Secondary prevention clinic as a hospital–territory integrated care model in ischemic heart disease: analysis of quality indicators and clinical outcomes.

Background

The increasing complexity of managing patients with ischemic heart disease requires the development of integrated hospital–community care models. In this context, secondary prevention clinics may represent an organizational strategy capable of improving clinical outcomes and healthcare quality indicators.

Methods

We performed an observational analysis of patients enrolled in a secondary prevention clinic for ischemic heart disease, with data updated to July 31, 2025. Demographic characteristics, cardiovascular risk factors, angiographic findings, clinical outcomes, and healthcare quality indicators were evaluated.

A total of 1,093 patients were included: 899 men (82.2%) and 194 women (17.7%), with a mean age of 65.46 years. Territorial outpatient activity involved 85 patients between January 1 and April 30, 2024.

Results

Major cardiovascular risk factors included hypertension in 745 patients, dyslipidemia in 784, diabetes in 296, current/former smoking in 392, and family history in 438 patients.

Angiographic characteristics showed incomplete revascularization in 212 patients, multiple stent implantation in 364, and multivessel disease in 435.

Clinical outcomes dimostrate:total rehospitalization rates of 2.4% at 6 months and 3.2% at 12 months.overall mortality of 0.6%;rehospitalizations for CABG/PCI of 0.73% at 6 months and 1.9% at 12 months, with procedure-related mortality of 0.13%.

Compared with patients managed exclusively by general practitioners, those followed in the clinic showed fewer medical-therapy rehospitalizations (6% vs 28%), fewer unchanged angiographic findings (34% vs 48%), and higher rates of appropriate revascularization (60% vs 24%).

The 12-month rehospitalization rate was lower in clinic-managed patients (4.34%) compared with historical cohorts (7.21% in 2010 and 8.01% in 2014).

Quality indicators showed first follow-up visits within 30 days in 45–73% of cases and LDL cholesterol target achievement in 74–89%, with improvement after the 2019 guideline update. Among territorially managed patients, LDL target achievement reached 89.2%.

Conclusions

A structured secondary prevention clinic represents an effective hospital–community integrated care model for ischemic heart disease, associated with low rehospitalization rates (3.2% at 12 months), low mortality (0.6%), and high cardiovascular risk-factor control. Continuous monitoring through quality indicators supports the role of structured secondary prevention in improving clinical outcomes and healthcare appropriateness. Inizio modulo