Challenges in heart failure care in four European countries: a comparative study.

BACKGROUND: In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. METHODS: A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. RESULTS: The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. CONCLUSION: Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills.

[Heart failure care in a digitalized future : A discourse on resource-sparing structures and self-determined patients]. / Herzinsuffizienzversorgung in einer digitalisierten Zukunft : Ein Diskurs zu ressourcenschonenden Strukturen und selbstbestimmten Patienten.

Digital health solutions, applications of artificial intelligence (AI) and new technologies, such as cardiac magnetic resonance imaging and cardiac human genetics are currently being validated in cardiac healthcare pathways. They show promising approaches for improving existing healthcare structures in the future by strengthening the focus on predictive, preventive and personalized medicine. In addition, the accompanying use of digital health applications will become increasingly more important in the future healthcare, especially in patients with chronic diseases. In this article, the authors describe a case of chronic heart failure (HF) as an example to provide an overview of how digitalized healthcare can be efficiently designed across sectors and disciplines in the future. Moreover, the importance of a self-determined patient management for the treatment process itself is underlined. Since HF is frequently accompanied by various comorbidities during the course of the disease that are often recognized only after a delay, the necessity for a timely simultaneous and preventive treatment of multiple comorbidities in cardiovascular diseases is emphasized. Against this background the currently separately applied disease management programs (DMP) are critically questioned. The development of a holistic DMP encompassing all indications for the treatment of chronic diseases may pave the way to a more efficient medical care system.

CASEPLUS-SimPat: An Intersectoral Web-Based Case Management System for Multimorbid Dementia Patients.

One main challenge of health care systems in future will be the care and treatment of dementia patients. To their advanced age, dementia patients do not only have limitations in cognition, perception, and articulation, but also suffer from several other diseases (multimorbidity). These patients have sophisticated needs for assistance, care, and treatment relying on different health care sectors. Well-known communication and coordination deficits between sectors are intensified in the case of dementia, to the above described limitations. Coordination processes concerning the transition of patients from hospitals to inpatient or outpatient aftercare pose particularly difficult. To show a possible future direction for improving intersectoral care of dementia patients, we developed the web-based case management system CASEPLUS-SimPat as part of the project SimPat "Securing Integrated Care for Multi-morbid Patients with Dementia using an IT-based Service Concept". CASEPLUS-SimPat allows health care professionals, hospital employees and general practitioners, to jointly access patient data and exchange information about the treatment of patients. The case management system was implemented in a three-tier architecture with a role-based authorization concept. A portal for relatives complements the system. By providing precise information and e-learning services, caring relatives are integrated into the care process. In a pilot test, CASEPLUS-SimPat shows a good usability. Adapting aspects, such as keywords used to structure entries will make it easier to find required information, and thus will increase usability. Next steps comprise integration of further health care professionals and care facilities as well as real-life testing in terms of feasibility and effectiveness.

Outcomes of Patients in Long-Term Opioid Maintenance Treatment.

BACKGROUND: Despite the importance of duration of opioid maintenance treatment (OMT), only few studies have reported outcomes of long-term OMT. OBJECTIVES: To describe outcomes of long-term (> 5 years) OMT patients with respect to substance use, physical and mental health, and socioeconomic characteristics. METHODS: Patients (n = 160) were recruited from 15 OMT offices in different regions of Germany. Data were collected using a structured interview at baseline, and clinical recordings, including urine drug screenings, during 12 monhts follow-up. RESULTS: Patients had a mean age of 44 years. During follow-up, 23% of patients showed indications of an alcohol problem. Cannabis was used by 56%, often frequently. Heroin was used by 28%, mostly infrequently. Three quarters of patients either had a non-substance related mental disorder (48.1%, most frequently affective and anxiety disorders) or somatic diagnosis (61.3%, frequently hepatitis C, HIV, or cardiovascular diseases), or both. Unemployment rate was 43.1% at baseline (27% for patients without comorbidity) and remained generally stable during follow-up. No arrests or incarcerations were recorded. During follow-up, 2.5% of patients prematurely terminated OMT, 2.5% regularly completed OMT. CONCLUSIONS: The sample as a whole was characterized by stable living conditions, high unemployment, low illicit opiate use, and a high retention rate. Continuation of OMT could enable further treatment of comorbidity and prevent resumption of a drug-dominated lifestyle. But it may well be asked how within the context of OMT further improvements can be achieved, especially with regard to further decrease of alcohol use and the treatment of depression.

