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J Am Coll Cardiol, 2004; 44:1354-1357, doi:10.1016/j.jacc.2004.04.061 © 2004 by the American College of Cardiology Foundation |
* Department of Medicine, Cardiovascular Diseases Section, Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Department of Medicine, Division of Cardiovascular Medicine, Department of Physiology, The Ohio State University, Columbus, Ohio
Manuscript received March 17, 2004; revised manuscript received April 16, 2004, accepted April 27, 2004.
* Reprint requests and correspondence: Dr. Philip B. Adamson, Department of Medicine, Cardiovascular Disease, 920 S. L. Young Boulevard, WP3120, Oklahoma City, Oklahoma 73104 (Email: Philip-adamson{at}ouhsc.edu).
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Specialized training programs for HF management are increasing because more complicated treatment modalities are required, as well as available, to achieve favorable clinical outcomes without relying on protracted and expensive in-hospital management (13–16). Specialized treatment centers that provide frequent follow-up and organized delivery of standard of care therapy, for example, have a dramatic impact on hospital use, re-admissions, and length of hospital stay (14–16). Most HF specialty treatment centers create a multidisciplinary team of providers that includes cardiologists who have a special interest or training in HF management and non-physician providers who follow algorithms to frequently evaluate patients and adjust their long-term medical therapy. The success of specialized treatment centers underscores the importance of applying standard of care medical therapy and demonstrates that patients with HF indeed have hope for a reduction of symptoms and enhanced survival. It also demonstrates that managing a large number of HF patients can be quite labor intensive and complicated. This makes it more difficult to achieve the results of specialty treatment centers in general cardiology or internal medicine practice settings.
To further complicate HF management, recently a new "class" of therapy for HF patients has emerged. In addition to maximal medical care (i.e., drug therapy), devices intended to prevent sudden cardiac death (implantable cardioverter-defibrillators [10]) and cardiac resynchronization devices (biventricular pacemakers [4–9]) reduce morbidity and mortality in appropriate patient populations. Devices under investigation for the treatment of HF include percutaneously applied ventricular assist devices, ultrafiltration, implantable hemodynamic monitoring systems, and others. For example, implanted monitoring systems provide continuous cardiovascular physiologic data that are still experimental, but promise to guide medical management and reduce episodes of severe decompensation in high-risk patients (17–19). As our understanding of opportunities with this new therapeutic class develops, new applications of device therapy in HF are emerging, creating substantially larger groups of patients in whom device therapy is appropriate. Although this is exciting and provides hope for a further reduction of HF morbidity and mortality, it may strain the available workforce qualified to implant devices. General cardiologists implant and follow most pacemakers, whereas most of the implantations and virtually all of the follow-up of implantable cardioverter-defibrillators are the responsibility of electrophysiologists. Electrophysiologists or cardiologists with higher volume pacemaker implant experience usually perform biventricular pacemaker system implantations aimed at cardiac resynchronization therapy. The dramatic increase in the number of implants, along with the expected epidemic of HF patients in the next 30 years, makes it clear that there is a need for larger numbers of providers that are competent in implanting the devices designed for patients with HF. Furthermore, currently an artificial and inefficient disconnect exists between implanting physicians and HF specialists. Many times, implanting physicians do not have specialized training or interest in HF management, and HF physicians do not have specialized training in implant procedures or long-term device management. Coupling an understanding of device therapy, including implantation techniques for some, with competence in HF management and pathophysiology will serve to further advance this very important and growing part of cardiovascular disease management.
Although non-cardiologist providers currently treat most HF patients, several studies demonstrate that specialist care is more likely to conform to consensus standards and produces better outcomes in HF (20–22). This suggests that current training programs for primary care providers (internal medicine and family practice) may not be delivering an adequate understanding of life-saving medical based therapeutic interventions. Device therapies are, then, another layer of complexity in which primary providers do not have expertise as a result of their training programs. That is not to say that primary care providers cannot learn the intricacies of chronic HF management, but specific training programs will be required to establish clinical competency. In the growing epidemic of HF, having more providers who have specialty training will only help deliver standards of care that will meet patients' needs in a cost-efficient manner.
This paper outlines a new curriculum, instituted at the University of Oklahoma Health Sciences Center and in a modified form at the Ohio State University, for training of interventional HF cardiologists and for training internists in HF management. The programs are designed to increase specially trained individuals with competency in the spectrum of complex HF management. We suggest that this pilot curriculum may provide the basis for a successful strategy to provide specially trained providers equipped to manage the growing epidemic of patients with HF. In the future, evaluation methods such as certification of special competency may be required to ensure that providers have appropriate training and clinical experience to treat this very important disease process.
The curriculum suggested calls for cardiovascular disease fellows to complete two years of general cardiology training followed by two years of training in HF management (Table 1). The general cardiology training portion of the HF fellowship conforms to requirements enunciated in accreditation and certification standards for general cardiology (12). In the third year of fellowship, HF training will consist of dedicated management of HF, including administration and supervision of inpatient and outpatient HF treatment programs. The fellow will gain expertise in advanced competency in echocardiography (23), as well as comprehensive medical management of the disease. The second year of training will ensure competency in device implantation and management. The device curriculum requirements will comply with guidelines outlined by the North American Society of Pacing and Electrophysiology/Heart Rhythm Society (NASPE-HRS) (24), including any updated training requirements published in the future. Training will be required to establish both cognitive and technical competency to implant cardiac defibrillators, pacemakers, and biventricular devices. Specific training in the future use of new devices, such as implantable hemodynamic monitoring systems, will be provided by this curriculum.
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In the future, HF management will very likely involve more devices for therapy and monitoring. In that spirit, we submit the suggested training goals for HF specialty fellowship. If a thoughtful approach to meet the needs of the upcoming HF epidemic is not entertained, our health care system is destined to provide substandard, cost-inefficient care, and many patients will continue to miss the benefit of life-saving interventions, including device management.
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P. B. Adamson, W. T. Abraham, C. Love, and D. Reynolds Reply J. Am. Coll. Cardiol., June 21, 2005; 45(12): 2098 - 2098. [Full Text] [PDF]
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