A heart failure center model helped to promote the standardized management and improve the prognosis of patients

IntroductionOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Despite the continuous improvement of living standards and medical conditions in China, the threat of cardiovascular disease to people’s health has been steadily increasing (1). In China, among the population over 25 years old, the standardized prevalence of heart failure (HF) is 1.1%, and the incidence rate is 275 per 100,000. It is estimated that there are currently 12.05 million HF patients, and the number of new cases each year is 2.97 million. Both the prevalence and incidence of HF rise significantly with age. The prevalence of HF is 1.38% among those over 35 years old, 3.09% among those aged 60–79 years, and 7.55% among those aged 80 years and above. The incidence of HF is 720 per 100,000 among those aged 60–79 years and 1,655 per 100,000 person-years among those over 80 years (2). HF represents the end stage of various heart diseases. According to past data, once a patient experiences acute heart failure (AHF), the in-hospital mortality rate ranges from 3.8% to 9.4%, and the mortality and rehospitalization rates within three months after discharge are 14% and 25% respectively (3). The 5-year survival rate of patients with chronic HF is even lower than that of cancer patients (4).

However, despite the continuous update of drugs and instruments related to HF, the prognosis of patients has not witnessed a remarkable improvement (5). Learning from the experience of chest pain centers in the management and treatment of patients with acute myocardial infarction (AMI), an increasing number of HF centers have emerged in China. These centers were established to facilitate standardized, multidisciplinary, and scientific management for HF patients (6). In line with the latest guidelines for the diagnosis and treatment of HF, these centers not only aimed to assist HF patients during their hospitalization but also endeavored to provide preventive care prior to medical consultation and enhance the long-term prognosis after discharge, aspects that have long been overlooked in China (7).

Our hospital (Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University) started to utilize the data management system of the Chinese Heart Failure Center to store the medical records of HF patients in 2019. In accordance with Chinese HF guidelines and the instructions of the Chinese HF Center headquarters, we made every possible effort to meet all the required details, ensuring that every HF patient received comprehensive attention. After 2 years of arduous work, our hospital was certified as a standard-version HF center by the Chinese HF Center headquarters in 2020, which meant that our center has met all of the criteria. Nevertheless, it remains uncertain whether there is a preconceived effect as we had anticipated. This study aimed to review and compare the management and long-term prognosis of HF patients in our hospital before and after the establishment of the HF center, and to observe the actual clinical significance of the HF center model. We present this article in accordance with the STROBE reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-437/rc).

MethodsOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Research objects

We used random number table method to select a total of 300 cases in the HF database of our hospital during January 2019–December 2022. Their medical data during the hospitalization and follow-up were collected. According to the certification date, 150 cases were collected from January 2019 to December 2020 (before the certification of HF center, control group) while 150 cases were from January 2021 to December 2022 (after the certification of HF center, center group). We initiated establishment of HF center and began to record data in the system in January 2019. Related work had been scheduling and implementing to meet HF head office’s criteria till certification in December 2020, which meant that patients in control group had basic medical records but did not receive strictly requested care. Meanwhile, patients in the center group have been given fully certificated services, as shown in Figure 1.

Figure 1 Flow chart of patients. HF, heart failure.

Inclusion criteria: HF was diagnosed according to patients’ condition and Chinese HF diagnosis and treatment guidelines (8); exclusion criteria: the patient refused to follow doctors’ instructions during the diagnosis and treatment or requested self-discharge.

Research methods

This study is a before-and-after review study. The relevant indicators were collected and compared in two groups. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics committee of our hospital (Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. Ethic-Expedited-2023-16), and individual consent for this retrospective analysis was waived due to the retrospective nature.

HF center establishment and maintaining

A HF center model governs not only doctors’ clinical decisions and nurses’ care within the hospital but also focuses on prevention and follow-up care outside the hospital. This model also calls for a multi-disciplinary treatment (MDT) for HF, incorporating departments such as nephrology, cardiothoracic surgery, and rehabilitation. In accordance with the requirements of the Chinese HF center head office, our center has been organizing free clinics and health screenings monthly in communities and villages. Simultaneously, health education sessions are provided. Once a HF patient arrives at our hospital (whether in the outpatient clinic or inpatient ward), a health record is established. Physicians and nurses offer personalized treatment to each patient based on the latest guidelines (8). After discharge, the patient will be contacted and guided regularly by our follow-up staff in the center. If a patient encounters any issues with medication or experiences discomfort, the staff will contact our physicians for guidance. Above all, the Chinese HF center head office has established a comprehensive framework of relevant rules that cover every detail throughout the entire process. Our center has fulfilled every requirement and was certified by the head office in 2020, indicating that our center has had a standardized level of HF treatment since then. Our center holds monthly meetings for quality control to ensure that patients are always treated in a normalized manner. The physicians regularly visit the demonstration HF centers to learn the latest guidelines and technologies.

