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Faculty of Health, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, CanadaKITE- Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON, M5G 2A2, Canada
Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON M5T 3M6, CanadaToronto General Research Institute, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada
Ted Rogers Centre for Heart Research, 661 University Ave, Toronto, ON M5G 1X8, CanadaPeter Munk Cardiac Centre, University Health Network, University of Toronto, 550 University Ave, Toronto, ON, M5G 2A2, Canada
Ontario Health-CorHealth Ontario, 4100 Yonge St, North York, ON M2P 2B5 CanadaMcMaster University, School of Nursing, 1280 Main Street West, Hamilton, ON, L8S 4L8
Corresponding author: Sherry L. Grace, PhD, FCCS, CRFC; Professor, Faculty of Health, York University – Bethune 368, 4700 Keele Street, Toronto, ON M3J 1P3, Canada. , Phone: (416) 736-2100 x.22364; Twitter
Affiliations
Faculty of Health, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, CanadaKITE- Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON, M5G 2A2, CanadaPeter Munk Cardiac Centre, University Health Network, University of Toronto, 550 University Ave, Toronto, ON, M5G 2A2, CanadaTemerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON M5S 1A8 Canada
Though heart failure patients benefit from multidisciplinary care in heart function clinics (HFC), utilization is suboptimal and inequitable. This study investigated factors influencing referral and patient access to HFCs from multiple stakeholders’ perspectives, namely policy-makers (PM), providers at HFCs and patients.
Methods
In this qualitative study, semi-structured interviews with a purposive sample of Ontario stakeholders were conducted between February-June 2020 and July-December 2022 (paused due to pandemic) via Teams. Interview transcripts were concurrently analyzed using systematic text condensation with Nvivo. Two authors coded individually, with disagreements discussed with senior author.
Results
Interviews with 7 HFC (6 physicians, 1 nurse), 6 PM and 4 patients were completed before saturation; five themes emerged. First, with regard to health system organization, stakeholders reported gaps related to continuity of care, limited capacity and insufficient funding. Second, with regard to referral appropriateness and timeliness, sub-themes related to unclear referral criteria, varying clinic scope, and delays in triage, testing and time-to-visit. The third theme related to clinic characteristics, raised issues of varying clinic services and composition of healthcare professions/expertise. The fourth theme regarding patient factors related to comorbidity/frailty, socioeconomic status, barriers due to location (parking, traffic) and affinity to specific providers. The final theme related to the COVID-19 pandemic concerned increased referral volumes, loss to follow-up care, transition to online delivery modalities and patient refusal of in-person visits. Many facilitators to improve HFC referral and access were raised.
Conclusions
Resources must be provided, and stakeholders brought together to standardize and integrate the HF care continuum.
Heart failure in Canada complex incurable and on the rise. Heart and Stroke Foundation of Canada. Accessed October 12, 2022. https://www.heartandstroke.ca/en/what-we-do/media-centre/news-releases/heart-failure-in-canada-complex-incurable-and-on-the-rise/
. As in other high-income countries, despite advancements in pharmacologic and device therapies, the epidemic of HF is rising alarmingly, with mortality and readmission rates alarmingly high
How Canada Is Failing People with Heart Failure - and How We Can Change That. 2022 Spotlight on Heart Failure. Heart and Stroke Foundation of Canada; 2022. Accessed October 10, 2022. https://heartstrokeprod.azureedge.net/-/media/pdf-files/canada/2022-heart-month/hs-heart-failure-report-2022-final.ashx?la=en&rev=245159ea1726419aaa6f71ae9e7692f3
. Given there is no cure, secondary prevention is the goal; clinical guideline recommendations to reduce disease progression and optimize quality of life are many
Chronic Heart Failure in Adults: Quality Standard. NICE National Institute for Health and Excellence; 2021. Accessed October 10, 2022. www.nice.org.uk/guidance/qs9
. However, it is challenging for providers to achieve optimal medical therapy for many reasons, including contraindications to therapy, dynamic changes in the clinical status of patients, comorbidities, and inertia
Assessment of Limitations to Optimization of Guideline-Directed Medical Therapy in Heart Failure From the GUIDE-IT Trial: A Secondary Analysis of a Randomized Clinical Trial.
. Moreover, it is challenging for patients to achieve optimal self-management as it requires sustained health behavior changes (e.g., daily medication adherence, weighing, diet, exercise, and symptom monitoring), which must be implemented in the context of psychosocial, cultural, environmental and economic barriers.
