[Integrated social and health care supported by home telemonitoring in patients with heart failure: the European SmartCare project in the Friuli Venezia Giulia Region]. / Efficacia delle cure integrate socio-sanitarie supportate dal telemonitoraggio domiciliare nello scompenso cardiaco: il progetto europeo SmartCare in Friuli Venezia Giulia.

BACKGROUND: Home care for patients with chronic diseases and specifically with heart failure (HF) is one of the main challenges of health care for the future. Telemedicine, applied to HF, allows intensive home monitoring of the most advanced patients, improving their prognosis and quality of life. The European SmartCare project was carried out in the Friuli Venezia Giulia (FVG) region with the aim of improving integrated health and social care in patients with chronic non-communicable diseases (CNCD) through home telemonitoring (TM) and promoting self-management and patient empowerment. METHODS: The SmartCare project in FVG was a prospective, randomized and controlled cohort study that enrolled, from November 2014 to February 2016, 201 patients in integrated home care ("usual care" [UC] in our study) to TM (n=100) or UC (n=101). Inclusion criteria were age >50 years, at least 1 CNCD (HF, chronic obstructive pulmonary disease, or diabetes) and 1 missing BADL. There were 19 drop-outs (9%) (12 in the TM arm; 7 in the UC arm; p=NS). All patients were followed by a multiprofessional team and stratified in the short-term pathway (3-6 months; average 4 ± 1 months; n=101), enrolled at discharge from hospitalization, or in the long-term pathway (6-12 months; mean 10 ± 3 months; n=100) for frail/chronic patients already followed in home care. RESULTS: The most frequent main diagnosis was HF (n=108, 54%), followed by diabetes (30%) and chronic obstructive pulmonary disease (16%). A Charlson score ≥3 was present in 75% of cases and over 60% were taking at least 7 drugs. Among the social characteristics of the enrolled population, 55% were living alone or with non-familial caregivers, 62% had primary education and 48% were non-self-sufficient. The days of hospitalization were significantly reduced only in the TM arm of the post-acute pathway (20 days of hospitalization avoided for 10 patient-months of follow-up, p=0.03) and the effect was mainly evident in patients with HF (p=0.02). A significant increase in the number of home accesses and telephone contacts were also documented in the TM group (12.7 and 13.7 more home interventions for 10 patient-months of follow-up; p=0.01 and p=0.002 in the post-acute and chronic pathway, respectively). CONCLUSIONS: The SmartCare-FVG project showed in patients with chronic diseases (mainly HF), in the post-acute phase of the disease, to significantly reduce the days of hospitalization with a limited and sustainable increase in the use of nursing home care resources.

Sex-related differences in chronic heart failure: a community-based study.

AIMS: To evaluate sex-related differences among real-life outpatients with chronic heart failure across the ejection fraction spectrum and to evaluate whether these differences might impact therapy and outcomes. METHODS: A total of 2528 heart failure patients were examined between 2009 and 2015 [mean age 76, 42% females; 59% with heart failure with preserved ejection fraction (HFpEF), 17% with heart failure with mid-range ejection fraction (HFmrEF) and 24% with heart failure with reduced ejection fraction (HFrEF)]. Females showed a higher prevalence of HFpEF than males. RESULTS: Females were older, less obese and with less ischaemic heart disease. They have renal failure and anaemia more frequently than males. There were no differences in terms of heart failure therapy in the HFrEF group, but a lower prescription rate of angiotensin-converting enzyme-I/AT1 blockers in HFmrEF and HFpEF and a higher prescription of mineralocorticoid receptor antagonists in the female group with HFpEF were observed. Crude rate mortality and composite outcome (death/heart failure progression) run similarly across sexes regardless of the ejection fraction categories. After adjustment, risk of mortality was significantly lower in females than males in the HFmrEF and HFpEF groups, whereas similar risk was confirmed across sexes in the HFrEF group. Considering prognostic risk factors, noncardiac comorbidities emerged in the HFpEF group. CONCLUSION: In a community-based heart failure cohort, females were differently distributed within heart failure phenotypes and they presented some different characteristics across ejection fraction categories. Although in an unadjusted model there was no significant difference for adverse outcomes, in an adjusted model females showed a lower risk of mortality in HFpEF and HFmrEF. Concerning sex-related prognostic risk factors, noncardiac comorbidities significantly affected adverse prognosis in females with HFpEF.

[Information to be provided to patients and their caregivers. The Italian Law 219/2017 on informed consent, advance directives, and do not attempt resuscitation order]. / Informazione al malato e alla famiglia. Legge 219/2017: pianificazione condivisa delle cure, disposizioni anticipate di trattamento, "do not attempt resuscitation order".

