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Intensive multidisciplinary care programme for frail patients

I Urreta, P Aranegi, J Artetxe, X Zubeldia, I Huerta, J.I. Emparanza


Rationale and Objectives: Patients with chronic diseases re-admitted for acute events are associated with a high use of hospital resources and represent a challenge for healthcare systems. In such cases, follow-up interventions at discharge can be effective. The widespread adoption of follow-up procedures not involving telemonitoring may greatly decrease re-admissions rates without the costs associated with telemedicine. To assess the impact of a structured follow-up programme on patient-perceived healthcare quality, treatment adherence, re-admissions and Emergency Department attendances.

Methods: This was a before and after study of 242 patients at risk of re-admission for chronic obstructive pulmonary disease (COPD) or heart failure (HF), recruited between 1st July 2009 and 30th June 2010 at Donostia Tertiary University Hospital (Gipuzkoa, Spain). The follow-up ended on 30th December 2010. The intervention involved identifying independent re-admitted patients, providing personalised information and a direct number to call in the event of clinical worsening, assigning specialists and liaison nurses, structured follow-up by telephone and appointments and contact with general practitioners. Patient perceived quality of care estimated was analyzed using a focus group technique. To assess the number of re-admissions and the Emergency Department attendances we estimated the relative risk reduction as a percentage and corresponding 95% confidence intervals.

Results: In terms of perceived quality of care, the most valued elements were related to having an assigned doctor/nurse and easy access in the event of worsening. Overall, 97.9% of patients reported full adherence to treatment (95% CI: 95.4-98.83).

Hospital bed days and Emergency Department attendances decreased by 60.7% (95% CI: 58.7-62.7) and 77% (95% CI: 73.2-80.3), respectively.

Conclusions: The intensive multidisciplinary care programme can reduce Emergency Department attendances and improve perceived quality of care in patients with HF and COPD.


Chronic diseases, chronic obstructive pulmonary disease, emergency department attendances, frail patients, heart failure, multidisciplinary care, multidisciplinary team, older patients, person-centered care, preventable admissions, re-admissions, treatmen

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Parker, S.G. (2005). Do Current Discharge Arrangements from Inpatient Hospital Care for the Elderly Reduce Readmission Rates, the Length of Inpatient Stay or Mortality, or Improve Health Status? Health Evidence Network. Copenhagen: World Health Organisation.

Rolstein, Z., Barabash, G. & Noy, S. (1996). Allocation of emergency ward patients to medicine departments: Increasing physicians' incentive to shorten length of stay. Public Health Reviews 24 (1) 37-48.

Government of the Basque Country - Department of Health and Consumer Affairs Estrategia para afrontar el reto de la Cronicidad en Euskadi. Ed. Eusko Jaurlaritza. Legal Dept. - BI-2345-2010

Jencks, S.F., Williams, M.V. & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine 360 (14) 1418–1428.

Mudge, A.M., Kasper, K., Clair, A., Redfern, H., Bell, J.J., Barras, M.A. & Pachana, N.A. (2011). Recurrent Readmissions in Medical Patients: a Prospective Study. Journal of Hospital Medicine 6 (2) 61-67.

Covinsky, K.E., Palmer, R.M., Fortinsky, R.H., Counsell, S.R., Stewart, A.L., Kresevic, D., Burant, C.J. & Landefeld, C.S. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of American Geriatrics Society 51 (4) 451-458.

Friedman, B. & Basu, J. (2004). The rate and cost of hospital readmissions for preventable conditions. Medical Care Research and Review 61 (2) 225-240.

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K. & Hamilton, K. (2009). Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program. Journal of American Geriatrics Society 57 (3) 395-402.

Matorras, P., Alonso, F. & Daroca, R. (1990). The multiple-admissions patients in internal medicine as a special type of hospital readmission. Anales de Medicina Interna 7 (7) 353-357.

Alonso, J.L., Llorente B., Echegaray M., Urbieta M.A. & Gonzalez, C. (2001). Hospital readmission in internal medicine. Anales de Medicina Interna 18 (5) 248-254.

Sicras, A. & Navarro, R. (1993). The evaluation of hospital readmissions in the internal medicine service. Medicina Clínica 101 (19) 732-735.

Perez, C.E. (2002). Ontario hospitals mergers, shorter stays and readmissions. Health Reports 14 (1) 25-36.

Michalsen, A., Konig, G. & Thimme, W. (1998). Preventable causative factors leading to hospital admissions with decompensated heart failure. Heart 80 (5) 437-441.

