In 2016, the Spanish Society of Cardiology (SEC) launched the SEC-Calidad project.1–3 SEC-Calidad has since incorporated new projects, such as SEC-Excelente, a quality accreditation program for cardiology departments and units in Spanish hospitals.4 The first process to be developed was that of heart failure (HF),4.5 whose 7-year logistical characteristics and results (2017-2023) were recently published.4

HF is not just a cardiovascular issue but is also a general health concern due to its high and growing incidence and prevalence6,7 and its elevated short- and long-term mortality.8,9 As shown by various clinical registries and the RECALCAR analysis,8–11 the in-hospital mortality of HF in Spain has not decreased in the last 15 years, remaining at about 10% and with major differences among autonomous communities.10,11 This is despite recent major advances in the diagnosis and treatment of HF.12 Long-term mortality remains very high, as do hospitalization and decompensation rates.8,9,12 The SEC-Excelente-IC program is focused on a fundamental aspect in HF care, namely, the organization of multidisciplinary HF programs and units, which is assigned a I A recommendation in clinical practice guidelines.12 The characteristics of each type of unit can be found in the consensus document serving as the basis of the program5; these basic properties have been accepted both in terms of nomenclature and characteristics by a similar accreditation program for HF units subsequently started in Europe by the European Society of Cardiology (ESC).13

As part of the SEC-Excelente program, units requesting accreditation are required to participate in a specific registry of patients followed up in the unit.4 In the present article, we report the results of the first 45 units accredited by the SEC-Excelente-IC program and analyze the characteristics, management, and 1-year outcomes of a contemporary series of patients with HF managed in specific and accredited HF units, as well as the differences among the different types of units.

The design and logistics of the SEC-Excelente-IC program were recently published,4 as well as the characteristics of the 3 types of HF units.4,5 Briefly, community units are located in primary hospitals without cardiology departments or on-site catheterization or electrophysiology capability. Specialized and advanced units are located in secondary or tertiary hospitals, within cardiology departments. The difference between the specialized and advanced units lies in the on-site availability in advanced units of heart transplant programs and long-term circulatory assist devices.5

The scientific committee of the SEC-Excelente-IC program drafted a registry project with a 1-year follow-up that required each accredited unit to include consecutive patients with HF managed in the unit during 2 specific 1-month periods (March and November) for 1 year. The study adhered to the requirements of the Declaration of Helsinki for research involving humans and was approved by the clinical research ethics committee of the Hospital Central de Asturias. All patients provided written informed consent. The present analysis comprises the outcomes of the first 45 accredited HF units, which have already completed a 1-year follow-up. Each participating center included the first consecutive patients with HF managed in their unit in 2 different months (March and October) from 2019 to 2021. Overall, 1716 patients were enrolled. Both hospitalized patients and outpatients with a recent admission (within the previous 3 months) could be included. At the 1-year follow-up visit after inclusion, data were collected on events (deaths, HF hospitalizations, and HF decompensations with or without admission) and treatment changes. We excluded from this analysis patients who died during the hospitalization that prompted their inclusion in the study (32 patients). In addition, 99 patients were lost to follow-up (5.6% of the total), leaving 1585 patients for event analysis (figure 1). There were no differences in loss to follow-up among the 3 types of units (figure 1). Decompensation without need for admission was defined as a visit to the emergency department or HF day hospital due to clinical worsening of the HF that, based on the judgment of the treating physician, required a diuretic dose increase or intravenous therapy with diuretics or inotropic agents, without hospital admission. Follow-up and management of all patients were conducted in accordance with the criteria of their physicians, with no prespecified intervention in the registry protocol.

Figure 1.

Study flow chart for patient inclusion and follow-up. AU, advanced unit; CU, community unit; SU, specialized unit.