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
, heart function clinics (HFCs) are comprehensive outpatient disease management clinics facilitating rapid care access to prevent acute decompensation, staffed by a multidisciplinary team of sub-specialists
Health Quality Ontario. Heart Failure Care in the Community for Adults. CorHealth Ontario; 2022. Accessed October 10, 2022. https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-heart-failure-quality-standard-en.pdf
AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
. HFCs provide assessment, patient education on self-management skills, medication optimization, and follow-up as needed. Some clinics are more specific to assessment for devices or advanced transplantation candidacy for example. HFCs have been shown to reduce HF-related mortality by 10-15%, HF-related hospitalizations by 30-56% and all-cause readmissions by 15-25%
. Therefore, guidelines from major cardiac societies globally recommend referral to these clinics, although there is no consensus in referral criteria regarding which patients would be best served
. There are issues related to referral (i.e., action required on behalf of healthcare providers and clinics) and access (i.e., action required by patient to go to appointments) that impede optimal use of these services. These challenges were exacerbated by the COVID-19 pandemic, when access to cardiac care was significantly reduced
Canadian Cardiovascular Society. Challenges and Opportunities: Cardiovascular Care and COVID-19. Canadian Cardiovascular Society Accessed October 13, 2022. https://ccs.ca/app/uploads/2022/04/CanadianCardiovascularSociety-e.pdf
Heart and Stroke Foundation of Canada. New survey reveals concern for people with heart disease or stroke. Published 2021. Accessed October 13, 2022. https://www.heartandstroke.ca/en/what-we-do/media-centre/news-releases/new-survey-reveals-concern-for-people-with-heart-disease-or-stroke/
. Moreover, a recent survey of HFCs across Canada recommended the development of explicit patient and risk-based guidance on who should or should not be seen in an HFC (including mode of delivery, which is very germane in the current COVID-19 era)
Assessment of Limitations to Optimization of Guideline-Directed Medical Therapy in Heart Failure From the GUIDE-IT Trial: A Secondary Analysis of a Randomized Clinical Trial.
. Therefore, the objectives of this study were to (a) investigate factors affecting referral and access to HFCs from multiple stakeholders’ perspectives, namely policy-makers (PM), providers in HFCs and patients with HF, and (b) identify facilitators to improve appropriate use.
METHODS
Design
This qualitative study was informed by an eight-member Expert Panel comprised of a patient organization, an HF administrator, HF physician sub-specialists, HFC provider, members of leading HF committees in the country, a scientist with content expertise, and methodologist. It was approved by the institutional review boards of University Health Network (CAPCR ID#19-6171) and York University, Toronto. All participants provided written informed consent. Interviews were conducted from February–June 2020, and then halted due to the COVID-19 pandemic. Interviews resumed in July 2022, and continued through December. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines
The study was conducted in Ontario, Canada, where healthcare delivery is under provincial jurisdiction. It is estimated that there are 36 HFCs in Ontario
Canadian Cardiovascular Society. Challenges and Opportunities: Cardiovascular Care and COVID-19. Canadian Cardiovascular Society Accessed October 13, 2022. https://ccs.ca/app/uploads/2022/04/CanadianCardiovascularSociety-e.pdf
. Each clinic serves a median of 200 patients/ year, with an estimated 2000 annual patient visits. Overall, 157 HF physicians and 60 nurse-practitioners (NPs) are providing care in these clinics. However, clinic services vary, with less than half offering implantable defibrillator or cardiac resynchronization therapy expertise, and only one-tenth with expertise in heart transplant or mechanical circulatory support. In addition, while most clinics optimize guideline-directed medical therapy along with medication and dietary consultation, remote monitoring and community partnerships for home visits are still very limited. Nevertheless, advanced care directives and end-of-life planning discussions are offered in most of these clinics
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
Three stakeholder groups were included and purposively sampled, namely: Ontario PMs/administrators (e.g., Ministry of Health, Health Quality Ontario, CorHealth Ontario / now Ontario Health, heads of major Divisions of Cardiology), healthcare providers currently working in HFCs (e.g., physicians, nurses), and patients with HF (including those who did and did not access clinics). Participants were interviewed until theme saturation was achieved.