[Telemedicine for patients with cardiac implants : Insights into everyday practice of remote monitoring in Germany in 2022]. / Telemedizinische Versorgung von Patienten mit kardialen Implantaten : Einblick in die telekardiologische Versorgungsrealität in Deutschland im Jahr 2022.

BACKGROUND: As telemedical structures continues to be developed in the German healthcare system, remote monitoring is becoming increasingly important to ensure comprehensive, outpatient, and tailored care. The national quality assurance measure "DOQUVIDE-Documentation of quality in the assessment of vital parameters by implanted devices" is used to provide insight into everyday care for patients with telemedicine-enabled devices in Germany. METHODS: DOQUVIDE is a measuring instrument for recording outpatient remote monitoring for patients with implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy with a pacemaker (CRT-P), CRT defibrillator (CRT-D) devices and event recorder. DOQUVIDE records telemedically measured vital signs as well as cardiac events and the associated procedures initiated by cardiologists using standardized forms. RESULTS: In 74 practices/clinics in 14 federal states, 6687 patients received telemedical care in 2022; 937 were newly enrolled. These (60% male) were on average 77.8 years old, mainly with New York Heart Association (NYHA) class II (62.6%). A total of 5801 electronic records were generated as a result of telecardiology events, of which 3590 were due to pathological atrial fibrillation and 1812 due to ventricular high-frequency episodes. 295 events were triggered by event recorders and 95 by device therapies. The main measures taken were telephone contacts or outpatient visits. CONCLUSION: Remote monitoring has become a reality in German healthcare. Standardized processes and the establishment of quality assurance measures enable the definition of common quality standards and the identification of the potential for further development and simplify implementation in day-to-day care for practices.

Adipositas Care and Health Therapy (ACHT) after Bariatric-Metabolic Surgery: A Prospective, Non-Randomized Intervention Study.

INTRODUCTION: Almost 25% of German adults have obesity and numbers are rising, making it an important health issue. Bariatric-metabolic surgery reduces body weight and complications for persons with obesity, but therapeutic success requires long-term postoperative care. Since no German standards for follow-up by family physicians exist, follow-up is provided by surgical obesity centers, but they are reaching their limits. The ACHT study, funded by the German Innovation Fund, is designed to establish and evaluate the follow-up program, with local physicians following patients supported remotely by obesity centers. METHODS: ACHT is a multicenter, prospective, non-randomized control group study. The 18-month ACHT follow-up program is a digitally supported, structured, cross-sectoral, and close-to-home program to improve success after bariatric-metabolic surgery. Four groups are compared: intervention group 1 starts the program immediately (3 weeks) after Roux-en-Y gastric bypass or sleeve gastrectomy (months 1-18 postoperatively), intervention group 2 begins the program 18 months after surgery (months 19-36 postoperatively). Intervention groups are compared to respective control groups that had surgery 18 and 36 months previously. In total, 250 patients, enrolled in the intervention groups, are compared with 360 patients in the control groups, who only receive standard care. RESULTS: The primary endpoint to compare intervention and control groups is the adapted King's score, a composite tool evaluating physical, psychological, socioeconomic, and functional health status. Secondary endpoints include changes in care structures and care processes for the intervention groups. Multivariate regression analyses adjusting for confounders (including the type of surgery) are used to compare intervention and control groups and evaluate determinants in longitudinal analyses. The effect of the intervention on healthcare costs will be evaluated based on health insurance billing data of patients who had bariatric-metabolic surgery in the 3 years prior to the start of the study and of patients who undergo bariatric-metabolic surgery during the study period. CONCLUSIONS: ACHT will be the one of the first evaluated structured, close-to-home follow-up programs for bariatric surgery in Germany. It will evaluate the effectiveness of the implemented program regarding improvements in health status, mental health, quality of life, and the feasibility of such a program outside of specialized obesity centers.

Hospital innovation portfolios: key determinants of size and innovativeness.