The Italian law 219/2017, enacted on January 31, 2018, regulates patients' informed consent, personalized care planning and advance directives. The law provides for patient's self-determination in all phases of life. This also applies to patients suffering from chronic, progressive, terminal disease such as heart failure. In fact, the clinical and psychosocial trajectory for heart failure patients demands an interdisciplinary, systemic approach. Advance directives should be tailor-made to patient's needs and dynamically updated through the course of the disease according to patient's and family informed and shared decision-making. Healthcare professionals will require education and training to stay up to the task both clinically, psychologically and emotionally.

Personalized support for chronic conditions. A novel approach for enhancing self-management and improving lifestyle.

OBJECTIVE: Solutions for improving management of chronic conditions are under the attention of healthcare systems, due to the increasing prevalence caused by demographic change and better survival, and the relevant impact on healthcare expenditures. The objective of this study was to propose a comprehensive architecture of a mHealth system aimed at boosting the active and informed participation of patients in their care process, while at the same time overcoming the current technical and psychological/clinical issues highlighted by the existing literature. METHODS: After having studied the current challenges outlined in the literature, both in terms of technological and human requirements, we focused our attention on some specific psychological aspects with a view to providing patients with a comprehensive and personalized solution. Our approach has been reinforced through the results of a preliminary assessment we conducted on 22 patients with chronic conditions. The main goal of such an assessment was to provide a preliminary understanding of their needs in a real context, both in terms of self-awareness and of their predisposition toward the use of IT solutions. RESULTS: According to the specific needs and features, such as mindfulness and gamification, which were identified through the literature and the preliminary assessment, we designed a comprehensive open architecture able to provide a tailor-made solution linked to specific individuals' needs. CONCLUSION: The present study represents the preliminary step towards the development of a solution aimed at enhancing patients' actual perception and encouraging self-management and self-awareness for a better lifestyle. Future work regards further identification of pathology-related needs and requirements through focus groups including all stakeholders in order to describe the architecture and functionality in greater detail.

[Objectives, organization and activities of a nurse-led clinic for outpatient cardiology care]. / Obiettivi, organizzazione e attività di un Ambulatorio Infermieristico Cardiologico di Continuità Assistenziale.

BACKGROUND: Cardiovascular diseases are the first cause of death worldwide. In the last decades, therapeutic advances have determined an increase in survival rates, with a subsequent rise in the number of elderly people suffering from chronic cardiovascular diseases and associated comorbidities requiring comprehensive, team-based multidisciplinary care. The aim of this study is to describe the organization, purposes and activities of a nurse-led cardiology clinic. METHODS: Between November 1, 2009 and October 31, 2014, the nurse-led clinics located within our Cardiology Outpatient Center provided care to 2081 out of 26 057 patients (8%) with complex healthcare needs, high cardiovascular risk and/or specific therapeutic indications or needs for reassessment; 1875 of these patients received nurse-led interventions: 451 (21.7%) in Chronic Heart Disease (CHD) care; 402 (19.3%) in Heart Failure (HF) care; 1022 (49.1%) at the Oral Anticoagulant Therapy (OAT) care, while 206 patients (9.9%) underwent Nurse Triage. Nursing assessment includes a clinical multidimensional analysis, with identification of relevant health issues and planning of a nursing intervention (education, intensified monitoring, and support to therapy) shared with the cardiologist in a joint report. RESULTS: The clinical characteristics and the social care needs of the patients who received nurse-led care were extremely heterogeneous. Patients with heart failure were the oldest (79 years), most severe (58.2% hospitalized last year), with Charlson index ≥3% (82.8 %); 72.4% were taking ≥7 drugs daily. The majority of them had medium-to-low education levels and more frequently lived alone, with disabilities, inadequate self-monitoring, and self-care behaviors. Patients on anticoagulant therapy were younger (71 years), in 75.9% of cases with atrial fibrillation, most frequently assisted by a caregiver and without functional limitations. The patients of these two nurse-led clinics (HF and OAT) were those who came most frequently after hospital discharge, presented mainly clinical instability and problems of adherence to the therapeutic programs, and needed in most cases a therapeutic intervention associated with an intensification of clinical/behavioral monitoring. CONCLUSIONS: Nursing assessment supports the specialist's intervention by intensifying clinical surveillance and therapeutic intervention in the most complex real-world patients. It provides information to complete the cardiological assessment and is essential to better understand patients' health and social care needs, and to suggest and coordinate a tailor-made plan.