitating causes of HF.23 A review of epidemiologic data concerning Asians was also consistent, with ACS as a precipitating factor for 28-53% of AHF.1,10 Similar to the West,24 hypertension was identifi ed as a common underlying cause of HF with uncontrolled hypertension being the second most common clinical status at presentation in Japan. Uncontrolled hypertension among Japanese AHF patients may be explained by the high salt intake and aging population.

There was remarkable variability in the estimated time patients spent in the ED across Asia. Patients in Japan and India were estimated to stay in the ED for only 2 hours, while those in China and Taiwan stayed for as long as18-25 hours. A lack of ED resources and the absence of an effi cient Observation Unit (OU) in the hospital are possible


102

reasons for the large variation in ED waiting times in Asia. Hospitals in Taiwan25 and Hong Kong26 reported longer waiting times due to lack of human resources and increased patient demand. Furthermore, a study comparing operational characteristics in ED observation units in the US and Asia27 showed that more effi cient operations may be related to greater experience and the availability of more advanced diagnostic and ancillary and consultant services. The concept of a dedicated OU emerged in the US approximately 30 years ago, but it is unclear when this began in Asia.27 Only 36% of the survey respondents reported that patients stayed in an OU. The signifi cant amount of time spent in the ED represents an important period where symptoms and signs of AHF are typically most severe, and timely therapeutic management may correlate with rapid improvement.28 Increasing evidence suggests that mortality can be reduced if patients are rapidly and accurately assessed in the ED, with prompt introduction of proper management.29 Furthermore, in countries such as Indonesia, Philippines and Hong Kong, 50-75% of the initial diagnosis is made by the internists, together with cardiologists and ED physicians. Collaboration between the ED, internal medicine and cardiology departments is therefore needed to improve early care pathways and facilitate patient enrollment in clinical trials targeting early treatment in AHF.30

It is widely recognized that HF exists in two forms – HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).4,31 While HFpEF is known to constitute half of the HF population in Western populations, the prevalence of HFpEF in Asian population is unknown. Our survey revealed that HFrEF was by far the predominant form of AHF presenting to cardiology centres in Asia. Among the 12 countries surveyed, HFpEF was reported to be common in only Hong Kong (55%) and Japan (50%), consistent with the fi ndings in United States. Among Asian countries surveyed, Japan and Hong Kong also have the highest proportions of elderly in their populations, comparable to Western countries such as Germany and the United States.32 Owan et al and Borlaug et al have reported that the prevalence of HFpEF relative to HFrEF in the US is rising at approximately 1% per year, with HFpEF rapidly becoming the most common HF type.33, 34 The diversity across Asia may refl ect different stages in epidemiologic transition, and it is possible that as Asian societies age a similar trend may be observed in the future. We also found either a relative lack of or under-utilization of outpatient HF programs in Asia – less than 1 in 6 AHF patients discharged from the hospital were enrolled in an outpatient HF program. Previous studies have demonstrated the benefi t of outpatient HF programs in reducing unplanned re-hospitalization rates. A home-based intervention program for HF patients discharged from the hospital showed that a single visit by a nurse or pharmacist to optimize medication management, identify early clinical deterioration and intensify medical follow up as appropriate led to fewer unplanned readmissions and lesser duration

of re-hospitalization.35 In Taiwan, discharged patients enrolled into a HF self-care program had improved HF symptoms, increased functional status and better quality of life.36 In another study, anxiety and low social support were independently associated with HF-related re-admission.37

These data suggest that the development of dedicated outpatient HF programs in Asia may be a particularly worthwhile priority for resource allocation.

LIMITATIONS

These fi ndings carry the inherent limitations of reporting and participation bias of all voluntary questionnaire-based surveys. As such, the fi ndings should be viewed as exploratory, rather than conclusive. The survey was not validated and results are based only on physician perception and understanding of the patient referral pathway of AHF at their institutions. Physicians were selected from an internal database and were located in urban areas. The patient care pathway in rural centers may be different and needs to be explored further. The 65% overall non-response rate and low participation among emergency room physicians/ geriatricians who are the fi rst point of contact for many patients is another limitation. Nonetheless, this is the fi rst to survey a diverse group of physicians from a wide geography where published data regarding the AHF patient pathway are very scarce. Due to limitations in resources, countries with particularly challenging constraints upon health services including Myanmar, Laos and Cambodia were not included in this survey. Nevertheless, our results highlight the diversity across regions in Asia, and support an urgent call for prospective studies. The importance of understanding these differences when planning global AHF trials is demonstrated in the EVEREST trial, where despite similar inclusion/ exclusion criteria, protocol completion and clinical trial outcomes differed across different geographic regions, potentially impacting response to investigational therapies.38, 39