BACKGROUND: Health care organizations face an increasing demand for strategic change and innovation; however, there are also several barriers to innovation that impede successful implementation. PURPOSES: We aimed to shed light on key issues of innovation management in hospitals and provide empirical evidence for controlling the size and innovativeness of a hospital's new health service and process portfolio. We show how health care managers could align the need for exploration and exploitation by applying both informal (e.g., employee encouragement) and formal (e.g., analytical orientation and reward systems) organizational mechanisms. METHODOLOGY: To develop hypotheses, we integrated the innovation management literature into the hospital context. Detailed information about the innovation portfolio of 87 German hospitals was generated and combined with multirespondent survey data using ratings from management, medical, and nursing directors. Multivariate regression analysis was applied. FINDINGS: The empirical results showed that an analytical approach increased the size of innovation portfolios. Employee encouragement amplified the degree of innovativeness of activities in the portfolio. Reward systems did not have direct effects on the composition of innovation portfolios. However, they adjusted bottom-up employee and top-down strategic initiatives to match with the existing organization, thereby decreasing the degree of innovativeness and enforcing exploitation. PRACTICE IMPLICATIONS: Hospitals should intertwine employee encouragement, analytical approaches, and formal reward systems depending on organizational goals.

[Artificial intelligence in cardiology : Relevance, current applications, and future developments]. / Künstliche Intelligenz in der Kardiologie : Relevanz, aktuelle Anwendungen und nächste Schritte.

Big data and applications of artificial intelligence (AI), such as machine learning or deep learning, will enrich healthcare in the future and become increasingly important. Among other things, they have the potential to avoid unnecessary examinations as well as diagnostic and therapeutic errors. They could enable improved, early and accelerated decision-making. In the article, the authors provide an overview of current AI-based applications in cardiology. The examples describe innovative solutions for risk assessment, diagnosis and therapy support up to patient self-management. Big data and AI serve as a basis for efficient, predictive, preventive and personalised medicine. However, the examples also show that research is needed to further develop the solutions for the benefit of the patient and the medical profession, to demonstrate the effectiveness and benefits in health care and to establish legal and ethical standards.

[Structural requirements and prerequisites for outpatient implantation of defibrillators, devices for cardiac resynchronization and event recorders]. / Strukturmerkmale und Voraussetzungen zur ambulanten Implantation von implantierbaren Defibrillatoren, Geräten zur kardialen Resynchronisation und Ereignisrekordern.

The possibility of outpatient implantation of defibrillators, devices for cardiac resynchronization, and event recorders (collectively called cardiac implantable electronic devices, CIEDs) is becoming increasingly important. In Germany, only a few options for outpatient implantation are currently realized. Furthermore, there is a lack of uniform, recognized, and binding quality criteria. This article provides insight into the current contract constellations for outpatient surgery and defines a first, holistic quality concept for outpatient implantations of CIEDs. The present works aims to initiate a discourse in the specialist society in order to define a coordinated, binding quality concept. Then, this should serve as the basis for future outpatient implantation services, enabling comparability and to contribute long-term evidence.

[Position paper on required competencies of nonphysician employees in telemedicine centers]. / Positionspapier zum Anforderungsprofil von nichtärztlichen Assistenzkräften in Telemedizinzentren.

The non-physician employees in telemedicine centers (TMC) play a decisive role in the care and treatment of patients with heart failure. For this reason, a holistic profile consisting of professional and methodological as well as social and personal competences is necessary, which should be built up or promoted in corresponding training concepts. This position paper underlines the urgency of appropriate and standardized further training of non-physician employees for quality assurance in TMCs and summarizes the requirements for the additional qualification of a telemedical assistant across the board.

Determinants of acceptance of patients with heart failure and their informal caregivers regarding an interactive decision-making system: a qualitative study.

OBJECTIVE: Heart failure is a growing challenge to healthcare systems worldwide. Technological solutions have the potential to improve the health of patients and help to reduce costs. Acceptability is a prerequisite for the use and a successful implementation of new disruptive technologies. This qualitative study aimed to explore determinants that influence the acceptance of patients and their informal caregivers regarding a patient-oriented digital decision-making solution-a doctor-at-home system. DESIGN: We applied a semistructured design using an interview guide that was based on a theoretical framework influenced by established acceptance theories. The interviews were analysed using a content analysis. SETTING: A multicentred study in four European countries. PARTICIPANTS: We interviewed 49 patients and 33 of their informal caregivers. Most of the patients were male (76%) and aged between 60 and 69 years (43%). Informal caregivers were mostly female (85%). The majority of patients (55%) suffered from heart failure with mild symptoms. RESULTS: Four main categories emerged from the data: needs and expectations, preferences regarding the care process, perceived risk and trust. Participants expressed clear wishes and expectations regarding a doctor-at-home, especially the need for reassurance and support in the management of heart failure. They were receptive to changes to the current healthcare processes. However, trust was identified as an important basis for acceptance and use. Finally, perceived risk for decision-making errors is a crucial topic in need of attention. CONCLUSION: Patients and informal caregivers see clear benefits of digitalisation in healthcare. They perceive that an interactive decision-making system for patients could empower and enable effective self-care. Our results provide important insights for development processes of patient-centred decision-making systems by identifying facilitators and barriers for acceptance. Further research is needed, especially regarding the influence and mitigation of patients and informal caregivers' perceived risks.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care.