PMs are those who plan, organise, direct, and coordinate health services. For recruitment of Ontario PMs, CorHealth Ontario’s Cardiac Hospital Administration committee members were contacted. HFCs were identified through a previous environmental scan
HF patient participants were reached through our patient partner organization the HeartLife Foundation(https://heartlife.ca/), social media, and the Ted Rogers Centre for Heart Research’s Heart Hub. Patient inclusion criteria included: living with HF in Ontario and English-language proficiency. Those with significant cognitive impairment, and lack of willingness to have the interview recorded were excluded from this study.
As interviews proceeded, expert panel members were asked to identify potential interviewees with characteristics that differed from participants (e.g., different types of institutions, professions, sex). For HF patients, attempts were made to recruit both males and females, and to have representation of patients living in and outside urban areas.
Procedure
Semi-structured interviews were conducted through Microsoft Teams; face-to-face interviews were avoided considering COVID-19. Potential interviewees were emailed an invitation to participate; non-responders were contacted again two weeks later. A reminder email was sent to the interviewees a few days before the interview, including the interview questions.
The interview questions were shared on screen throughout, and all parties had their cameras on. Interviews were audio-recorded, but also video-recorded so that non-verbal communication could also be considered in analyses. Facial expressions, hand gestures, tone of voice, and pauses were noted in each interview. Interviews were led by a senior member of the team (SG or LA), and a trainee observed to take notes (AF or TM). Interviews were approximately 45 minutes in length.
Materials
To capture the diverse array of perspectives by stakeholder type, a separate semi-structured interview guide was designed for each. The interview guides were developed based on our reviews of literature
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
. Input from the expert advisory panel was solicited and incorporated into the final the interview guides (see Supplemental Appendix S1). When data collection resumed in 2022, questions about the impact of the pandemic on HFC access were added to the interview guides.
Analyses
First, each interview transcript was cleaned to ensure accuracy and anonymity. Then, data coding was performed individually by two authors (TM, AH, AF or AA) concurrently with data collection. The data were analysed using NVivo version 12. Given the three stakeholder groups, transcripts were analyzed using systematic text condensation
. Each transcript was read thoroughly to obtain a general impression. Then, the meaning-bearing units that described the same central meaning were identified by going through each transcription systematically. Next, a codebook was developed based on extracted meaning units, with constant comparison applied to identify, expand, or merge themes across the stakeholder groups
. All codes were subsequently read through and analyzed for similarities and differences across participants and stakeholder groups. This was followed by a reconciliation meeting to review and come to agreement on the coding for each transcript, as well as the text condensation. Any disagreements were reconciled through discussion with the senior author (SG). The identified themes and sub-themes-- illustrated by quotes from the interviewees-- were then reviewed by the Expert Panel for confirmation, which adds credibility to the findings.
RESULTS
A total of 17 interviews were conducted before saturation was achieved; five were conducted post-pandemic. Characteristics of the seven HFC providers, six PM and four patient respondents are shown in Table 1. Analysis revealed five themes with associated sub-themes, as illustrated in Figure 1. With the addition of the COVID-19 question, an additional theme was identified; there were not many other differences in responses before and after the pandemic. Exemplary quotes are shown in Supplemental Table S1. Facilitators to address challenges identified are shown in Table 2.
Table 1Characteristics of interview participants, by stakeholder group
n (%) / median (range)
Patients
4 (23.52%)
Sex (n, % female)
2 (50.00%)
Age (years)
34 (20-65)
Geography / Residence
Urban
3 (75.00%)
Other
1 (25.00%)
Duration living with HF (years)
5 (2-11)
Recent visit to emergency department for HF (n, % yes)
Table 2Facilitators to Referral and Access to HF clinics as perceived by stakeholder groups
THEME
FACILITATOR
Health System Organization
Department / committee meetings across continuum of care, to track patient flow and timeliness / wait for 1st HF clinic visit
Triage tool for the emergency department
Facilitating relationship between tertiary and community HF clinics, to extend capability of community clinics. E.g., •Spoke – hub – node CorHealth Ontario policy§ •Augmenting capacity of Family/Ontario Health Teams •Leverage cardiac rehabilitation programs in communities without HF clinics
Electronic referral, leveraging electronic medical records
Training/education of emergency physicians regarding clinic availability and services
Linkage with nursing homes
Referral Appropriateness and Timeliness
A one-stop online resource for referring physicians to characterize HF severity and act accordingly e.g., •COACH trial
Clear referral criteria (e.g., I-NEED-HELP acronym from American College of Cardiology Expert Consensus Decision Pathway for Optimization of HF Treatment
2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues about Heart Failure with Reduced Ejection Fraction.
