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Improving Access & Quality of the HF Journey Team


The Access Team is led by Dr. Sean Virani of Vancouver General Hospital, Vancouver, BC, Canada.  

Advances in the treatment of heart failure (HF) have improved the prognosis and quality of life for people with HF. Unfortunately, significant disparities in timely access to integrated and coordinated health care for people with HF exist across Canada and are exacerbated in vulnerable populations. Barriers to improving the care of patients with HF include delayed diagnosis, inadequate patient empowerment, poor support systems, discontinuity of care after hospital discharge, and underuse of proven therapies (HS HF Roundtable 2021). This team proposes a multi-pronged approach that engages patients to identify their priorities and seeks solutions that are adaptable to the Canadian healthcare ecosystem (10 provinces, 3 territories and Indigenous populations). The main objectives of the Access Team are then:

  1. Empower patients to improve HF care

  2. Improve early diagnosis and prevention of HF

  3. Improve access to data to better inform and integrate patients, caregivers (primary care and HF teams) and decision makers. 

Team Lead

Dr. Sean Virani
Vancouver General Hospital

“My sister, 18 years old, had significant HF symptoms. She consulted a general practitioner and was told she probably had a virus or needed to rest... She died of sudden death, with HF 3 weeks later!”
- Sylvain Bédard
Access team members
Aim 1

Patient empowerment to improve care in HF 

 

This project, led by the Patient Engagement Team (Dr. Davina Banner-Lukaris, Marc Bains and CEPPP) and Dr. Sean Virani, evaluates the impact of specific patient empowerment initiatives. The team develops and evaluates tools to facilitate patient empowerment while educating healthcare providers about the benefits of empowering patients in their own care. In collaboration with WelTel, a company that leverages the use of 2-way SMS and other communication modalities, powered by AI algorithms to support continuity of care that improves health outcomes while streamlining clinical workflows, the team will develop AI-derived text messages and prompts to improve communication between patients and their health care team. 

In British Columbia (BC), a pilot study using WelTel and BC primary care Guidelines for HF is being developed to assess the feasibility of an mHealth intervention to promote HF self-care and improve patient outcomes. Patients will be randomized to either usual care or intervention arm, in which they will receive daily text messages asking about health status, blood pressure, heart rate, and weight, and providing education. Patients' responses will be analyzed using built-in natural language AI software, which will notify the healthcare team if the patient needs to be triaged for a phone or video call, a clinic visit, or further follow-up. At this stage, the procotol is under development.  

Dr. Davina Banner-Lukaris
University of Northern British Columbia

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Marc Bains
HeartLife

Aim 2

Improving early diagnosis and prevention of HF

HF is often diagnosed late in the course of the disease. Approximately 50% of initial diagnoses are made in the emergency department when patients present with acute decompensation. For many patients, this is the most distressing and confusing period of their HF journey. There are several reasons for delay in the diagnosis of HF. These include a lack of awareness of HF in the general population (so that people with symptoms do not seek medical attention) and inadequate diagnostic tools in primary care. In addition to working with Heart and Stroke to improve awareness of HF, this team will use new technologies and AI to help diagnose HF in primary care. 

One of the studies that will help achieve this goal is the MAPLE-CHF study.

MAPLE-CHF: Multidisciplinary Approach for high-risk Patients Leading to Early Diagnosis in Canadians with Heart Failure.

The MAPLE-CHF study is the Canadian arm of the SYMPHONY (Screening for earlY heart failure diagnosis and Management in Primary care or at HOme using Natriuretic peptides and echocardiographY) study, an international collaboration of 5 randomized controlled trials screening for HF using common study design elements and endpoints in 5 respective countries (Canada, Scotland, Sweden, Denmark, United States). In each country, individuals will first be pre-screened for HF risk factors. 

The primary objective of MAPLE-CHF is to evaluate whether a strategy of NT-proBNP and AI echocardiography in primary care increases the number of patients diagnosed with HF at 6 months, compared with usual care. This study will recruit participants in British Columbia and Quebec and will be led by Dr. Anique Ducharme (Montreal Heart Institute) and Dr. Nathaniel Hawkins (University of British Columbia). The protocol has been developed and is under REB review.

