Novel primary care-led shared care program provides effective care for stable heart failure patients
V Panday, R Wong, Y C Lim, P I N G Chai, L F Ng, J E A N N E Ong, T O N Y Li, J I R E H Ong, M E L Tan, Y S Kwan, W H Tan, L Y Ng, T W Lim, W Q LinAbstract
Introduction
In Singapore, the rising prevalence of heart failure (HF) among a rapidly ageing population has led to an exponential increase in demand for HF specialist clinic services, leading to a strain on the specialist clinic services. The Heart Failure Shared Care programme (SC) was conceptualised in September 2024 to facilitate the joint management of patients with stable heart failure between HF specialists and primary care providers (PCP). This allows for HF patients to be seen at longer intervals at specialist clinics and thereby freeing up capacity.
Aims
We aimed to evaluate the effectiveness of SC in managing stable HF patients, assessing factors such as cardiovascular risk factor (CVRF) control, guideline-directed medication therapy (GDMT) utilisation and safety signals of unplanned clinic review and hospital admission.
Methodology
A retrospective analysis of patients enrolled under the SC programme from 16th September 2024 to 8th October 2025 was conducted with events monitored until 14th October 2025. The outcomes were CVRF control and medication utilisation. The outcomes were assessed at 3 time points: (1) 1 year prior to enrolment, (2) at time of enrolment to SC programme and (3) at follow-up.
Results
Figure 1 outlines the SC model. Under the SC programme, HF patients were reviewed by PCP every 4 to 6 months with an annual review by the HF specialist. Table 1A describes the characteristics of patients enrolled. A total of 88 patients were enrolled, with the majority being male. Majority of patients had reduced ejection fraction, with ischemic cardiomyopathy being the predominant aetiology. Table 1B highlights the CVRF control and medication utilisation at different timepoints. There was a significant improvement in low-density lipoprotein (LDL) from 1 year ago, to enrolment, to follow-up (2.40 ± 2.28mmol/L vs 1.92 ± 0.754mmol/L vs 1.69 ± 0.620 respectively, p= 0.0360). Hypertension and diabetes control was similar across different timepoints. There was no significant difference in utilisation of GDMT and adjunct therapy between different timepoints (GDMT utilisation: 36, 62.1% vs 39, 67.2% vs 38, 65.5% respectively, p= 0.838). As depicted in Table 1C, no increase in safety signals of unplanned specialist clinic review or hospitalisation were observed. There was no mortality observed during follow-up.
Conclusion
The SC programme provides effective care in stable HF patients. A high standard of GDMT use was maintained at 1 year follow-up in our SC programme. Lipid management improved during follow-up. The programme appears to be safe with no safety signals and mortality observed.Heart Failure Shared Care ProgrammeFor image description, please refer to the figure legend and surrounding text.Table 1For image description, please refer to the figure legend and surrounding text.