title: [Continuity of care in heart failure: pilot study of the Tuscany region].
abstract: BACKGROUND
  Heart failure (HF) is one of the leading causes of hospitalization and medical expenditure, especially in elderly patients. Cooperation between specialists and general practitioners may improve outcomes. A 1-year hospital-territory disease management program was designed in collaboration with the Tuscany Region and the Ministry of Health involving specialists, general practitioners and nurses to investigate the impact of our model on healthcare organization and hospitalization rates in patients with HF.
  
  
  METHODS
  The program used a web-based clinical report form, and monitoring of patients from specialists and nurses was coordinated by the general practitioners. We enrolled 106 patients (78.3% male, mean age 74.6 years), with a mean left ventricular ejection fraction 49% and mean Charlson index 2.2.
  
  
  RESULTS
  A statistically significant reduction was observed in the number of hospitalizations and emergency calls compared with the previous year. HF severity did not substantially changed in 69.8% of patients, whereas it improved in 17.0% and worsened in 13.2% (NYHA class).
  
  
  CONCLUSIONS
  Our preliminary data suggest that cooperation between hospitals and medical systems in the territory by means of a web-based clinical report may result in better management of healthcare interventions in the territory with subsequent reduction of hospitalizations. An extension of this model is now ongoing for collecting data from different areas, both within and outside Tuscany.
authors: Cardiologia Generale 1, Azienda Ospedaliero-Universitaria Careggi, 50126 Firenze, Italy. frmazzuo@tin.it
authors: Francesco
authors: F
authors: Mazzuoli
authors: Gabriele
authors: G
authors: Castelli
authors: Carlo
authors: C
authors: Nozzoli
authors: Valerio
authors: V
authors: Verdiani
authors: Fabrizio
authors: F
authors: Muscas
authors: Massimo
authors: M
authors: Mammucari
authors: Gianluigi
authors: G
authors: Condorelli
authors: Giovanni
authors: G
authors: Pecciarini
authors: Ennio
authors: E
authors: Sarli
authors: Gian Franco
authors: GF
authors: Gensini
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D007558:Italy; D008297:Male; D010865:Pilot Projects