{"id":"8c3a49be2a2d","type":"article","url":"https://hartvaat.nl/2026/09/01/gestructureerd-arts-verpleegkundig-nazorgtraject-verbetert-zorgkwaliteit-en-medi/","title":"Gestructureerd arts-verpleegkundig nazorgtraject verbetert zorgkwaliteit en medicatie-adherentie na hartinfarct of hartfalen","title_en":"[Feasibility and outcomes of a structured doctor-nurse follow-up program following hospitalization for myocardial infarction or heart failure: the Phase 1 of the DIMACC Project].","category":"hartfalen","category_label":"Hartfalen","professions":["cardioloog","huisarts"],"tags":[],"journal":"Giornale italiano di cardiologia (2006)","doi":"10.1714/4755.47728","source_url":"https://doi.org/10.1714/4755.47728","authors":["Fausto Avanzini","Alfredo Corticelli","Donata Saltafossi","Luisa Chiappa","Paola Di Giulio","Lorenzo Acone","Erica Arienti","Chiara Bersano","Patrizia Bertocchi","Chiara Bova","Chiara Casarola","Alessio Conti","Giuseppe Iacuitti","Barbara Lucia","Maria Grazia Paone","Gerarda Viviana Russo","Morgana Santambrogio","Sara Tonetto","Felice Achilli"],"significance":4,"published":"2026-09-09","source_date":"2026-09-01","image":"https://hartvaat.nl/global/img/f1e482da8016.webp","kennis":["https://hartvaat.nl/kennis/hartfalen/palliatief-hartfalen/","https://hartvaat.nl/kennis/hartfalen/hartfalen-en-zwangerschap/"],"congress":"","summary_en":"A prospective observational quality improvement project evaluated a structured physician-nurse follow-up program for patients hospitalised for acute myocardial infarction or heart failure. Of 331 included patients, follow-up completion rates were 84.4% for AMI and 77.9% for HF, with over 90% meeting ESC quality-of-care indicators and high medication adherence. While risk factor control and lifestyle modifications remained challenging, the programme demonstrated high feasibility and patient satisfaction. The findings support the value of coordinated, phase-based post-discharge care to improve continuity and quality in cardiovascular recovery.","created":"2026-09-02T01:15:41Z","updated":"2026-09-02T01:15:43Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Een prospectief observatief kwaliteitsverbeteringsproject in Italië onderzocht de haalbaarheid van een gestructureerd arts-verpleegkundig nazorgtraject voor patiënten na een acuut hartinfarct of hartfalen. Van de ingeschreven patiënten voltooide 84,4% (AMI) en 77,9% (HF) het traject, waarbij meer dan 90% voldeed aan de ESC-zorgindicatoren en de medicatie-adherentie hoog was. Hoewel de zorgkwaliteit en tevredenheid gunstig waren, bleven risicofactorcontrole en leefstijladvies aandachtspunten. Het model toont aan dat een gefaseerde, multidisciplinaire nazorg na ontslag haalbaar is en de continuïteit van zorg kan verbeteren.","abstract_original":"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."}