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Specialized multi-disciplinary heart failure clinics in Ontario, Canada: an environmental scan
© Wijeysundera et al.; licensee BioMed Central Ltd. 2012
Received: 16 October 2011
Accepted: 31 July 2012
Published: 3 August 2012
Multi-disciplinary heart failure (HF) clinics have been shown to improve outcomes for HF patients in randomized clinical trials. However, it is unclear how widely available specialized HF clinics are in Ontario. Also, the service models of current clinics have not been described. It is therefore uncertain whether the efficacy of HF clinics in trials is generalizable to the HF clinics currently operating in the province.
As part of a comprehensive evaluation of HF clinics in Ontario, we performed an environmental scan to identify all HF clinics operating in 2010. A semi-structured interview was conducted to understand the scope of practice. The intensity and complexity of care offered were quantified through the use of a validated instrument, and clinics were categorized as high, medium or low intensity clinics.
We identified 34 clinics with 143 HF physicians. We found substantial regional disparity in access to care across the province. The majority of HF physicians were cardiologists (81%), with 81% of the clinics physically based in hospitals, of which 26% were academic centers. There was a substantial range in the complexity of services offered, most notably in the intensity of education and medication management services offered. All the clinics focused on ambulatory care, with only one having an in-patient focus. None of the HF clinics had a home-based component to care.
Multiple HF clinics are currently operating in Ontario with a wide spectrum of care models. Further work is necessary to understand which components lead to improved patient outcomes.
Heart failure (HF) is a complex, progressive syndrome characterized by abnormal heart function resulting in poor exercise tolerance, recurrent hospitalizations, and reductions in both quality of life, and survival . Although tremendous progress has been made in pharmacologic and device therapy, HF patients continue to have a poor prognosis, with an annual mortality ranging from 5% to 50% . The incidence of HF is projected to increase, with estimates suggesting a three-fold increase in HF hospitalizations over the next decade . Alternative targeted health care delivery models have therefore been of particular interest in HF, as a means of improving both quality of life and survival .
Disease management through multi-disciplinary community care clinics has been shown to improve patient outcomes in different health conditions, including diabetes, chronic kidney disease, and cancer [4, 5]. The potential benefits of a multi-disciplinary strategy in HF include improved utilization and adherence with evidence-based medications. This model of care may also address the complex interplay between medical, psychosocial, and behavioural factors facing these patients and their caregivers . Multiple previous randomized studies and meta-analyses have evaluated the efficacy of such clinics with some suggesting a reduction in mortality in excess of 20% [1, 3, 6]. However, interpreting this literature is challenging because of substantial heterogeneity in the composition of the HF clinics, the interventions they offer, and the population studied [3, 7].
Currently, specialized HF clinics do not receive specific funding from the Ontario Ministry of Health and Long Term Care (MOHLTC), the third party payer for government insured health services in the province. It is not known how widely available specialized HF clinics are in Ontario, nor has their composition, or the services they offer, been described. Therefore, it is unclear if the efficacy of HF clinics in randomized trials is generalizable to the HF clinics currently in place in Ontario. Our objective was to address these important gaps in knowledge, through a comprehensive field evaluation, whereby real world practice for HF patients in Ontario was assessed in 2010. Specially, we aimed to understand the current availability of specialized HF clinics in the province, and the intensity and complexity of services offered.
Canada is divided into 13 distinct territories or provinces, with Ontario being the most populous. Based on the most recent census, 12.2 million of Canada’s 31.6 million people lived in Ontario. The Ontario population is concentrated around major urban areas, with only 15% living in rural settings, defined as a population less than 1000 persons and less than 400 persons per km2.
There is universal access to medical care in Canada without user-fees or out-of-pocket payments. Health care funding is determined at the provincial level. In 2006, the Ontario Ministry of Health and Long-Term Care transferred the responsibility for planning, integrating and funding of health services within the province to 14 regional Local Health Integration Networks (LHIN).
Identification of Heart Failure Clinics
For the purpose of this project, a specialized HF clinic was defined as a clinic that consists at a minimum of a physician and a nurse, one of whom has specialized training/interest in HF. This definition is consistent with that used in recent systematic reviews of HF clinics .
We utilized three approaches to identify clinics. First, all hospitals listed on the MOHLTC site (http://www.health.gov.on.ca) were contacted. Notices were posted in the Cardiac Care Network (CCN) webpage. Finally, we used snow-ball sampling, an approach often used in qualitative or mixed methods research studies, to evaluate ‘hidden populations’ .
