LETTERA DI DIMISSIONE

DIAGNOSI FATTORI DI RISCHIO DECORSO CLINICO LA CONDIZIONE DI RISCHIO DEL

PAZIENTE LA DIETA SUGGERITA L’ATTIVITÀ FISICA

CONSIGLIATA LA TERAPIA SUGGERITA IL CALENDARIO DEI PROSSIMI

APPUNTAMENTI

Ospedale

Cardiologo

ambulatorialeMMG

paziente

PROGRAMMAZIONEPROGRAMMAZIONE

PROGRAMMAZIONEPROGRAMMAZIONE

CONDIVISIONECONDIVISIONECONDIVISIONECONDIVISIONE

CONTINUITA’ ASSISTENZIALE

CONTINUITA’ ASSISTENZIALE

CONTINUITA’ ASSISTENZIALE

CONTINUITA’ ASSISTENZIALE

Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease

L. Kristin Newby, MD, MHS; Nancy M. Allen LaPointe, PharmD; Anita Y. Chen, MS; Judith M. Kramer, MD, MS; Bradley G. Hammill, MA; Elizabeth R. DeLong, PhD; Lawrence H. Muhlbaier, PhD; Robert M. Califf, MD From the Duke Centers for Education

and Research on Therapeutics at the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. CIRCULATION 2006

Use of evidence-based therapies for CAD has improved but remains suboptimal. Although improved discharge prescription of these agents is needed, considerable attention must also be focused on understanding and

improving long-term adherence.

IMPACT OF MEDICAL THERAPY DISCONTINUATION ON MORTALITY AFTER MYOCARDIAL INFARCTION

PM Ho, JA Spertus, FA Masoudi, KJ Reid, ED Peterson, DJ Magid, HM Krumholz, SJ Rumsfeld

Arch Intern Med 2006

Medication therapy discontinuation after MI is commun and occurs early after discharge. Patients who discontinue taking evidence-based medications are incresed mortality risk.These findings suggest the need to improve the transition of care from the hospital tooutpatient setting to ensure that patients continue to take medications that have mortalitybenefit

Kaplan-Meier survival curve comparing patients discontinuing

use of all medications at 1 month with patients continuing use

of 1 or more medications among patients discharged with all 3

medications (log-rank test, P<.001).

Kaplan-Meier survival curve comparing patients discontinuing use of all

medications at 1 month with patients continuing use of 1, 2, or all 3 medications

among patients discharged with all 3 medications (log-rank test, P<.001).

RELATIONSHIP BETWEEN ADHERENCE TO EVIDENCE-BASED PHARMACOTHERAPY AND LONG-TERM MORTALITY AFTER

ACUTE MYOCARDIAL INFARCTION

JAMA 2007

Jeppe N Rasmussen, Alice Chong, David A. Alter

JAMA 2007

ADHERENCE WITH STATIN THERAPY IN ELDERLY PATIENTS WITH AND WITHOUT ACS

CA Jackevicius, MM Pharmd, JV Tu

JAMA 2002

Context  Landmark clinical trials have demonstrated the survival benefits of statins, with benefits usually starting after 1 to 2 years of treatment. Research prior to these trials of

older lipid-lowering agents demonstrated low levels of 1-year adherence. Objective  To compare 2-year adherence following statin initiation in 3 cohorts of patients:

those with recent acute coronary syndrome (ACS), those with chronic coronary artery Disease (CAD), and those without coronary disease (primary prevention).

Design and Setting  Cohort study using linked population-based administrative data from Ontario.

Patients  All patients aged 66 years or older who received at least 1 statin prescription between January 1994 and December 1998 and who did not have a statin prescription in the prior year were followed up for 2 years from their first statin prescription. There were

22 379 patients in the ACS, 36 106 in the chronic CAD, and 85 020 in the primary prevention cohorts.

Main Outcome Measures  Adherence to statins, defined as a statin being dispensed at least every 120 days after the index prescription for 2 years.

Results  Two-year adherence rates in the cohorts were only 40.1% for ACS, 36.1% for chronic CAD, and 25.4% for primary prevention. Relative to the ACS cohort, nonadherence was more likely among patients receiving statins in the chronic CAD (relative risk [RR], 1.14; 95% CI, 1.11-1.16) and primary prevention cohorts

(RR, 1.92; 95% CI, 1.87-1.96).

Conclusions  Elderly patients with and without recent ACS have low rates of adherence to statins. This suggests that many patients initiating statin therapy may receive no or limited benefit from statins because of

premature discontinuation.

