Patients recovering from COVID-19 pneumonia in sub-acute care exhibit severe frailty: Role of the nurse assessment.

AIMS AND OBJECTIVES: To document the level of frailty in sub-acute COVID-19 patients recovering from acute respiratory failure and investigate the associations between frailty, assessed by the nurse using the Blaylock Risk Assessment Screening Score (BRASS), and clinical and functional patient characteristics during hospitalisation. BACKGROUND: Frailty is a major problem in patients discharged from acute care, but no data are available on the frailty risk in survivors of COVID-19 infection. DESIGN: A descriptive cross-sectional study (STROBE checklist). METHODS: At admission to sub-acute care in 2020, 236 COVID-19 patients (median age 77 years - interquartile range 68-83) were administered BRASS and classified into 3 levels of frailty risk. The Short Physical Performance Battery (SPPB) was also administered to measure physical function and disability. Differences between BRASS levels and associations between BRASS index and clinical parameters were analysed. RESULTS: The median BRASS index was 14.0 (interquartile range 9.0-20.0) denoting intermediate frailty (32.2%, 41.1%, 26.7% of patients exhibited low, intermediate and high frailty, respectively). Significant differences emerged between the BRASS frailty classes regards to sex, comorbidities, history of cognitive deficits, previous mechanical ventilation support and SPPB score. Patients with no comorbidities (14%) exhibited low frailty (BRASS: median 5.5, interquartile range 3.0-12.0). Age ≥65 years, presence of comorbidities, cognitive deficit and SPPB % predicted <50% were significant predictors of high frailty. CONCLUSIONS: Most COVID-19 survivors exhibit substantial frailty and require continuing care after discharge from acute care. RELEVANCE TO CLINICAL PRACTICE: The BRASS index is a valuable tool for nurses to identify those patients most at risk of frailty, who require a programme of rehabilitation and community reintegration.

[ANMCO/SIC/SIT Consensus document: The future of telemedicine in heart failure]. / Documento di consenso ANMCO/SIC/SIT: Il futuro della telemedicina nello scompenso cardiaco.

Telemedicine applied to heart failure patients is a tool for recording, remote transmission, storage and interpretation of cardiocirculatory parameters and/or diagnostic images, useful, as emphasized by the latest guidelines, to allow for intensive home monitoring in patients with advanced heart failure or during the vulnerable post-acute phase to improve the prognosis and quality of life for patients.Recently, several meta-analyses have shown that the patterns of care supported by telemedicine are not only effective, but also economically advantageous. The benefit is unquestionable with a 30-35% reduction in mortality and a 15-20% reduction in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management as all modern devices can transmit technical and diagnostic data. However, telemedicine can bring benefits to the patient with heart failure only if it is part of a shared and integrated, multidisciplinary and multiprofessional "Chronic Care Model". Moreover, the future development of remote telemonitoring programs in our country goes through the primary use of products certified as medical device, field validation of organizational solutions proposed, a legislative and administrative adaptation to new care methods and the widespread growth of competence in clinical care to remotely manage the complexity of chronicity.With this consensus document the Italian Cardiology reaffirms its willingness to contribute to the government of the tumultuous and fragmented technological development, proposing a new phase of qualitative assessment, standardization of processes and testing the application of telemedicine to heart failure.

Biodex Fall Risk Assessment in the Elderly With Ataxia: A New Age-Dependent Derived Index in Rehabilitation: An Observational Study.

The aim of this study was to evaluate if the Biodex Fall Risk Assessment could provide an age-adjusted index useful for classifying patients at "risk of fall."This was a cohort study conducted on 61 chronic patients, in stable conditions, having a history of ataxia, difficulty in walking or loss of balance, and aged >64 years. These patients were coming from home to our Institute undergoing a period of in-hospital standard rehabilitation. Assessment of clinical parameters was performed at entry. Functional scales (Functional Independence Measure [FIM] for motor and cognitive function, Barthel G, Tinetti POMA), and the Biodex Fall Risk Index (FRI) were performed at entry and discharge. The Normalized FRI, obtained adjusting FRI to the reported maximum predictive FRI for the relevant age, identified 2 types of patients: those with a greater risk of fall than expected for that age, labeled Case 1 (Normalized FRI>1); and those with an equal or even lesser risk of fall than expected for that age, labeled Case 0 (Normalized FRI≤1).FRI, Normalized FRI as well as independent variables as age, sex, pathology group, FIM, BarthelG, were considered in a multiple regression analysis to predict the functional improvement (i.e., delta Tinetti Total score) after rehabilitation.Normalized FRI is useful in assessing patients at risk of falls both before and after rehabilitation. At admission, the Normalized FRI evidenced high fall risk in 46% of patients (Case 1) which decreased to 12% after rehabilitation, being greater than age-predicted in 7 patients (Case 1-1) despite the functional improvement observed after the rehabilitation treatment. Normalized FRI evidenced Case 1-1 patients as neurological, "very old" (86% in age-group 75-84 years), and with serious events at 18 to 24 months' follow-up. Normalized FRI, but not FRI, at admission was a predictor of improvement in Tinetti Total scores.The normalized FRI effectively indicated patients at higher risk of fall, in whom health deterioration, falls, or cognitive decline was later documented at follow-up. The normalized FRI could be a standardized measure for identifying frailer patients becoming a further criterium of discharge home and marker of fall risk at home.

