Heart failure burden 3 HEART FAILURE BURDEN

Heart failure burden 3 HEART FAILURE BURDEN Course: Tutor: Institution: Date: INTRODUCTION Worldwide research estimates that approximately half of the world's population are diagnosed with heart failure. Close to half a million people are living with this sickness in England while in Australia the prevalence of heart failure is about one to two percent of the population. The cost of seeking medical care or attention is very high and for this reason, people who suffer from it experience the high cost of living because of health care. A disease that attacks or affects many people concurrently in a community is known as an epidemic thus heart failure can be categorized as an epidemic. In the developed countries there has been a significant improvement in the quality of life and the standard of healthcare, still, the rise of the number of heart failure patients is negatively impacting the national health strategies. SYNDROMES Heart failure is a disease that comprises of many clinical syndromes which manifest as shortness of breath and fatigue due to fluid retention as a result of cardiac abnormalities. Most commonly a patient of heart failure suffers from underlying coronary heart disease and is frequently having a history of myocardial infarction, hypertension along with idiopathic cardiomyopathy and vascular heart disease. RISK FACTORS Risk factors contributing to heart failure include age, family history of heart disease, diabetes, history of smoking, poor diet, patients with obesity, high cholesterol levels, excessive alcohol intake, and inadequate physical activity. People landing in a hospital with acute heart failure often have other diseases which have shared risk factors, such as renal disease, diabetes, and pulmonary disease. Heart failure leads to hypertension and coronary heart disease which in turn affects the heart pump action. Heart failure is increasing in prevalence; in the UK alone it has affected close to nine hundred thousand people and new cases are reported annually. Mostly it affects older people. It has been observed that 5% of the patients of heart failure are over 75 years of age, with a trend of rising incidence in the higher age group. The heart failure prevalence is observed to rise with age and is rarely found in people younger than 50 years. Two-thirds of Australian adults with heart failure are above 65 years of age7. In a developed country like Australia and England with the improvement in health care availability we can see a relative aging in the general population, seeing this we can assume that there will be a further increase in the number of heart failure patients which will further add to increase the burden on the clinical and public health resources. COST OF MEDICATION Heart failure has turned out to be an expensive and high-cost burden to public health care resource, patients of heart failure have multiple admission rates at advanced disease stage which accounts to a very high amount of health care expense. If we look back at the data, in the year 2007-2008, England and Wales had 60,000 admissions with heart failure, this group of patients required 750,000 bed days. Prevalence of heart failure in Australia is estimated at 1 -2% with a higher prevalence among indigenous tribes, women, and people living in remote and rural regions3. The hospitalization rate for Australia is close to average for countries in the Organization for Economic Co-operation and development that is 240 to 244 per 100,000 people in 20159. In Australia, the number of hospitalization ranged from 90 to 632 per 100,000 people across the 324 local areas, though the number varied from 169 per 100,000 people in Australian Capital Territory to 344 in the northern territory. EFFECTS OF HEART FAILURE Heart failure is a gradually progressive condition, in the long term though there is a fatal outcome following a long and painful incurable period; this has a major impact not only on the patient but also on their care providers and families. Like Cancer, heart failure has a significant impact on the patients' daily livelihood and it results in a significant impairment on quality of life. Common reasons for hospitalization with acute heart failure are infections along with non-adherence to medications and not following the imposed dietary and fluid restrictions. It has been observed that the risk of readmission for heart failure is more in male genders, people falling into lower socio-economic strata and people who are in an aged care setting. National Heart Failure audit in the UK had reflected that of all the patients dying of heart failure only 6% of patients received palliative supportive care. In England, the guidance issued by the National Institute for Health Care and Excellence (NICE) not only for diagnosis but also for the treatment of heart failure both in acute and chronic forms. New health care models of care aim to speed up access to Echo, but a shortage of technically trained staff remains a limiting factor in improving standards of care. Despite all advances even in a developed country like England and Australia heart failure causes a significant burden for patients and health care systems. Heart failure is responsible for the death of nearly 50 to 75 % of patients within five years of diagnosis. In Australia heart failure amounts to a significant financial burden amounting to about 1 to 3 % of overall health care budget, this expense has been observed to be a consequence of repeated hospitalization which also results in a longer hospital stay. TREATMENT Management of heart failure requires multidisciplinary care which is provided across acute and primary care sectors and it requires a combination of strategies. Non-pharmacological approach to heart failure includes strategies which include physical activity programs, awareness of the benefits of physical activities, and fluid or dietary management. Often there is a need for pharmacological therapy along with these non-pharmacological modalities. Diuretics are amongst the most commonly used medicine along with angiotensin-converting enzyme inhibitors and beta-blockers. One of the major problems with pharmacotherapy is the