Charity-funded national audit examines access to advanced heart failure treatment

For the first time, a national audit across the UK and Ireland has revealed significant variation in access to advanced heart failure treatments, highlighting a major unmet need for patients who may benefit from lifesaving therapies.

Published in the British Medical Journal subsidiary journal Open Heart, the work was led by the Transplant Cardiology Working Group (TCWG), a collaboration of consultant cardiologists from all heart transplant centres in the UK and Ireland, including Harefield Hospital.  

The audit was funded by Royal Brompton & Harefield Hospital Charity, enabling the first UK‑wide picture of how patients access advanced heart failure care.

Dr Owais Dar, consultant cardiologist at Harefield Hospital, played a key role in the study. Harefield Hospital also acted as the host organisation for data collection and analysis.

Prior to this audit, there was no UK-wide data showing how many eligible patients were being referred for AHF therapies, how appropriate those referrals were, or whether referral patterns varied based on key factors such as geography, gender or age. Estimates of need had previously relied on studies from North America.

The audit reviewed all inpatient and outpatient referrals to advanced heart failure services between  January and April 2024. Its aim was to understand referral patterns, assess equity of access, and determine whether referrals for advanced heart failure therapies were appropriate.

Heart failure occurs when the heart cannot pump enough blood to meet the body’s needs. Advanced heart failure (AHF) refers to patients who continue to experience severe symptoms and poor quality of life despite optimal treatment, defined using specific clinical criteria. 

Treatment options for AHF include heart transplantation (HTx) and left ventricular assist devices (LVAD), an implanted mechanical pump that supports the heart’s function. However, access to these interventions depends on timely and appropriate referral to one of the seven transplant centres in the UK and Ireland. 

In England and Wales alone, there are an estimated 60-70,000 heart failure related hospital admissions each year. While not all patients are suitable for advanced therapies, a substantial number may be eligible, including the 8000 patients aged 18-64. However, currently fewer than 1% (approximately 300 patients per year) receive a heart transplant or LVAD, highlighting a significant unmet need. 

To address this gap, consultants from all UK and Ireland collaborated on this national evaluation of AHF referrals over a 4-month period. The study combined referral data with population census data and the Index of Multiple Deprivation (2019) to examine the impact of age, ethnicity, gender, socioeconomic status and geography. Data analysis was conducted at Harefield Hospital combining multiple datasets to generate new insights. 

During the study period, 416 patients were referred for assessment, with 56% referred as outpatients and 44% as inpatients. Of the 233 outpatient referrals, 29% were considered unsuitable due to factors such as body mass index, poorly controlled diabetes, smoking or alcohol consumption – and a further 44% were considered too well for advanced therapies. This meant that only 63 outpatient patients during this period were appropriate referrals. 

The audit found significant regional variation in referral rates, ranging from 0 to over 30 referrals per million population after adjustment for population size and age eligibility. However, this variation was not linked to distance from a transplant centre or levels of deprivation. Although the study did not assess this, the authors suggest that one possible explanation for the disparity is clinical awareness and local referral culture. The study also identified a gender disparity, with women making up only 1 in 3 patients being assessed for AHF therapies. 

Overall, the findings highlight a lack of standardisation in AHF referral pathways and underline the need for clearer guidance and improved clinical awareness. The findings will be used to inform future service planning, training and referral pathways, helping ensure that patients who may benefit from AHF therapies are identified earlier and more consistently across the UK and Ireland. 

Commenting on the findings, Dr Owais Dar, said: “For the first time, we have data proving what we have long suspected. This inaugural national audit shows marked variation in referrals for heart transplant and LVAD therapy  across the UK and Ireland, highlighting opportunities to improve equity of access, patient optimisation, and service delivery.”