Multidisciplinary Disease Management Research Articles

Multidisciplinary Management of Cutaneous Squamous Cell Carcinoma of the Scalp: An Algorithm for Reconstruction and Treatment.

Background: Scalp-associated cutaneous squamous cell carcinoma (cSCC) presents formidable treatment challenges, especially when it leads to full-thickness defects involving bone. Aggressive or recurring cases often demand a multidisciplinary approach. Leveraging our surgical experience and a literature review, we introduce a therapeutic algorithm to guide the selection of reconstruction methods, particularly for locally advanced lesions, furthermore showing the synergy between surgery and other therapies for comprehensive, multidisciplinary disease management. Methods: Our algorithm stems from a retrospective analysis of 202 patients undergoing scalp cSCC resection and reconstruction over a 7-year period, encompassing 243 malignancies. After rigorous risk assessment and documentation of surgical procedures, reconstruction methods were therefore related to malignancy extent, depth, and individual clinical status. Results: The documented reconstructions included 76 primary closures, 115 skin grafts, 7 dermal substitute reconstructions, 33 local flaps, 1 locoregional flap, and 1 microsurgical free flap. Patients unsuitable for surgery received radiotherapy or immunotherapy after histological confirmation. Precise analysis of tumor characteristics in terms of infiltration extent and depth guided the selection of appropriate reconstruction and treatment strategies Combining these insights with an extensive literature review enabled us to formulate our algorithm for managing scalp cSCCs. Conclusions: Effectively addressing scalp cSCC, especially in locally advanced or recurrent cases, demands a systematic approach integrating surgery, radiotherapy, and immunotherapy. Our multidisciplinary team's decision-making algorithm improved patient outcomes by offering a broader spectrum of therapeutic options that can synergistically achieve optimal results.

Role of oral health in heart and vascular health: A population-based study.

Conditions such as hypertension, cardiovascular diseases, and hypercholesterolemia, are a major public health challenge. This study investigates the influence of oral health indicators, including gum bleeding, active dental caries, tooth mobility, and tooth loss, on their prevalence in Hungary, considering socioeconomic, demographic, and lifestyle factors. Data from the 2019 Hungarian European Health Interview Survey with 5,603 participants informed this analysis. Data were accessed from the records maintained by the Department of Health Informatics at the University of Debrecen between September and November 2023. Variable selection employed elastic net regularization and k-fold cross-validation, leading to high-performing predictors for weighted multiple logistic regression models. Sensitivity analysis confirmed the findings' validity. Significant links were found between poor oral health and chronic cardiac conditions. Multiple teeth extractions increased hypertension risk (OR = 1.67, 95% CI: [1.01-2.77]); dental prosthetics had an OR of 1.45 [1.20-1.75]. Gum bleeding was associated with higher cardiovascular disease (OR = 1.69 [1.30-2.21]) and hypercholesterolemia risks (OR = 1.40 [1.09-1.81]). Oral health improvement may reduce the risk of cardiac conditions. This underscores oral health's role in multidisciplinary disease management.

HerzMobil Tirol – A telemedical, integrated disease management program for patients with heart failure

