Di Lenarda A

Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study

Background Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile. Setting Heart failure outpatient clinic. Methods Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1–6) was used as an index of global functional impairment. Results Mild to moderate frailty (frailty score = 2–3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4–6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were &U20AC; −1003.31 for frailty score 1 (95% confidence interval −3717.00–1709.00), &U20AC; 1104.72 for frailty score 2 (−280.6–2491.00), &U20AC; 2635.42 for frailty score 3 (352.60–4917.00, P = 0.025) and &U20AC; 419.53 for frailty score 4–6 (−1909.00–2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations. Conclusion This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care.

[ANMCO Position paper: Direct new oral anticoagulants for the prevention of thromboembolic complications in patients with atrial fibrillation: clinical scenarios and future perspectives].

It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.

[ANMCO/SIC Consensus document: The heart failure network: organization of outpatient care].

Changing demographics and an increasing burden of multiple chronic comorbidities in western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of-hospital phases of HF. The needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for hospitalized HF and those followed up at HF clinics.The Working Group on Heart Failure of the Italian Association of Hospital Cardiologists (ANMCO) has drafted a consensus document for the organization of a national HF care network. The aims of this document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among healthcare professionals. In this document, HF clinics are classified into three groups: 1) community HF clinics, devoted to the management of stable patients in strict liaison with primary care, regular re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, 2) hospital HF clinics, that target both new-onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for medicine units and community clinics; 3) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. These different types of HF clinics are integrated in a dedicated network for the management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multiprofessional providers to ensure continuity of care. This consensus document is expected to promote a more efficient organization of HF care, in particular for elderly patients and in transition phases from acute to chronic HF, by networking outpatient cardiology offer and primary care.Changing demographics and an increasing burden of multiple chronic comorbidities in western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of-hospital phases of HF. The needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for hospitalized HF and those followed up at HF clinics.The Working Group on Heart Failure of the Italian Association of Hospital Cardiologists (ANMCO) has drafted a consensus document for the organization of a national HF care network. The aims of this document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among healthcare professionals. In this document, HF clinics are classified into three groups: 1) community HF clinics, devoted to the management of stable patients in strict liaison with primary care, regular re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, 2) hospital HF clinics, that target both new-onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for medicine units and community clinics; 3) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. These different types of HF clinics are integrated in a dedicated network for the management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multiprofessional providers to ensure continuity of care. This consensus document is expected to promote a more efficient organization of HF care, in particular for elderly patients and in transition phases from acute to chronic HF, by networking outpatient cardiology offer and primary care.

Who should implement cardiovascular prevention and health promotion

Diego Vanuzzo1, Clara Pinna2, Simona Giampaoli3, Lorenza Pilotto1, Giorgio Brianti4, Nora Coppola5, Andrea Di Lenarda6, Francesco Antonini-Canterin7, Giancarlo Miglio8, Loris Zanier9, Luigi Canciani10, Romano Paduano11, Doriano Battigelli12, Fabio Samani13, Silvio Brusaferro14 1Centro di Prevenzione Cardiovascolare, AAS 4 “Friuli Centrale”, Udine 2Dipartimento di Prevenzione, AAS 2 “Bassa Friulana Isontina”, Palmanova (UD) 3Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Roma 4Dipartimento di Prevenzione, AAS 4 “Friuli Centrale”, Udine 5Area Promozione della Salute e Prevenzione, Direzione Centrale Salute Friuli Venezia Giulia, Trieste 6Centro Cardiovascolare, AAS 1 “Triestina” e Università degli Studi, Trieste 7Cardiologia Preventiva e Riabilitativa, AAS 6 “Friuli Occidentale”, Pordenone e Sacile 8AAS 3 “Alto Friuli-Collinare-Medio-Friuli”, San Daniele del Friuli, già Epidemiologia, ASS 4 “Medio Friuli”, Udine 9Servizio di Epidemiologia e Flussi Informativi, Direzione Centrale Salute Friuli Venezia Giulia, Udine 10Medico di Medicina Generale, Responsabile Nazionale Area Prevenzione della Società Italiana di Medicina Generale, Codroipo (UD) 11Medico di Medicina Generale, FIMMG Regionale Friuli Venezia Giulia, Trivignano Udinese (UD) 12Medico di Medicina Generale, Formatore Centro Regionale di Formazione per l’Area delle Cure Primarie, Trieste 13Già Direttore Generale, ASS 6 “Friuli Occidentale”, Pordenone, Vicepresidente Nazionale di Federsanità ANCI 14Struttura Accreditamento, Valutazione del Rischio Clinico e Valutazione delle Performance Sanitarie, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine