Reduced in-hospital mortality for heart failure with clinical pathways: the results of a cluster randomised controlled trial.

BACKGROUND: Hospital treatment of heart failure (HF) frequently does not follow published guidelines, potentially contributing to HF high morbidity, mortality and economic cost. The Experimental Prospective Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was undertaken to determine how clinical pathways (CP) for hospital treatment of HF affected care variability, guidelines adherence, in-hospital mortality and outcomes at discharge. Methods/ DESIGN: Two-arm, cluster-randomised trial. Fourteen community hospitals were randomised either to the experimental arm (CP: appropriate therapeutic guidelines use, new organisation and procedures, patient education) or to the control arm (usual care). The main outcome was in-hospital mortality; secondary outcomes were length and appropriateness of the stay, rate of unscheduled readmissions, customer satisfaction, usage of diagnostic and therapeutic procedures during hospital stay and quality indicators at discharge. All outcomes were measured using validated instruments available in literature. RESULTS: In-hospital mortality was 5.6% in the experimental arm (n = 12); 15.4% in controls (n = 33, p = 0.001). In CP and usual care groups, the mean rates of unscheduled readmissions were 7.9% and 13.9%, respectively. Adjusting for age, smoking, New York Heart Association score, hypertension and source of referral, patients in the CP group, as compared to controls, had a significantly lower risk of in-hospital death (OR 0.18; 95% CI 0.07 to 0.46) and unscheduled readmissions (OR 0.42; 95% CI 0.20 to 0.87). No differences were found between CP and control with respect to the appropriateness of the stay, costs and patient's satisfaction. Except for electrocardiography, all recommended diagnostic procedures were used more in the CP group. Similarly, pharmaceuticals use was significantly greater in CP, with the exception of diuretics and anti-platelets agents. DISCUSSION: The introduction of a specifically tailored CP for the hospital treatment of HF was effective in reducing in-hospital mortality and unscheduled readmissions. This study adds to previous knowledge indicating that CP should be used to improve the quality of hospital treatment of HF. TRIAL REGISTRATION NUMBER: NCT00519038.

[The results of the experimental prospective study on the effectiveness and efficiency of the implementation of clinical pathways]. / I risultati dello studio sperimentale prospettico di efficacia ed efficienza dell'implementazione dei percorsi assistenziali.

Our study was undertaken to determine how the use of care pathways in hospital affected the quality of the care of the patients. We performed a cluster-randomized trial. The use of diagnostic procedures and of medical treatments was more appropriate in the care pathways group, as well as the discharge process. As a consequence the outcomes indicators adopted in our study showed better performances in the care pathways group when compared to the usual care group. Our study added evidences on the value of clinical pathways that can be effectively used to improve the quality of hospital care. The use of CP helped to create a constant dialogue within the clinicians, ensured that important areas of treatment were not overlooked and unnecessary delays were prevented by timely interventions. We think that our results are reliable because we adopted a cluster-randomized controlled trial design that is widely accepted as the most reliable method of determining effectiveness of complex interventions in healthcare.

[Quality, success, and appropriateness of using home care through the Local Health Station No. 13 in Novara]. / Studio della qualità, degli esiti e dell'appropriatezza di utilizzo delle cure domiciliari nell'Azienda Sanitaria Locale no 13 di Novara.

The research is aimed at evaluating the quality, appropriateness and outcomes of home-care services in the District of Novara of ASL 13, by experimenting a multidimensional model of analysis based on the current clinical records. In this study, we analysed 102 cases of admittance to Integrated Home-care Services (IHS) (50 women and 52 men; average age 72.5). The analysis of the levels of activity highlighted a widespread under-use of the service and an insufficient quality of the clinical records. The management of patients was appropriate in 43.14% of the cases, in terms of intensity and complexity of the received care. 50% of the subjects did not present such characteristics as to need IHS, while 7.86% of the patients evidenced dubious appropriateness, according to an adequate healthcare intensity unaccompanied by a sufficient complexity of the interventions. As far as outcomes are concerned, we were able to highlight how relatively few subjects actually reached the objective of the healthcare plan (26.47%). On the whole, the experimented model of analysis allowed us to trace an effective picture of the quality of the service, by highlighting its critical elements and helping in finding specific actions of improvement.

[Epidemiologic study on the performance of a smoking prevention program in an adolescent population]. / Studio epidemiologico per la realizzazione di un programma di prevenzione del tabagismo in una popolazione di adolescenti.

In the last few years, the relative number of adolescent smokers has increased, which indicates the need to boost the adoption of new preventive strategies aimed at this part of the population. In order to be effective, preventive actions should be put in the local setting thoroughly knowing the target population and any specific-predictive factors of the insurgence of smoking addiction. To this purpose, we conducted a study aimed at describing the prevalence of smoking addiction in a population of 2472 adolescents and at identifying any predisposing factors. From the analysis of the results, both predisposing and protective factors emerged, together with many formative requests from the adolescents. On the basis of such results, we were able to create ad hoc preventive interventions. The proposed strategy seems to be potentially valid; however, we will be able to express a more precise judgment only at the end of the implementation phase.