How has the systematization of comprehensive care avoided hospitalisation for heart failure?
M Blanquet, P Berland, C Vergne, L Gaulen, P Losorgio-Petitjean, G Breysse, L GerbaudAbstract
Introduction
Heart failure (HF) and frailty are major issues in developed and aging countries. The healthcare pathway "Heart Failure" is a reorganization of care supply that has been implemented to consider both the specificity of heart failure care and the global health through a comprehensive frailty screening. Patients at risk or affected by heart failure are included.
Purpose
The main objective was to assess the effectiveness of this reorganization through the outcome "reduction of the rate of hospitalization for heart failure", in a cohort followed up for one year.
Methods
A cohort study took place in a single community hospital located in Auvergne, south center France, between 28 February 2023 and 31 December 2025. Patients were eligible if they were 18 years old or over and, lived at home. Patients were not included if they were under guardianship, not agreed that their medical data were kept for analysis and if their clinical situation was not relevant. Patients benefit from a comprehensive baseline assessment performed by a doctor and an integrated care nurse. The comprehensive baseline assessment includes heart failure specific care, screening for comorbidities and multidimensional screening for frailty. The comprehensive assessment attempts to consider the complexity of patient health state, as several associations exist between heart failure, its comorbidities and multidimensional frailty. Patients were taken in charge by the HP-HF doctor-nurse duet in coordination with teams managing the patients in primary care. Patients were followed up for one year. The main outcome were the rate of hospitalization for heart failure. Hospitalization rate for heart failure the year before and the year following the entrance in the HP-HF were compared to measure the efficiency by using the McNemar's chi-square test for paired series.
Results
In the 88 patients included, the mean age was 75.39 (SD 12.03) years old, and there were 46.59% of women. Patients were affected by HF in 59.21% of the cases and were at risk in 27.63 % (no cardiomyopathy) and 13.16% (cardiomyopathy without HF) of the cases. The patients had 907 health needs, mean 10.31 (SD 3.36). The five most common frailties screened were by decreased order: poor oral health (75.00%), loss of independence (61.64%), socioeconomic vulnerability (60.61%), drugs-induced iatrogenesis (58.14%), and malnutrition (52.38%). Hospitalization for heart failure decreased significantly with 6.02% in the 12 months after vs. 25.30% of patients hospitalized in the 12 months before (p = 0.0003).
Conclusion
A comprehensive baseline assessment by a doctor-nurse duet combined with an integrated care management based on primary healthcare professionals, for patients with HF, has reduced hospitalization by fourfold.Modelling of the hollistic approachFor image description, please refer to the figure legend and surrounding text.Patients health needsFor image description, please refer to the figure legend and surrounding text.