The Heart Failure Virtual Consultation\u2009—\u2009a powerful tool for the delivery of specialist care and the democratization of knowledge in the community

Abstract

Although a declining incidence of heart failure (HF) has been reported,1 the overall prevalence of HF is growing particularly as the population ages.2 The populations affected by, and at risk of, HF are expanding, due to the increasing prevalence of HF risk factors, improved survival from myocardial infarction and improved therapies for HF. With this growth in the patient population, a rise in the rate of hospitalisations and economic costs involved is extremely likely. In the presence of limited healthcare resources, significant challenges exist in terms of optimal management of patients with HF. Ideally, HF management should be centred in primary care setting, with streamlined access to specialist cardiologist advice and services when required. There are, however, many obstacles to optimal community-based HF care, including a lack of familiarity and confidence among primary healthcare providers with implementation of guideline-recommended therapies. Moreover, the profile of HF patients is changing, such that they are progressively older with multiple co-morbidities, adding to the complexity of disease management. In addition, access to specialist cardiology services is often limited, with lengthy waiting times for outpatient-based cardiology care.3,4 A survey of general practitioners (GPs) carried out in 2014 by the National Clinical Heart Failure Programme in Ireland identified a number of barriers experienced by GPs in the delivery of HF care. Among these, lack of access to specialist advice, lack of confidence in interpreting diagnostic tests and a perceived need for further HF education were particularly prevalent (Gallagher J., personal communication). It is imperative, therefore, that systems be created which facilitate the dissemination of knowledge to the GPs who are at the coalface of HF management, as well as providing more timely access to expert HF advice and services. The availability of accurate data regarding the prevalence and incidence of HF in Ireland remains limited. A recent report estimated a national prevalence rate of 2% in the adult population (25–69 years), increasing to 10% in those aged 70 years and older.4 The Irish Healthcare System is a mixed public–private system. Approximately 40% of the population has access to free GP care but there are no structured programmes for chronic disease care in general practice apart from diabetes and asthma. All people have access to free hospital outpatient care. The use of internet-based video conferencing has the potential to revolutionise the management and care of patients with HF and other chronic diseases, by facilitating more comprehensive care delivery in the community setting. To this end, we established a ‘Heart Failure Virtual Consultation’ (HFVC) service, whereby GPs, specialist cardiologists, HF specialist nurses, and other healthcare professionals, liaise on a bi-weekly basis via a real-time web-based conferencing service, to discuss HF care both in general terms and with regard to specific patient cases. The HFVC is distinct from other eHealth initiatives in its duality of function — not only to provide appropriate healthcare intervention for individual patients, but also to act as a system of knowledge transfer to GPs.5 The HFVC forum allows the dissemination of HF specific knowledge via three pathways — specialist presentations on a HF core syllabus (CME accredited), individual patient case discussions, whereby management conundrums are outlined and specialist advice given, and group discussions regarding specific aspects of HF management. The goal of the HFVC, modelled on the US-born ECHO project, is to provide a platform for the ‘Democratization of knowledge’, i.e. the spread of specialist knowledge to healthcare providers in the community, with the aim of increasing confidence and competence in the delivery of evidence-based HF care.5 The initial study of this intervention involved hepatologists and primary care providers in the US and showed that similar outcomes in terms of sustained viral response in heptatis C treatment when patients were treated by primary care providers using web conferencing support from specialists.6 We hypothesised that the HFVC service would have the potential to benefit all three stakeholders involved — patients, GPs and HF specialists. Benefits for those patients whose cases are discussed arise through the rapid access to specialist input, without the long wait to attend the outpatient clinic and through elimination of the requirement for patient travel in many cases. The many other patients attending the participating GPs also stand to benefit, through the improved confidence and competence of the GP in question in delivering optimal evidence-based HF care. The GPs themselves benefit through the learning opportunities provided via the didactic lectures and case-based discussions, as well as through the group interactions involving other GPs. Finally, the HF specialists stand to benefit through the fostering of collegiate relationships with the community care teams, improved communication, and reduction in outpatient waiting lists with the removal of those patients who are ‘seen’ virtually. We have previously demonstrated the benefits of the HFVC model for the individual patients discussed, with reduced waiting time for specialist opinion, and reduced requirement for patient travel.7 Here, we explored the educational and self-efficacy impacts of the Virtual Consultation service on the participating GPs via interviews and a self-efficacy questionnaire. Over a defined 10 month period, 72 virtual clinics took place, 160 individual patient referrals were received, and 270 patient appointments were made in total. Baseline patient demographics are described in Table 1. Fifty GPs engaged with the clinic, with 19 returning the online questionnaire (38% response rate). Two hundred and thirty CME credits were awarded. For patients, the estimated total travel saved was 15 781 km. GPs said if the HFVC were not available they would have referred 68.75% of patients to the cardiology outpatients or emergency departments, 26.25% of patients would have had unsupervised investigation or intervention such as echocardiogram or medication titration, and 5% of GPs said they would have done nothing. On average GPs had attended 12 clinics. Of the GPs that returned the questionnaire, 92% said that the HFVC has been useful to a high degree for ‘Interpretation of laboratory values associated with HF, e.g. natriuretic peptide, renal function’, 75% said the HFVC had been useful to a ‘High degree’ for improving their pharmacological management of HF, and 75% said they now felt competent in their ‘Ability to identify suitable investigations for patients who may have HF’. However, only 42% felt competent in their ‘ability to assess and manage co-morbidities in patients with HF’. In relation to knowledge dissemination, 83% of respondents felt the HFVC was of major benefit to their ‘Enhanced knowledge about management and treatment of HF patients’, 100% said major