compliance with the therapy and this has been observed to be lacking among most of the elderly heart failure patients. A surgical procedure like coronary artery bypass graft surgery, cardiac resynchronization therapy with or without insertion of an implantable cardiac defibrillator as a supportive device also comes with its own set of risks, mortality, and morbidity. DIAGNOSIS Advancing age in itself is a factor that predicts poor prognosis among patients of heart failure, among the patients receiving care the patients presenting with refractory symptoms despite optimal therapy end up having repeated hospital admissions and have poor long term outcome. It has also been seen that patients requiring frequent hospitalization with more than at-least three admissions within six months period have poor long term prognosis. Patients having limitations with daily living activities and those dependent for more than three activities of daily living have been found to be candidates of poor outcome. Cardiac cachexia has been seen in heart failure patients and is associated with poor diagnosis. DIET Heart failure patients have poor food and water intake which results in cardiac cachexia and electrolyte imbalance, patients with resistant hypernatremia have a poor outcome. Patient with poor food intake have deficient protein levels and significantly low albumin level has been found to predict poor prognosis. Heart failure patients often have rhythm irregularities for which they often require implantable defibrillator devices, the group of patients who experience multiple shocks from their device belong to the high-risk group with poor prognosis. Patient with co-morbid conditions like terminal cancer, renal failure, chronic liver disease have a poor prognosis. Primary care teams and hospital should put in place models of care so that there is a use of systematic approach to identify people at high risk of heart failure, assess and investigate people with suspected heart failure, provide and document the delivery of appropriate advice and treatment and offer regular review to people with established heart failure. The National Service Framework (NSF) goal for every primary care team is to ensure that all those with heart failure are receiving a full package of appropriate investigation and treatment. On the other hand, it is desirable that every hospital is able to provide a complete and comprehensive package with adequate follow up strategies to patients with heart failure. A regular follow up for patients after discharge has been recognized as a measure to prevent readmission. Since heart failure is a disease of the elderly age group, the emphasis has been on teaching and advocating compliance with drug therapy along with regular follow up using routine hospital visits, telemedicine, and remote monitoring. Education of these patients in lifestyle modification practices has been successful in preventing sedentary lifestyle. CREATING AWARENESS OF SENSITIZATION Despite all the measures heart failure still remains to have a significant burden on health care in Australia and England, with similar prevalence. Heart failure management needs priority from the government and the health care providers requiring sensitization of the population towards the needs of a patient with heart failure. The need for cardiac rehabilitation and increasing access to cardiac rehabilitation programs along with awareness helps people suffering from heart failure and people at risk of heart failure to be able to take protective measures, increases compliance with food and fluid restrictions along with better understanding of pharmacotherapy leading to increase of compliance and provides an opportunity to follow up compliance. Cardiac rehabilitation programs provide psychosocial support to the heart failure patients as well as the family supporting the heart failure patients. The cardiac rehabilitation programs provide the opportunity to provide and emphasize on the exercise as therapy and are a source of exercise training. Optimal pharmacotherapy and its compliance can be better followed up with the means of cardiac rehabilitation programs. POOR MEDICAL SERVICES The higher prevalence of heart failure in the rural and remote areas of Australia and England is an indicator of poor availability of advanced health care facilities at these regions. The priority of the health care system to provide access to better health care facilities is a long term and expensive goal with financial and resource restriction. The need and deficit at this level need to be resolved with the help of the use of technology like telemedicine to provide primary care to the patients at risk of heart failure in the rural locations with limited access to urban healthcare and to follow up with education, compliance and providing psychosocial and supportive care. Remote monitoring and follow up serves as a tool for providing supportive care and follow up in rural areas where frequent visit for follow up with the hospital is not practical. Heart failure patients often require repeat hospital admissions due to poor compliance and follow up. Setting up a measure to continue to follow up of heart failure patients will prevent the incidence of re-admissions and help reduce the financial burden. Identifying patients with a high number of risk factors and a regular follow up with compliance to therapy, lifestyle modification and on time surgical intervention will help reduce the number of patients suffering from heart failure and will help reduce the financial burden of both Australia and England. Family-based outreach models have been on priority in Australia and England to provide care to heart failure patients. It has been seen that the incidence of heart failure has been more in patients receiving care in old age homes when compared to patients being cared for by family. The need for sensitization of family towards heart failure helps improve compliance and provides the opportunity for timely intervention. STRATEGIES FOR PREVENTION OF HEART FAILURE The health schemes need to incorporate strategies to prevent heart failure by preventing risk factors like the sensitization towards smoking and tobacco chewing