Disease Management Program Heart Failure
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1 Insuficiência Cardíaca HCor Disease Management Program Heart Failure Felix Ramires Professor Livre-Docente FMUSP Coordenador do Programa de IC HCor felix.ramires@incor.usp.br
2 Heart Failure - Epidemiology 36% Any-mention of death Mozaffarian D, et al. Circulation, 2015
3 Heart Failure - Epidemiology Mozaffarian D, et al. Circulation, 2015
4 Heart Failure - Epidemiology Prevalence Hospital discharge Go A S, et al. Circulation, 2014
5 Heart Failure Epidemiology Hospitalization - Brazil CV HF Total CV Total Admission: CV Admission: HF Admission: DATASUS 2007
6 Heart Failure Epidemiology Hospitalization - Brazil Brazil - population: Hospitalization on 2002: 1- Pregnancy, delivery and puerperium 2- Respiratory diseases 3- CV Diseases Clinical causes: 1- Pneumonia 2- Asthma 3- Heart Failure Albanesi Filho FM. Arq Bras Cardiol 2005; 85:155-6
7 Heart Failure Epidemiology Latin America Bochi EA, et al. JAAC, 2013
8 Brazilian Registry Heart Failure Arq Bras Cardiol, 2014
9 Disease Management Program Heart Failure
10 Heart Faiulure Program PIC- HCor
11 Heart Failure Program Nurse VISIT 1- Any Unit Checked the Inclusion / Exclusion Criteria Contact to the Assistant Physisian for Science / Consent Medical Condition Stable Patient approach: -Presenting PIC-HCor -inclusion into the program -multidisciplinary team alert -start to fill the chart data Unstable Family approach: -Presenting PIC-HCor -inclusion into the program -multidisciplinary team alert -start to fill the chart data Medical Condition Stable VISIT 2 - Inpatient Unit Approaching the patient and / or Family -Delivery all guidance material, and guiding about it -Clarifying the disease -Self-care orientation -strengthening in adherence to pharmacological and non-pharmacological -orientation to discharge VISIT 3 - Inpatient Unit -By demand DISCHARGE FOLLOW-UP phone
12 Heart Failure Program Interventions
13 Heart Failure Program Team Training Heart Failure Meetings and Scientific Sessions Monthly meetings Literature distribution for each specific area
14 Heart Failure Program PIC-HCor 421 Patients Included 1114 Hospitalizations In 2014: 243 hospitalizations Until April 2015: 90 admissions Sex HF Etiology 1% 1% 0% 1% 1% MCDI 31% 12% 23% Isquemica Valvar 69% Masculino Feminino 61% Chagássica Inflamatória Infiltrativa Tóxica Puerperal Mean age: 73.6 years (29-98) Median Age: 75 years
15 Heart Failure Program Guidelines
16 Heart Failure Program Benchmark
17 Heart Failure Program Benchmark
18 Heart Failure Program Evaluation Time for Rehospitalization Survival Get With The Guidelines
19 120% 100% 60% 40% 96% Heart Failure Program Quality Indicators Hospital discharge instructions 88% 82% 67% 76% 86% 77% 72% 66% 94% 95% 95% 94% 93% 97% 97% 100% 88% 85% 83% 100% 60% 40% 20% 0% 56% Beta-blocker at discharge 88% 92% 89% 100% 90% 96% 100% 20% 6% 0% Betabloqueador Meta ACE/ARB at discharge LV assessment 100% 60% 40% 20% 0% 56% 65% 74% 74% 76% 73% 82% 78% 100% 60% 40% 20% 0% 64% 91% 95% 98% 98% 89% 100% 96% 89% Prescrição de IECA/BRA Meta Ecocardiograma Meta
20 100% 60% 40% 20% 0% 47% 69% 81% 82% 86% Heart Failure Program Quality Indicators Espironolactone at discharge OAC at discharge 100% 92% 100% 100% 60% 40% 20% 0% 19% 37% 53% 68% 83% 67% 50% 88% 100% Antagonista de Aldosterona Meta ACO em FA Meta Smoking cessation 100% 60% 40% 20% 0% 100% 100% 100% 100% 100% * * 100% * Aconselhamento Cessação de Tabagismo Meta
21 100% 60% 40% 20% 0% 100% 100% 100% 100% jan/15 fev/15 mar/15 abr/15 Betabloqueador Heart Failure Program Quality Indicators Follow-up Keeping Beta-blocker at home Meta 100% 60% 40% 20% 0% Keeping ACE/ARB at home 100% 100% 100% 100% jan/15 fev/15 mar/15 abr/15 IECA/BRA Meta 100% 60% 40% 20% Get to the ER when adivised to 99% 100% 100% 100% 86% 0% jan/15 fev/15 mar/15 abr/15 Procurou atendimento médico Meta
22 Heart Failure Program Mortality 14,0% 12,0% 12,60% 12,60% 12,60% 12,60% 12,60% 11,1% 10,0% 9,0% 9,1% 9,1% 9,1% 8,0% 6,0% 4,0% 3,2% 6,7% 6,6% 6,6% 6,6% 6,6% 6,0% 6,2% 5,0% 5,0% 5,2% 5,5% 4,4% 4,4% 4,4% 4,4% 4,4% 4,5% 4,4% 4,4% 4,4% 2,0% 0,0% jan/15 fev/15 mar/15 abr/15 0,0% Mortalidade ADHERE ANAHP BREATHE
23 Dias Heart Failure Program Time to Hospitalization
24 Heart Failure Program Médico: Felix Ramires Victor Issa Paulo Pego Fabio Jatene Enfermeira: Carolina Padrão Amorim Barbara Tamburim Karla Aparecida da Silva Ricardo Cunha Fisioterapia: Gizela Galacho Lucas Thiago Sampaio Correia Renata Andrade Gomes Laura Carraro Ana Carolina Cinanena Cihtya Ramos Psicologia: Julia Fernandes Caldas Frayha Viviane dos S. Gonçalves Ribeiro Assistência Social: Elaine Cristina Dalcin Seviero Simone Aparecida Gonçalves Farmácia: Evelyn Cristina Torreta Menezes Karen Priscila da Silva Melissa Ferreira Renata Baccaro Madeu Nutrição: Fernanda Dalpicolo Camila Moreno Fernanda Giuditta Orciolli Rafaela Emi Hasegawa
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