CONCLUSION

Our questionnaire-based survey demonstrates the heterogeneity of the AHF patient pathway in Asia. These fi ndings underscore the need for prospective studies to evaluate these differences and guide resource allocation, preventive efforts and design of AHF clinical trials in Asia.

ACKNOWLEDGEMENTS

The authors would like to thank Quintiles team members across the region that helped reach out to physicians to complete the survey, particularly NaRae Baek, Evangeline Costelo, Liling Chen, Audrey Ho, Ariel Hsu, Eric Nam, Tamaki Ogino,Yi Chin Ong, Hung Pham, Manish Thadhani, Piyanuch Tiativiriyakul, Vivien Tien, Henu Tonang, Suqiong Wang, Carrie Wong, Qing Zhang; and Lixia Zhang for administrative support.


103

CONFLICT OF INTEREST

CSL is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; serves as a Consultant for Novartis and Bayer and as a member of the clinical endpoints committee for DC Devices; and receives research grants from Boston Scientifi c, Medtronic and Vifor Pharma. DH, YNL, AS, RM, and KW are employees of Quintiles East Asia Pte Ltd. EZL is a former employee

of Quintiles East Asia Pte Ltd. DH, YNL, AS, RM, KW and EZL have not received any additional payment from Quintiles for the conduct of this research.

FUNDING

This work was supported in part by National University Health System, Singapore (Contract No. YWA21152).

Country Number of

Physicians

Contacted

Number of Survey

Responses Received

Response Rate

China 30 9 30%

Hong Kong 12 2 17%

India 26 11 42%

Indonesia 29 5 17%

Japan 9 9 100%

Malaysia 10 3 30%

Philippines 29 7 24%

Singapore 10 3 30%

South Korea 8 8 100%

Taiwan 12 3 25%

Thailand 8 4 50%

Vietnam 17 6 35%

Total 200 70 35%

TABLES

Table 1A. Survey response rates


104

FIGURES

Table 1B. Specialties of the 70 physician responders*

Specialty* N Percentage

Cardiologist with an interest in heart

failure

37

53%

Cardiologist 34 49%

Internist (Internal Medicine) 6 9%

Interventional Cardiologist 3 4%

Geriatrician 2 3%

Emergency Room Physician 1 1%

Electrophysiologist 1 1%

*A physician may have more than one medical specialty.


FIGURE LEGENDS

Figure 2

* Other for Figure 2A includes congenital heart disease, valvular heart disease, and infl ammation. * Other for Figure 2B includes arrhythmia, hypervolemia after surgery, thyrotoxicosis, valvular heart disease.**Each patient may have more than one precipitating factor or clinical status identifi ed at presentation.

105


106


107

Open Access: This article is distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0) which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

REFERENCES

1. Sakata Y, Shimokawa H. Epidemiology of HF in Asia. Circ J 2013;77:2209-2217.

2. Mosterd A, Hoes AW. Clinical epidemiology of HF. Heart 2007;93:1137-1146.

3. Forouzanfar MH, Moran A, Phillips D, Mensah G, Ezzati M, Naghavi M, et al. Prevalence of HF by cause in 21 regions: global burden of diseases, injuries and risk factors – 2010 Study. J Am Coll Cardiol 2013;61(10_S).

4. Lam CSP, Donal E, Krainer EK, Vasan RS. Epidemiology and clinical course of HF with preserved ejection fraction. Eur J Heart Fail 2011;13(1):18-28.

5. Yang YN, Ma YT, Liu F, Li XM, Huang Y, Tang Q, et al. Incidence and distributing feature of chronic heart failure in adult population of Xinjiang. Zhonghua Xin Xue Guan Bing Za Zhi. 2010:38(5):460-4.