Healthcare Cost and Utilization Project net. Available at: http:// Accessed on April 6, 2010

van Walraven, C., Bennett, C., Jennings, A., Austin, P.C. & Forster, A.J. (2011). Proportion of hospital readmissions deemed avoidable: a systematic review. Canadian Medical Association Journal 183 (7) E391-402.

Voss, R., Gardner, R., Baier, R., Butterfield, K., Lehrma, S. & Gravenstei, S. (2011). The Care Transitions Intervention. Translating From Efficacy to Effectiveness. Archives of Internal Medicine 171 (14) 1232-1237.

Shepperd, S., McClaran, J., Phillips, C.O., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. & Barras, S.L. (2010). Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 20 (1) DOI:10.1002/14651858.CD000313.pub3.

Chiu, W.K. & Newcomer, R. (2007). A systematic review of nurse assisted case management to improve Hospital Discharge Transition Outcomes for the elderly. Professional Care Management 12 (6) 330-336.

Shepperd, S., Doll, H., Angus, RM., Clarke, M.J., Lliffe, S., Kalra, L., Ricauda, N.A. & Wilson, A.D. (2008). Hospital at home admission avoidance. Cochrane Database of Systematic Reviews 4, DOI:10.1002/14651858.CD007491.

Inglis, S.C., Clark, R.A., McAlister, F.A., Ball, J., Lewinter, C., Cullington, D., Stewart, S. & Cleland, J.G.F. (2010). Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews 8, DOI: 10.1002/14651858.CD007228. pub2.

Dar, O., Riley, J., Chapman, C., Dubrey, S.W., Morris, S., Rosen, S.D., Roughton, M. & Cowie, M.R. (2009). A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study. European Journal of Heart Failure 11 (3) 319-325.

Maric, B., Kaan, A., Ignaszewski, A. & Lear, S.A. (2009). A systematic review of telemonitoring technologies in heart failure. European Journal of Heart Failure 11 (5) 506-517

Tran, K., Polisena, J., Coyle, D., Coyle, K., Kluge, E.H.W., Cimon, K., McGill, S., Noorani, H., Palmer, K. & Scott, R. (2008). Home telehealth for chronic disease management (Technology report number 113). Ottawa: Canadian Agency for Drugs and Technologies in Health.

Polisena, J., Tran, K., Cimon, K., Hutton, B., McGill, S., Palmer, K. & Scott, R.E. (2010). Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of Telemedicine and Telecare 16 (3) 120-127.

Vitacca, M., Bianchi, L., Guerra, A., Fracchia, C., Spanavello, A., Balbi, B. & Scalvini, S. (2009). Tele-assistance in chronic respiratory failure patients: a randomised clinical trial. European Respiratory Journal 33 (2) 411-418.

Chaudhry, S.I., Mattera, J.A., Curtis, J.P., Spertus, J.A., Herrin, J., Lin, Z., Phillips, C.O., Hodshon, B.V., Cooper, L.S. & Krumholz H.M. (2010). Telemonitoring in Patients with Heart Failure. New England Journal of Medicine 363 (24) 2301-2309.

Ducharme, A., Doyon, O., White, M., Rouleau, J.L. & Brophy, J.M. (2005). Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial. Canadian Medical Association Journal 73 (1) 40-45.

McAlister, F.A., Stewart, S., Ferrua, J. & McMurray, J.J.V. (2004). Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomised trials. Journal of the American College of Cardiology 44 (4) 810–819.

Kasper, E.K., Gerstenblith, G., Hefter, G., Van Anden, E., Brinker, J.A., Thiemann, D.R., Terrin, M., Forman, S. & Gottlieb, S.H. (2002). A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. Journal of the American College of Cardiolgy 39 (3) 471-480.

Dickstein, K., Cohen-Solal, A., Filippatos, G., McMurray, J.J., Ponikowski, P., Poole-Wilson, P.A., Strömberg, A., van Veldhuisen, D.J., Atar, D., Hoes, A.W., Keren, A., Mebazaa, A., Nieminen, M., Priori, S.G., Swedberg, K. & ESC Committee for Practice Guidelines (CPG). (2008). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). European Journal of Heart Failure 10 (10) 933-989.

Krum, H., Jelinek, M., Stewart, S., Sindone, A., Atherton, J., Hawkes, A. & CHF Guidelines Core Writers. (2006) Guidelines for the prevention, detection and management of people with chronic heart failure in Australia 2006. Medical Journal of Australia 185 (10) 549-557.