Nutritional Counseling

Weight Management

Blood Pressure

Lipid Management

Diabetes Management

Tobacco Cessation

Psychosocial Management

Physical Activity Counseling

Exercise Training

The (cost-)effectiveness of an individually tailored long-term worksite health promotion programme on physical activity and nutrition:

design of a pragmatic cluster randomised controlled trialSuzan JW Robroek1    , Folef J Bredt2     and Alex Burdorf1    

1Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands2LifeGuard Inc., PO Box 1366, 3500 BJ Utrecht, The Netherlands

BackgroundCardiovascular disease is the leading cause of disability and mortality in most Western countries. The prevalence of several risk factors, most notably low physical activity and poor nutrition, is very high. Therefore, lifestyle behaviour changes are of great importance. The worksite offers an efficient structure to reach large groups and to make use of a natural social network. This study investigates a worksite health promotion programme with individually tailored advice in physical activity and nutrition and individual counselling to increase compliance with lifestyle recommendations and sustainability of a healthy lifestyle.Methods/DesignThe study is a pragmatic cluster randomised controlled trial with the worksite as the unit of randomisation. All workers will receive a standard worksite health promotion program. Additionally, the intervention group will receive access to an individual Health Portal consisting of four critical features: a computer-tailored advice, a monitoring function, a personal coach, and opportunities to contact professionals at request. Participants are employees working for companies in the Netherlands, being literate enough to read and understand simple Internet-based messages in the Dutch language. A questionnaire to assess primary outcomes (compliance with national recommendations on physical activity and on fruit and vegetable intake) will take place at baseline and after 12 and 24 months. This questionnaire also assesses secondary outcomes including fat intake, self-efficacy and self-perceived barriers on physical activity and fruit and vegetable intake. Other secondary outcomes, including a cardiovascular risk profile and physical fitness, will be measured at baseline and after 24 months. Apart from the effect evaluation, a process evaluation will be carried out to gain insight into participation and adherence to the worksite health promotion programme. A cost-effectiveness analysis and sensitivity analysis will be carried out as well.DiscussionThe unique combination of features makes the individually tailored worksite health promotion programme a promising tool for health promotion. It is hypothesized that the Health Portal's features will counteract loss to follow-up, and will increase compliance with the lifestyle recommendations and sustainability of a healthy lifestyle.

To increase compliance with lifestyle recommendation and sustainabilityOf a healthy lifestyle

Questionnaire

A critical realist approach to understanding and evaluating heart health programmes

Clark AM, MacIntyre PD, Cruickshank J

Secondary prevention programmes for Coronary Heart Disease aim to reduce cardiovascular risks and promote health in people with heart disease.

Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and

effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach,

this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient

contextual factors, and thereby fails to account for programme variations. Alternative constructivist

approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws

on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual,

programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach

embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how

a critical realist approach can guide research into secondary prevention programmes is provided.

Health 2007

A practical approach to reducing cardiovascular risk factorsFonarow GC

Rev Cardiovasc Med. 2007

Despite overwhelming evidence supporting the benefits of cardiovascular protective therapies and risk reduction in patients with or at risk for coronary heart disease, these strategies remain underutilized in clinical practice. Preventive cardiology

guidelines from the American Heart Association, the American College of Cardiology, and others focus on primary and secondary prevention with the use of medications,

risk factor control measures, and lifestyle modification. Still, a "treatment gap" remains between the guidelines and their actualization. A systematic approach including both inpatient

and outpatient measures is necessary.

• Consolidamento della stabilità clinica

• Riduzione del rischio di futuri eventi

• Gestione ottimale del paziente nel lungo periodo

In this study protocol the design of a pragmatic cluster randomised controlled trial on worksite health promotion is presented. The study is designed to evaluate the (cost)effectiveness of an individually tailored long-term worksite health promotion programme on PA and nutrition. It is hypothesized that the unique combination of critical features (a computer-tailored advice, a monitor function, a personal coach, and the opportunity to contact professionals at request) counteracts the main factors for ineffective WHPP (lack of participation, adherence to the WHPP and sustainability), and leads to a change in lifestyle. By conducting an extensive process evaluation we gain insight into the effective elements of worksite health promotion. By registering several process variables it is possible to find out if participants with a higher adherence to the (separate parts of the) WHPP are more likely to comply with the lifestyle recommendations. With the health check as starting point for the WHPP, it is aimed to increase participation. The Health Portal's critical features are aimed to counteract loss to follow-up, and increase adherence to the intervention programme, compliance with lifestyle recommendations, and sustainability of a healthy lifestyle. Because of the long-term follow-up, sustainability of healthy behaviour will be facilitated.The cost-effectiveness of the extensive Health Portal will be compared to the cost-effectiveness of the standard WHPP. In conclusion, this study evaluates a promising intervention on healthy behaviour and results will provide insight into cost-effectiveness and the effective elements of WHPP.