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current "one-size-fits-all" approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.

[Current status and future of telemonitoring : Scenarios for telemedical care in 2025]. / Aktueller Stand und Zukunft des Telemonitoring : Szenarien für die telemedizinische Versorgung im Jahr 2025.

Telemonitoring is an already realized implementation of digital transformation in the healthcare system. It has the potential to support and secure a sustainable and comprehensive provision of healthcare for a rising number of chronically ill patients, e. g. patients with chronic heart failure. Remote regions in particular can profit from the benefits of telemonitoring; however, so far telemonitoring services have not become truly established in the German healthcare market. Together with experts from politics, science and practice, a scenario analysis "Health Care System 2025 - A Place for Telemonitoring?" was carried out with the aim to examine the future development of the healthcare market and to draw conclusions for providers of telemonitoring services or devices. The scenario analysis contained two workshops and an expert survey and was supported by a scenario software. The current drivers and barriers of the diffusion of telemonitoring were identified and the most relevant factors that influence the future development of the healthcare market were discussed. Based on those influencing factors, three different scenarios were determined: (1) administrating rather than shaping, (2) safely into the future and (3) interconnected and digital world. In the subsequent consequence analysis activities were defined, which describe the necessary infrastructure, software instruments, organizational structures and provision of services and discuss possible activities, which prepare telemonitoring solutions for the future.

Information and Communication Gaps in Intersectoral Healthcare Processes for Dementia Patients.

In addition to general barriers of information exchange and communication in intersectoral healthcare processes, the healthcare process of dementia patients has unique requirements regarding the communication and information exchange of the various healthcare professionals and non-professional caregivers, such as relatives or their legal caregivers. We conduct a process analysis to determine the status quo of such healthcare processes in the region of Darmstadt, Germany and elicit existing gaps in the information and communication exchange. We identify key processes by performing a document analysis and conducting interviews with seven different healthcare professionals. The results of a weak point analysis based on advanced event driven process chains (EPC) point out 32 information and communication gaps summarized in four categories: "information exchange", "information transfer" "information provision" and "activity impulse". Our results show further opportunities regarding the support of caring relatives and primary care physicians.

Challenges in personalised management of chronic diseases-heart failure as prominent example to advance the care process.

Chronic diseases are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs. Heart failure is one of the most prominent, prevalent and complex chronic conditions and is accompanied with multiple other chronic diseases. The current approach to care has important shortcomings with respect to diagnosis, treatment and care processes. A critical aspect of this situation is that interaction between stakeholders is limited and chronic diseases are usually addressed in isolation. Health care in Western countries requires an innovative approach to address chronic diseases to provide sustainability of care and to limit the excessive costs that may threaten the current systems. The increasing prevalence of chronic diseases combined with their enormous economic impact and the increasing shortage of healthcare providers are among the most critical threats. Attempts to solve these problems have failed, and future limitations in financial resources will result in much lower quality of care. Thus, changing the approach to care for chronic diseases is of utmost social importance.

Prediction and personalised treatment of atrial fibrillation-stroke prevention: consolidated position paper of CVD professionals.

Atrial fibrillation (AF) is one of the major morbidity and health economic factors in Europe and often associated with several co-morbidities. This paper (1) underlines the importance of highly professional AF management utilising a multi-disciplinary expertise, especially considering the role of AF regarding the stroke risk and prevention, (2) demonstrates the consolidated position of CVD professionals and (3) emphasises those research aspects that could deepen the understanding of the emergence and the treatment of AF and therefore helps to provide a personalised preventive and more effective management of AF. Specialised calls are considered for that within the new European Programme 'Horizon 2020'.