[Integrated models between hospital and field for patients with heart failure]

Chronic heart failure is a major health problem, which is growing parallel to the increasing proportion of elderly in the population. Recurrent hospitalizations occur in about half of the subjects within 6 months after the initial admission. Several co-morbidities usually coexist in these patients and influence resource utilization and outcome. The high re-admission rates and low proportion of patients who are currently enrolled in specific follow-up programs underscore the existing pitfalls in outpatient care, and the lack of co-operation between hospital departments and out-of-hospital clinics or general practitioners. As a consequence, up to half of the hospital admissions may be caused by potentially preventable factors. As worldwide health-care cost-containment escalates, it becomes crucial to develop new cost-effective strategies to improve the quality of care of more severe patients. The implementation of clinic-based heart failure programs showed some evidence of an improvement in functional status and in the frequency of hospital readmissions. However, patients referred to Heart Failure Clinics represent a selected population of patients compared to the overall population of "real-world" elderly patients with incapacitating symptoms, serious co-morbidities and frequent inability to attend an outpatient clinic. Few trials are currently available to verify the efficacy of a clinic-based approach in such patients, with discordant results. Other studies have extended the multidisciplinary program to the patient's home. These strategies might be particularly appropriate and cost-effective if targeted to elderly and higher-risk patients, and appear to be of particular relevance given the phenomenon of progressive aging of the general population. The results of our intensive, nurse-monitored, homecare surveillance on quality of life and hospitalization rate in elderly patients with refractory heart failure who previously failed to reach the goal of clinical stability with a clinic-based program extend the effectiveness of heart failure programs, in terms of quality of life and hospital readmission, to terminally ill subjects with short life expectancy and very high resource utilization.