Antoni and Beatriu Bayés (B&B in the text), Head of Cardiology and respectively Medical Director of the University Hospital Germans Trias i Pujol (HUGTiP), in an interview made by Anna García-Altés (AGA in the text), Head of the Catalan Health System Observatory, explain their efforts of improvement for patients with heart failure and expose what direction cardiologic medicine should take for innovation.
AGA: You attended the Results Centre’s workshop in the Hospital of Sant Pau on innovative experiences in the field of cardiology. What are your views?
B&B: We believe that the initiative to hold these kind of meetings is very interesting and necessary, given that all those innovative experiences that enhance aspects of management assistance and sharing processes are essential.
AGA: What would you highlight most from this workshop?
B&B: What we’d like to highlight regarding this workshop is the transparency in the indicators’ presentation and the individual analysis that the centres’ professionals or managers have undertaken in order to justify the differences. Also we’d like to emphasize the enthusiasm in sharing those ideas and projects that have improved the indicators or that demanded courses of action towards improvement.
AGA: The Service of Cardiology of Hospital Germans Trias i Pujol has already interacted in the Observatory of Innovation in Health Management (OIGS) with a shared experience related to the calculation of risk of heart failure. Can you explain roughly this initiative?
B&B: The idea of building a death risk calculator for patients with heart failure that, in addition to the classical clinical parameters and treatment information, would also use modern biomarkers that have been demonstrated to be able to improve predictability in these patients. Once the calculator was developed a website was designed and launched (www.bcnbiohfcalculator.cat) which was opened to professionals. Then, it was decided to create an app, to facilitate the use of the calculator from a smartphone.
AGA: What would be the main advantage of applying such a tool? Can it be used in patients’ regular monitoring cases and also in emergency interventions?
B&B: The BCN Bio HF Calculator is a tool that allows calculating the risk of death probability in 1, 2 and 3 years and life expectancy in outpatients with a heart failure condition. It’s not suitable for patients in the emergency room at the moment.
The great innovation of this new calculator is that, first, a combination of various clinical variables (age, sex, NYHA functional class, estimated renal glomerular filtration, sodium, haemoglobin, and ejection fraction of the left ventricle) is used along with treatment variables (diuretics doses, treatment with statins, beta-blocks and IECA-ARA2), together with a combination of new biomarkers (ST2 reflecting the stretch, fibrosis, inflammation and myocardial remodelling, the NTproBNP reflecting the stretch of cardiomyocytes, and the highly sensitive troponin T, which reflects myocardial injury). All this significantly increases the accuracy of this tool.
AGA: Is this calculator already used throughout the Catalan health system or is it currently used only in some cases?
B&B: The BCN Bio HF Calculator is being used on a voluntary basis by a growing number of Catalan professionals. There is also an English version and one in Mandarin and is already in use in the United States and China.
AGA: What role did the OIGS play in promoting this project?
B&B: We are still working with the OIGS to facilitate incorporating this tool into all the workstations of professionals in Catalonia that may need it.
AGA: We have also been told that you are about to introduce a new experience. Do you want to tell us about it?
B&B: The new experience is an activity of care management that can prevent readmissions for heart failures. The name is CSIIC (Consulta de Suport per als pacients Ingressats per Insuficiència Cardíaca) (Advice of Support for Patients Hospitalized for Heart Failure) and is basically one more element in the development of the HF route to the Northern Metropolitan District.
The aim of CSIIC is to individually attend to all heart failure patients discharged from hospital, by a team of nurses, family doctor, internist and cardiologist. This program aims at educating the patient about the disease, drugs dose adjustment and regular visits during the first 30 days. Thereafter, the patient is sent to his GP or, depending on severity criteria, is monitored by the heart failure unit at the hospital. This experience has been ongoing for a year and has shown a 40% reduction in readmissions for heart failure.
AGA: Where do you believe that the advances in the management improvement in cardiac medicine should go next?
B&B: Progress is needed in the following directions:
- Territorial segmentation of tertiary services, so that complex patients can be treated in hospitals with experience.
- Better control and ambulatory management for chronic patients, together with teams of internal medicine and primary care, to achieve true continuum of chronic patient care.
- Increased activity of day hospitals at the expense of conventional hospitalization.
- Increased activity for semi-critical patients, for a fast and efficient drainage of the critical unit.
- Care integration of all actors involved in the management of patients with heart disease, from the GP to cardiac surgeon.
- Eventually, integrative resource management capacity: human resources, financial resources…