Heart Failure

Care in the Community for Adults

Resources The Quality Standard In Brief Advisory Committee About

Summary

This quality standard addresses care for adults who have heart failure, including the assessment and diagnosis of people with suspected heart failure. It applies to community settings, including primary care, specialist care, home care, hospital outpatient clinics, and long-term care.

This quality standard does not address care provided in hospital emergency departments or inpatient settings. It does not discuss heart failure related to congenital cardiac conditions. It also does not address the primary prevention of heart failure, although it does provide guidance on risks and lifestyle factors that may affect the progression of heart failure. These may be topics addressed in future quality standards.

Scope of This Quality Standard

This quality standard addresses care for people 18 years of age or older who have heart failure, including the assessment and diagnosis of people with suspected heart failure. It does not address heart failure owing to congenital cardiac conditions. It also does not address the primary prevention of heart failure, although it does provide guidance on risks and lifestyle factors that may affect the progression of heart failure.

This quality standard applies to community settings, including primary care, specialist care, home care, hospital outpatient clinics, and long-term care. It does not address care provided in hospital emergency departments or inpatient settings. Health Quality Ontario and the Ministry of Health and Long-Term Care have developed the Quality-Based Procedures: Clinical Handbook for Heart Failure (Acute and Postacute) to provide guidance on hospital care for people with heart failure.

This quality standard includes 10 quality statements on areas identified by CorHealth Ontario and Health Quality Ontario’s Heart Failure Care in the Community Quality Standard Advisory Committee as having high potential to improve the quality of care in Ontario for people with heart failure.

Terminology Used in This Quality Standard

The New York Heart Association (NYHA) classification system describes heart failure symptoms. Below are the definitions for the four classifications:

Class I—no symptoms
Class II—symptoms during ordinary activity
Class III—symptoms with less than ordinary activity
Class IV—symptoms at rest or with any minimal activity

The heart failure population can be divided into three major subpopulations based on ejection fraction:

“Heart failure with reduced ejection fraction” (HFrEF) refers to a left ventricular ejection fraction that is less than or equal to 40%
“Heart failure with preserved ejection fraction” (HFpEF) refers to a left ventricular ejection fraction that is equal to or greater than 50%
“Heart failure with midrange ejection fraction” (HFmrEF) is a relatively new classification, referring to an intermediate group with a left ventricular ejection fraction of 41% to 49%

Each quality statement applies to all three of these subpopulations, unless specifically mentioned in the text of the statement.

In this quality standard, the term “caregiver” refers to family members, friends, or supportive people not necessarily related to the person with heart failure. The person with heart failure must give appropriate consent to share personal information, including medical information, with their caregiver(s).

The term “care provider” is used to acknowledge the wide variety of providers who may be involved in the care of people with heart failure. The term includes both regulated health care professionals, such as dietitians, nurses, nurse practitioners, occupational therapists, pharmacists, physicians, physiotherapists, psychologists, and social workers, as well as unregulated health care providers. Our choice to use “care provider” does not diminish or negate other terms that a person may prefer.

The term “substitute decision-maker” refers to a person who makes care and treatment decisions on another person’s behalf if or when that person becomes mentally incapable of making decisions for themselves. The substitute decision-maker makes decisions based on their understanding of the person’s wishes, or, if these are unknown or not applicable, makes choices that are consistent with the person’s known values and beliefs and in their best interests.

Why This Quality Standard Is Needed

Heart failure is a complex clinical syndrome characterized by the heart’s inability to pump enough blood to meet the body’s demands. The most common symptoms of heart failure include shortness of breath, fatigue, and ankle swelling. Heart failure is a progressive, ultimately fatal condition: 50% of people with heart failure die within 5 years of diagnosis, and over 90% die within 10 years. People with heart failure also often have multiple comorbidities: in Ontario, 37% of people with heart failure have four or more coexisting chronic conditions.

In 2015 in Ontario, roughly 250,000 people had diagnosed heart failure, or about 1.8% of the province’s entire population. Prevalence varied across the province, from 1.34% in the Mississauga Halton Local Health Integration Network (LHIN) to 2.53% in the North East LHIN. Heart failure is one of the five leading causes of hospitalization and 30-day readmissions, and the most common cause of hospitalization for people over age 65. Health care utilization related to heart failure has a substantial economic impact: the Heart and Stroke Foundation estimates that heart failure accounts for $2.8 billion in Canadian health care spending each year.

There are opportunities to improve care for people with heart failure in Ontario and to reduce the health system burden of this disease. A number of regional variations in heart failure care and outcomes have been identified across Ontario: for example, in 2015/16 among people hospitalized for heart failure, the percentage who received a recommended follow-up visit with a primary care provider within 7 days of hospital discharge ranged from 37% in the North West LHIN to 55% in the Central West LHIN. The percentage of people who were readmitted to hospital within 30 days of discharge ranged from 18% in the Waterloo Wellington LHIN to 24% in the South East and North East LHINs.

These regional differences in processes of care and outcomes may be linked to variations in the care people with heart failure receive in the community. Based on evidence and expert consensus, the 10 quality statements that make up this quality standard provide guidance on high-quality care, with accompanying indicators to help care providers and organizations monitor and improve the quality of care.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

People with heart failure should receive services that are respectful of their rights and dignity and that promote shared decision-making and self-management.