Clinic relationship with emergency and inpatient departments at hospital, so can support shorter length of stay, which is hospital goal for reimbursement reasons
Linkage with referring providers and other providers in circle of care (e.g., give them information they need to manage patient [while ensuring good communication about medication changes], etc.)
Linking with other HF patient care resources (e.g., palliative, community / home care [weighs, blood pressure assessment])
Protocol for non-physician/ nurse to handle patient symptoms / medication changes by phone, so clinic has capacity for new patients
Electronic dashboard tracking referrals, current patient load, and discharge eligibility
Patient Factors
Protocol for non-physician/ nurse to handle patient symptoms / medication changes by phone so patients do not need to travel in
First, with regard to health system organization, sub-themes of gaps in continuity of care, limited capacity and insufficient funding were raised. With regard to the former, respondents spoke to the importance of timely identification/ diagnosis of HF patients by a primary care provider, who would then refer to an internist or cardiologist. The specialist would then refer to the HFC where appropriate. Emergency and primary care physicians must be aware of HFC availability as well, to support appropriate and equitable referral of patients
. With regard to capacity/ volumes, clinics should be located based on regional incidence of HF, with capacity and expertise to match the population. While location is becoming less important with the increased availability of virtual care, some visits should be in-person. Moreover, there was wide variation in terms of capacity of each HFC, and their approach to managing referrals when they were at capacity, as well as variation in terms of clinic approach to discharging patients; some kept patients through to end-of-life, others for 1 year or until they were stable / fully titrated on medical therapy, to create capacity for new patients. Finally with regard to funding, the main issue was that there was no way to bill directly for clinic services except for physician time. Thus, the funding and resources (e.g., overhead, administrative support, nurses) to run the clinic were coming from the global hospital budget, which was often insufficient and perceived as undependable.
Second, with regard to referral appropriateness and timeliness, sub-themes related to unclear referral criteria, varying clinic scope, as well as delays in triage, testing and time-to-visit. Referral criteria/scope varied widely by clinic, often depending upon the expertise of the physicians. As outlined above, many required a patient be seen by a cardiologist first; other clinics based acceptance on number of hospital visits, medication factors (including adherence), or need for advanced therapies, for example. These criteria were not explicitly stated in many cases—neither at the clinic, nor with referring clinicians; this often resulted in receipt of “inappropriate” referrals, which many clinics then spent time re-directing elsewhere. There was lack of consensus on what the clinic referral criteria should be, with some clinics tightening or changing criteria over time to reduce unmanageable referral volumes, again often without targeted communication to the referral base. With regard to appropriateness, many clinics perceived they are not receiving referrals for the patients who are most in need, but have not had the ability to test this directly. The timeliness/efficiency of the referral process was also perceived as deficient. Clinics were aiming to reduce re-admissions, particularly with the government focus on reducing the 30-day rates, thus patients need to be seen well before 30 days from hospital discharge. However, often clinics received incomplete referrals, which creates delays in assessing appropriateness for HFC services as well as determining priority.
The third theme related to clinic characteristics, raised issues of how variation in clinic services and composition of healthcare professions / expertise impacted patient referral. As outlined above, clinics varied in the information required to consider and accept patients. They also had different modes of accepting referrals, with more options preferable. Services also varied from clinic to clinic; for example, some clinics focused on candidacy for devices or advanced therapies, while others focus on more general HF care, such as medication titration. With regard to the latter, the nature of the healthcare providers also varied and their number. Some had one physician, others many, who could be specialists or sub-specialists. Others had a mix of nurses and specialist nurse-practitioners. The nature of the allied health care complement and administrative staff varied as well, all impacting the number and type of patients that could be seen and when. Finally, they also varied in how they covered physician cancellations, again impacting access to care.
The fourth theme regarding patient and social factors related to comorbidity / frailty, socioeconomic status, barriers due to location and affinity to specific providers. For instance, some patients had physical limitations, necessitating accompaniment by a caregiver. Clinic location had implications for proximity to home / travel time and conditions, parking cost and availability, as well as traffic density. Patients preferred providers with shorter wait times-- for both an appointment date, and then on the day of the appointment, they wanted the provider to be on time. Some patients lacked primary care providers or preferred the subspecialty care at the HF clinic to their cardiologists/referring physicians, so were pursuing care based on provider preference / bedside manner, rather than appropriateness.