6. Ng TP, Niti M. Trends and ethnic differences in hospital admissions and mortality for congestive heart failure in the elderly in Singapore, 1991 to 1998. Heart. 2003;89:865-870.

7. Lee S, Khurana R, Leong KTG. Heart failure in Asia: the present reality and future challenges. Eur Heart J Suppl 2012;14(suppl A):A51-A52.

8. Lansang EZ, Tang V, Ranade S, Caveney E, Ng N, Saldanha LM, et al. The patient care pathway for type 2 diabetes mellitus in Asian countries: implications on target physician group for diabetes clinical trials. J Diabetes Metab 2014;5:331.

9. Adams KF Jr., Fonarow GC, Emerman CL, LeJemtel TH, Constanzo MR, Abraham WT, et al. Characteristics and outcomes of patients hospitalized for HF in the United States: rationale, design, and preliminary observations from the fi rst 100,000 cases in the acute decompensated HF national registry (ADHERE). Am Heart J 2005;149(2):209-216.

10. Atherton JJ, Hayward CS, Ahmad WAW, Kwok B, Jorge J, Hernandez AF, et al. Patient characteristics from a regional multicenter database of acute decompensated HF in Asia Pacifi c (ADHERE International – Asia Pacifi c). J Card Fail 2012;18(1):82-88.

11. Maggioni AP, Dahlstrom U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObervational research programme: the HF pilot survey (ESC-HF Pilot). Eur J Heart Fail 2010;12(10):1076-1084.

12. Zannad F, Mebazaa A, Juilliere Y, Cohen-Solal A, Guize L, Alla F, et al. Clinical profi le, contemporary management and one-year mortality in patients with severe acute HF syndromes: the EFICA study. Eur J Heart Fail 2006;8:697-705.


108

13. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute HF patients: description of population. Eur Heart J 2006;27:2725-2736.

14. Spinar J, Parenica J, Vitovec J, Widimsky P, Linhart A, Fedorco M, et al. Baseline characteristics and hospital mortality in the acute HF database (AHEAD) main registry. Crit Care 2011;15:1-13.

15. Hamaguchi S, Kinugawa S, Tsuchihashi-Makaya M, Goto K, Yamada S, Yokoshita A, et al. Loop diuretic use at discharge is associated with adverse outcomes in hospitalized patients with HF: a report from the Japanese cardiac registry of HF in cardiology (JCARE-CARD). Circ J 2012;76:1920-1927.

16. Sato N, Kajimoto K, Keida T, Mizuno M, Minami Y, Yumino D, et al. Clinical features and outcome in hospitalized HF in Japan (from the ATTEND registry). Circ J 2013;77:944-951.

17. Youn YJ, Yoo BS, Lee JW, Kim JY, Han SW, Jeon ES, et al. Treatment performance measures affect clinical outcomes in patients with acute systolic failure: report from the Korean Heart Failure Registry. Circ J 2012;76:1151-1158.

18. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle- income countries. Curr Probl Cardiol. 2010:35(2):72-115.

19. Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M, et al. The global health and economic burden of hospitalizations for HF: lessons learned from AHF registries. J Am Coll Cardiol. doi:10.1016/j.jacc.2013.11.053. Published online ahead of print 27 January 2014.

20. O’Connor CM, Miller AB, Blair JEA, Konstam MA, Wedge P, Bahit MC, et al. Causes of death and rehospitalization in patients hospitalized with worsening HF and reduced left ventricular ejection fraction: results from effi cacy of vasopressin antagonism in HF outcome study with tolvaptan (EVEREST) program. Am Heart J 2010;159:841-849.

21. Maggioni AP, Dahlstorm U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObservational research programme: regional differences and 1-year follow-up results of the HF pilot survey (ESC-HF Pilot). Eur J Heart Fail 2013;15:808-817.

22. Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. Executive summary of the guidelines on the diagnosis and treatment of acute HF. Eur Heart J 2005;26:384-416.

23. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Factors identifi ed as precipitating hospital admissions for HF and clinical outcomes: fi ndings from OPTIMIZE – HF. Arch Intern Med 2008;168:847-854.

24. Kannel WB, Gordon T. Evaluation of cardiovascular risk in the elderly: the Framingham study. Bull N Y Acad Med 1978;54:573-591.