HF center data system

Our center has input the health records of every HF patient into the Chinese HF center data system. These records encompass a patient’s basic characteristics, clinical features, test results, medication, follow-up information, and prognosis. This system is beneficial for physicians in making clinical decisions, tracking a patient’s treatment process, and conducting quality control. Moreover, the system is interconnected among different HF centers, which facilitates the sharing and resolution of various complex cases.

Data collected

We meticulously collected and analyzed the data of the baseline clinical features of patients. These features include gender, age, body mass index (BMI), HF risk factors (such as chronic myocardial ischemia, AMI, hypertension, valvular disease, diabetes), laboratory test results [hemoglobin, creatinine, N-terminal pro-B-type natriuretic peptide (NT-proBNP)], the initial New York Heart Association (NYHA) heart function grade (9), left ventricular end-diastolic diameter (LVDD) and ejection fraction (LVEF), as well as HF classification: heart failure with reduced ejection fraction (HFrEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF) (10).

We focused on the standardized indicators of patient diagnosis and treatment management. These encompasses the proportion of NT-proBNP and echocardiography utilized in the diagnosis process, the proportion of HFrEF patients using angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blockers (ARBs)/angiotensin receptor neprilysin inhibitor (ARNI), β-receptor blockers, and the follow-up rates (at 1 week, 1 month, 3 months, and 1 year after discharge).

Clinical prognostic indicators were also considered. These include the NT-pro-BNP level at discharge, the distance of the 6-minute walking test (11), cardiac function grade, the average duration and incidence of major adverse cardiac and cerebrovascular events (MACCE, including cardiovascular death, non-fatal myocardial infarction, non-fatal Stroke and revascularization) (12) during hospitalization, and repeated cardiac ultrasound parameters (LVDD, LVEF), the distance of the 6-minute walking test, cardiac function grade, readmission rate, and MACCE rate within one year after discharge.

Endpoints and definition

The primary endpoints include MACCE (defined as in-hospital all-cause death, AMI, or ischemic stroke) in hospitalization and MACCE in 1 year; the secondary endpoints include indicators of clinical outcomes in hospitalization (NT-proBNP before discharge, 6-minute walking distance, heart function grade of NYHA before discharge, average duration in hospital, days) and 1 year after discharge (LVDD, LVEF, 6-minute walking distance, heart function grade of NYHA, readmission rate).

Quality control

The definition and judgment criteria of the collected contents and indicators were formulated and observed stringently. The data were input by two researchers independently. In case of conflicting data, a de novo check would be conducted, and the data would ultimately be revised by the team leader. A random inspection of 10% of the group data was carried out for content review, and the data would be considered eligible if the compliance rate was higher than 95%. We selected patients who took HF-related drugs during the corresponding period to control selection bias. Direct investigations of other drugs that might affect the prognosis of inpatients and outpatients were also performed to avoid confounding bias.

Addressing missing data

Identify missing data by screening the dataset to know its extent and pattern, distinguishing among Missing Completely at Random (MCAR), Missing at Random (MAR), and Missing Not at Random (MNAR). Using mean/median/mode to perform data imputation. Assessing the impact of including or excluding variables with missing values to ensure the robustness of the results.

Statistical analysis

SPSS 23.0 statistical software package was used for data processing. Measurement data were expressed as mean ± standard deviation. Normality test (Kolmogorov-Smirnov test) and homogeneity of variance test were performed before comparison between groups. Paired sample t-test and independent sample t-test were used for measurement data to conform normal distribution and homogeneity of variance of the population. Rank-sum test was used for data that did not conform to the normal distribution. Count data were analyzed by Chi-squared test. P<0.05 was considered statistically significant.

ResultsOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

There were no differences between groups in baseline clinical features such as age, sex ratio, BMI, HF risk factors, laboratory tests at admission, initial cardiac function grade, cardiac ultrasound results (LVDD, LVEF), and HF classification, as shown in Table 1.

The proportion of patients in the center group using NT-proBNP (94.7% vs. 87.3%, P=0.03) and echocardiography (88.7% vs. 78.7%, P=0.02) was higher, more HFrEF patients in the center group took ACEI/ARB/ARNI (87.0% vs. 72.2%, P=0.03) and β receptor blockers (82.7% vs. 66.7%, P=0.03), and the follow-up rates of 1 week (90.7% vs. 80.0%, P=0.01), 1 month (84.7% vs. 72.0%, P=0.01), 3 months (76.7% vs. 64.0%, P=0.02) and 1 year (88.0% vs. 79.3%, P=0.04) after discharge were relatively high in the center group, see in Table 2.

