The application of the Diagnostic Therapeutic Care Pathway for the geriatric patient with anemia at the hospital of Cosenza, Italy: a management tool or a quality project?

BACKGROUND: Many studies in literature, indicate that the prognosis of hospitalized elderly patients is substantially related to the presence of concomitant diseases (multi-morbidity) along with physical, cognitive, biological and social functional impairments. These patients, therefore, require the expertise of a multi-professional and multi-disciplinary team operating in a Multi Dimensional Rating (MDR). MDR explores the multiple facets of the elderly and it is considered the tool of choice to define prognosis, especially in the case of compromised elderly patients with clinical or functional problems. MDR is satisfactory and it can be applied if it is included in a diagnostic therapeutic care pathway, which is a management tool that achieves best practices and efficiency in healthcare professionals that learn from each other. METHODS: Considering that about 80% of elderly patients has anemia, a condition often underestimated, it has been necessary to create a Diagnostic and Therapeutic Care Pathway (DTCP) with the goal to increase the level of medical awareness on this specific medical problem, and outline clear care paths for the patient. The DTCP in question was promoted by the Geriatric ward of Cosenza's Hospital by setting up a multidisciplinary working group and editing an algorithm. Indicators and standards were chosen to evaluate performance and procedures: all this has required several meetings and counseling sessions between the coordinator of DTCP and the Quality and Accreditation Operative Unit (OU). The verification of the path activities has been realized by examining the documented evidence produced. RESULTS: Preparing the indicators and standards for anemia, DTCP was a particularly challenging step of the work. DTCP has been correctly applied to more than 50% of cases, but was inapplicable to patients who either were very sick or had a very mild form of anemia. CONCLUSION: The analysis of this first phase shows that DTCP is both beneficial to the patient (framed and accompanied in her/his hospitalization and subsequent follow-up) and it facilitates the work of the physician. However, there are some limitations in its application because it is not always possible to measure indicators in every ward that participates in the DTCP.

Continuous relation between left ventricular mass and cardiovascular risk in essential hypertension.

The detection of left ventricular (LV) hypertrophy on echocardiography is a powerful risk indicator in essential hypertension. However, the prognostic impact of LV mass values within the "normal" range and the shape of the relation between LV mass and prognosis remain unclear. Thus, 1925 white subjects with uncomplicated essential hypertension underwent off-therapy 24-hour blood pressure monitoring and M-mode echocardiography. During 4. 0+/-2 years of follow-up, there were 181 major cardiovascular events (2.4/100 patient-years) and 49 deaths from all causes. In the 5 gender-specific quintiles of LV mass distribution (partition values: 92, 105, 120, and 138 g/m(2) in men and 79, 91, 102, and 116 g/m(2) in women), cardiovascular event rates were 0.8, 1.7, 2.2, 2.9, and 4. 3 per 100 patient-years. After adjustment for several risk factors, including 24-hour ambulatory blood pressure, the relative risk (RR) of developing a cardiovascular event increased progressively from the first quintile (RR 1) to the second (RR 1.6, 95% CI 0.8 to 3.1), third (RR 1.9, 95% CI 1.01 to 4.0), fourth (RR 3.0, 95% CI 1.5 to 5. 8), and fifth (RR 3.5, 95% CI 1.8 to 6.8) quintile. For all-cause death, the RR in the fifth quintile compared with the first quintile was 4.3 (95% CI 1.2 to 13.4). In conclusion, the powerful relation between LV mass and risk of cardiovascular disease in subjects with uncomplicated essential hypertension is continuous over a wide range of LV mass values, even below the current "upper normal" limits. The relation remains significant after control for traditional risk factors, including ambulatory blood pressure.