Racco Franco, Gabrielli Domenico, Deales Alberto
Area Qualità dei Processi Assistenziali e Reti Cliniche, Agenzia Regionale Sanitaria Marche, Ancona.
G Ital Cardiol (Rome). 2010 Mar;11(3):239-45.
Chronic diseases represent a major clinical and social problem. Both institutions and professionals are called upon to provide accurate and efficient care at all stages in the clinical pathway. Heart failure (HF) is one of the most chronic diseases with the highest impact on survival, quality of life, and overall costs and assistance. However, healthcare support is often fragmented and with little attention to coordination through the different stages of the clinical pathway.
On the basis of the synergistic approach for implementation of clinical pathways between the Regional Healthcare Agency of the Marche Region and the consensus document of the Italian Federation of Cardiology, we decided to conduct a survey on assistance programs to patients with HF in the Marche Region. The questionnaire was modeled on one developed by the Italian Association of Hospital Cardiologists (ANMCO) during the years 2004-2005, and was sent to all facilities participating in the Cardiology Network of the Marche Region; all the 15 facilities surveyed answered correctly.
An outpatient HF clinic is available only in 5 of the 15 facilities surveyed. Five facilities have dedicated medical staff, whereas only 3 facilities have nursing staff. A clinical pathway is planned with general practitioners only in 2. The discharge letter is well structured and also provides a direct management of follow-up controls. None of the facilities offer medical or nursing staff to support patients at home.
In the Marche Region, although few in number, outpatient HF clinics provide good-quality care. Clinical pathways are currently implemented in 2 facilities. Another clinical pathway, however, is going to be developed including all hospital facilities (Cardiology, Internal Medicine, Geriatrics) and out-of-hospital healthcare providers (local care planning, general practitioners, outpatient specialists) with the active participation of all professionals involved in the clinical pathways of HF patients.
慢性病是一个重大的临床和社会问题。机构和专业人员都需要在临床路径的各个阶段提供准确、高效的护理。心力衰竭（HF）是对生存、生活质量、总体成本和医疗救助影响最大的慢性病之一。然而，医疗支持往往分散，很少关注临床路径不同阶段之间的协调。
基于马尔凯大区地方医疗机构之间实施临床路径的协同方法以及意大利心脏病学联合会的共识文件，我们决定对马尔凯大区心力衰竭患者的救助项目进行一项调查。问卷以意大利医院心脏病学家协会（ANMCO）在2004 - 2005年期间制定的问卷为蓝本，并发送给马尔凯大区心脏病学网络的所有参与机构；所有接受调查的15个机构都正确作答。
在接受调查的15个机构中，只有5个设有门诊心力衰竭诊所。5个机构有专门医护人员，而只有3个机构有护理人员。只有2个机构计划与全科医生共同制定临床路径。出院小结结构完善，还提供后续检查的直接管理。没有一个机构提供医护人员上门支持患者。
在马尔凯大区，门诊心力衰竭诊所数量虽少，但提供高质量护理。目前有2个机构实施临床路径。然而，另一条临床路径即将制定，包括所有医院机构（心脏病学、内科、老年医学）和院外医疗服务提供者（地方护理规划、全科医生、门诊专科医生），并让参与心力衰竭患者临床路径的所有专业人员积极参与。
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