A two-year longitudinal study on strain and needs in caregivers of advanced ALS patients.

Our objective was to explore strain and needs in caregivers of advanced ALS patients and correlate this burden with patient's clinical condition and caregiver's sociodemographic status. Fifty-eight caregivers completed the Family Strain Questionnaire-short form (FSQ-SF) and Caregiver Needs Assessment (CNA) during patients' hospitalization (T0); 39 caregivers were reassessed at 6-12 months (T1) and 13 caregivers at 18-24 months (T2) follow-up. FSQ-SF and CNA total scores (CNA-T), including the CNA subscores 'Emotional/Social Support Needs' (CNA-E) and 'Information/Communication Needs' (CNA-I), were compared to patients' clinical condition (measured by ALSFRS-R and FVC %) and caregivers' sociodemographic status. Results showed that high strain level was found in 80% of caregivers and persisted over time. At T0, CNA-T was moderate and was not correlated to site of ALS onset, patients' clinical variables, or caregiver's sociodemographic characteristics; CNA-I subscore was significantly correlated to bulbar onset. CNA-T and CNA-I were significantly reduced at T1 (both, p < 0.01). Caregivers' parental relationship to patient (filial) and working status influenced caregivers' needs. After a longer follow-up (T2), CNA-E significantly decreased vs. T0 score (p < 0.02). In conclusion, over time, caregivers of advanced ALS patients show persisting high strain while needs decline, although the level still remains high. Further studies are needed to propose the most appropriate support.

Blood pressure control and treatment adherence in hypertensive patients with metabolic syndrome: protocol of a randomized controlled study based on home blood pressure telemonitoring vs. conventional management and assessment of psychological determinants of adherence (TELEBPMET Study).

BACKGROUND: Inadequate blood pressure control and poor adherence to treatment remain among the major limitations in the management of hypertensive patients, particularly of those at high risk of cardiovascular events. Preliminary evidence suggests that home blood pressure telemonitoring (HBPT) might help increasing the chance of achieving blood pressure targets and improve patient's therapeutic adherence. However, all these potential advantages of HBPT have not yet been fully investigated. METHODS/DESIGN: The purpose of this open label, parallel group, randomized, controlled study is to assess whether, in patients with high cardiovascular risk (treated or untreated essential arterial hypertension--both in the office and in ambulatory conditions over 24 h--and metabolic syndrome), long-term (48 weeks) blood pressure control is more effective when based on HBPT and on the feedback to patients by their doctor between visits, or when based exclusively on blood pressure determination during quarterly office visits (conventional management (CM)). A total of 252 patients will be enrolled and randomized to usual care (n = 84) or HBPT (n = 168). The primary study endpoint will be the rate of subjects achieving normal daytime ambulatory blood pressure targets (< 135/85 mmHg) 24 weeks and 48 weeks after randomization. In addition, the study will assess the psychological determinants of adherence and persistence to drug therapy, through specific psychological tests administered during the course of the study. Other secondary study endpoints will be related to the impact of HBPT on additional clinical and economic outcomes (number of additional medical visits, direct costs of patient management, number of antihypertensive drugs prescribed, level of cardiovascular risk, degree of target organ damage and rate of cardiovascular events, regression of the metabolic syndrome). DISCUSSION: The TELEBPMET Study will show whether HBPT is effective in improving blood pressure control and related medical and economic outcomes in hypertensive patients with metabolic syndrome. It will also provide a comprehensive understanding of the psychological determinants of medication adherence and blood pressure control of these patients. TRIAL REGISTRATION: Clinical Trials.gov: NCT01541566.

Heart failure. Optimal postdischarge management of chronic HF.

Not all strategies for the management of chronic heart failure have been shown to be equally effective in improving outcomes, and the ideal programme has yet to be defined. The WHICH? trial sheds some light on whether a clinical, in-hospital or a home-based strategy of care is superior and cost-effective.

Healthcare continuity from hospital to territory in Lombardy: TELEMACO project.

OBJECTIVES: To verify implementation and use of TELEMACO (TELEMedicina Ai piccoli COmunilombardi; http://www.telemaco.regione.lombardia.it/), which provides specialized continuity of care with innovative healthcare services in remote areas of the Lombardy region of Italy; to design a network in the territory for sharing of continuityof- care programs; and to allow the relevant health authorities to collect cost data to establish a model for sustainable pricing for implementing these services. METHODS: TELEMACO provides home-based telemanagement services for patients with chronic heart failure and chronic obstructive pulmonary disease (COPD), as well as second-opinion teleconsultations in cardiology, dermatology, diabetology, and pulmonology for general practitioners and second-opinion teleconsultations on digital images in cases of traumatic brain injury and stroke. A total of 2 service centers, 10 cardiology and pneumology departments, 30 specialists, 176 general practitioners, 40 nurses, 2 emergency departments, and 2 consultant hospitals were involved. RESULTS: A total of 166 patients with chronic heart failure and 474 patients with COPD were enrolled. There were 4830, 51, and 44 second-opinion teleconsultations for cardiologic, dermatologic, and diabetic conditions, respectively. There were 147 second-opinion teleconsultations on digital images, 68 for stroke, and 79 for traumatic brain injury. Implementation of TELEMACO introduced innovations in working methods and provided evidence to the health authorities for allocating funds for such services. CONCLUSIONS: TELEMACO provided evidence that there is a growing need for home management of patients using telemedicine, a common and efficacious approach that can ensure care continuity, especially in chronic diseases.

Tele-assistance in patients with amyotrophic lateral sclerosis: long term activity and costs.

PURPOSE: To describe i) nurse's utilisation and associated costs during 4-year tele-assistance in amyotrophic lateral sclerosis (ALS) ii) optimal time for initiating tele-assistance. METHOD: 73 ALS patients after hospital discharge were followed up on voice by phone calls conducted by a nurse through a clinical card which was tested for feasibility, efficacy and utility. Number of patients simultaneously assisted/month, calls/patient, fixed and variable costs were calculated. RESULTS: Time between disease's diagnosis and the beginning of tele-assistance was 720 ± 971 days. ALS patients' percentage managed by nurses through tele-assistance increased over time by 628%. Tele-assistance integrated care (TAIC) followed up patients with a total of 5073 telephone calls. Steady state activity was reached at the 3rd year employing 5 ± 3 calls/pt/month (time/call 64 ± 44 min). Implementing the card was feasible, useful and effective by operator. Survival from diagnosis of ALS was 1224 ± 1150 days. Survival was related to tracheotomy. CONCLUSION: TAIC is a feasible tool to manage up to 25 ALS patients/month/nurse and costs about €105.00 per patient per month. Tele-assistance is proposed at 2/3 of time course of the disease.

Tele-assistance in chronic respiratory failure: patients' characterization and staff workload of 5-year activity.

BACKGROUND: The issue of how to optimize the routine use of tele-assistance (TA) in the clinical care remains to be addressed. Skills and costs of human resources represent the major component to care for chronic patients with TA. METHODS: We investigated (1) the change in patient population, mortality, and staff utilization/cost during the first 5-year activity of a TA program (24-h availability of a call center, pulse oxygen device, and second medical opinion) dedicated to chronic respiratory failure patients and (2) the staff time dedicated to each new patient admitted to the service. RESULTS: Three-hundred and ninety-six patients (age 64 +/- 17 years; 296 men) were reviewed across 5 years of activity. Patients followed/year increased over time, particularly for amyotrophic lateral sclerosis subjects. Calls/month dramatically increased from 60 to 290, with a 5-year number of calls equal to 12.952. The doctor's time dedicated to TA decreased over time, whereas the nurse's time increased allowing a cost saving of 39% when compared with budgeted salary costs. The number of home ventilated patients did not change, remaining over 78%. The mortality rate increased over time (from 6% to 11%). Both chronic obstructive pulmonary disease (COPD) and No-COPD patients used the TA service more frequently during the winter, and COPD used it also in the summer. CONCLUSIONS: A stable TA service dedicated to chronic respiratory failure may be reached after 4 years. Across years, (1) number of patients increased, with COPD and ventilated subjects being the most representative; (2) calls varied during seasons; (3) doctor's workload decreased, saving salary costs; and (4) each new enrolled patient may require 73 and 27 min/month of nurse and doctor, respectively.

