[Outpatient medical and nurse management program in patients with chronic heart failure in a large territorial area in Piedmont. Four years of follow-up].
BACKGROUND
Chronic heart failure is the leading cause of hospitalization and readmissions. In the last years many strategies based on the interaction of multi-competence programs have been evaluated to improve its management.


METHODS
We evaluated the feasibility of an outpatient management program for patients with chronic hearth failure jointly treated by hospital, territorial cardiologists, nurses and primary physicians in a large area of Piedmont. Between January 2001 and January 2005, 122 consecutive patients (26.2% female, mean age 66 +/- 11 years) with chronic heart failure were enrolled in the study. Etiology was: coronary heart disease 40.2%, dilated cardiomyopathy 18%, hypertension 18%, unknown 14%, valvular heart disease 4.9%, other 4.9%. Cardiologists were expected to assess etiology, to perform instrumental examinations and titration of beta-blockers; nurses to reinforce patient education to monitor adherence to pharmacological and dietary therapy. Patients were subsequently followed by primary physicians. The endpoints were to compare: 1) hospitalization and emergency department admissions in the 12 months before the first evaluation and every year after referral; 2) Minnesota questionnaire, NYHA functional class, pharmacological therapies at the referral time and at the end of follow-up.


RESULTS
One hundred and fifteen patients were followed for 47 +/- 1.5 months (5.6% drop out). Thirty-four patients died (29.5%), 11 non-cardiac causes, 14 congestive heart failure, 6 sudden cardiac death, 3 cardiac transplantation. Ejection fraction improved from 31 +/- 10 to 36 +/- 12%. Emergency department admissions and hospitalizations decreased from 54 and 56 respectively in the year before the first evaluation to 14 and 21 per year (p < 0.001). NYHA classes I-II improved from 65.5 to 87.7% and NYHA classes III-IV were reduced from 34.5 to 12.3%. The Minnesota score decreased from 25 to 21.9. Patients treated with ACE-inhibitors + angiotensin II receptor blocker therapy increased from 91 to 96%, beta-blockers from 35.2 to 69%, potassium sparing drugs increased from 54 to 64%.


CONCLUSIONS
Our study showed that a medical and nurse outpatient management program for patients with chronic heart failure, also in a large urban and country area, decrease number of hospitalizations and improve functional class and adherence to medical therapy. These results kept constant over time in the subsequent 4 years.
Conte
Maria Rosa
MR
U.O.A. di Cardiologia, Ospedale degli Infermi, ASL 5 Piemonte, Rivoli (TO). mrconte@asl5.piemonte.it
Mainardi
Loredana
L
Iazzolino
Emesto
E
Casetta
Marzia
M
Asteggiano
Riccardo
R
Lai
Fulvio
F
Lusardi
Raffaella
R
Sasso
Luigia
L
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000553:Ambulatory Care / Q000592:standards*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology / Q000451:nursing / Q000628:therapy*; D006760:Hospitalization; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D009723:Nurse-Patient Relations; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D010353:Patient Education as Topic; D015397:Program Evaluation; D012189:Retrospective Studies; D012424:Rural Population; D011795:Surveys and Questionnaires; D014505:Urban Population
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors