Presentazione sul tema: "LETTERA DI DIMISSIONE DIAGNOSI FATTORI DI RISCHIO DECORSO CLINICO"— Transcript della presentazione:
1 LETTERA DI DIMISSIONE DIAGNOSI FATTORI DI RISCHIO DECORSO CLINICO LA CONDIZIONE DI RISCHIO DEL PAZIENTELA DIETA SUGGERITAL’ATTIVITÀ FISICA CONSIGLIATALA TERAPIA SUGGERITAIL CALENDARIO DEI PROSSIMI APPUNTAMENTI
3 Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery DiseaseL. Kristin Newby, MD, MHS; Nancy M. Allen LaPointe, PharmD; Anita Y. Chen, MS; Judith M. Kramer, MD, MS; Bradley G.Hammill, MA; Elizabeth R. DeLong, PhD; Lawrence H. Muhlbaier, PhD; Robert M. Califf, MD From the Duke Centers for Educationand Research on Therapeutics at the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.CIRCULATION 2006Questo lavoro dimostra come dal 95 al 2002 sia aumentato il n° di pz che riceve un trattamento completoUse of evidence-based therapies for CAD has improved butremains suboptimal. Although improved discharge prescription of these agentsis needed, considerable attention must also be focused on understanding andimproving long-term adherence.
4 IMPACT OF MEDICAL THERAPY DISCONTINUATION ON MORTALITY AFTER MYOCARDIAL INFARCTIONPM Ho, JA Spertus, FA Masoudi, KJ Reid, ED Peterson, DJ Magid, HM Krumholz, SJ RumsfeldArch Intern Med 2006ASA + betablocco + statine (molti)Medication therapy discontinuation after MI is commun and occurs early after discharge.Patients who discontinue taking evidence-based medications are incresed mortality risk.These findings suggest the need to improve the transition of care from the hospital tooutpatient setting to ensure that patients continue to take medications that have mortalitybenefit
5 Kaplan-Meier survival curve comparing patients discontinuing use of all medications at 1 monthwith patients continuing useof 1 or more medications amongpatients discharged with all 3medications (log-rank test, P<.001).Kaplan-Meier survival curve comparingpatients discontinuing use of allmedications at 1 month with patientscontinuing use of 1, 2, or all 3 medicationsamong patients discharged with all 3medications (log-rank test, P<.001).
6 RELATIONSHIP BETWEEN ADHERENCE TO EVIDENCE-BASED PHARMACOTHERAPY AND LONG-TERM MORTALITY AFTERACUTE MYOCARDIAL INFARCTIONJeppe N Rasmussen, Alice Chong, David A. AlterJAMA 2007
8 ADHERENCE WITH STATIN THERAPY IN ELDERLY PATIENTS WITH AND WITHOUT ACSCA Jackevicius, MM Pharmd, JV TuJAMA 2002Context Landmark clinical trials have demonstrated the survival benefits of statins, withbenefits usually starting after 1 to 2 years of treatment. Research prior to these trials ofolder lipid-lowering agents demonstrated low levels of 1-year adherence.Objective To compare 2-year adherence following statin initiation in 3 cohorts of patients:those with recent acute coronary syndrome (ACS), those with chronic coronary arteryDisease (CAD), and those without coronary disease (primary prevention).Design and Setting Cohort study using linked population-based administrative datafrom Ontario.Patients All patients aged 66 years or older who received at least 1 statin prescriptionbetween January 1994 and December 1998 and who did not have a statin prescription inthe prior year were followed up for 2 years from their first statin prescription. There were22 379 patients in the ACS, 36 106 in the chronic CAD, and 85 020 in the primaryprevention cohorts.Main Outcome Measures Adherence to statins, defined as a statin being dispensedat least every 120 days after the index prescription for 2 years.Results Two-year adherence rates in the cohorts were only 40.1% for ACS, 36.1%for chronic CAD, and 25.4% for primary prevention. Relative to the ACS cohort,nonadherence was more likely among patients receiving statins in the chronicCAD (relative risk [RR], 1.14; 95% CI, ) and primary prevention cohorts(RR, 1.92; 95% CI, ).
9 Conclusions Elderly patients with and without recent ACS have low rates of adherence to statins. This suggests that many patients initiatingstatin therapy may receive no or limited benefit from statins because ofpremature discontinuation.
11 The (cost-)effectiveness of an individually tailored long-term worksite health promotion programme on physical activity and nutrition:design of a pragmatic cluster randomised controlled trialSuzan JW Robroek1 , Folef J Bredt2 and Alex Burdorf1 1Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands2LifeGuard Inc., PO Box 1366, 3500 BJ Utrecht, The NetherlandsBackgroundCardiovascular disease is the leading cause of disability and mortality in most Western countries. The prevalence of several risk factors, most notably low physicalactivity and poor nutrition, is very high. Therefore, lifestyle behaviour changes are of great importance. The worksite offers an efficient structure to reach largegroups and to make use of a natural social network. This study investigates a worksite health promotion programme with individually tailored advice in physicalactivity and nutrition and individual counselling to increase compliance with lifestyle recommendations and sustainability of a healthy lifestyle.Methods/DesignThe study is a pragmatic cluster randomised controlled trial with the worksite as the unit of randomisation. All workers will receive a standard worksite healthpromotion program. Additionally, the intervention group will receive access to an individual Health Portal consisting of four critical features: a computer-tailored advice,a monitoring function, a personal coach, and opportunities to contact professionals at request. Participants are employees working for companies in the Netherlands,being literate enough to read and understand simple Internet-based messages in the Dutch language. A questionnaire to assess primary outcomes (compliance withnational recommendations on physical activity and on fruit and vegetable intake) will take place at baseline and after 12 and 24 months. This questionnaire alsoassesses secondary outcomes including fat intake, self-efficacy and self-perceived barriers on physical activity and fruit and vegetable intake. Other secondaryoutcomes, including a cardiovascular risk profile and physical fitness, will be measured at baseline and after 24 months. Apart from the effect evaluation, a processevaluation will be carried out to gain insight into participation and adherence to the worksite health promotion programme. A cost-effectiveness analysis and sensitivityanalysis will be carried out as well.DiscussionThe unique combination of features makes the individually tailored worksite health promotion programme a promising tool for health promotion.It is hypothesized that the Health Portal's features will counteract loss to follow-up, and will increase compliance with the lifestyle recommendations and sustainability ofa healthy lifestyle.To increase compliance with lifestyle recommendation and sustainabilityOf a healthy lifestyleQuestionnaire
12 A critical realist approach to understanding and evaluating heart health programmesClark AM, MacIntyre PD, Cruickshank JHealth 2007Secondary prevention programmes for Coronary Heart Disease aim toreduce cardiovascular risks and promote health in people with heart disease.Though programmes have been associated with health improvementsin study populations, access to programmes remains low, and quality andeffectiveness is highly variable. Current guidelines propose significantmodifications to programmes, but existing research provides little insight into whyprogramme effectiveness varies so much. Drawing on a critical realist approach,this article argues that current research has been based on an impoverishedontology, which has elements of positivism, does not explore thesocial determinants of health or the effects on outcomes of salientcontextual factors, and thereby fails to accountfor programme variations. Alternative constructivistapproaches are also weak and lacking in clinical credibility.An alternative critical realist approach is proposed that drawson the merits of subjectivist and objectivist approachesbut also reflects the complex interplay between individual,programme-related, socio-cultural and organizational factorsthat influence health outcomes in open systems. This approachembraces measurement of objective effectiveness butalso examines the mechanisms, organizational and contextual-relatedfactors causing these outcomes. Finally, a practical example of howa critical realist approach can guide research into secondary prevention programmes is provided.
13 A practical approach to reducing cardiovascular risk factorsFonarow GC Rev Cardiovasc Med. 2007Despite overwhelming evidence supporting the benefits of cardiovascular protectivetherapies and risk reduction in patients with or at risk for coronary heart disease,these strategies remain underutilized in clinical practice. Preventive cardiologyguidelines from the American Heart Association, the American College of Cardiology,and others focus on primary and secondary prevention with the use of medications,risk factor control measures, and lifestyle modification. Still, a "treatment gap" remainsbetween the guidelines and their actualization. A systematic approach including both inpatientand outpatient measures is necessary.