People with heart failure should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, disability, and background (including self-identified cultural, linguistic, ethnic, and religious backgrounds). Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, services should be actively offered in French and other languages.

Care providers should be aware of the historical context of the lives of Indigenous peoples throughout Canada and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities. This quality standard uses existing clinical practice guideline sources developed by non-Indigenous groups, which may not include culturally relevant care or acknowledge traditional Indigenous beliefs and practices. Therefore, it is important for care to be adapted to ensure that it is culturally appropriate and safe for First Nations, Inuit, and Métis peoples in Ontario.

A high-quality health system is one that provides appropriate access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

People with heart failure benefit from care provided by a care provider or care team with the knowledge, skill, and judgment to provide evidence-based treatment for heart failure while also addressing all their primary health care needs. The goal of heart failure management is to improve symptoms, function, quality of life, and prognosis.

How Success Can Be Measured

The Heart Failure Care in the Community Quality Standard Advisory Committee has worked with CorHealth Ontario to identify a small number of overarching goals for this quality standard. These have been mapped to indicators that providers may want to monitor to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

In this section, we list indicators that can be used to monitor success provincially, given currently available data. If additional data sources are developed, other indicators could be added.

Process indicators:

Percentage of people with newly diagnosed heart failure who receive an electrocardiogram and a chest x-ray
Percentage of people with newly diagnosed heart failure who receive an echocardiogram
Percentage of people with newly diagnosed heart failure aged 65 years and over who are dispensed quadruple therapy
- Stratify by:
  - Angiotensin receptor-neprilysin inhibitor (ARNI) or angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB); beta blocker(s); mineralocorticoid receptor antagonist (MRA); sodium glucose transport 2 (SGLT2) inhibitor
  - ARNI or ACE inhibitor or ARB
  - Beta blocker(s)
  - MRA
  - SGLT2 inhibitor
- Note: Owing to the limitations of administrative data, it is possible to access provincial drug data only for people with heart failure who are over 65 years of age. Further, it is not possible to separate the diagnosis of heart failure with reduced ejection fraction from other forms of heart failure. About 50% of people with heart failure have heart failure with reduced ejection fraction and should receive quadruple therapy (see Quality Statement 5)
Percentage of people who were hospitalized or treated in the emergency department for heart failure who are seen by a primary care physician, cardiologist, or internal medicine physician within 7 days of leaving the hospital
- Note: Owing to the limitations of administrative data, it is only possible to measure the percentage of people with heart failure seen by a physician. However, current best practice is for people with heart failure to be seen by a member of their community health care team within 7 days of leaving the hospital; this team could include a registered nurse or nurse practitioner in addition to a physician (see Quality Statement 9)

Outcome indicators:

Percentage of people with newly diagnosed heart failure who die within 30 days of diagnosis of heart failure from any cause of death
Percentage of people with newly diagnosed heart failure who die within 1 year of diagnosis of heart failure from any cause of death
Rate of hospital admissions and emergency department visits per 1,000 person days for people with heart failure for:
- Heart failure–specific reasons
- Any reason(s)
Percentage of people who were hospitalized or treated in the emergency department for heart failure who are readmitted within 30 days of discharge for:
- Heart failure–specific reasons
- Any reason(s)

How Success Can Be Measured Locally

Providers may want to assess the quality of care they provide to people with heart failure and monitor their own quality improvement efforts. It may be possible to do this using their own clinical records, or they might need to collect additional data.

In addition to the overall measures of success, each quality statement within the standard is accompanied by one or more indicators. These indicators are intended to guide the measurement of quality improvement efforts related to the implementation of the statement.

To assess how equitably care is being provided, the quality standard indicators and the overall indicators can be stratified by patient socioeconomic and demographic characteristics, such as income, education, language, age, sex, and gender.

What Does It Mean for Patients and Caregivers?

My experience as a caregiver to a loved one with heart failure taught me that having the right information and asking the right questions can effect change in the way patients receive care. When my husband was discharged from hospital after major cardiac surgery without any touchpoints or arrangements made for follow-up care in my home community (ultimately leading to a hospital readmission), I learned a lot about the value of a supported transition. The quality standard for heart failure addresses this, which is one of the many reasons it is such an important resource.

The quality standard is direct and easy to read and can help patients and caregivers navigate the health care system. It empowers them ask the right questions to their care team about when, where, and how care should be delivered and helps build comfort and prompt discussion around potentially difficult topics, such as palliative care. By providing a common ground, quality standards will help ensure the unique needs of patients and caregivers in all pockets of the province are met.

- Kathy Smith, Lived Experience Advisor

What Does It Mean for Providers?

I believe the quality standard recognizes and appreciates that it takes a village to care to people with heart failure. We need to communicate and collaborate with a variety of care providers to improve patient outcomes and the patient and caregiver experience.

– Karen Harkness, Registered Nurse, Heart Function Clinic

Timeline for This Quality Standard

This quality standard was completed in February 2019.

Updated: January 2022

Evidence to Improve Care