A hidden population is one in which a sample frame (i.e. a list of all the members of the population) cannot be constructed, thereby preventing probability sampling . An alternative that does not require a sampling frame is snow-ball sampling, whereby new members are selected from the social network of existing members of the sample .
In this method, a number of seeds are first selected . These seeds are members of the hidden population that have been identified. The seeds are interviewed and form stage 0 of the sampling process. The seeds identify other members of the population, who are in turn approached in the next generation of sampling (stage 1). This process is continued until the desired sample size is reached. This method has been successfully utilized in a myriad of cardiac studies [10–12].
Seed heart failure clinics
Clinic name and location
Cornwall: Cornwall Community Hospital
Hamilton: Heart Function Clinic - Hamilton Health Sciences Corporation
Kingston: Hotel Dieu Hospital
Kitchener: St. Mary's Hospital
London: London Health Sciences Centre
Oakville: Oakville-Trafalgar Memorial Hospital
Orillia: Orillia Soldiers' Memorial Hospital
Ottawa: University of Ottawa Heart Institute
Owen Sound: Grey Bruce Health Services
Picton: Prince Edward Family Health Team Heart Failure Clinic
Toronto: University Health Network (UHN) (1)
Toronto: University Health Network (UHN) (2)
Toronto: Mt Sinai Heart Function Clinic
Toronto: St Michael’s Hospital Heart Function Clinic
Toronto: Sunnybrook Hospital Heart Function Clinic
The physician or nursing lead at each clinic was approached and a semi-structured interview conducted to establish the scope of the practice. The lead was asked to identify any other HF clinics, which may serve patients in the vicinity (1st sampling stage). We continued to accrue new sampling stages until no new clinics were identified, at which point the sample was saturated.
Regional differences in access to HF Clinics
The boundaries of each LHIN were used to assess any geographic inequalities in access to HF clinics. We first determined the population size overall and of persons greater than the age of 65 years in each LHIN. The number of prevalent HF cases in each LHIN is not known. To approximate the burden of HF per LHIN, we used previously published data on the number of hospital discharges per LHIN with a most responsible diagnosis of HF in the fiscal years 1997–2001 . We then determined the annual rate of HF hospital discharges per HF clinic in each LHIN as another estimate of the regional distribution of access to care.
Heart failure disease management scoring instrument (HF-DMSI)
Points to be assigned
1 = Provider alone
2 = Patient alone
3 = Patient with some inclusion of caregiver
4 = Patient with a caregiver who is central to the intervention
Education and counselling aimed at supporting self-care
0 = No mention of education
1 = Focus solely on importance of treatment adherence
2 = Focus on treatment adherence including some creative methods of improving adherence
3 = Focus on surveillance but no mention of actions to be taken in response to symptoms (eg, no flexible diuretic management)
4 = Emphasis on surveillance, management, and evaluation of symptoms in addition to treatment adherence
0 = No mention of medication regimen
1 = Some mention of medications (eg, importance of medication compliance) but not an active part of the intervention. No attempt to intervene with provider to get patients on an evidence-based medication regimen
2 = Evidence-based medication regimen advocated but no follow-up with patient or provider to monitor the suggestion
3 = Medication regimen monitored, attempt made to get the patient on evidence-based medications, with follow-up monitoring done with patient or provider
Social support Peer support
0 = No mention of a peer support intervention
1 = Peer support mentioned but not integral to intervention
2 = Peer support integral component of intervention
Surveillance by provider:
0 = No use of remote monitoring or telehealth
1 = Remote monitoring is used in conjunction with other interventions that form the main intervention used
2 = Telehealth is essential component of intervention
1 = Single generalist provider (eg, physician, nurse, pharmacist)
2 = Single HF expert provider (eg, physician, nurse, pharmacist)
3 = Multidisciplinary intervention
Method of communication
1 = Mechanized via internet or telephone
2 = Person-to-person by telephone
3 = Face-to-face, individual, or in a group
4 = Combined: Face-to-face at least once alone or in a group with individual telephone calls in between meetings
Intensity and complexity
1 = ≤1 mo
2 = ≤3 mo
3 = ≤6 mo
4= > 6 mo
1 = Low: single contact with little or no follow-up
2 = Moderate: >1 but <4 and/or infrequent contact or contacts of short duration
3 = High: multiple contacts of significant duration
1 = Hospital: Inpatient only
2 = Clinic/outpatient setting
3 = Home-based
4 = Combination of settings
Briefly, the HF-DMSI focused on the composition of the HF team (single practitioner vs. multi-disciplinary team) and the content of the HF intervention such as education (scored from 0 to 4, with 4 as the more comprehensive education program), and medication management (scored from 0 to 3). The environment of the HF clinics was categorized as those that only focused on inpatients with HF (score of 1) versus those that focused only on outpatients seen in clinic (score of 2), those that were home-based with the intervention taking place in the patients’ residence (score of 3), with clinics that had components in more than one setting receiving the highest score of 4. Peer support, remote monitoring, and the duration and complexity of contact were also measured. The instrument was designed to provide a separate score for each category. The HF-DMSI has content validity and an excellent inter-rater reliability with a intra-class correlation coefficient of 0.918 .