14 Consolidamento della stabilità clinica Riduzione del rischio di futuri eventiGestione ottimale del paziente nel lungo periodo
18 In this study protocol the design of a pragmatic cluster randomised controlled trial on worksite healthpromotion is presented. The study is designed to evaluate the (cost)effectiveness of an individuallytailored long-term worksite health promotion programme on PA and nutrition. It is hypothesized that theunique combination of critical features (a computer-tailored advice, a monitor function, a personal coach,and the opportunity to contact professionals at request) counteracts the main factors for ineffective WHPP(lack of participation, adherence to the WHPP and sustainability), and leads to a change in lifestyle.By conducting an extensive process evaluation we gain insight into the effective elements of worksitehealth promotion. By registering several process variables it is possible to find out if participants with ahigher adherence to the (separate parts of the) WHPP are more likely to comply with the lifestylerecommendations. With the health check as starting point for the WHPP, it is aimed to increase participation.The Health Portal's critical features are aimed to counteract loss to follow-up, and increase adherence to theintervention programme, compliance with lifestyle recommendations, and sustainability of a healthy lifestyle.Because of the long-term follow-up, sustainability of healthy behaviour will be facilitated.The cost-effectiveness of the extensive Health Portal will be compared to the cost-effectiveness of thestandard WHPP. In conclusion, this study evaluates a promising intervention on healthy behaviour andresults will provide insight into cost-effectiveness and the effective elements of WHPP.
19 Cardiologo ambulatoriale Stratificazione prognosticastima del rischio cardiovascolareOTTIMIZZAZIONE DELLA TERAPIA FARMACOLOGICAProgramma di training fisico controllato per i pazienti eleggibiliEducazione e counseling con interventi finalizzati a favorire il ritorno ad una vita attiva, a modificare lo stile di vita, a tenere sotto adeguato controllo i fattori di rischioIMPOSTAZIONE DI UN FOLLOW-UP APPROPRIATOOspedalepazienteCardiologoambulatorialeMMGPROGRAMMAZIONECONDIVISIONECONTINUITA’ASSISTENZIALE
20 Sistemi di comunicazione efficaci Sistema informatizzato:per l’archiviazione e la trasmissione a distanza delle informazioni cliniche necessarie per la gestione dell’assistenza, adottando tutti i presidi per la salvaguardia della privacy;per la produzione e l’utilizzo condiviso di linee guida e di percorsi assistenziali;in collegamento con banche dati e registri, e all’esterno con l’Agenzia per i Servizi Sanitari Regionali, scambiando dati ed informazioni in grado di favorire una più corretta programmazione degli interventi cardiologici sul territorio.La lettera di dimissione
21 I presupposti per garantire il funzionamento della Rete Intensificare la collaborazione e relazione tra MMG e CardiologoIntendersi sui percorsi e obiettiviStrutture competenti ad intercettare il paziente nelle varie fasi della malattiaDenominatore comune: qualità delle prestazioni ed uso razionale delle risorse
22 Gli Obiettivi Consolidamento della stabilità clinica Riduzione del rischio di futuri eventiGestione ottimale del paziente nel lungo periodo
23 Ambulatori di Prevenzione CV identificare e modificare i fattori di rischio, nel tentativo di ridurre la conseguente morbilità e mortalità della malattia cardiovascolare;imparare ad identificare i sintomi precoci della malattia coronarica, al fine di ridurre il ritardo di ricovero in ambito ospedaliero dei pazienti affetti da patologie acute (infarto, sindromi coronariche acute);addestrare la popolazione alla conoscenza delle procedure organizzative da attuare in caso di attacco cardiaco acuto;migliorare la capacità funzionale sia dei pazienti a rischio cardiovascolare che dei cardiopatici noti pianificando e individualizzando l’attività fisica ed eventualmente sportiva, definendo con precisione i carichi di lavoro;Sostenere e razionalizzare la cardiologia preventiva sia primaria che secondaria con interventi mirati attraverso i mass media, conferenze divulgative ed opuscoli. Considerare questa funzione come risorsa gestionale strategica per raggiungere gli obiettivi del Paino Sanitario Nazionale e Regionale.
27 PROGRAMMAZIONE concordata per garantire continuità assintenziale approccio medico multidisciplinare, nelle quali si rende spesso necessariol’intervento accanto al Cardiologo anche di altre figure professionali(Internisti, Nutrizionisti, Nefrologi, Diabetologi, Psicologi, Fisioterapisti, ecc.)Percorsi differenziati per ciascun paziente in base a età, sesso, profilo di rischio,capacità funzionaleCardiopatia di base: Alto rischio - IMA - CCH - Scompenso, eccStato del paziente e fase della sua malattia
28 Continuità Assistenziale Si ha "continuità assistenziale" quando vi è uniformità di criteri di valutazione e trattamento indipendentemente dalla singola sede o soggetto con cui il paziente viene in contatto e, quindi, il piano di cura viene seguito e/o rivisto con criteri condivisi, permettendo di assicurare una comunicazione razionale ed efficace tra i diversi livelli assistenziali, la migliore cura dei pazienti ed il corretto uso delle risorseCONDIVISIONE