An innovative patient-centred approach to heart failure management: the Best Care heart failure integrated disease management program

Background The management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline directed care, however, the impact of IDM in the community setting requires further evaluation. Methods A retrospective evaluation of community-based IDM. Patient characteristics were described, and evaluation of outcomes using a pre- and post-intervention design were HF-related health service use, quality of life, and concordance with guideline-directed medical therapy (GDMT). Results 715 patients were treated in the program (2016 to 2023), 219 in a community specialist clinic and 496 in 25 primary care clinics. The overall cohort was predominantly male (60%), mean age of 73.5 years (±10.7), and 60% with HF reduced ejection fraction.In patients with ≥6 months of follow-up (N=267), pre vs post annualized rates of HF-related acute health services decreased from 36.3 to 8.5 hospitalizations/100 patients/year, p<0.0001, 31.8 to 13.1 ED visits/100 patients/year, p<0.0001, and 152.8 to 110.0 urgent physician visits/100 patients/year, p=0.0001. GDMT improved; patients receiving triple therapy and quadruple therapy increased by 10.1% (95%CI;2.4%,17.8%) and 19.6% (95%CI;12.0%,27.3%), respectively. Within these groups optimal dosing was achieved in 42.5% (95%CI;32.0%,53.6%) and 35.0% (95%CI;23.1%,48.4%), respectively. In patients with at least one follow-up (N=286) over 50% experienced a clinically relevant improvement in quality of life. Conclusion A community-based IDM program for HF, may reduce HF-related acute health service use, improve quality of life and GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.