[Cardiac rehabilitation : a multidisciplinary program of cardiovascular prevention of essential importance]

Cardiovascular diseases and especially coronary artery disease remain the first cause of mortality in Switzerland. Comprehensive cardiac rehabilitation is a validated multidisciplinary intervention, which represents the most appropriate strategy of implementing an effective secondary cardiovascular prevention to reduce the impact of cardiovascular diseases. However, less than half of patients after a myocardial infarction and a tiny proportion of patients with heart failure participate in a rehabilitation program in our country. This article summarizes the current state of cardiac rehabilitation in Switzerland, as well as future developments of cardiac tele-rehabilitation that have accelerated due to the COVID-19 pandemic.

Autoantibodies against apolipoprotein A-1 and phosphorylcholine for diagnosis of non-ST-segment elevation myocardial infarction

OBJECTIVES

To explore the diagnostic accuracies of anti-apolipoproteinA-1 (anti-ApoA-1) IgG and anti-phosphorylcholine (anti-PC) IgM alone, expressed as a ratio (anti-ApoA-1 IgG/anti-PC IgM), and combined with the Thrombolysis In Myocardial Infarction (TIMI) score for non-ST-segment elevation myocardial infarction (NSTEMI) (NSTEMI-TIMI score) to create a new diagnostic algorithm - the Clinical Autoantibody Ratio (CABR) score - for the diagnosis of NSTEMI and subsequent cardiac troponin I (cTnI) elevation in patients with acute chest pain (ACP).

METHODS

In this single-centre prospective study, 138 patients presented at the emergency department with ACP without ST-segment elevation myocardial infarction. Anti-ApoA-1 IgG and anti-PC IgM were assessed by enzyme-linked immunosorbent assay on admission. Post hoc determination of the CABR score cut-off was performed by receiver operating characteristics analyses.

RESULTS

The adjudicated final diagnosis was NSTEMI in 17% (24/138) of patients. Both autoantibodies alone were found to be significant predictors of NSTEMI diagnosis, but the CABR score had the best diagnostic accuracy [area under the curve (AUC): 0.88; 95% confidence interval (CI): 0.82-0.95]. At the optimal cut-off of 3.3, the CABR score negative predictive value (NPV) was 97% (95% CI: 90-99). Logistic regression analysis showed that a CABR score >3.3 increased the risk of subsequent NSTEMI diagnosis 19-fold (odds ratio: 18.7; 95% CI: 5.2-67.3). For subsequent cTnI positivity, only anti-ApoA-1 IgG and CABR score displayed adequate predictive accuracies with AUCs of 0.80 (95% CI: 0.68-0.91) and 0.82 (95% CI: 0.70-0.94), respectively; the NPVs were 95% (95% CI: 90-98) and 99% (95% CI: 94-100), respectively.

CONCLUSION

The CABR score, derived from adding the anti-ApoA-1 IgG/anti-PC IgM ratio to the NSTEMI-TIMI score, could be a useful measure to rule out NSTEMI in patients presenting with ACP at the emergency department without electrocardiographic changes.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

BACKGROUND

Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time.

METHODS

We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort.

RESULTS

Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score > or = 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results.

CONCLUSION

A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

Patients' knowledge of drug treatments after hospitalisation: the key role of information

QUESTION UNDER STUDY

Patients often do not know the reasons for taking their medications after hospital discharge. We investigated whether lack of such knowledge was associated with patients' report of not having received information about their medications while hospitalised.

METHODS

Patients with at least one long-term drug (ie, prescribed for more than 30 days) discharged from the wards of general internal medicine of a teaching hospital were included in the study. Patients' knowledge of the reasons for taking these drugs and their report of having received information while hospitalised were assessed by phone one week after discharge.

RESULTS

362 (98.6%) of 367 enrolled patients could be interviewed and provided data on 1693/1871 (90.5%) long-term drugs prescribed at discharge. Patients knew the reasons for taking 1382 (81.6%) drugs and reported having received information about 259 (15.3%) of them. In the adjusted analysis, the reason for taking a drug was less likely to be known when introduced during hospitalisation (OR: 0.7; 95%CI: 0.5 to 0.9), among older patients (OR for > or =80 years of age v/s 20-59: 0.41; 95%CI: 0.22 to 0.76) and among those staying longer (OR per additional hospital day: 0.96; 95%CI: 0.94 to 0.99); such knowledge was strongly and positively associated with the report of having received information during hospitalisation (OR: 7.3; 95%CI: 3.2 to 16.1).

CONCLUSION

Patients' report of having received information about their long-term drugs during hospitalisation was associated with a significantly higher knowledge of the reasons for taking them. However, receipt of such information was only infrequently reported.

Patients' knowledge of drug treatments after hospitalisation: the key role of information

QUESTION UNDER STUDY

Patients often do not know the reasons for taking their medications after hospital discharge. We investigated whether lack of such knowledge was associated with patients' report of not having received information about their medications while hospitalised.

METHODS

Patients with at least one long-term drug (ie, prescribed for more than 30 days) discharged from the wards of general internal medicine of a teaching hospital were included in the study. Patients' knowledge of the reasons for taking these drugs and their report of having received information while hospitalised were assessed by phone one week after discharge.

RESULTS

362 (98.6%) of 367 enrolled patients could be interviewed and provided data on 1693/1871 (90.5%) long-term drugs prescribed at discharge. Patients knew the reasons for taking 1382 (81.6%) drugs and reported having received information about 259 (15.3%) of them. In the adjusted analysis, the reason for taking a drug was less likely to be known when introduced during hospitalisation (OR: 0.7; 95%CI: 0.5 to 0.9), among older patients (OR for > or =80 years of age v/s 20-59: 0.41; 95%CI: 0.22 to 0.76) and among those staying longer (OR per additional hospital day: 0.96; 95%CI: 0.94 to 0.99); such knowledge was strongly and positively associated with the report of having received information during hospitalisation (OR: 7.3; 95%CI: 3.2 to 16.1).

