What Happens When a Whole Region Rethinks Heart Failure Care?

In a region of the globe that tends to reserve heart failure treatment for episodes of acute decompensation, Cleveland Clinic Abu Dhabi has established a unique program aimed at keeping patients healthy and out of the hospital.

The new multispecialty hospital’s program is staffed by heart failure cardiologists and cardiothoracic surgeons supported by a multidisciplinary team of nurse coordinators, nurse practitioners, pharmacotherapy specialists, case managers, dietitians and physical therapists who provide care for all stages of the disease, with an emphasis on prevention.

“Our value lies in providing guideline-directed management of heart failure in a way that addresses long-term morbidity and mortality,” says Feras Bader, MD, who spearheads the program. “We seek to prevent hospitalization by treating heart failure-related comorbidities, partnering with patients at the psychosocial level and educating patients and families.”

Learning from regional experience

Although heart failure is as prevalent in the Middle East as in the West, heart failure care is not as comprehensive in the region. “These are resource-intensive programs, so it’s natural that these programs are not yet fully developed in emerging economies,” explains Dr. Bader, a heart failure and transplant cardiologist.

Dr. Bader was serving as a medical director of the University of Utah’s advanced heart failure and transplant program when he was invited by Kuwait’s Ministry of Health to establish a heart failure program in that country. During a two-year leave from Utah, he set up the program and staffed it with physicians and nurses. Yet other positions were left unfilled, leaving patient and family member education, appointment-making, administrative paperwork and other aspects of care to the medical staff. “The need for truly comprehensive, multidisciplinary management was a new concept that required a significant effort to implement,” he observes.

Through this experience, Dr. Bader realized the importance of establishing comprehensive management for patients from the beginning. He says the experience prepared him to help build a classic multidisciplinary program at Cleveland Clinic Abu Dhabi when opportunity knocked.

“The United Arab Emirates’ (UAE) healthcare landscape is developing rapidly, and Cleveland Clinic Abu Dhabi is a premier example of a highly developed healthcare system,” he notes. “We have the infrastructure and resources necessary to build a heart failure program on an international level.”

Meeting extensive patient education needs

Cleveland Clinic Abu Dhabi now attracts patients with heart failure from throughout the UAE and the region. Most have had little to no education in their disease, so the staff devotes extensive time to teaching patients.

“Often our patients have not been taught the basics of their disease, so education carries 10 times more weight here than it does in the West,” Dr. Bader says.

Nurse educators teach self-care, pharmacists discuss medications, dietitians teach heart-healthy eating, physical therapists demonstrate exercises, and cardiologists ensure that patients understand how each aspect contributes to avoiding deterioration.

Educational materials have been translated into Arabic, and culturally sensitive tools were developed for use by all patients. “This is unique for the Middle East,” Dr. Bader notes.

Being accustomed to brief interactions with physicians, most patients are not used to calling nurses to report new symptoms or changes in status. However, they quickly see value in the system and readily take advantage of it.

“We expected it would be hard to get patients to adopt our approach, but with time and education, they adhere closely to the program,” Dr. Bader says.

Making patient education a priority in heart failure: Dr. Bader with a patient.

Remote monitoring to flag problems early

Also notable is the heart failure program’s close, two-way cooperation with cardiac electrophysiologists specializing in arrhythmias. On one hand, the heart failure program refers patients who meet guideline indications for implantation of devices that protect and improve lives (defibrillators and biventricular devices). On the other hand, the electrophysiologist conveys crucial information from a patient’s implanted device to the heart failure specialist. Such information sharing has been proven to improve patient outcomes.

Once implanted, the cardiac rhythm devices are monitored remotely from the comfort of patients’ homes for signs of trouble. This service, which is unique to the region, aims to improve clinical outcomes by reducing hospitalizations and also reducing unnecessary well-patient visits.

Patients are provided with a wireless console that, when plugged into an electrical outlet, automatically sends reports from the patient’s implanted device to a secure website. When the device detects fluid accumulation or an arrhythmia, the cardiologist calls the patient and provides appropriate guidance. “It allows us to intercept problems between office visits,” explains electrophysiologist Khalid Al Muti, MD.

The same technology is used for patients with syncope, palpitations or atrial fibrillation; an implantable loop recorder may be inserted under the skin. The wireless console again transmits abnormal findings to the treating cardiologists, allowing them to remotely establish a diagnosis and monitor the patient’s response to therapy.

Cleveland Clinic Abu Dhabi is not currently reimbursed for monitoring, since the service is new to the UAE and requires a CPT code to be established, but staff hope that will soon change. “We are closely observing our patients, to demonstrate to regulatory agencies that remote monitoring works,” Dr. Al Muti notes.

Early evidence of the multidisciplinary program’s value comes by way of sharp declines in patients’ hospitalizations for heart failure. “We have multiple examples of patients who used to be admitted to the hospital once a month but who now have not been admitted once since they started coming to us,” says Dr. Bader.

Success proves contagious

The program continues to evolve, with the potential for procedures like left ventricular assist device implantation to be offered in the future.

Meanwhile, Cleveland Clinic Abu Dhabi’s approach to heart failure appears to be changing the region’s attitudes toward the condition in an enduring way. As regional physicians express interest in learning how to manage patients in a similar fashion, awareness of the advantages of a specialty heart failure program is growing.

“We are gratified to see this program being a top priority for Cleveland Clinic Abu Dhabi,” says Dr. Bader. “It’s having an impact for patients here and beyond.”