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HF is a major health concern in Western countries, with epidemiological findings indicating an even worse outlook in the coming years.14,15 Recent studies indicate a prevalence of 1% to 3%, with an upward trend, due to increases in HF with preserved ejection fraction and a stabilization in the rates of HF with reduced ejection fraction.14 HF incidence ranges between 1 and 20 per 1000 person-years, with an average of 3 per 1000 person-years in Western countries and mortality rates of 15% to 30% at 1 year and 50% to 75% at 5 years.14,15 This is despite major advances in its diagnosis and management in recent decades.9,12 The wider range of treatment possibilities can improve patients’ outcomes and quality of life but also somewhat complicates their management. Consequently, the implementation and development of new health care management models have been critical, such as HF units and programs. Compared with routine health care models, these units have been shown, over many years, to reduce HF hospitalizations and decompensations, and even mortality in some studies.16 They have become the gold standard management approach for patients with this disease, with a class I A indication in clinical practice guidelines.12 However, these programs must meet recommended quality standards, maintain them over time, and achieve the appropriate outcomes.3,5

The SEC has been a pioneer, both in Europe and more globally, in the development of a quality accreditation program for HF units,4,5,17 a program currently being implemented for all member countries by the Heart Failure Association of the ESC.13,18 One of the requirements for quality accreditation in the SEC-Excelente-IC program is the participation of accredited units in a prospective registry permitting analysis of the characteristics of the patients included and monitoring of their outcomes and event rates. The present results of the first 45 units accredited by the SEC in Spain, with 1716 patients included from 2019 to 2021 and followed up for 1 year, confirm the severity of HF. The overall 1-year mortality was 16.9%, with a HF hospitalization rate of 30.4%, a HF decompensation without hospitalization rate of 11.9%, and a total decompensation rate, including hospitalizations, of 42.4%. These figures are comparable to those from the most recent European registries19,20 and clinical trials21 and are better than those from other population-based studies.14,22–24 For example, 1-year mortality was 18% in the ESC-HFA EORP Heart Failure Long-Term Registry19 and 17.4% in the ESC-HF Pilot Survey,20 while annual mortality was 14% in the GALACTIC study.24 In population-based studies, the 1-year mortality was 33% in a Danish registry22 and 18% in a British registry.23 In Spain, the 1-year mortality after HF hospitalization between 2016 and 2019 in the RECALCAR registry, which included more than 178 000 patients admitted to Spanish publicly funded hospitals, was 26.9% and the rate of HF readmissions was 28.4%.24

In-hospital mortality was low in the present study, at only 2.6%, vs 10% in the RECALCAR registry.11 This low mortality may be because patient age was lower in our study than in the RECALCAR registry11 and because our registry specifically included patients admitted to cardiology departments, who have, in addition to a younger age, a worse comorbidity profile and higher mortality. The pharmacological treatment was appropriate and comparable to that of similar studies.19,20,25 In our registry, 74.6% of the patients received angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or valsartan/sacubitril, 56.6% received mineralocorticoid receptor antagonists, 80% received beta-blockers, and 84.6% received diuretics. Given that almost 40% of the patients had HF with preserved fraction, these data are similar to those of the European registry based on type of HF.25 There was a notably low use of SGLT2 inhibitors, used by 40.1%, currently indicated for any type of HF regardless of the ejection fraction.12 This is due to the timing of patient inclusion in the registry.

In the present study, we specifically analyzed the differences among the 3 types of Spanish HF units defined by the SEC-Excellence-HF program4,5 and accepted by the Heart Failure Association of the ESC.13 Although there were some significant differences in the characteristics and management of the patients with HF followed up in the different types of units (community, specialized, and advanced), many of the most important characteristics were relatively homogeneous and management largely adhered to clinical practice guideline recommendations (table 1, table 2, and table 3). The 1-year incidence of major events, including total mortality, HF hospitalizations, and HF decompensations, was significantly higher in community units, with rates 2 to 3 times higher than those of the specialized and advanced units (table 4). This difference was largely due to the better outcomes in the specialized units, as shown in table 4 via a separate comparison of the 3 types of units. Advanced units had a significantly lower mortality than community units but similar incidences of hospitalizations, total decompensations, and a composite of death and HF hospitalization. This could be due to the characteristics of the patients followed up in the advanced units, who may be candidates for heart transplantation or circulatory support implantation owing to their more severe profile. Because specialized and advanced units are more similar to each other in terms of organization and resource access, a joint analysis was performed of both types of units vs community units. The above-mentioned multivariate results indicated that follow-up in a community unit was an independent predictor of worse outcomes (table 5).

