HEARTLAND Protocol FHIR Implementation Guide - Compilação de desenvolvimento local (v0.1.0) construída pelas ferramentas de compilação FHIR (HL7® FHIR® Standard). Veja o Diretório de versões publicadas

Background

Background — Why HEARTLAND

The Rural Heart Failure Gap

Heart failure (HF) affects approximately 6.7 million US adults, with rural populations bearing a disproportionate burden. Patients living in rural counties face:

• Distance: Mean distance to cardiology care reaches 87 miles in counties without a cardiologist, compared to 16 miles in counties with one.
• Mortality: One-year mortality after HF hospitalization is approximately 21% in rural HF patients versus 17% in urban — a gap that has widened over the past decade.
• Readmission: 23% 30-day readmission rates persist in rural HF cohorts despite national quality improvement programs.
• Workforce: Critical Access Hospitals frequently operate with one to two nurses and no on-site cardiologist, pharmacist, or dedicated HF program.
• GDMT optimization: Fewer than 1% of US HF patients simultaneously achieve target doses of all four guideline-directed medical therapy (GDMT) classes — and the proportion is even lower in rural settings.

The Implementation Gap

No published implementation protocol provides a comprehensive, operational framework for primary care-led HF management specifically designed for rural and resource-limited settings in the United States.

Existing tools fill adjacent but distinct roles:

• Get With The Guidelines-HF (GWTG-HF) — quality benchmarking platform; not an operational protocol.
• ESC-HF-LT — European registry; not designed for US rural workflows.
• MAGGIC, GWTG-HF Risk Score, SHFM — risk scores that omit distance-to-care and social support despite robust evidence of prognostic relevance.

HEARTLAND closes this gap with a tiered protocol explicitly designed around the realities of low-resource US care delivery.

Three Pillars

1. Tiered Implementation. Three facility tiers (Minimal / Standard / Advanced) match protocol intensity to available staffing and technology. A Critical Access Hospital with 1-2 nurses can begin at Tier 1 with realistic targets; a regional referral center can operate Tier 3 with rapid-sequence GDMT and full RPM.

2. Two Monitoring Tracks. Track A (digital, app-based) and Track B (analog, telephone) follow identical clinical algorithms. The Hozho Trial validated that voice telephone optimization is not a fallback but a primary effective intervention, achieving substantial absolute increases in GDMT class addition.

3. Pragmatic Risk Stratification. The HEARTLAND 10-input risk score (0-18 points) explicitly includes distance-to-cardiology and limited social support — variables omitted from MAGGIC, GWTG-HF, and SHFM despite a 3.74-fold mortality increase associated with perceived social isolation in HF cohorts.

Evidence Levels

Recommendations are labeled to help clinicians calibrate confidence:

• Established — strong guideline support (e.g., SGLT2i for all HF phenotypes per 2022 AHA/ACC/HFSA guideline).
• Emerging — recent trials not yet fully incorporated into guidelines (e.g., finerenone for HFpEF per FINEARTS-HF).
• Pragmatic — tools developed for clinical utility without formal statistical validation (e.g., the HEARTLAND Risk Score itself).

Operational Principles

• Generic Bridge. Generic ACE-I/ARB, beta-blocker, and spironolactone cost approximately $15/month. Generic therapy is superior to no therapy. Never delay treatment while waiting for paperwork.
• Human Filter. All non-emergency monitoring alerts pass through licensed clinician telephone assessment before emergency department referral. Avoids false-positive cascades from raw device alerts.
• Task-Shifting. Clinical decisions remain with licensed clinicians; data collection and education delivery distribute across available workforce (RN/MA, family caregivers, IVR systems).

Citation

HEARTLAND Protocol v3.2. Cureus, 2026. Zenodo DOI 10.5281/zenodo.18566403.