RESUMO
BACKGROUND: Healthcare expenditure in the Netherlands is increasing at such a rate that currently 1 in 7 employees are working in healthcare/curative care. Future increases in healthcare spending will be restricted, given that 10% of the country's gross domestic product is spent on healthcare and the fact that there is a workforce shortage. Dutch healthcare consists of a curative sector (mostly hospitals) and nursing care at home. The two entities have separate national budgets (25â¯bnâ¯+ 20â¯bn respectively) AIM: In a proof of concept, we explored a new hospital-at-home model combining hospital cure and nursing home care budgets. This study tests the feasibility of (1) providing hospital care at home, (2) combining financial budgets, (3) increasing workforces by combining teams and (4) improving perspectives and increasing patient and staff satisfaction. RESULTS: We tested the feasibility of combining the budgets of a teaching hospital and home care group for cardiology. The budgets were sufficient to hire three nurse practitioners who were trained to work together with 12 home care cardiovascular nurses to provide care in a hospital-at-home setting, including intravenous treatment. Subsequently, the hospital-at-home programme for endocarditis and heart failure treatment was developed and a virtual ward was built within the epatient record. CONCLUSION: The current model demonstrates a proof of concept for a hospital-at-home programme providing hospital-level curative care at home by merging hospital and home care nursing staff and budgets. From the clinical perspective, ambulatory intravenous antibiotic and diuretic treatment at home was effective in safely achieving a reduced length of stay of 847 days in endocarditis patients and 201 days in heart-failure-at-home patients. We call for further studies to facilitate combined home care and hospital cure budgets in cardiology to confirm this concept.
RESUMO
AIM: To investigate whether blood biomarkers measured routinely at hospital admission in myocardial infarction (MI) patients can improve the admission GRACE score for the composite endpoint of all-cause mortality and non-fatal MI at 6â¯months. METHODS: 2055 patients treated for MI in the Northwest clinics, the Netherlands, between 2013 and 2016 were examined. As part of the prevailing MI treatment protocol, 19 biomarkers were measured and the GRACE score was ascertained. Information on the composite endpoint was derived from municipal registries and electronic medical records. We applied elastic net logistic regression (LR) analysis to select biomarkers that had statistically significant additive prognostic value on top of the GRACE score. We then studied the prognostic performance of the LR model containing the GRACE score and the selected biomarkers. RESULTS: At six months follow-up 143 (6.96%) reached the composite endpoint. Nine variables were included in the final LR model: GRACE score, urea, sodium, potassium, alkaline phosphatase, LDL cholesterol, glucose, hemoglobin and C-reactive protein. This extended GRACE score model showed improved discrimination (C-statistic 0.76 vs 0.70, pâ¯=â¯<0.001) and classification (continuous net reclassification index 0.49, pâ¯<â¯0.001) compared with the GRACE score only. CONCLUSION: The ability of the GRACE score for detecting MI patients at high risk for mortality or MI within 6â¯months, was significantly improved by adding several biomarkers measured routinely at admission.