Given that all participating units met the quality standards of the SEC-Excelente-IC program, we must consider the reason for these differences because it may have practical implications for the management of patients with HF.

First, as shown in table 1, table 2, and table 3, these results may have been influenced by the significant differences found in certain variables. Patients followed up in community units were older, had a higher prevalence of chronic pulmonary disease, were more likely to have been admitted for HF in the previous year, and were less likely to be receiving valsartan/sacubitril and SGLT2 inhibitors. However, they also had some characteristics theoretically associated with better outcomes, such as a higher proportion of tachycardia-induced cardiomyopathy as the HF etiology, more de novo HF, and a lower prevalence of renal failure. Irrespective of this consideration, follow-up in a community unit remained an independent predictor of higher mortality and hospitalization at 1 year in the multivariate study, as shown in table 5. Management in a specialized or advanced unit was associated with 41% lower mortality (P = .002), 39% fewer HF hospitalizations (P = .012), and 42% fewer HF decompensations vs a community unit.

Thus, there may be other explanations for these striking differences, probably related to the characteristics and functioning of the 3 types of units. As already mentioned and detailed in the document defining the 3 types of units, community units, due to their location in primary hospitals, their smaller size, and their likely lack of cardiology departments and, thus, on-site catheterization and electrophysiology, would have distinct organizational and resource characteristics. In contrast, specialized and advanced units are located in second- or third-level hospitals, within cardiology departments, and have a full services portfolio and the standard resources (catheterization, electrophysiology, and cardiac surgery) and, therefore, a larger number of cardiologists.

Although we did not quantify the number of cardiologists and nursing staff per unit and how many are full-time, how long the units have been operating and their trajectory, or the level of coordination with primary care, these aspects could have influenced the different outcomes. Patient volume may also be higher in specialized units, which may have affected the results. Indeed, in this registry, the mean number of patients included by specialized units was much higher (63.8% vs 16.1%) than in the community units, reflecting the higher volume of patients followed by specialized units. Regardless, we did not analyze the outcomes of patients who were not followed in any unit. Their outcomes would probably have been even worse than those of the community units. The mortality and hospitalization data of these patients were similar to or worse than those found in the above-mentioned population registries.22–24

The data from our study indicate that the establishment of a national accreditation program for HF units by a scientific society is both feasible and durable. Although there are notable differences in the characteristics and management of patients with HF followed up in different unit types (community, specialized, and advanced), many of the most important characteristics are largely homogeneous and management adheres to clinical practice guideline recommendations. Follow-up in a community HF unit was associated with higher rates of mortality, HF hospitalization, and HF decompensation at 1 year vs follow-up in a more specialized unit. Therefore, coordination between care levels and collaboration among different units appears necessary to further enhance outcomes.

The SEC-Excelente-IC accreditation program has been funded by unconditional grants from Servier and Rovi to the SEC. The SEC-Excelente-IC registry has been funded by an unconditional grant from Rovi.

The study adhered to the requirements of the Declaration of Helsinki for research involving humans and was approved by the clinical research ethics committee of the Hospital Central de Asturias. SAGER (Sex and Gender Equity in Research) guidelines have been considered.

Artificial intelligence has not been used in the preparation of this work

All authors have contributed equally to the drafting of this document.

The authors have no conflicts of interest to declare.