Because the HF-DMSI does not provide an overall summary score, and could not be used to rank clinics, we performed a concept mapping exercise, using an HF expert panel. The concept mapping exercise consisted of two parts [15, 16]. In part 1, we determined the relative importance of each of the 10 categories of the HF-DMSI, based on consensus of the expert panel. In the second part, each of the clinics identified were categorized by the expert panel into three intensity groups, based on their scores on the HF-DMSI, influenced by the implicit weighting system revealed in part 1. Further description of this process is found in Additional file 1 Appendix A.
Institutional review board
The ethics review board of the University of Toronto approved this protocol. When required by local institutional regulations, separate institutional review board approval was acquired for each participating clinic. Consent for the use of the structure survey results was obtained from the physician lead for each identified HF clinic.
HF clinic identification
Regional distribution of HF clinics
Geographic distribution of clinics
# HF Clinics
population per HF Clinic
age 65 years and over in LHIN
>65 years population per HF clinic
annual HF discharge per HF clinic
Erie St. Clair
North Simcoe Muskoka
In order to estimate the burden of HF across Ontario, we used data which showed over the 5 years from 1998 to 2002, 42,367 patients were discharged with a diagnosis of HF. As seen in Table 3, given the 34 clinics, on average each HF clinic would be able to serve 200 HF discharges per year. However, there was substantial regional variability, with greater than a 7fold difference between LHINs with HF clinics. For example in Waterloo, there was a HF clinic for 84 HF discharges, compared to one HF clinic per 626 HF discharges in the North East LHIN.
The majority (80.6%) of clinics were physically based in hospitals with 25.8% being part of an academic institution. In total, 143 HF clinic physicians worked at the 30 identified clinics. The majority of clinics were run by cardiologists.
Access to allied health professionals
Characteristics of 30 identified clinics
Mean number of Physicians
% of clinics with cardiologist
% of clinics with internists
% of clinics with family physicians
% of physicians with heart failure training
Mean Number of Nurses
% Community Based
Mean Annual Total Visits
Mean Annual Total New Patients
% Access to Onsite Echocardiography
% Access to Onsite Nuclear Cardiology Testing
% Access to Onsite Angiography
% Access to Onsite exercise Stress Testing
Mean Exam Rooms
ALLIED HEALTH PROFESSIONALS
% Access to Dietician (In Clinic)
% Access to Pharmacist (In Clinic)
% Access to Physiotherapy (In Clinic)
% Access to Counselor (In Clinic)
% Affiliated with Cardiac Rehabilitation
% Involved in other Chronic Disease Management
Intensity and complexity
Clinic intensity and complexity
(n = 30)
Clinic intensity types
(n = 10)
(n = 13)
(n = 7)
3.3 ± 0.6
3.7 ± 0.5
3.2 ± 0.6
3.0 ± 0.6
Education and counselling aimed at supporting self-care
3.2 ± 1.0
3.9 ± 0.3
3.1 ± 1.0
2.6 ± 1.1
2.7 ± 0.5
3.0 ± 0
2.8 ± 0.4
2.1 ± 0.7
0.3 ± 0.5
0.6 ± 0.7
0.2 ± 0.4
0.3 ± 0.5
0.7 ± 0.8
1.0 ± 0.8
0.8 ± 0.8
0.1 ± 0.4
2.5 ± 0.6
3.0 ± 0
2.5 ± 0.5
2.0 ± 0.8
Method of communication
3.6 ± 0.5
4.0 ± 0
3.5 ± 0.5
3.4 ± 0.5
4.0 ± 0
4.0 ± 0
4.0 ± 0
4.0 ± 0
2.6 ± 0.6
3.0 ± 0
2.6 ± 0.5
2.0 ± 0.6
2.0 ± 0.2
2.0 ± 0
1.9 ± 0.3
2.0 ± 0
In this environmental scan of HF clinics in the province of Ontario, Canada, we were successfully able to identify 34 HF clinics. There was substantial inequity in access to care, with two LHINs having no identified HF clinics, and a wide range in the population served by each clinic. As anticipated, the clinics were varied in structure and the services offered. The greatest variation in terms of intensity and complexity was in terms of the education service offered. Remote monitoring and a home-base component to the HF clinic services were notably absent in most clinics.