The final theme related to the COVID-19 pandemic concerned increased referral volumes, transition to online delivery modalities, and loss to follow-up care, exacerbated by patient refusal of in-person visits. Some patients were trying to avoid the healthcare system for fear of contracting the virus, or could not get in to see primary care providers. Relatedly, clinics reported more referrals, many of which were not appropriate. Clinics reported patients or caregivers refused necessary in-person visits on some occasions, including situations where informal caregivers were not vaccinated or did not want to mask, and hence would not be allowed entry to the clinic where they were located in a hospital with such infection control policies. Where virtual appointments were appropriate, capacity to treat these patients hinged on the technological capability of not only the clinic, but also patient's access, in terms of hardware/devices, software, technical support and verbal communication skills. Many older patients joined the virtual appointments with support of their adult children.
DISCUSSION
This was the first study to investigate multi-level factors in referral and access to HFCs in a public health system, including during the COVID-19 pandemic
. This was conducted in Ontario, Canada where urgently needed, given a recent report from the Auditor General highlighted that the recommended HFC community model was not fully implemented across the province, despite demonstrated benefit in several regions
Office of the Auditor General of Ontario. Value for Money Audit: Cardiac Disease and Stroke Treatment. Office of the Auditor General of Ontario; 2021:1-85. Accessed December 20, 2022. https://www.auditor.on.ca/en/content/annualreports/arreports/en21/AR_Cardiac_en21.pdf
. The major themes, which coalesced across the multiple stakeholders interviewed, were health system organization-related challenges, referral appropriateness and timeliness, variation in clinic characteristics, patient-related factors and the pandemic (Figure 1).
Consistent with quantitative surveys of HFCs and reviews in the country
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
, the major challenges to an optimal continuum of care for HF patients appear to be the lack of regional coordination of care at the government level, the limited number of clinics and limited capacity of existing clinics, lack of organization, standardization and clarity on the purpose and specialization of clinics given the existing variation
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
, the lack of formal communication channels across the continuum and circle of care, as well as lack of guidance on who should or should not be referred to HFCs. Consistent with the literature on access to other outpatient chronic disease care
, patient-related barriers identified related to social determinants of health, their health status, transportation (parking cost, traffic, distance), time, and technology.
There were some conflicting viewpoints and needs expressed among stakeholders. For example, patients refused in-person visits for fear of contracting COVID-19 or could not come on-site because the informal carers accompanying them were not in compliance with COVID-related policies. However, based on types of diagnostic tests, length of time since seeing a patient or level of risk, providers often need to have in-person rather than virtual visits. There was also some tension between the need to reduce variation in HFC capacity and approach but also to match these to the population, particularly given the diversity in Ontario.
Many facilitators to improve HF care in the community and reduce the need for acute care were identified (Table 2). CorHealth-- which promotes the "spoke-hub-node" model -- is an important mechanism to support coordination across the continuum of care and between HFCs, to facilitate better care coordination, standardization, efficiency and patient-centeredness, even in the COVID-19 context. This model suggests that level of care and setting should be based on patient risk and complexity, from “spokes” for stable, low-risk patients to receive care in the community, to tertiary “nodes” where high-risk patients with complex needs receive care in an advanced cardiac hospital. There was an HFC network in the province, where the “node” level of the recommended “spoke-hub-node” model was in place, however it ceased due to insufficient support. The system needs connection to primary care “spokes” and “hubs” in a fully regional model, and that is explored in some of our forthcoming work. And again, given population and geographic diversity in the province, the standardized model should be resourced and implemented based on regional needs.
Standardized, evidence-based recommendations regarding who should be referred to HFCs are also needed. The I-NEED-HELP acronym from the American College of Cardiology Expert Consensus Decision Pathway for Optimization of HF Treatment is an example of a such recommendation for advanced patients; Canadian guidelines provide some direction as well (see Table 2 of
. The intervention comprised a point-of-care algorithm which stratified HF patients based on risk of death, to support hospital discharge decisions, but importantly this was coupled with rapid follow-up in HFCs for those discharged. Some interviewees were part of the trial, and greatly advocated for the model (Table 2), which would also improve referral appropriateness and timeliness. With results demonstrating significant 30-day reductions in mortality and morbidity with the rapid access care, implementation should be pursued. Finally, clinic staffing and funding policy should be re-visited, so they can be resourced to provide a full cadre of needed care in a patient-centred manner.