Patients in the center group had lower NT-proBNP levels (1,760±934 vs. 2,279±1,085 pg/mL, P<0.001), longer distance in the 6-minute walk test (364±117 vs. 330±135 m, P=0.02), better cardiac function grade (2.1±0.6 vs. 2.3±0.7, P=0.01) at discharge and shorter average duration (7.3±2.5 vs. 8.9±2.1 days, P<0.001) in hospital. Similarly, patients in the center group had better cardiac function grade (1.6±1.0 vs. 2.0±0.9, P=0.001), shorter LVDD (47.3±10.9 vs. 52.4±11.6 mm, P<0.001), higher LVEF (48.7%±12.8% vs. 43.6%±11.5%, P=0.001), longer distance in the 6-minute walk test (395±111 vs. 358±120 m, P=0.01), and lower rates of readmission (8.7% vs. 16.0%, P=0.02) and MACCE (4.7% vs. 11.3%, P=0.03) in 1 year after discharge, as shown in Table 3.

DiscussionOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

HF has always been a global issue. Researchers and physicians have been making extensive efforts to improve the prognosis of HF patients. In recent years, numerous new drugs and instruments have emerged. Sodium-dependent glucose transporters-2 (SGLT-2) inhibitors (13), mineral-corticoid receptor antagonist (MRA) (14), and soluble guanylate cyclase (sGC) agonists (15) have brought new ideas and hopes to HF treatment. Cardiac resynchronization therapy (CRT) (16), His bundle pacing (HBP) (17), and left ventricular assist device (LVAD) (18) also serve as auxiliary means that contribute to HF therapy.

Nevertheless, new medications and devices are often too costly to be widely adopted in developing countries. It will take several years for these new advancements to be actually applied in medical institutions like our hospital (a central hospital in a fourth-tier city), not to mention community-level medical institutions in China (2). Therefore, in addition to in-hospital medications, attempting to prevent HF attacks before clinical manifestation and providing follow-up care outside the hospital may be crucial measures.

As a crucial institution for emergency rescue of heart attacks, chest pain centers (CPCs) have been established in many countries (19). In China, CPCs are not only in charge of handling severe illnesses related to acute chest pain but also focus on prevention and follow-up care. Based on the mature experience of CPCs and combined with big-data platforms and information technology, HF centers have been widely set up in China, using CPC as a template and foundation.

For most doctors and nurses, the HF center is a new concept. In the past, the idea of treating HF mainly revolved around medical care within the hospital. Diagnoses and treatments varied among different doctors based on their personal experiences. Although the MDT care model has been promoted for years, it has not been widely adopted in China. However, the HF center model has opened up a brand-new avenue for HF management.

Our center organizes free clinics, health screenings, and conducts education sessions every month in communities and villages with the aim of preventing HF attacks. Once a HF patient arrives at our hospital, a health record linked to the Chinese HF patients’ database will be created. Physicians and nurses will provide each patient with MDT treatment based on the latest guidelines. After discharge, the patient will be contacted and guided regularly by our follow-up staff in the center.

With the help of the data system, we can regularly review our daily work for quality control, enabling us to identify deficiencies and make timely corrections, which was unimaginable before. The system also reminds us to conduct follow-up work regularly, which was easily overlooked in the past. Above all, the Chinese HF center head office has established a comprehensive framework of relevant rules that cover every detail throughout the entire process.

The Chinese HF center head office is supposed to conduct a re-evaluation every three years for each HF center, aiming to assess whether the HF center still meets all the requirements. Our center was scheduled to be re-evaluated in 2023, and thus we needed to sort through a large number of retrospective documents. Therefore, we initiated this study to determine whether the HF center model truly makes a contribution. As a result, we are delighted to find that the HF center model is indeed effective.

In the center group, the proportion of patients using NT-proBNP and echocardiography for diagnosis is higher, and the ratio of patients using ACEI/ARB/ARNI and β-blocker prior to discharge is also higher, indicating that the diagnosis and treatment process has been standardized. With the assistance of the data system, the follow-up rate during each period after discharge is higher. Thanks to all these efforts, HF patients have achieved a better prognosis both inside and outside the hospital. At discharge, patients in the center group have a lower NT-proBNP level, can cover a longer distance in the 6-minute walking test, have a better cardiac function classification, and have a shorter average hospital stay. One year later, the corresponding indicators remain better than those of the control group, and the readmission rate and the incidence of MACCE are lower.

However, it should be noted that this study is a single-center observational one. The sample size of the included subjects is relatively small, thereby limiting the statistical significance. The study methods adopted a controlled before-and-after review, and it was difficult to avoid relevant statistical biases. There was a relatively high rate of follow-up loss, and the prognosis beyond 1 year requires further investigation.

ConclusionsOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

The HF center model is capable of standardizing the diagnosis and treatment management of HF patients and significantly improving the prognosis of patients. Therefore, it should be actively promoted.

AcknowledgmentsOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

We are grateful to the English-language proofreading software developed by Elsevier we used during the writing process. This software has helped us refine our language, making our manuscript more accurate and clearer, which has enhanced the overall quality of our research presentation.

FootnoteOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-437/rc

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-437/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-437/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-437/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics committee of our hospital (Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. Ethic-Expedited-2023-16) and individual consent for this retrospective analysis was waived due to the retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

ReferencesOther Section

• Introduction
• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

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