A heart failure network model to improve outcome and trans-sectoral guideline-directed medical treatment utilization

Heart failure (HF) is a major cause of hospitalization, mortality and healthcare costs. Reducing its socioeconomic burden is a key global public health priority. HF networks are recommended to improve screening and management of HF patients. We developed and implemented a multi-sectoral HF network in Northern Germany aimed at optimizing patient outcomes.

A regional HF network was established by integrating 12 pre-existing local networks into a state-wide, multi-sectoral HF network. Data from HF-coded patients were analysed for two time periods: pre-implementation (2018-2020) and post-implementation (2021-2023). Patient trajectories through the healthcare system were examined using both inpatient and outpatient datasets. We report on the network's implementation across urban, island and rural areas, along with associated challenges and benefits. A roadmap of HF patient trajectories was created, identifying key healthcare entry points and informing a three-pillar theory of change to address the national HF burden. Post-implementation, outpatient treatment cases increased markedly (2018-2020 n = 1237 vs. 2021-2023 n = 2563; +101.3%, P < 0.001), as did referrals from specialists (2018-2020 n = 290 vs. 2021-2023 n = 434, +49.7%, P = 0.013), general practitioners (2018-2020 n = 369 vs. 2021-2023 n = 435, +17.9%, P = 0.26), and inpatient admissions (2018-2020 n = 2342 vs. 2021-2023 n = 2608, +20.7%, P = 0.03). HF rehospitalization rates showed no significant difference yet despite a positive trend (2018-2020 20.3% vs. 2021-2023 17.9%; P = 0.295), while in-hospital mortality remained stable (2018-2020 8.8% vs. 2021-2023 10.2%; P = 0.1).

Implementation of a novel multi-sectoral HF network enabled the analysis of patient trajectories and identification of areas for improvement in HF care. Observed shifts in referral patterns and increased treatment activity indicate early positive trends that support the potential of such networks in enhancing HF management and reducing disease burden.