25. Patients overly reliant on emergency services: NHIA. Taipei Times. 2014 Apr 7; p 3.

26. Rainer T. Why are Hong Kong’s emergency departments so understaffed? Emergency Physicians international. Issue 11.

27. Komindr A, Baugh CW, Grossman SA, Bohan JS. Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia. International Journal of Emergency Medicine 2014; 7:1-8.

28. Teerklink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomized, placebo-controlled trial. Lancet 2013;381:29-39.

29. Cowie M, Bell D, Butler J, Dargie H, Gray A, McDonagh T, et al. Acute heart failure – a call to action. Br J Cardiol 2013;20(suppl 2):S1-S11.

30. Collins SP, Levy PD, Pang PS, Gheorghiade M. The role of the emergency department in acute HF clinical trials – enriching patient identifi cation and enrollment. Am Heart J 2013;165:902-909.

31. Chatterjee K, Massie B. Systolic and diastolic HF: differences and similarities. J Card Fail 2007;13:569-576.

32. Data.worldbank.org [homepage on the Internet]. Available from: http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS/countries?display=default/. Accessed April 25, 2014.

33. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfi eld MM. Trends in prevalence and outcome of HF with preserved ejection fraction. N Engl J Med 2006;335:251-259.

34. Borlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J; doi:10.1093/eurheartj/ehq426. Published online ahead of print 7 December 2010

35. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive HF discharged from acute hospital care. Arch Intern Med 1998;158:1067-1072.

36. Wang SP, Lin LC, Lee CM, Wu, SC. Effectiveness of a self-care program in improving symptom distress and quality of life in congestive HF patients: a preliminary study. J Nurs Res 2011:19:257-266.

37. Makaya MT, Kato N, Chishaki A, Takeshita A, Tsutsui H. Anxiety and poor society support are independently associated with adverse outcomes in patients with mild HF. Circ J 2009;73:280-287.

38. Blair JEA, Zannad F, Konstam MA, Cook T, Traver B, Burnett JC Jr, et al. Continental differences in clinical characteristics, management, and outcomes in patients hospitalized with worsening HF. J Am Coll Cardiol 2008;52:1640-1648.

39. Butler J, Subacius H, Vaduganathan M, Fonarow GC, Ambrosy AP, Konstam MA, et al. Relationship between clinical trial site enrollment with participant characteristics, protocol completion and, outcomes. J Am Coll Cardiol 2013;61:571-579.


109

PHYSICIAN CONTACT, SPECIALTY AND PRACTICE INFORMATION Title: First Name: Last/Family Name:

Institution/Practice Name: Department:

Address:

Town/City: State/County/Province:

ZIP/Postcode: Country:

Phone: Fax: Mobile/Cell:

Email:

Medical or Surgicalspecialty

Internist (Internal Medicine) Cardiologist (General) Cardiologist with an interest in Heart Failure

Cardiac Surgeon

Geriatrician Emergency Room Physician Pulmonologist Nephrologist Other: _____________________

Practice setting University Hospital General Hospital – Public General Hospital – Private

Medical Center Specialty Centers Other – please specify:

Academic Or Non-academic hospital

Academic Hospital (affiliated with a medical school or a teaching hospital for residents/ fellows)

Non-academic Hospital 2 How many acute heart failure patients are admitted at your hospital per month? ______________ 3 Where do these patients come from (i.e. where is the point of first medical contact for the patient)?

Please select all applicable choices, and provide percentage (Total must equal 100%.) Direct self-referral (“walk-in”) Ambulance-directed from home Referral from GP Referral from another hospital Other, please specify

_____% _____% _____% _____% _____%

4 What is the heart failure (HF) status at presentation? Please provide the percentage (Total must equal 100%)

New onset Worsening of chronic condition

_____% _____%

5 What is/are the precipitating factor(s) in patients with HF at presentation? Please select all applicable choices, and provide percentage

acute coronary syndrome (ACS) ___% myocardial ischemia ___% atrial fibrillation ___% infection ___% bradyarrhythmia ___% ventricular arrhythmia ___%

iatrogenic ___% uncontrolled hypertension ___% renal dysfunction ___% anemia ___% non-cardiac (please specify)__________ ___% others (please specify) ______________ ___%