Results of this study have implications not only for policy, but also for future research. While many HFC access facilitators were identified, the expert panel perceives it would be premature to develop guidance until the viewpoint of those who refer patients to HFCs, namely primary and acute HF care providers, are also sought, and until evidence regarding appropriate but also feasible HFC inclusion and exclusion criteria is undertaken (e.g., test the I-NEED-HELP acronym from American College of Cardiology Expert Consensus Decision Pathway for Optimization of HF Treatment
2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues about Heart Failure with Reduced Ejection Fraction.
). With this information, an expert panel could be convened to undertake a formal, evidence-based process to develop recommendations on improving the HFC system.
Caution is necessary when interpreting the results. First, representative generalizability is not established through qualitative research, so while purposive sampling was used and saturation was achieved, applicability to other provinces or healthcare systems cannot be known. And it should be noted that the patient population did not have rural representation and there were few HCP working at non-tertiary centres. Second, while face-to-face interviews are ideal, given the COVID-19 pandemic, interviews were performed via videoconference. However, one member of the research team notated non-verbal communication during each interview. Finally, the nature of the study design precludes causal conclusions.
In conclusion, this qualitative study gleaned the perspectives of PMs, HFCs and patients regarding gaps in referral and access to HFCs –gaps which impede optimal care quality and hence quantity of patient life-- in a public healthcare system. Main themes identified related to health system organization, referral appropriateness and timeliness, clinic-related factors, patient-related factors, as well as the COVID-19 pandemic. It is hoped these findings, congruent with quantitative and other local evidence, as well as the recent Auditor General’s report, will spur consideration of care alignment with CorHealth Ontario’s regional model of integrated care and the recent COACH trial findings. Resources must be provided and stakeholders brought together to standardize and integrate the HF care continuum, so that patients who need HFC care most will access and benefit from such care.
Acknowledgements
We are grateful to other members of the Expert advisory panel who gave input on the ideas and interview guide, including Drs. Doug Lee, Sean Virani, and the patient partners from the HeartLife Foundation.
Heart failure in Canada complex incurable and on the rise. Heart and Stroke Foundation of Canada. Accessed October 12, 2022. https://www.heartandstroke.ca/en/what-we-do/media-centre/news-releases/heart-failure-in-canada-complex-incurable-and-on-the-rise/
How Canada Is Failing People with Heart Failure - and How We Can Change That. 2022 Spotlight on Heart Failure. Heart and Stroke Foundation of Canada; 2022. Accessed October 10, 2022. https://heartstrokeprod.azureedge.net/-/media/pdf-files/canada/2022-heart-month/hs-heart-failure-report-2022-final.ashx?la=en&rev=245159ea1726419aaa6f71ae9e7692f3
Chronic Heart Failure in Adults: Quality Standard. NICE National Institute for Health and Excellence; 2021. Accessed October 10, 2022. www.nice.org.uk/guidance/qs9
Assessment of Limitations to Optimization of Guideline-Directed Medical Therapy in Heart Failure From the GUIDE-IT Trial: A Secondary Analysis of a Randomized Clinical Trial.
The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey.
Health Quality Ontario. Heart Failure Care in the Community for Adults. CorHealth Ontario; 2022. Accessed October 10, 2022. https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-heart-failure-quality-standard-en.pdf
AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Canadian Cardiovascular Society. Challenges and Opportunities: Cardiovascular Care and COVID-19. Canadian Cardiovascular Society Accessed October 13, 2022. https://ccs.ca/app/uploads/2022/04/CanadianCardiovascularSociety-e.pdf
Heart and Stroke Foundation of Canada. New survey reveals concern for people with heart disease or stroke. Published 2021. Accessed October 13, 2022. https://www.heartandstroke.ca/en/what-we-do/media-centre/news-releases/new-survey-reveals-concern-for-people-with-heart-disease-or-stroke/
Office of the Auditor General of Ontario. Value for Money Audit: Cardiac Disease and Stroke Treatment. Office of the Auditor General of Ontario; 2021:1-85. Accessed December 20, 2022. https://www.auditor.on.ca/en/content/annualreports/arreports/en21/AR_Cardiac_en21.pdf
2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues about Heart Failure with Reduced Ejection Fraction.
This research was supported through a post-doctoral fellowship from the Ted Rogers Centre for Heart Research, University Health Network, Canada. No other specific grant was received from any funding agency in the public, commercial or not-for-profit sectors.
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