has been helpful to reduce the incidence of cancer. Similarly, the focus on obesity and healthy exercise based lifestyle will help reduce the risk factors. Early diagnosis and treatment of heart disease like rheumatic fever will help prevent the progress to rheumatic heart disease. Providing access to better health care and preventing the progression of kidney disease in patients with heart failure will help reduce the incidence of heart failure. Improving access to dialysis for a rural and remote location will help prevent renal complications in heart failure patients. The health care burden of heart failure has been on the rise, and the incidence is comparable in developed nations like England and Australia. Looking at the prevalence of heart failure burden in developed countries like Australia and England it is not wrong to consider Heart failure as an epidemic. A higher incidence of heart failure has been reported from rural areas, which indicates poor compliance and follow up leading to worsening of heart failure resulting in mortality burden of the country. CONCLUSION To conclude heart failure is a progressive disease with an array of presentation, restricting the day to day activity of the individual. The present-day strategy of the health care system is to recognize the risk factors and it is the need of the hour for the health care system to implement measures to take care of the risk factors. With control and early detection of the disease, the various treatment modalities can delay the progress of heart disease into heart failure. Early diagnosis of myocardial dysfunction and timely supportive management can prevent the loss of myocardial function. In patients of rheumatic fever with long term prophylaxis the onset of myocarditis and endocarditis can be reversed and the long term antibiotic treatment and halt the onset of rheumatic heart disease, thus reducing the prevalence of vascular heart disease. In patients with vascular heart disease, the onset of life-limiting symptoms is quite late thus by the time the symptoms develop the patient already has developed cardiac dysfunction. The incidence of heart failure is more in such patients, however in patients on regular management and timely corrective surgical intervention a better quality of life can be achieved. The cost of hospitalization can be reduced by ensuring proper medical compliance and regular follow up of patients. Heart failure patients need psychological and social support to deal with the limitations with their daily activity. Education and training and sensitization towards self-care and the importance of compliance with medical advice will most like ensure a better outcome in patients with heart failure. The patients of heart failure have been found to be suffering from co-morbid conditions, which make a life for the patient more miserable. The long term outcome in patients with heart failure and comorbid disease is poor, it is in priority of the health care department to formulate policies to target early detection of such conditions and to take corrective measure early so as to delay the onset of disease and if not then to delay the progress of the disease into a life restricting condition. The health department has been formulating policies to ensure maximum reach and from time to time many legal measures are being taken by the government to reduce the risk factors, like the increasing awareness of smoking has led to the reduction of number of individuals taking up smoking and it has also motivated many smokers to quit smoking, this in-turn has led to a reduction in the incidence of cancer and this measure also reduces the incidence of heart failure as smoking is also a risk factor for heart failure. More of similar measures need to be taken up to further check the incidence of heart failure. Heart failure has been observed to be more in lower socio-economic strata of the population, and this is directly related to the affordability of the advance health care and adds to the national heart disease burden. It is also not wrong to say that the maximum number of patients with irregular compliance and follow up is among people with lower socio-economic status. It is also been observed that the rural population is difficult to follow up regularly at the hospital due to distance from the health care system. The role of far outreach programs for providing regular counseling and guidance to ensure regular medications and compliance with medical advice. The role of timely intervention to check the spread of infectious disease and active intervention to treat added infection will help prolong the life of heart failure patient. The world population is aging. The burden of heart failure is also going to increase with this, it is of prime importance to check the risk factors early in life to halt the onset of disease and the to ensure the regular and optimum treatment to check further progress of disease and worsening of symptoms. The developed countries like Australia and England have been successful in controlling the spread and load of infectious diseases and now have been burdened with a progressive and life-limiting disease like heart failure. On comparing the incidence of heart failure in the two countries and reflecting on the financial burden we can conclude that heart failure is a disease that needs to be addressed at all the levels, by providing better hospital care as well as primary care to ensure early diagnosis and rapid treatment to prevent worsening of the disease and to enable the individual to live a better and productive life. REFERENCES Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M, Nodari S, Lam CS, Sato N, Shah AN, et al. 2014 The global health and economic burden of hospitalizations for heart failure. Lessons learned from hospitalized heart failure registries. Journal of the American College of Cardiology 63 1123–1133. Townsend N, Bhatnagar P, Wilkins E, Wickramasinghe K & Rayner M 2015 Cardiovascular disease statistics. London: British Heart Foundation. (available at: https://www.bhf.org.uk /publications/ statistics/cvd-stats-2015). Sahle BW, Owen AJ, Mutowo MP, Krum H, Reid CM. 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