Heart failure (HF) is a global health problem with an increasing an increasing incidence and prevalence and thus a major impact on healthcare systems. The 1-year mortality is 23.6% in patients with acute HF. Hospitalization for acute HF is associated with higher mortality and recurrent hospitalization. The majority of readmissions occurs early after hospital discharge: about 25% of patients are readmitted within the first month with a 50% proportion of HF-related causes of readmissions.
 Therefore, in 2012 the Austrian province of Tyrol launched the HerzMobil Tirol (HMT) program, which is a multidisciplinary post-discharge disease management program for HF patients. It is supported by a telemedical monitoring system and embedded in a network of specialized nurses, resident physicians, and secondary/tertiary referral centers. After initial project phases, HMT reached its adolescence in 2017 and was adopted as regular service. This ensures reimbursement of the program by the social security system. 
 HMT is based on: (1) patient education to improve patient empowerment, (2) nurse-led care for early detection of imminent decompensation, (3) patient-held mobile phone for daily data acquisition and transmission of blood pressure, heart rate, body weight, well-being and drug intake, including nurse and physician-controlled telemonitoring, (4) continuous optimization of guideline-based HF therapy for long-term stabilization, and (5) network communication to assure comprehensive HF management across venues;
 Patients enter HMT at the end of hospitalization for acute HF. Patient education is delivered by specialized HF nurses. On discharge, each patient is assigned to a resident network physician near his/her home. Network physicians supervise the management of the patient and optimize individualized guideline-directed medical therapy. Discharge information including a detailed treatment plan from the hospital is communicated to the HMT network. Within HMT, patients are supervised for 3 months. Telemedically transmitted patient data are reviewed daily by HF nurses and weekly by network physicians. Out-of-limit data are automatically signaled so that interventions, for example, adjustment of diuretics, can follow immediately. Face-to-face visits of the patient with the network physician are scheduled 1, 4, and 12 weeks after discharge. HF nurses monitor patients’ compliance with medication, maintain telephone contact with patients if necessary and adjust HF medication according to the network physicians’ instructions. Additionally, a home visit by the HF nurse is scheduled immediately after discharge to complete disease- and equipment-related education and to ensure that prescribed medication is available. At the end of the managed care program, structured transfer of patients to regular care is organized. Regular HF network meetings of physicians and nurses are scheduled every 3 months.
 A recently publication demonstrated the effectiveness of the program as indicated by a significant reduction of HF readmission and all-cause mortality within 6 months for patients in the HMT program compared to usual-care patients. 
 HerzMobil was adopted in other provinces of Austria following the Tyrolean model. It is continuously further developed. In a next step, the coronary heart disease will be included in the HMT model. An extension of the program with physical activity aspects is planned.

Abstract 14339: Guideline-Directed Intensive Management Improves Long-Term Survival and Compliance of Pulmonary Hypertension Patient

Introduction: Although the overall survival of PH patients improved in the current era, better management of PH patients still needs further exploration. Hypothesis: We hypothesized that guideline-directed, nurse-led, and multidisciplinary intensive management of PH patients would improve the overall survival of PH patients. Methods: We prospectively enrolled patients with PH from October 2013 to December 2020. Patients were divided into intensive management group and usual care group voluntarily. Intensive management was nurse-led and delivered by multidisciplinary teams, including patient education, symptoms monitoring, and patient adherence improvement with careful outpatient assessment every 3 months and medicine prescription whenever needed. Patients with usual care were treated by primary cardiologists’ consultants and telephone follow-ups every year. Results: Overall, 413 PH patients were finally included with a median follow-up period of 25.2 months(interquartile range: 12.4-44.3 months). Both overall survival (p<0.001) and event-free survival (p=0.008) of the intensive management group were significantly higher than the usual care group. After adjustment of age and sex, intensive management was also an independent protective predictor for both primary [all-cause mortality, HR 0.378, 95% CI (0.214-0.668), p<0.001] and composite endpoints [all-cause mortality and re-hospitalization, HR 0.648, 95% CI (0.454-0.927), p=0.017]. Conclusions: Guideline-directed, nurse-led, multidisciplinary intensive disease management strategy could be an ideal method to further improve the overall survival and event-free survival of PH patients.

Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score-Matched Study.

The beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance-reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF. This was a retrospective propensity score-matched cohort study using the Taiwan National Health Insurance Research Database. In total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis. All patients were followed up after discharge for all-cause mortality, emergency visits within 30days, and length of stay and medical expenses for readmission within 180days after discharge. After propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio= 0.520, 95% CI= 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank= 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180days post discharge (all P < .001). HF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.

Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study

BackgroundThe creation of Family Health Teams in Ontario was intended to reconfigure primary care services to better meet the needs of an aging population, an increasing proportion of which is affected by frailty and multimorbidity. However, evaluations of family health teams have yielded mixed results.MethodsWe conducted interviews with 22 health professionals affiliated or working with a well-established family health team in Southwest Ontario to understand how it approached the development of interprofessional chronic disease management programs, including successes and areas for improvement.ResultsQualitative analysis of the transcripts identified two primary themes: [1] Interprofessional team building and [2] Inadvertent creation of silos. Within the first theme, two subthemes were identified: (a) collegial learning and (b) informal and electronic communication.ConclusionEmphasis on collegiality among professionals, rather than on more traditional hierarchical relationships and common workspaces, created opportunities for better informal communication and shared learning and hence better care for patients. However, formal communication and process structures are required to optimize the deployment, engagement, and professional development of clinical resources to better support chronic disease management and to avoid internal care fragmentation for more complex patients with clustered chronic conditions.

