Management of Heart Failure in Belgium (2001)

The overall population in Belgium is estimated to be approximately 11 000 000 people. In 1995, 15% of the population were more than 65 years of age. Heart failure in Belgium, as in other countries, is a common, disabling and lethal condition, which represents a major economic burden for the public health sector. Direct costs incurred by heart failure represent 1–2% of the total expenditure of the public health sector. The percentage of these costs, linked to hospitalisations, is more than 60% and the cost of medication is nearly 6%. The costs are a function of the severity of heart failure. The evaluation of the severity and incidence of heart failure remains difficult because of the lack of agreed definition, making its diagnosis difficult. What we know is that the incidence and prevalence of the heart failure syndrome are increasing in our greying population. Based on the Diagnostic Related Groups (DRG) provided by the Health Ministry, patients with heart failure represent, for 1998, 21 766 hospital admissions with an average hospital length of stay of 14.5 days. This is a slight increase compared with 1997. Health care in Belgium is a combination of a private and public system. The rate for reimbursement for examinations, hospitalisation and treatment is decided by the National Institute for Health and Disability Insurance (NIHDI). The NIHDI is essentially made up of state representatives (politicians), public health insurance companies and doctors. The doctors may or may not be totally or partially connected to an agreement with the NIHDI. According to this agreement, they must respect the set price for each examination and consultation. In return, they are entitled to some benefits, especially in cases of incapacity or in retirement. For each consultation, examination and hospitalisation, the majority of the expense will be covered by health insurance companies for salaried employees (for non-salaried employees only hospitalisation costs are covered). People can take out extra insurance to reduce their contribution to these costs, or to avoid supplementary costs when their doctors are not party to the agreement. Having health insurance is a legal obligation in Belgium. Patients are free to choose their general practitioner (GP). The new trend is that only one GP collates the medical data for a patient and refers them to different specialists if needed. Patients receive better reimbursement for ‘loyalty’ to one GP. In Belgium, hospital financing is determined by complex rules based partly on Diagnosis Related Groups (DRG). The NIHDI, which does not have access to the statistics relating to diagnoses and treatment, has reconstructed different DRGs using financial information from hospital bills. The average costs and the average length of stay for a group of conditions (e.g. heart disease) in terms of hospitalisation can be estimated using the administrative data collected for the DRG, or the information collected by the health insurance companies. With regard to treatment, the reimbursement for medication is decided upon by the NIHDI and in some cases this compensation is subject to certain conditions, which must be verified by the doctor. For instance, angiotensin converting enzyme (ACE) inhibitors, can be prescribed if another prior treatment has proven inefficient for the treatment of heart failure (diuretics, digoxin,…). In the same way, angiotensin II receptor antagonists are not recognised for their use in the treatment of heart failure. Therefore, the medication can be prescribed but will not be reimbursed. In terms of prevention, statins are not covered if the total cholesterol is <250 mg/dl even in patients with ischemic heart disease. These limitations make it difficult to implement guidelines, especially for heart patients who receive multiple treatments. The fact that some effective medication is not covered can make the total cost unaffordable, and lead patients to refuse treatment. Moreover, a social decision has to be made: how far can we go to improve quality of life (QOL), to prolong lifetimes (which will probably increase costs)…? Excepting the patients, not only doctors but three other major players have a role in this decision, each with very different aims. The public and private insurance companies will consider this choice in terms of costs and bonuses. The State, represented by the NIHDI, will see it in terms of social and financial regulation. The health partners, like hospitals and pharmaceutical industries, will think in terms of costs, but also about the important role of employment. Finally, the doctors will consider ethics and QOL. The management of HF in Belgium is very different according to the category of heart failure patients. This will be discussed hereafter in details for each category of patients. In general, the medical infrastructure is represented by GPs, office-based cardiologists or internists and hospitals. GPs constitute the primary care for patients with heart failure in a great majority of the cases. In a questionnaire based on a paper published a few years ago by Edep and co-workers 1, distributed to 150 GPs, 70% of them assume to diagnose and manage HF alone in patients class II–III against 25% cardiologists and 5% internists or geriatricians. It falls to 40% in patients with class more than III. Eighty percent of the GPs use ECG and chest X-rays to confirm the diagnosis as a first choice test, 62% refer the patients for an echocardiogram and 70% will give ACE inhibitors as first line therapy. Cardiologists will more often ask for an echocardiogram, stress test and cardiac catheterisation. Actually, there are no cardiologists specialised in the clinical management of HF in Belgium and there are no HF clinics, although it has been recently suggested 2. There is a working group of the Belgian Society of Cardiology devoted to heart failure. There are approximately 25 centres performing cardiac surgery in Belgium but the trend is to reduce the number of surgical centers by imposing normative limits in terms of minimal number of interventions by centre. There are seven centres performing heart transplantation, with a total number of heart transplantations of approximately 100/year (120 in 1999). The mean delay to transplantation is 6–8 months. Since 1990, the age of the donors has increased by 10 years 3. Approximately 8% of the patients on the waiting list will die before transplantation. Less than 10% of the patients arrive with an implantable defibrillator to the transplantation. The long term ventricular assistance devices are reimbursed only for patients on the waiting list (with a total number <20/year). Asymptomatic left ventricular dysfunction is usually under-diagnosed. Diagnosis is made because of other concomitant conditions (e.g. history of ischemic