Practices of Referring Patients to Advanced Heart Failure Centers

Background: Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers. Methods: We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients' demographics, referring providers' characteristics, referral circumstances, and evaluation outcomes were collected. Results: The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1-3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly. AHF therapies were not offered because patients were too sick (38.0% 45.1%) or for psychosocial reasons (20.3%-28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy. and 14.5% were referred to hospice. Conclusions: In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.

Automated summary

The majority of referrals for advanced heart failure therapies came from heart failure cardiologists, with a prevalence of late referrals in high-risk patients. Patients referred by heart failure cardiologists were more likely to be offered AHF therapies. Late referrals correlated with worsened outcomes, highlighting the need for education among clinicians regarding the benefits and appropriate timing of referrals to AHF centers.