Galindo, J. (coord..). (1998). Técnicas de Investigación en Sociedad, Cultura y Comunicación, p. 525. (1st edn.). México. Addison Wesley Longman.

Yu, D.S.F., Thompson, D.R. & Lee, D.T. (2006). Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. European Heart Journal 27 (5) 596-612

Task Force for the Diagnosis and Treatment of CHF of the European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure: full text (Updated 2005). (retrieved 25 August 2005).

Karmel, R., Lloyd, J. & Hales, C. (2007). Older Australians in Hospital. Bulletin no 53. Cat no AUS 92. Canberra: Australian Institute of Health and Welfare.

Stewart, S., Jenkins, A., Buchan, S., McGuire, A., Capewell, S. & McMurray, J.J.V. (2002). The current cost of heart failure to the National Health Service in the UK. European Journal of Heart Failure 4 (3) 361-371.

Gaikwad, R. & Warren, J. (2009). The Role of home-based information and communication technology interventions in chronic disease management: a systematic literature review. Health Informatics Journal 15 (2) 122-146.

Dellifraine, J.L. & Dansky, K.H. (2008). Home-based telehealth: a review and meta-analysis. Journal of Telemedicine and Telecare 14 (2) 62-66.

Gwadry-Sridhar, F.H., Flintoft, V., Lee, D.S., Lee, H. & Guyatt, G.H. (2004). A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure. Archives of Internal Medicine 164 (21) 2315-2320.

Chen, H.F., Kalish, C. & Pagan, J.A. (2011). Telehealth and Hospitalization for Medicare Home Healthcare Patients. American Journal of Managed Care 17 (6 Special No.) e224-e230.

Klersy, C., De Silvestri, A., Gabutti, G., Raisaro, A., Curti, M., Regoli, F. & Auricchio, A. (2011). Economic impact of remote patient monitoring: an integrated economic model derived from a meta-analysis of randomized controlled trials in heart failure. European Journal of Heart Failure 13 (4) 450-459.

Graves, N., Courtney, M., Edwards, H., Chang, A., Parker, A. & Finlayson, K. (2009). Cost-effectiveness of an intervention to reduce emergency re-admissions to Hospital among older patients. PLoS ONE 4 (10) e7455.

Jaarsma, T., van der Wal, M.H.L., Lesman-Leegte, I., Luttik, M.L., Hogenhuis, J., Veeger, N.J., Sanderman, R., Hoes, A.W., van Gilst, W.H., Lok, D.J., Dunselman, P.H., Tijssen, J.G., Hillege, H.L., van Veldhuissen, D.J. (2008). Value of basic and intensive management of patients with heart failure; results of a randomised controlled clinical trial. Nederlands Tijdschrift Geneeskunde 152 (37) 2016-2021.

Krumholz, H.M., Currie, P.M., Riegel, B., Phillips, C.O., Peterson, E.D., Smith, R., Yancy, C.W., Faxon, D.P. & American Heart Association Disease Management Taxonomy Writing Group. (2006). A taxonomy of disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group. Circulation 114 (13) 1432-1445.

Bayón, J.C., Ortuño, E., Asua, J., Artetxe, J. & Emparanza, J.I. (2010). Evaluación de los resultados de la telemonitorización de pacientes con insuficiencia cardiaca y enfermedad obstructiva crónica. Plan de Calidad para el Sistema Nacional de Salud del Ministerio de Sanidad y Política Social. Basque Office for Health Technology Assessment; 2010. Informes de Evaluación de Tecnologías Sanitarias: OSTEBA Nº 2009/03.

Boren, S.A., Wakefield, B.J., Gunlock, T.L. & Wakefield, D.S. (2009). Heart failure self-management education: a systematic review of the evidence. International Journal of Evidence-Based Healthcare 7 (3) 159-168.

Grady, K.L. (2008). Self-care and quality of life outcomes in heart failure patients. Journal of Cardiovascular Nursing 23 (3) 285-292.

Bourbeau, J., Collet, J.P., Ducruet, T., Schwartzman, K., Nault, D. & Bradley, C. (2006). Economic benefits of self-management education in COPD. Chest 130 (6) 1704-1711.

Gadoury, M.A., Renzi, P., Rouleau, M., Maltais, F., Julien, M., Beaupré, A., Nault, D., Schwartzman, K., Bourbeau, J. & Chronic Obstructive Pulmonary Disease axis of the Respiratory Health Network, Fonds de la recherche en santé du Québec. (FRSQ). (2005). Self-management reduces both short-and long-term hospitalisation in COPD. European Respiratory Journal 26 (5) 853-857.



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