cardiomyopathy, valvular heart disease), or during screening for the complications of other diseases such as hypertension. For the assessment of these diseases, patients will often have an echocardiograph performed. This will identify left ventricular dysfunction. The cardiologist, inside or outside the hospital, is therefore the first one involved in the diagnosis of these asymptomatic patients. On the other hand, many patients make little of their complaints or decrease their level of activity so that their symptoms remain undetected. These patients can be classed in the same group and the diagnosis is often made late. In this group of patients, left ventricular dysfunction is also often diagnosed on the basis of more systematic examinations carried out when patients are hospitalised for other reasons (e.g. enlargement of the heart during pre-operative chest X-rays). Therefore, these patients are most often diagnosed by the resident cardiologist or intern, using the echocardiogram, radionuclide ejection fraction or gated SPECT. If the patient is mobile, the specialist will suggest a treatment that either he will initiate, or the GP, who will follow the patient's progress and will adapt the treatment according to the response. Further examination to reassess the patient will usually be carried out under specialist advice, or following a deterioration in the patient's condition. If the patient is hospitalised at the time of diagnosis, the treatment will be initiated by the specialist and then followed and adapted by the GP's in the same way. A precise evaluation of the percentage of drugs used in patients with asymptomatic HF is very difficult, due to the role and the intensity of the underlying disease (hypertension, ischemic cardiomyopathy, etc.), the degree of left ventricular dysfunction (systolic, diastolic or both) and the role of concomitant disease (diabetes,…). Most of the time symptomatic heart failure is suspected by the GP on a clinical basis, especially in patients with a higher degree of symptoms (more than NYHA class I–II). The GP can also perform and interpret an ECG on their own and diagnose ventricular dysfunction in patients with symptomatic complaints and ECG abnormalities. In order to confirm the diagnosis, laboratory examinations, chest X-rays and echocardiographs are widely available in surgeries and hospitals. GPs can have their diagnosis of heart failure confirmed without any specialist advice if they ask only for examinations not carried out by these specialists (e.g. only chest X-rays), and therefore initiate the treatment by themselves. However, most of them ask for an echocardiograph, which is non-invasive and widely available. Radionuclide examinations are usually performed in hospital centres, and these investigations are requested by cardiologists, interns or geriatricians for out-patients or during hospitalisation, and are rarely ordered first by a GP. Within this group, the treatment can be initiated by the GP alone or with the advice of a specialist. They will assess the patient and decide whether a more complete evaluation is required or not, and if the treatment needs to be adapted. This is done on a clinical basis, with or without the advice of a specialist. Usually, if the symptoms and the signs are becoming worse, despite modification of treatment, or when patients are developing the higher class of heart failure, the GP refers the patient to a specialist for further examination and different treatment. If a spell in hospital is necessary, the treatment will be modified by the resident specialist and then followed by the GP. As regards non-medical treatment of heart failure (revascularisation, heart transplantation, multiple sites pacing, laser therapy, valve replacement, etc.), further investigations are usually ordered by hospital cardiologists and the patients are transferred to cardiology centres that are able to perform such therapeutic techniques. Similarly, concepts such as myocardial viability are well known in Belgium by cardiologists, but clinical investigations in this field are mainly conducted in hospitals, and rarely at the request of a GP or private cardiologist. Based on the recently published data from the PRIM II trial 4, digoxin is prescribed by Belgian cardiologists in 60% of the patients with moderate to severe HF, high dose of diuretics in 4%, amiodarone in 20%, high dose of ACE inhibitors in 15%, beta-blockers in 10%, calcium antagonists in 2%, anticoagulation in 22% (18% in atrial fibrillation), antiplatelet agents in 32% and nitrates in 35%. In this trial 92% of the patients have received ACE inhibitors due to protocol. Treatment by ACE inhibitors is usually prescribed in this group of patients (estimated to be approx. 60%), <15% of the patients will receive beta-blockers, however beta-blockers are directly prescribed by the GPs in a minority of the patients. In this group the patients are often referred, possibly by their GPs, to the hospital emergency service where they are evaluated and treated. Knowledge in this field is directly related to the availability of information. In Belgium, many cardiologists have been involved in papers contributing to the better comprehension of ‘diastology’, and to the understanding of the clinical impact of left ventricular diastolic function. Through national conferences and many international publications, the cardiological community has been well informed about this concept and about the possibility of easily performing a non-invasive evaluation of the diastolic function using echocardiography. Unfortunately, the concept has not been transmitted to GPs, who are unfamiliar with heart physiology and filling waves observed with catheter and echodoppler. Therefore, this group of patients is essentially covered by cardiologists. The management of heart failure must take into account the role of the different actors and the choice of society of these actors that could dramatically influence the way to approach the disease. There are no large survey studies available in Belgium regarding the epidemiology of heart failure syndrome. However, some of the hospital data that are available from the costs and administrative data at the level of the NIHDI and of the insurance companies give relevant information regarding epidemiological evolution of the disease. There is no multidisciplinary intervention program or shared-care program (with primary nursing) in place in Belgium for the management of heart failure. The future would be a long-term and multidisciplinary approach to maintain the patient's well being and reduce hospital admissions and costs. On the other hand, the identification of asymptomatic patients at high risk of heart failure to prevent the development of clinical heart failure in structured care will improve the prognosis and well being of our patients.