Abstract
Background: The co-existence of cardiopulmonary diseases is common due to shared risk factors, overlap in presenting features and pathophysiological pathways. Chronic obstructive pulmonary disease (COPD) and Heart Failure (HF) are notably leading causes of morbidity and mortality worldwide.1 In line with Sláintecare’s aim2, the Dublin North West Community Specialist Team have pioneered an innovative combined model of care for evaluation and treatment of patients with concomitant cardiopulmonary diseases.
Challenges: Cardiopulmonary disease poses significant diagnostic and therapeutic challenges. Patients with these conditions often face prolonged waiting times for specialist consultations and diagnostic testing. This delay potentially leads to adverse clinical outcomes, including advanced disease severity at presentation, increased risk of exacerbation and hospital admissions.
Methods: We piloted an Integrated Cardiopulmonary Clinic. This is an innovative interdisciplinary clinic, where patients are assessed concomitantly by consultants, nurses and physiotherapists from both specialties. During their clinic visit patients also had pivotal cardiopulmonary diagnostic testing performed. A comprehensive treatment plan was then formulated following an in-depth multidisciplinary discussion, wherein diverse perspectives and expertise converged to manage this patient cohort with complex needs. The inaugural clinic took place in April 2023 and is held monthly.
Results: Over a 6 months period, five clinics were conducted with 20 patients attending (male 12: female 8). The majority of patients were ex-smokers and patient’s age ranged from 50 to 84 years. Referrals to the clinic were mainly for assessment of undifferentiated breathlessness (60%) and recurrent exacerbations of premorbid cardiorespiratory disease (35%). The cardiorespiratory cases were either COPD with ischemic heart disease (IHD) +/-HF (50%) or obstructive lung disease with cardiac risk factors (50%). In this cohort, 75% had at least one exacerbation and 45% had prior hospitalisations in the previous 12 months. Comprehensive assessment resulted in new respiratory diagnoses of COPD (40%), asthma (5%), and dysfunctional breathing (10%) while cardiac diagnoses included HF (30%), IHD (10%), hypertension (15%) and valvular heart disease (5%). New cardiorespiratory diagnoses were identified in 30% of patients. The majority of patients required further investigations (85%). Onward referrals were made as appropriate to multidisciplinary specialist clinics to address risk factor modification, HF medication titration, inhaler optimisation, oxygen review and rehabilitation. Notably, this novel approach has improved scheduling efficiency, minimizing the need for multiple appointments and promoting sustainability with positive feedback.
Conclusion: The establishment of this Integrated Cardiopulmonary Clinic has resulted in the delivery of holistic care leading to optimised care pathways. This collaborative approach with dynamic interchange of expertise has enriched the decision-making process and also facilitated timely and efficient management of these patients with complex needs. We envisage that this high quality service will deliver long-term positive health and financial outcomes.
Future Steps: Cardiopulmonary diseases can be treated in a joint clinic setting with significant symptomatic and prognostic benefits. This initiative aims to achieve timely diagnostic accuracy, reduce exacerbations and hospitalisations leading to improved prognosis. Additionally, similar joint clinics could potentially be implemented in all specialist ambulatory care hubs, resulting in improved chronic disease management.