Survey for Understanding the Patient Referral Pathway for Hospitalized Acute Heart Failure in Asia


110

acute pulmonary edema ___% decompensated HF ___% hypertensive HF ___% predominant right HF ___%

ACS/HF ___% predominant cardiorenal syndrome (potentially requiring dialysis) ___% cardiogenic shock ___% other, please specify: ___%

7 What criteria do you use to distinguish between HF preserved ejection fraction (HFpEF) and HF reduced EF (HFrEF)? Please select only one

LVEF≥35% LVEF≥40% LVEF≥45% LVEF≥50% LVEF≥55%

**Note: For the succeeding questions, please provide separate responses for HFpEF & HFrEF.**

8 When evaluating acute heart failure patients at the ER, what signs/ symptoms/ laboratory results would warrant hospital admission? HFpEF _______________________________________________________________________ ____________________________________________________________________________________ HFrEF _______________________________________________________________________ ____________________________________________________________________________________

9 What percentage of heart failure patients seen at the ER get admitted? HFpEF ___% HFrEF ___%

10 Where do patients get admitted? HFpEF Note: (Total = 100%)

HFrEF Note: (Total = 100%)

Observational unit ___% ___% General Medical Ward ___% ___% Cardiology Ward ___% ___% Coronary Care Unit ___% ___% Intensive Care Unit ___% ___% Other ____________ ___% ___%

11 Please estimate the time an admitted acute heart failure patient stays in your hospital before being discharged. HFpEF HFrEF ER ___ hours ___ hours Observational Ward (ward where patient is observed but not admitted to the hospital)

___ days ___ days

Hospital Ward ___ days ___ days Coronary Care/ Intensive Care Unit ___ days ___ days

Other, please specify_________ ___ days

___ days

6 What is the overall clinical status at presentation? Please select all applicable choices, and provide percentage.


111

12 PATIENT REFERRAL PATHWAY FOR HOSPITALIZED ACUTE HEART FAILURE / ACUTE HEART FAILURE ON TOP OF CHRONIC HEART FAILURE

*Physician Categories:

1. Internist (Internal Medicine) 5. Geriatrician 9. Nephrologist 2. Cardiologist (General) 6. Emergency Room Physician 10. Other, please specify

________________________________ 3. Cardiologist with an interest in heart failure 7. Pulmonologist 4. Cardiac surgeon 8. Hepatologist

a. What percentage of your hospitalized acute heart

failure patients belong to each category (Note: total

percentage must be = to 100%).

b. How do you describe the care you provide for the patients?

Please choose the best option: Option 1 - I am directly involved in the investigation & treatment management of the patient. Option 2. I am a consulting physician (ie consulting on management).

c. Who would typically make the initial diagnosis of

each category?

Please indicate physician category*

d. Does the physician who treats the patient change when there is disease progression (ie symptoms remain uncontrolled) occurs?

e. If yes to (d), please comment on physician referral pathway which occurs with disease progression

When referral occurs

f. Would the patient be referred back to the initial doctor managing the care?

Physician referred to

Please indicate

physician category

When referral occurs

If yes, when would this occur?

HFpEF ____ (%) Yes No Yes No When? ___________

HFrEF ____ (%) Yes No Yes No When? ___________

13 When is a patient deemed fit for discharge (signs/ symptoms/ laboratory results)? HFpEF _______________________________________________________________________ ____________________________________________________________________________________ HFrEF _______________________________________________________________________ ____________________________________________________________________________________

14 Where is the patient discharged to?

HFpEF

(Note: Total = 100%) HFrEF

(Note: Total = 100%) Transfer to another hospital ___% ___% Return home ___% ___% Rehabilitation center ___% ___% Outpatient heart failure program ___% ___%

15 What is the in-hospital mortality rate? HFpEF ___% HFrEF ___%

16 What is the rehospitalisation rate in 1 month (30 days)?

HFpEF ___% HFrEF ___%

17 Do you follow any hospital/ national or international guidelines for the management of Heart Failure?

Yes No

18 If yes, please provide name

19 Would you like to receive a copy of the results of this survey?

Yes No

Thank you for taking the time to complete this questionnaire.

physicians’ perception of the patient care pathway for ... jantung negara, malaysia (ro) 10manila...

Documents