Multi-disciplinary ambulatory complex disease management clinics are increasingly studied as the preferred modality of ambulatory care delivery for chronic diseases such as HF [1, 3, 4, 6, 17]. Advocates of such clinics highlight the many randomized clinical trials that show the efficacy of such clinics in reducing mortality and rehospitalisation [3, 18–31]. Importantly, although these clinics are grouped together in systematic reviews and meta-analyses, there is heterogeneity in the models evaluated and services offered . Prior to implementing these clinics in routine practice, it is critical to understand which components are central to the intervention. Several meta-analyses have attempted to address this research question using the published literature [3, 18–22, 27, 28]. McAlister and colleagues evaluated 29 trials enrolling a total of 5,039 patients . Because of substantial heterogeneity, they did not report an overall summary statistic . They found that multi-disciplinary clinics improved mortality, while tele-monitoring improved re-hospitalization rates . Holland and colleagues contrasted studies that incorporated home visits, or between visits telephone calls, to those that were solely hospital or clinic based . In the 30 trials that were included in their analysis, they found that reductions in hospitalization were limited to studies that included either a home-based or telephone based component to the intervention.
Our study provides a number of insights for policy makers who are planning the implementation of such disease management systems in other regions. The proliferation of heart failure clinics in Ontario has occurred without specific guidance as to their structure, in part due to the absence of dedicated funding. This has resulted in considerable variation in important components such as education, and the notable absence of key features such as a home-based component or remote monitoring. Our findings are consistent with that seen by Driscoll and colleagues who found substantial variation in the care provided at HF management programs across Australia, raising concerns about the quality of care provided to these patients .
Understanding the association between heterogeneity in clinic model and outcomes such as mortality and re-hospitalization is the logical next step in order to address if quality of care is compromised by this variation in care models. In patients discharged after a HF hospitalization who were treated at HF clinics, we observed a 1-year mortality of 22.8% and a 1-year rehospitalisation rate for HF of 44.2%. There was a striking 1.5 fold variation in mortality between clinics and a 2.5 fold variation in re-hospitalization rates. This highlights the need to identify which clinic-level components are predictive of improved outcomes, such that one can provide clinicians and policy-makers clear guidance when designing specialized HF clinics. These are foci of further research for our group.
Disease management through specialized HF clinics is recommended by guidelines for patients recently hospitalized with HF or at high risk for decomposition [6, 17]. Currently, there is a paucity of data on what proportion of these patients are indeed seen at HF clinics. Although, this study was not designed to address this question, based on our estimates of annual HF discharges in the province and the annual number of new patients seen in HF clinics, it is likely that an only small proportion of appropriate patients are cared for at HF clinics. This is consistent with data from Australia, which suggests only 20% of eligible HF patients are seen at specialized HF clinics . In addition, the catchment area served by each HF clinic (353,800 persons) in our study is larger than that seen in others surveys, such as one in Denmark (1 HF clinic per 115,000 persons) suggesting that there is less access in Ontario compared to other regions [32, 33]. Moreover, our environmental scan suggests that there is substantial variation in access to HF clinics across the province. The absence of specific MOTHLC funding for the HF clinics may be a contributing factor. Elucidation of the underlying mechanisms for this disparity will be important for policy makers.
Our study must be interpreted in the context of several limitations. First, although we used a number of different methods to locate all HF clinics in the province, we cannot confirm that all clinics were in fact identified. We used an instrument to evaluate intensity and complexity; this did not cover all potential service components. Indeed, it does not include post-discharge planning, which has been identified by some studies as a critical component to reduce early rehospitalisation. Finally, although we have categorized clinics into intensity strata based on expert opinion, the relevance of such categories is dependent on their association with improved patient outcomes.