Ospedale

Cardiologo

ambulatoriale MMG

paziente

PROGRAMMAZIONE

CONDIVISIONE

CONTINUITA’

ASSISTENZIALE

Stratificazione prognostica stima del rischio cardiovascolareOTTIMIZZAZIONE DELLA TERAPIA FARMACOLOGICAProgramma di training fisico controllato per i pazienti eleggibiliEducazione e counseling con interventi finalizzati a favorire il ritorno ad una vita attiva, a modificare lo stile di vita, a tenere sotto adeguato controllo i fattori di rischioIMPOSTAZIONE DI UN FOLLOW-UP APPROPRIATO

• Sistema informatizzato:– per l’archiviazione e la trasmissione a distanza delle

informazioni cliniche necessarie per la gestione dell’assistenza, adottando tutti i presidi per la salvaguardia della privacy;

– per la produzione e l’utilizzo condiviso di linee guida e di percorsi assistenziali;

– in collegamento con banche dati e registri, e all’esterno con l’Agenzia per i Servizi Sanitari Regionali, scambiando dati ed informazioni in grado di favorire una più corretta programmazione degli interventi cardiologici sul territorio.

• La lettera di dimissione

Sistemi di comunicazione efficaci

Intensificare la collaborazione e relazione tra MMG e Cardiologo

Intendersi sui percorsi e obiettivi

Strutture competenti ad intercettare il paziente nelle varie fasi della malattia

Denominatore comune: qualità delle prestazioni ed uso razionale delle risorse

I presupposti per garantire il funzionamento della Rete

Gli ObiettiviGli Obiettivi

• Consolidamento della stabilità clinica

• Riduzione del rischio di futuri eventi

• Gestione ottimale del paziente nel lungo periodo

• Consolidamento della stabilità clinica

• Riduzione del rischio di futuri eventi

• Gestione ottimale del paziente nel lungo periodo

1. identificare e modificare i fattori di rischio, nel tentativo di ridurre la conseguente morbilità e mortalità della malattia cardiovascolare;

1. imparare ad identificare i sintomi precoci della malattia coronarica, al fine di ridurre il ritardo di ricovero in ambito ospedaliero dei pazienti affetti da patologie acute (infarto, sindromi coronariche acute);

1. addestrare la popolazione alla conoscenza delle procedure organizzative da attuare in caso di attacco cardiaco acuto;

1. migliorare la capacità funzionale sia dei pazienti a rischio cardiovascolare che dei cardiopatici noti pianificando e individualizzando l’attività fisica ed eventualmente sportiva, definendo con precisione i carichi di lavoro;

1. Sostenere e razionalizzare la cardiologia preventiva sia primaria che secondaria con interventi mirati attraverso i mass media, conferenze divulgative ed opuscoli. Considerare questa funzione come risorsa gestionale strategica per raggiungere gli obiettivi del Paino Sanitario Nazionale e Regionale.

Ambulatori di Prevenzione CV

PROGRAMMAZIONE concordata per garantire

continuità assintenziale

approccio medico multidisciplinare, nelle quali si rende spesso necessario l’intervento accanto al Cardiologo anche di altre figure professionali (Internisti, Nutrizionisti, Nefrologi, Diabetologi, Psicologi, Fisioterapisti, ecc.)

Percorsi differenziati per ciascun paziente in base a età, sesso, profilo di rischio, capacità funzionaleCardiopatia di base: Alto rischio - IMA - CCH - Scompenso, eccStato del paziente e fase della sua malattia

Si ha "continuità assistenziale" quando vi è

uniformità di criteri di valutazione e trattamento

indipendentemente dalla singola sede o soggetto con

cui il paziente viene in contatto e, quindi, il piano di

cura viene seguito e/o rivisto con criteri condivisi,

permettendo di assicurare una comunicazione

razionale ed efficace tra i diversi livelli assistenziali, la

migliore cura dei pazienti ed il corretto uso delle risorse

CONDIVISIONE

Continuità Assistenziale