IMPLEMENTATION OF AN INPATIENT CARDIOLOGY SERVICE IN GUYANA TO IMPROVE HEART FAILURE OUTCOMES: PRELIMINARY ANALYSIS

Abstract

Improved control of communicable diseases and longer life expectancy in low and middle income countries (LMICs) has resulted in an increased prevalence of cardiovascular disease. Heart failure (HF) represents a significant proportion of this growing burden but there remain significant limitations in both resources and capacity for treating HF in LMICs. Guyana is a small nation of 771 000 people that illustrates the growing need for organized cardiovascular care in these settings. In partnership with the Libin Cardiovascular Institute, a multi-disciplinary inpatient cardiology service and cardiac intensive care unit was implemented at the Georgetown Public Hospital (GPH) in January 2016 to improve cardiovascular outcomes. We conducted an interrupted time-series cohort study of patients admitted with a primary diagnosis of HF. Our two cohorts included patients admitted between January 1, 2015 and December 31, 2015 (before implementation) and those admitted between July 1, 2016 until April 26, 2017 (after implementation) with a period to account for service implementation. Manual chart review was performed in the pre-implementation cohort to confirm the primary diagnosis and establish presence of outcomes. Outcomes of interest included length of hospitalization, medication at discharge, readmission rates, in-hospital mortality and 90 day mortality. An online database was designed to summarize hospital stays for both cohorts and capture post-implementation outcomes. We identified 405 patients admitted with a primary diagnosis of HF with mean age 59.4± 15.8 and 56% being female. There were 201 (49.6%) patients admitted in the pre-implementation period. Patients admitted post-implementation were hospitalized for a similar duration (8.2 days vs 9.2 days, p=0.36) and had similar in-hospital mortality (2.9% vs 5.5%, p=0.15) and 90-day readmission rates (16.7% vs 11.0%, p=0.11) compared to patients admitted before service implementation. However, they were more likely to be discharged on a beta-blocker (66% vs 38%, p < 0.01) or mineralocorticoid receptor antagonist (32% vs 13%, p < 0.01) and less likely to die within 90 days (3.4% vs 8.0%, p=0.04). Implementation of a multi-disciplinary cardiology service in Guyana reduced the incidence of death at 90 days as well as other key performance indicators. While readmission rates were not affected, this may be related to improved follow-up after hospital discharge. This preliminary data suggests that building capacity in chronic disease care, in this case a dedicated inpatient heart failure service, has the potential to significantly bridge care gaps and encourage use of guideline-directed medical therapy in LMICs.