CONCLUSION

Patients' report of having received information about their long-term drugs during hospitalisation was associated with a significantly higher knowledge of the reasons for taking them. However, receipt of such information was only infrequently reported.

Durée d’hospitalisation, programmation de la sortie et politique de raccourcissement des séjours : avis des patients et des soignants

BACKGROUND

In the context of health care cost containment, we interviewed hospitalized patients and their health care teams concerning the length of stay they considered necessary and hospital discharge. Patients were also interviewed on the present tendency to shorten hospital stays.

METHODS

Prospective study conducted in a subacute internal medicine ward with 254 consecutive patients and their health care teams.

RESULTS

The mean evaluation of the length of stay considered as necessary was not significantly different between patients (9.7 days, SD=9.5) and their health care teams (9.6, SD=8.5). However, agreement between the two parties was moderate (r=0.64). Hospital discharge was considered as planned in similar proportions (18% vs 22% respectively), but was reported as more 'assured' by health care teams than by patients (p<0.001). Health care teams and patients approved discharge planning in 200 cases (63.3%), but agreement was only moderate (Kappa 0.43, IC 95%=0.34-0.51). Regarding the tendency to shorten hospital stays, patients'responses were favorable in only 9%, clearly unfavorable in 17% and disclosed explicit fears in 54% of the cases.

CONCLUSIONS

These results show that what patients and health care teams consider the necessary length of stay and the right time for hospital discharge can diverge notably. They highlight the difficulties of medical decisions in the context of cost containment, and the fundamentally asymmetrical character of the relationship between patients and health care teams.

Age and quality of in-hospital care of patients with heart failure

BACKGROUND

Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined.

METHODS

A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models.

RESULTS

Charts of 371 patients were reviewed. Mean age was 75.7 (+/-11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by -2.6% (95% CI: -7.1 to 1.9) for patients aged 70 to 79, by -8.7% (95% CI: -13.0 to -4.3) for patients aged 80 to 89, and by -19.0% (95% CI: -26.6 to -11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified.

CONCLUSIONS

In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluated.

Relationship between hospital length of stay and quality of care in patients with congestive heart failure

OBJECTIVE

To determine the relationship between hospital length of stay (LOS) and quality of care in patients admitted for congestive heart failure (CHF).

METHODS

This observational study was conducted in the medical wards of the Geneva University Hospitals, Geneva, Switzerland. A random sample of 371 patients was drawn from the 1084 patients discharged alive with a principal diagnosis of CHF between January 1997 and December 1998. Explicit criteria grouped into three scores were used to assess the quality of processes of care: admission work-up (admission score); evaluation and treatment during the stay (treatment score); and readiness for discharge (discharge score). The association between LOS and quality of care was analysed using linear regression with adjustment for clinical characteristics.

RESULTS

The mean proportion of criteria met were 80% for the admission score, 66% for the treatment score, and 76% for the discharge score. Mean (SD) LOS was 13.2 (8.8) days. The admission score was not associated with LOS, but the treatment score increased by 0.5% (95% CI 0.3 to 0.7; p < 0.001) with each additional day in hospital and the discharge score increased by 2.5% (95% CI 1.6 to 3.3; p < 0.001) per day from admission to day 10 but remained unchanged thereafter. Adjustment for potential confounders did not substantially modify these relationships.

CONCLUSIONS

In patients with CHF there is a significant association between LOS and the quality of the treatment provided, as well as with readiness for discharge. Appropriate reorganisation of processes of care should accompany attempts at reducing LOS to avoid detrimental effects on quality of care.

Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics?

PURPOSE

To determine if early unplanned readmissions of patients hospitalized for heart failure are associated with suboptimal in-hospital care or with the clinical and demographic characteristics of the patient.

SUBJECT AND METHODS

We performed a case-control study among patients discharged with a principal diagnosis of heart failure. Cases included all patients unexpectedly readmitted within 31 days of discharge; controls were randomly selected from among those not readmitted. Quality of care was measured using explicit criteria reflecting the admission work-up, evaluation and treatment, and readiness for discharge.

RESULTS

Ninety-one cases and 351 controls were included. There was no significant association between early unplanned readmissions and the scores for quality of the admission work-up or evaluation and treatment during the stay. There was a significant association between readiness for discharge and subsequent early readmission: for each 10% decrease in the proportion of fulfilled criteria, the odds of readmission increased by 14% (95% confidence interval [CI] 1. 01 to 1.28, P = 0.04) for all-cause readmissions and by 19% (95% CI: 1.04 to 1.36, P = 0.01) for heart-failure-related readmissions. In a multiple logistic regression model, previous diagnosis of heart failure (odds ratio [OR] = 2.9, 95% CI: 1.7 to 4.8, P <0.001), age (OR = 3.3, 95% CI: 1.3 to 8.5, P = 0.01 for patients aged 65 to 79 years and OR = 4.1, 95% CI: 1.6 to 11, P = 0.004 for patients aged 80 years and older), and history of cardiac revascularization (OR = 2.1, 95% CI: 1.2 to 3.9, P = 0.01) showed a stronger association with early unplanned all-cause readmissions than the readiness-for-discharge score (OR = 1.16, 95% CI: 1.02 to 1.31, P = 0.02). Similar findings were seen for heart failure-related readmissions.

CONCLUSIONS

Among patients with heart failure, early unplanned readmissions were not associated with suboptimal admission work-up or evaluation and treatment but were weakly associated with readiness for discharge. However, they were strongly associated with the patients' clinical and demographic characteristics.