On the other hand, pharmacists play an integral role in the prevention of worsening HF, particularly through medication optimization. Indeed, several high-quality RCTs have shown that having a pharmacist on the team caring for patients with HF improves outcomes. In January 2021, pharmacists in Vancouver established the PHARM-HF (Pharmacist-led Rapid Medication optimization for Heart Failure) clinic model, a virtual, remote-based, pharmacist-led outpatient clinic specializing in HF medication optimization. Patients are followed for a short period of time (3-4 months) with frequency (every 1-2 weeks) and then discharged back to their referring cardiologist. Early data has shown promising results in terms of improving the optimal medical therapy score. Based on these promising results, the team initiated the PHARM Optimal-HF pilot study, a local implementation of the PHARM-HF clinic, in which 60 eligible HF patients will be randomized to either usual care or intervention (usual care + referral to the PHARM-HF clinic for medication optimization). Patients will be followed remotely at 3, 6 and 12 months. The study will evaluate the feasibility of implementing this model on a larger scale and will measure the modified Optimal Medical Therapy Score and patient-reported outcome measures using questionnaires. This pilot study is funded by the Canadian Foundation for Pharmacy and recruitment is ongoing.

Prevention and ealry diagnosis of HF could also be done through genetics analyses, as proposed in the Genetics and outcomes of dilated cardiomyopathy in the heart faiure clinic study. 

Heart failure clinics care for patients with a variety of heart problems, most commonly weaknesses in heart muscle function. We believe that a large number of patients with poor heart muscle function, or cardiomyopathy, can be explained by genetics. It is likely that depending on the genetic problem, some can improve with medications, but others will continue to deteriorate, which is why it is important to know the cause of the disease in order to adapt our treatments. Moreover, some cardiomyopathies run into families, and genetic testing can help determine if family members need to be screened for heart problems, to prevent complications. In this study, we will utilize data from selected patients with cardiomyopathy at the Montreal Heart Institute Heart Failure Clinic to understand if genetics influence presentation, response to treatment, and prevention of health problems in family members. The descriptive objectives are to determine the proportion and nature of genetic variants and family disease in patients with dilated cardiomyopathy (DCM)at the HF clinic, according to the subtype of DCM, and to describe the DCM echocardiography phenotype at baseline according to genotype. The predictive objectives are to identify whether the DCM subtype and genotype are associated with HF outcomes, and to assess for the presence of interaction between environmental factors and genotype on outcomes. Dr. Maxime Tremblay-Gravel, a cardiologist at the Montreal Heart Institute and recipient of an Early Career Investigator Grant from the CHF Alliance, leads this retrospective cohort study. 

Sylvain Bédard
CEPPP

Dr. Anique Ducharme
Montreal Heart Institute

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Dr. Nathaniel Hawkins
University of British Columbia

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Dr. Anthony Tang
University Hospital London HSC

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Dr. Ricky Turgeon
University of British Columbia

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Dr. Maxime Tremblay-Gravel
Montreal Heart Institute

Improving access to data to better inform and integrate patients, cargivers (primary care and HF teams) and decision makers

Digital health approaches can be used to improve access to care in at least 6 ways: 1) by monitoring individual patient health trackers, ranging from simple measures (blood pressure, heart rate, weight) to complex information (defibrillator downloads) using AI; 2) by empowering patient, educating them, and improving self-care; 3) by improving communication between patients and their healthcare providers; 4) by improving connections within the Canadian health record system and the separate multiple EMR systems in use; 5) as a learning and quality assurance tool; and 6) as a resource using Electronic Medical Records (EMR) and AI to identify patterns and at-risk patients. Our network partners with CANet and the University of Western Ontario to integrate VIRTUES for the management of HF (VIRTUES-HF). VIRTUES (Virtual Integrated Reliable Transformative User-Driven E-health System) is a cloud-based technology designed with patients to help them manage their health. VIRTUES integrates all health data in an accurate, concise and secure manner, with patient ownership and access for both patients and physicians; provides near real-time feedback of performance and recommendations for management adjustments to patients and caregivers; assists patients with symptom management; and provides personalized education on their health conditions. VIRTUES uses the latest digital health standard, Fast Health care Interoperability Resources (FHIR), which is designed to integrate biosensor and multi-sensor technology for remote monitoring of HF patients at home in their communities. The integrated data will be interpreted and presented in a user-friendly manner to patients and caregivers for a co-management of health conditions. VIRTUES was developed and is used for the management of patients with implantable electrical devices and for patients tested positive for COVID who were confined and managed at home in health regions across seven provinces. VIRTUES is being adapted for remote management of patients with atrial fibrillation and post-myocardial infarction. This project is developed by Dr. Anthony Tang (University Hospital London HSC), Dr. Robert McKelvie (Western University) and Dr. Eileen O'Meara (Montreal Heart Institute).

Dr. Eileen O'Meara
Montreal Heart Institute

Aim 3

Dr. Robert McKelvie
Western University

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