In summary, through our environmental scan, we found that despite the absence of specific governmental funding, there are at least 34 HF multidisciplinary clinics in operation in the province of Ontario. These clinics have a wide range of services offered. Further research on understanding which of these service components are associated with improved patient outcomes will aid policy makers and clinicians to determining the optimal care model for these complex patients.
We acknowledge and thank the contributions of all nurses, administrators and physicians at the participating HF Clinics, in addition to members of the steering committee and ICES advisory group.
Clinic name: MD Nurse & Administrators
Cornwall Heart Failure Clinic: P. De Young and M. Watt
Kitchener-St. Mary's Hospital: S. Smith, D. Lowry, C. Rinne, G. Heckman
Minto Mapleton-Family Health Team: V. LaForge
Credit Valley Hospital: H. Strauss, S. Tierney, J. Cyriac, J. Burtcher, S. Kremer, R. Gandhi, M. Druck, J. Jovanovic, J. Nikhil, K. Nagi, M.Maingi
Burlington Mememorial Hospital: B. Stevens, D. Weber
Hotel Dieu Hospital: J. McCans, P. Staples, W. Earle
Picton-Prince Edward Family Health Team: P. Wattam
University Health Network: H. Ross, L. Belford, D. Delgado, P. Billia, P. Liu, S. Mohammad
Ottawa, H. Haddad, L. Clark, L. Mielniczuk
Trillium A. Gupta, D. Button, D. Harrison, P. Kannampuzha, T. Kalaparambath, M. Kirigin, C. Lazaam, C. LeFeuvre, G. Puley, T. Rebane, B. Sevitt, M. Platinov, I. Singh, R. Watson, S. Tishler, V. fluxar
Orillia Soldier's Memorial Hospital: J. MacFadyen, D. Campbell, S. Crewe, J. Jefferies, D. Bhatt
Georgian Bay Family Health Team: E. Goode, G. Edwards
North York General Hospital: A. Cheng, J. Coldwell, R. James, S. Klein, K. Kwok, B. Lubelsky, P. Myron, R. Rose, M. Strauss, Earl teitelbaum
London Health Sciences Centre: P. Pflugfelder, J. Hoffman
London Health Sciences Centre: M. Arnold, A. Smith
Kitchener New Vision-Family Health Team: A. Horton
Queensway-Carleton Hospital: F. Miller, J. Steele, R. Grewal, T. McKibbin, Lindsey
Ross Memorial: N. Krishnan, C. Follet, D. Kazhila
Mt. Sinai Hospital: S. Mak, A. Schofield, G. Newton, J. Parker, E. Azevedo
Oakville Trafalgar Memorial Hospital: M. Heffernan, J. Orfi, D. McConachie, R. Mao, V. Chiamvimonvat, M. Feneck
South Lake Regional: J. Symmmes, T. Fair, P. Hacker, L. Blair, R. Chun, J. Allen, M. Srivamadevan, J. Habot, M. Thangaroopan
Scarborough-General Site: S. Roth, E. King, J Cherry, E. Davies, A. Rosenbloom, G. Vertes, K. Yared
Mt Forest: K. Shelig, D. Horrigan
Owen Sound-Grey Brice Health Sciences Center: A. Becks
Hamilton Health Sciences Center: R. McKelvie and L. Paul
St. Michael's Hospital: A. Al-Hesayen: G. Moe
Toronto East General Hospital: V. Ovchinnikov and S. Garner
Sunnybrook Hospital: R. Myers
Kitchener Center for family medicine: B. Ruby
Steering Committee: H. Abrams, D. Alter, M. DeMelo, F. Wagner, M. Parry, K. Kingsbury, S. Tierney and M. Arnold
Institute for Clinical Evaluative Sciences (ICES) Advisory: J.V. Tu, P. Austin, X. Wang
Dr. Murray Krahn holds the F. Norman Hughes Chair in Pharmacoeconomics at the Faculty of Pharmacy, University of Toronto. This analysis was funded by funding provided to The Toronto Health Economics and Technology Assessment (THETA) Collaborative by the Ministry of Health and Long-Term Care of Ontario (MOHLTC). The funding organization did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by the Ontario MOHLTC is intended or should be inferred.
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