An Innovative Patient-Centred Approach to Heart Failure Management: The Best Care Heart Failure Integrated Disease-Management Program.

Background: The management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline-directed care, but the impact of IDM in the community setting requires further evaluation. Methods: A retrospective evaluation of community-based IDM. Patient characteristics were described, and outcomes using a pre- and post-intervention design were HF-related health-service use, quality of life, and concordance with guideline-directed medical therapy (GDMT). Results: 715 patients were treated in the program (2016 to 2023), 219 in a community specialist-care clinic, and 496 in 25 primary-care clinics. The overall cohort was predominantly male (60%), with a mean age of 73.5 years (± 10.7), and 60% with HF with reduced ejection fraction. In patients with ≥ 6 months of follow-up (n = 267), pre vs post annualized rates of HF-related acute health-service use decreased from 36.3 to 8.5 hospitalizations per 100 patients per year, P < 0.0001, from 31.8 to 13.1 emergency department visits per 100 patients per year, P < 0.0001, and from 152.8 to 110.0 urgent physician visits per 100 patients per year, P = 0.0001. The level of concordance with GDMT improved; the number of patients receiving triple therapy and quadruple therapy increased by 10.1% (95% confidence interval [CI], 2.4%,17.8%) and 19.6% (95% CI, 12.0%, 27.3%), respectively. Within these groups, optimal dosing was achieved in 42.5% (95% CI, 32.0%, 53.6%) and 35.0% (95% CI, 23.1%, 48.4%), respectively. In patients with at least one follow-up visit (n = 286), > 50% experienced a clinically relevant improvement in their quality of life. Conclusions: A community-based IDM program for HF, may reduce HF-related acute health-service use, improve quality of life and level of concordance with GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.

Contexte: La prise en charge de l'insuffisance cardiaque (IC) représente un défi en raison de la complexité des traitements recommandés. La prise en charge intégrée des maladies est un modèle efficace qui favorise les soins reposant sur les lignes directrices, mais la portée de ce modèle en milieu extra-hospitalier mérite une évaluation plus approfondie. Méthodologie: Évaluation rétrospective de la prise en charge intégrée des maladies à l'échelle communautaire. Les caractéristiques des patients ont été établies. Les résultats mesurés avant et après l'intervention ont été l'utilisation des services de santé liés à l'IC, la qualité de vie et le degré de concordance avec le traitement médical recommandé par les lignes directrices. Résultats: Au total, 715 patients ont été traités dans le cadre du programme (de 2016 à 2023) : 219 dans une clinique communautaire de soins spécialisés et 496 dans 25 cliniques de soins primaires. Dans l'ensemble, la majorité des patients étaient de sexe masculin (60 %). L'âge moyen était de 73,5 ans (± 10,7 ans). Soixante pour cent des patients présentaient une IC avec fraction d'éjection réduite. Chez les patients ayant fait l'objet d'un suivi pendant ≥ 6 mois (n = 267), les taux annualisés d'utilisation des services de santé aigus liés à l'IC avant et après l'intervention sont passés de 36,3 à 8,5 hospitalisations pour 100 patients par année (p < 0,0001), de 31,8 à 13,1 visites aux urgences pour 100 patients par année (p < 0,0001) et de 152,8 à 110,0 consultations avec un urgentologue pour 100 patients par année (p = 0,0001). On a observé une augmentation du degré de concordance avec le traitement médical recommandé par les lignes directrices. Le nombre de patients recevant une trithérapie et une quadrithérapie a également augmenté de 10,1 % (intervalle de confiance [IC] à 95 % : 2,4 % à 17,8 %) et de 19,6 % (IC à 95 % : 12,0 % à 27,3 %), respectivement. Dans ces groupes, la dose optimale a été atteinte chez 42,5 % (IC à 95 % : 32,0 % à 53,6 %) et 35,0 % (IC à 95 % : 23,1 % à 48,4 %) des patients, respectivement. Plus de 50 % des patients ayant effectué au moins une visite de suivi (n = 286) ont obtenu une amélioration cliniquement pertinente de leur qualité de vie. Conclusions: Un programme communautaire de prise en charge intégrée de l'IC peut réduire l'utilisation des services de santé liés à l'IC, améliorer la qualité de vie et augmenter le degré de concordance avec le traitement médical recommandé par les lignes directrices. Bien qu'ils soient encourageants, ces résultats préliminaires issus de l'évaluation d'un programme en contexte réel doivent être confirmés par la réalisation d'une étude à répartition aléatoire et contrôlée.

Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study.

BACKGROUND: Severe exacerbation of chronic obstructive pulmonary disease (COPD) is a trajectory-changing life event for patients and a major contributor to health system costs. This study evaluates the real-world impact of a primary care, integrated disease management (IDM) programme on acute health service utilisation (HSU) in the Canadian health system. METHODS: Interrupted time series analysis using retrospective health administrative data, comparing monthly HSU event rates 3 years prior to and 3 years following the implementation of COPD IDM. Primary outcomes were COPD-related hospitalisation and emergency department (ED) visits. Secondary outcomes included hospital bed days and all-cause HSU. RESULTS: There were 2451 participants. COPD-related and all-cause HSU rates increased in the 3 years prior to IDM implementation. With implementation, there was an immediate decrease (month 1) in COPD-related hospitalisation and ED visit rates of -4.6 (95% CI: -7.76 to -1.39) and -6.2 (95% CI: -11.88, -0.48) per 1000 participants per month, respectively, compared with the counterfactual control group. After 12 months, COPD-related hospitalisation rates decreased: -9.1 events per 1000 participants per month (95% CI: -12.72, -5.44) and ED visits -19.0 (95% CI: -25.50, -12.46). This difference nearly doubled by 36 months. All-cause HSU also demonstrated rate reductions at 12 months, hospitalisation was -10.2 events per 1000 participants per month (95% CI: -15.79, -4.44) and ED visits were -30.4 (95% CI: -41.95, -18.78). CONCLUSIONS: Implementation of COPD IDM in a primary care setting was associated with a changed trajectory of COPD-related and all-cause HSU from an increasing year-on-year trend to sustained long-term reductions. This highlights a substantial real-world opportunity that may improve health system performance and patient outcomes.

A messaging standard for environmental inspections: is it time?

Environmental health (EH) services in the United States lag behind other areas of public health and health care with respect to information system interoperability and data sharing. This is partly due to an absence of well-defined use cases, the lack of direct economic drivers and resources to improve, the multiple jurisdictional elements that govern EH services across the United States, and no central organization to drive modernization of EH data. We summarize the status of EH information systems; argue for greater interoperability, including use cases for a messaging standard for environmental inspections; and present recommendations to better align EH services and data modernization efforts currently underway in other areas of public health.

The impact of integrated disease management in high-risk COPD patients in primary care.

Patients with chronic obstructive pulmonary disease (COPD) have a reduced quality of life (QoL) and exacerbations that drive health service utilization (HSU). A majority of patients with COPD are managed in primary care. Our objective was to evaluate an integrated disease management, self-management, and structured follow-up intervention (IDM) for high-risk patients with COPD in primary care. This was a one-year multi-center randomized controlled trial. High-risk, exacerbation-prone COPD patients were randomized to IDM provided by a certified respiratory educator and physician, or usual physician care. IDM received case management, self-management education, and skills training. The primary outcome, COPD-related QoL, was measured using the COPD Assessment Test (CAT). Of 180 patients randomized from 8 sites, 81.1% completed the study. Patients were 53.6% women, mean age 68.2 years, post-bronchodilator FEV1 52.8% predicted, and 77.4% were Global Initiative for Obstructive Lung Disease Stage D. QoL-CAT scores improved in IDM patients, 22.6 to 14.8, and worsened in usual care, 19.3 to 22.0, adjusted difference 9.3 (p < 0.001). Secondary outcomes including the Clinical COPD Questionnaire, Bristol Knowledge Questionnaire, and FEV1 demonstrated differential improvements in favor of IDM of 1.29 (p < 0.001), 29.6% (p < 0.001), and 100 mL, respectively (p = 0.016). Compared to usual care, significantly fewer IDM patients had a severe exacerbation, -48.9% (p < 0.001), required an urgent primary care visit for COPD, -30.2% (p < 0.001), or had an emergency department visit, -23.6% (p = 0.001). We conclude that IDM self-management and structured follow-up substantially improved QoL, knowledge, FEV1, reduced severe exacerbations, and HSU, in a high-risk primary care COPD population. Clinicaltrials.gov NCT02343055.