The SUMMA Project: a feasibility study on telemedicine in selected Italian areas.

Telemedicine is achieving relevant clinical importance in rural areas in the management of patients. The Second opinion Unificata per Medici di Medicina generAle (SUMMA) Project was designed to evaluate the feasibility of a joint telemedicine service application across general practitioners and clinical specialists in Italy. The secondary objective of the study included the comparison of telemedicine with the routine general practitioners' approach and a cost-effectiveness evaluation. One hundred and thirty-five general practitioners from Lombardy, Molise, and Valle d'Aosta were enrolled. An ad hoc questionnaire was used to evaluate the feasibility, approval, efficacy, and satisfaction of telemedicine among the general practitioners. Ninety-three general practitioners used the telemedicine consultation (responders) for a total of 1,396 calls (1,264 for cardiology, 65 for dermatology, 32 for diabetology, 22 for rheumatology, and 13 for pneumology). In cardiology, telemedicine was used to address all problems without further action in 733 cases (61%). Ninety-eight percent of responders indicate satisfaction with telemedicine. The cost of telemedicine in our study was estimated to be 25.36 Euros/contact. In conclusion, the SUMMA Project demonstrated for the first time clinically the effectiveness of second-opinion consultation by general practitioners and therefore fulfilling the actual needs in areas usually managed by the National Health System.

[Cardiac event recorder yields more diagnoses than 24-hour Holter monitoring in patients with palpitations]. / Diagnostica del cardiopalmo accessuale: event recorder transtelefonico versus elettrocardiogramma dinamico secondo Holter.

BACKGROUND: Palpitations are a common symptom that sometimes results from a substantial cardiac arrhythmia. A 24-hour Holter monitoring is usually used, but the yield of this instrument is low in patients whose symptoms occur infrequently. The aim of this study was to compare the diagnostic yield and the cost-effectiveness of transtelephonic event recorder (TER) with those of Holter monitoring in patients with intermittent palpitations. METHODS: Three hundred and ten patients with intermittent palpitations were allocated to the study and randomly assigned to receive a TER or 24-hour Holter monitoring. TER was given to patients until recording was obtained while symptoms occurred or was used at most for 7 days. At enrollment, a basal trace was recorded. Patients with palpitations recorded the one lead ECG trace and sent it by phone (fixed or mobile) to the telemedicine call center where a trained nurse compared the trace with the basal one and checked the patient's symptoms. The cardiologist reported "on-line" all the traces sent in the presence of an arrhythmic event and "stored and forwarded" all the other traces. Standard methods were used for Holter recording and reading. RESULTS: Patients with palpitations during the examination were 119 (76.8%) in the group of TER and 74 (47.8%) in the Holter group (p < 0.000) with an efficacy increase of 29% for TER. In symptomatic patients there were no differences between the two groups about the presence or absence of arrhythmias checked in the ECG traces; the time necessary to make a presence/absence diagnosis of arrhythmias was 2.97 +/- 2.74 days with the event recorder. The total cost of 155 tests made with Holter was altogether 9605.35 Euro (costs per test 61.97 Euro), while the one of TER was 6019.2 Euro (cost par test 38.83 Euro). The cost-effectiveness analysis was 129.80 Euro for Holter and 50.57 Euro for TER, with a saving of 79.23 Euro for every diagnosis made. CONCLUSIONS: TER allows to detect intermittent palpitations in real time; it is more useful and effective than Holter; moreover this effectiveness was also confirmed by the cost analysis in which TER resulted less expensive.

Assessment of prehospital chest pain using telecardiology.

Two hundred general practitioners were equipped with a portable electrocardiograph which could transmit a 12-lead electrocardiogram (ECG) via a telephone line. A cardiologist was available 24 h a day for an interactive teleconsultation. In a 13-month period there were 5073 calls to the telecardiology service and 952 subjects with chest pain were identified. The telecardiology service allowed the general practitioners to manage 700 cases (74%) themselves; further diagnostic tests were requested for 162 patients (17%) and 83 patients (9%) were sent to the hospital emergency department. In the last group a cardiological diagnosis was confirmed in 60 patients and refuted in 23. Seven patients in whom the telecardiology service failed to detect a cardiac problem were hospitalized in the subsequent 48 h. The telecardiology service showed a sensitivity of 97.4%, a specificity of 89.5% and a diagnostic accuracy of 86.9% for chest pain. Telemedicine could be a useful tool in the diagnosis of chest pain in primary care.