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HFSA Heart Failure Clinic Database - Survey #2
Please allow about 6 minutes to complete this survey.
*
1.
Facility Information
(Required.)
Facility Name
Facility Address
City
State
Zip
Name of individual providing clinic/facility information
Title of individual providing clinic/facility information
Email of individual providing clinic/facility information
*
2.
At your site, which best describes your clinic?
(Required.)
General HF
Advanced HF
Dedicated HFrEF
Dedicated HFpEF
*
3.
Does your clinic offer hospital-based care, ambulatory, or both?
(Required.)
Hospital
Ambulatory
Both
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4.
What is the primary source and specialty of patient referrals?
(Required.)
Affiliation
Specialty
Source Type
Community
System-based
Other
Cardiologist
General Practitioner
Internal med
Hospitalist
Pulmonologist
CT Surgery
Other
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5.
Among HF patients seen at your clinic, to the best of your abilities, please estimate what percentage fall into these categories?
(Required.)
HFrEF %
HFmEF %
HFpEF %
HCM
*
6.
To the best of your ability, please estimate the average number of patients with Hypertrophic Cardiomyopathy (HCM) your facility manages annually.
(Required.)
None
1-50
51 -100
101-200
>200
*
7.
Do you maintain/participate in registries for the following conditions? (select all that apply)
(Required.)
HCM
Sarcoid
Amyloid
Other
None
*
8.
Does your clinic have the ability to collect co-morbidities for your HF patient population?
(Required.)
Yes
No
*
9.
Would you like to be contacted by the following about future clinical trial opportunities?
(Required.)
HFSA
Clinical trial sponsors
Pharmaceutical companies
Medical device companies
No, I would prefer not to be contacted
*
10.
Does your facility offer medication access through a formulary or onsite pharmacy?
(Required.)
Specialty
Compounding
Other
None
*
11.
What are the pharmacy delivery options available at your facility (in clinic, hospital or infusion center)? (select all that apply)
(Required.)
Buy-and-bill
Specialty pharmacy
Compounding pharmacy
Meds-to-Beds
Other
*
12.
Which medications are administered onsite? (select all that apply)
(Required.)
IV loop diuretic
IV thiazide diuretic
IV inotrope with vasodilator properties
Oral or IV electrolyte replacement
IV iron
Oral potassium binders
TTR amyloid drugs
Subcutaneous Furosemide
None
*
13.
Do you routinely aggregate EMR or registry data for research or quality improvement?
(Required.)
Yes
No
*
14.
Has your facility integrated or begun to integrate AI into practice and how is it incorporated? (select all that apply)
(Required.)
Imaging
ECG
Risk stratification
Remote monitoring
Our facility has not integrated AI
Other (please specify)
*
15.
Which tools/platforms are used to manage and analyze your data? (select all that apply)
(Required.)
REDCap
Microsoft
EPIC
Cerner
Tableau
SAS
SPSS
Python
R
Other
QLIK
None
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