New heart failure certification plan gains momentum: subspecialty will target advanced cases.

WASHINGTON -- Plans to accredit training programs and certify cardiologists in a new secondary subspecialty of advanced heart failure and transplantation cardiology are meant to improve the care of patients who have the most complicated forms of heart failure, according to physicians involved in the process.

Some general internists have expressed concern about the new subspecialty, citing the potential for further erosion of their scope of practice, their perceived expertise, and the continuity of patient care. (See commentary on p. 7.) But cardiologists specializing in heart failure told INTERNAL MEDICINE NEWS that such concerns can be allayed through a better understanding of the reasons behind the subspecialty's development.

Dr. Barry Greenberg, president of the Heart Failure Society of America (HFSA), commented that "these concerns are ones that come up not infrequently when people first hear about the concept, but once they learn about what's intended, it really melts away," especially in light of the soaring caseload of heart failure, which will require continued involvement by general internists.

The effort to officially develop the subspecialty reflects an ongoing movement toward greater specialization in the treatment of advanced heart failure in hospitals around the country, in conjunction with recent advances in drugs and devices. Dr. Greenberg and others started the process to formalize the subspecialty to ensure that it "was developing in a logical and cohesive manner," he said in an interview.

Previously, "a lot of the device companies and pharmaceutical companies were beginning to ... anoint people as heart failure specialists because they had some expertise or training or interest in a particular area of heart failure," said Dr. Greenberg, director of the advanced heart failure treatment program at the University of California, San Diego. "That's really a bad direction to be going in, because the complexity of management now and the opportunities for doing different things are so vast that we don't want this to be oriented toward somebody who simply goes in one direction."

Dr. M. Douglas Leahy, an internist at Summitt Medical Group in Knoxville, Tenn., said that further subspecialization could jeopardize the coordination of care between internists and subspecialists.

"Care coordination is crucially important," Dr. Leahy said. "The concern I think a number of us have is that if you start carving this out, then these patients are running to every doctor in town, and then each doctor often doesn't know what the other doctor is doing and sometimes their therapies are in conflict with each other."

The prevalence of heart failure in the United States is projected to increase from 5.2 million in 2004 to 30 million in 2037. The number of hospital discharges, which grew from 700,000 in 1990 to 1.02 million in 2004, is expected to continue rising. The estimated total annual cost of U.S. heart failure treatment is nearly $29 billion, although the true societal costs are probably substantially greater, Dr. Greenberg said.

With few heart failure specialists to go around, "even if this were successful beyond my wildest dreams, it would never cut into the practice of an internist," he said. "There are so many of these patients that the internist will still be the primary person taking care of these individuals. What we would like to develop over the next several years ... is a partnership between the primary care and internal medicine physicians and the heart failure specialists."

General internists can do a thorough job in caring for patients with "run-of-the-mill congestive heart failure ... but really ill patients can be best served probably by someone who has the capability to consider" advanced therapies, Dr. Leahy said.

Dr. James Young, chairman of the division of medicine at the Cleveland Clinic, agreed. "If you look at some of the guidelines that have been put together to support the creation of this subspecialty, one big thing in there is physician education about when you should refer a patient to a heart failure specialist." Heart failure specialists should be taking care of severe cases that require aggressive therapies, he said.

"These were patients that internists were referring to cardiologists in the past," Dr. Greenberg added. "Now they have a specific pathway for sending these patients to heart failure specialists."

Dr. Ali Ahmed, an internist and geriatrician who is director of the geriatric heart failure clinic at the University of Alabama at Birmingham, suggested in an interview that internists may want to refer new patients to heart failure specialists or cardiologists if they are unsure about the diagnosis or cause of the heart failure, or if the clinician is unsure about optimal treatment choices.

Rationale for the Subspecialty

Cardiovascular disease-related deaths and morbidity have declined and flattened out in recent decades, but heart failure-related deaths have continued to rise, "which has translated into an increasing number of hospitalizations," said Dr. Marvin A. Konstam, chief of cardiology at Tufts-New England Medical Center, Boston. This pattern of disease--as well as the "rainbow of therapies" that will be coming in the next decade--"calls out for specialization."

In July 2007, the American Board of Internal Medicine agreed to certify physicians in the new subspecialty of advanced heart failure and transplantation cardiology. The next steps involve obtaining approval from the American Board of Medical Specialties and developing training program requirements with the Accreditation Council of Graduate Medical Education.

The American Board of Internal Medicine also will need to write the certifying examination and create "grandfather" criteria for board certification of physicians who already consider themselves heart failure cardiologists, said Dr. Mariell L. Jessup, medical director of heart failure and cardiac transplantation at the Hospital of the University of Pennsylvania, Philadelphia.

Certification would require 1 additional year of training in an ACGME-accredited advanced heart failure and transplant cardiology program or, during the initial 3-5 years of the subspecialty, a written statement describing the candidate's previous clinical experience in order to be grandfathered into certification and allowed to take the exam, according to Dr. Jessup. She, Dr. Greenberg, Dr. Konstam, and other heart failure specialists spoke about the new subspecialty at the annual meeting of the HFSA.

Mortality in heart failure patients continues to be "unacceptably high," with an average survival of less than 15% over 5 years in one study. Much of the recent improvement in survival is in patients with reduced, rather than preserved, ejection fraction (N. Engl. J. Med. 2006;355:251-9), Dr. Greenberg said.

Subspecialists in heart failure could help to better use evidence-based drug treatments and devices such as implantable cardioverter defibrillators (ICDs); these interventions are substantially underused. But tailoring treatment to individual patients has become difficult because "the palette from which we choose our therapy and we select our strategies is a lot more complex than it was just a few years ago," Dr. Greenberg said.

Cardiologists manage about 17% of heart failure patients, compared with 43% managed by internists, 29% by family physicians, and 11% by other specialists. Cardiologists have been shown to measure left ventricular ejection fraction significantly more often than do primary care physicians, while also prescribing ACE inhibitors and [beta]-blockers significantly more often to patients with an ejection fraction of less than 45%. These practice patterns have been shown to result in significantly fewer deaths and cardiovascular hospitalizations with cardiologists than with primary care physicians (J. Am. Coll. Cardiol. 2003;41:69-72).

Another study measured differences in practice patterns between heart failure specialists and cardiologists in treating patients with mild to moderate chronic heart failure. Heart failure specialists prescribed medications associated with better outcomes significantly more often than did cardiologists. But the key difference was that heart failure specialists prescribed target doses of ACE inhibitors significantly more often than did cardiologists, Dr. Greenberg said at the meeting.

Also, evidence points to a treatment gap between patients with mild to moderate versus advanced chronic heart failure. Investigators in the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study found that patients with high-risk chronic heart failure were less likely than were low- and average-risk patients to receive ACE inhibitors, angiotensin II receptor blockers, and [beta]-blockers at hospital discharge and 90 days after discharge (JAMA 2005;294:1240-7).

Training of New Subspecialists

"Advanced heart failure is going to stay [at major medical centers] because of the complexity of these procedures, [which] drive all of these other areas--interventional cardiology, electrophysiology, imaging, and cardiac surgery," said Dr. Konstam, immediate past president of the HFSA. The new subspecialty model will "differentiate large medical centers from community-based partners."

In a 2005 survey of 170 U.S. cardiology training programs that was conducted by the HFSA, 45 of them already had advanced heart failure training programs and another 17 were considering starting such a program, Dr. Jessup said.