Summary
Heart failure (HF) is approaching epidemic proportions worldwide and is the leading cause of hospitalization in the elderly population. High rates of readmission contribute substantially to excessive health care costs and highlight the fragmented nature of care available to HF patients. Disease management programs (DMPs) have been implemented to improve health outcomes, patient satisfaction, and quality of life, and to reduce health care costs. Telemonitoring systems appear to be effective in the vulnerable phase after discharge from hospital to prevent early readmissions. DMPs that emphasize comprehensive patient education and guideline-adjusted therapy have shown great promise to result in beneficial long-term effects. It can be speculated that combining core elements of the aforementioned programs may substantially improve long-term cost-effectiveness of patient management.
We introduce a collaborative post-discharge HF disease management program (HerzMobil Tirol network) that incorporates physician-controlled telemonitoring and nurse-led care in a multidisciplinary network approach.
Zusammenfassung
Herzinsuffizienz ist der häufigste Grund für Krankenhausaufnahmen bei älteren Patienten. Die hohe Anzahl rascher Wiederaufnahmen nach Entlassung sind mit hohen Kosten verbunden und widerspiegeln die bislang unzureichende Versorgung dieser Patienten. Disease-Management-Programme (DMPs) sollen die Schnittstellenproblematik zwischen Krankenhaus und niedergelassenem Bereich sowie Lebensqualität und klinischem Langzeitverlauf verbessern, die Eigenkompetenz von Patienten stärken und langfristig die Kosteneffektivität der Versorgung erhöhen. Mit Hilfe von telemedizinischen Einrichtungen können die häufigen Wiederaufnahmen in der vulnerablen Phase nach Krankenhausentlassung reduziert werden. Eine langfristige Stabilisierung ist allerdings nur mit DMPs möglich, welche eine umfassende Schulung von betroffenen Patienten sowie eine konsequente Therapieoptimierung zum Ziel haben. Es ist wahrscheinlich, dass die Kombination derartiger DMPs mit telemedizinischen Systemen sowohl die Effizienz als auch die Kosten-Effektivität der Patientenversorgung verbessert.
Wir berichten über ein integratives Versorgungsprojekt für Patienten nach akuter kardialer Dekompensation, bei dem ein nicht-invasives Telemonitoringsystem in ein umfassendes, sektorenübergreifendes Betreuungsnetzwerk eingebunden ist.
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Von der Heidt, A., Ammenwerth, E., Bauer, K. et al. HerzMobil Tirol network: rationale for and design of a collaborative heart failure disease management program in Austria. Wien Klin Wochenschr 126, 734–741 (2014). https://doi.org/10.1007/s00508-014-0665-7
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DOI: https://doi.org/10.1007/s00508-014-0665-7