Gestructureerd arts-verpleegkundig nazorgtraject verbetert zorgkwaliteit en medicatie-adherentie na hartinfarct of hartfalen

BACKGROUND: The year following hospitalization for acute myocardial infarction (AMI) or acute heart failure (AHF) is associated with a high risk of rehospitalization and death, often related to inadequate patient follow-up. To improve care and prognosis in these patients, the DIMACC Project (DIMissioni ACCompagnate) was developed: a structured physician-nurse follow-up program aimed at ensuring continuity of care between hospital and community settings through successive phases. Phase 1 evaluated the feasibility of the program and the clinical outcomes observed during the first year. METHODS: The DIMACC Project is a prospective observational quality improvement project conducted at the Cardiology Unit of Pio XI Hospital in Desio, in collaboration with the Community Health Centres of Giussano and Cesano Maderno. Patients hospitalized for AMI or AHF between May 1, 2023 and April 30, 2024 were offered 12-month risk-tailored follow-up pathways, including periodic examinations and 2-3 physician-nurse outpatient visits. RESULTS: Of the 343 patients discharged after AMI and 133 after AHF, 263 (76.7%) and 68 (51.5%), respectively, were included in Phase 1. Follow-up was completed by 222 AMI patients (84.4%) and 53 AHF patients (77.9%). Patient adherence to the proposed follow-up and satisfaction were high. Quality of care was also high: 6 out of 7 European Society of Cardiology quality indicators of care for the follow-up of AMI and 10 out of 14 for AHF were achieved in more than 90% of cases. Adherence to recommended pharmacological treatments was high. Critical issues emerged in risk factor control and adherence to recommended lifestyle changes. CONCLUSIONS: The first year of the DIMACC Project demonstrates the feasibility of this follow-up model, and shows favourable clinical outcomes.