ABSTRACT
INTRODUCTION AND OBJECTIVES: The efficacy of heart failure programs has been demonstrated in clinical trials but their applicability in the real world practice setting is more controversial. This study evaluates the feasibility and efficacy of an integrated hospital-primary care program for the management of patients with heart failure in an integrated health area covering a population of 309,345. METHODS: For the analysis, we included all patients consecutively admitted with heart failure as the principal diagnosis who had been discharged alive from all of the hospitals in Catalonia, Spain, from 2005 to 2011, the period when the program was implemented, and compared mortality and readmissions among patients exposed to the program with the rates in the patients of all the remaining integrated health areas of the Servei Català de la Salut (Catalan Health Service). RESULTS: We included 56,742 patients in the study. There were 181,204 hospital admissions and 30,712 deaths during the study period. In the adjusted analyses, when compared to the 54,659 patients from the other health areas, the 2083 patients exposed to the program had a lower risk of death (hazard ratio=0.92 [95% confidence interval, 0.86-0.97]; P=.005), a lower risk of clinically-related readmission (hazard ratio=0.71 [95% confidence interval, 0.66-0.76]; P<.001), and a lower risk of readmission for heart failure (hazard ratio=0.86 [95% confidence interval, 0.80-0.94]; P<.001). The positive impact on the morbidity and mortality rates was more marked once the program had become well established. CONCLUSIONS: The implementation of multidisciplinary heart failure management programs that integrate the hospital and the community is feasible and is associated with a significant reduction in patient morbidity and mortality.
Subject(s)
Heart Failure/therapy , Patient-Centered Care/organization & administration , Primary Health Care/organization & administration , Adolescent , Adult , Aged , Aged, 80 and over , Disease Management , Feasibility Studies , Female , Heart Failure/epidemiology , Humans , Male , Middle Aged , National Health Programs , Patient Care Team , Patient Readmission/statistics & numerical data , Program Evaluation , Spain/epidemiology , Urban Population , Young AdultABSTRACT
En las ciencias sociales y de la salud actualmente comienza a ser conocido un diseño denominado como "experimento natural", que se caracteriza por ser un tipo de cuasi-experimento en que la asignación de tratamiento no es hecha por el investigador sino por un agente exógeno tal como una ley, una política sectorial o un fenómeno natural. Esa intervención exógena implícita permite que se formen grupos con bajos niveles de sesgos de selección inicial, por lo que la comparación de resultados encontrados en esos grupos (grupos afectados por la ley, la política o fenómeno natural respecto del grupo contrafáctico que no es afectado) permite predecir los efectos de la ley, política sectorial o fenómeno natural casi tan eficientemente como en la creación de grupos aleatorios de tratamiento y control.
Currently in social science research it is used a new research design defined as a "natural experiment", where the researcher has none participation in the treatment assignment because it has been directly done for an exogenous agent such as a law, a social policy or a natural event. This implicit exogenous intervention allows that low-level pre-determined selection bias groups be formed. Therefore, the comparison on results being found between these groups (law-affected group, social policy-affected group, or natural event-affected group versus contrafactic groups not being affected) allow to predict the effect of this law, social policy, or natural event almost so efficiently like happen in randomly created treatment-and-control groups.