Management of testicular tumours in patients with undescended testes- a challenging but rewarding task: experience from a tertiary care cancer centre in India.

Primary objective: To study patients' clinical profile and outcomes with germ cell tumours developing in undescended testes. Case records of patients enlisted in the prospectively maintained 'testicular cancer database' at our tertiary cancer care hospital from 2014 to 2019 were retrospectively reviewed. Any patient who presented with testicular germ cell tumour with a documented history/diagnosis of undescended testes, whether surgically corrected or not, was considered for this study. The patients were managed along the standard lines of treatment for testicular cancer. We evaluated clinical features, difficulties and delays in diagnosis and complexities in management. We evaluated event-free survival (EFS) and overall survival (OS) using the Kaplan-Meier Method. Fifty-four patients were identified from our database. The mean age was 32.4 years (median age 32, range: 15-56 years). Seventeen (31.4%) had developed cancer in orchidopexy testes, and 37 (68.6%) presented with testicular cancer in uncorrected cryptorchid testes. The median age at orchidopexy was 13.5 years (range: 2-32 years). The median time from symptom onset to diagnosis was 2 months (1-36 months). There was a delay in the initiation of treatment of more than 1 month in 13 patients, with the longest delay being 4 months. Two patients were initially misdiagnosed as gastrointestinal tumours. Thirty-two (59.25%) patients had seminoma, and 22 (40.7%) patients had non-seminomatous germ cell tumours (NSGCT). Nineteen patients had metastatic disease at presentation. Thirty (55.5%) patients underwent orchidectomy upfront while in 22 (40.7%) patients, orchidectomy was done after chemotherapy. The surgical approach included high inguinal orchidectomy, exploratory laparotomy or laparoscopic surgery per the clinical situation. Post-operative chemotherapy was offered as clinically indicated. At a median follow-up of 66 months (95% CI: 51-76), there were four relapses (all NSGCT) and one death. The 5-year EFS was 90.7% (95% CI: 82.9-98.7). The 5-year OS was 96.3% (95% CI: 91.2-100). The tumours in undescended testes, particularly those without prior orchiopexy, often presented late and with bulky masses, requiring complex multidisciplinary management. Despite the complexity and challenges, our patient's OS and EFS matched that of patients with tumours in normally descended testes. Orchiopexy may help in earlier detection. In the first such series from India, we show that testicular tumours in the cryptorchid are also as curable as the germ cell tumours developing in the descended testis.A multidisciplinary disease management group with expertise in managing complex cases is crucial for a favourable outcome in these groups of patients. We also found that orchiopexy done even later in life confers an advantage in terms of early detection in a subsequently developing testicular tumour.

Thyroid storm in a postpartum and uncontrolled graves' disease patient: the challenges of accurate and multidisciplinary disease management

Background: Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although pregnancy hyperthyroidism is a relatively uncommon, thyroid crisis is a medical emergency caused by hyperthyroidism exacerbation with symptoms of organ decompensation in one or more organs. Therefore, managing this disease in pregnant women is critical as well as the safety of using antithyroid drugs for pregnant women and the foetus. Case presentation: A 26-year-old woman presented to the Dr Soetomo General Academic Hospital Surabaya, Indonesia with complaints of shortness of breath that had worsened one hour before the admission as well as sudden fever, diarrheal, anxiety, and decreased consciousness. The patient had hyperthyroidism for three years, and the controls were inconsistent. The patient was diagnosed with P1101 postpartum day 1, thyrotoxicosis due to Graves' disease, thyroid crisis, hypertension, microcytic hypochromic anemia, hypoglycemia, hypoalbuminemia, keratitis, and lagophthalmos. The patient was treated with supportive therapy with an oxygen mask 8 liters per minute (lpm), intravenous fluids, and antipyretic acetaminophen 500 mg every 8 hours. Propylthiouracil 400 mg loading dose followed by maintenance 6x100 mg, 8 drops of Lugol's solution after propylthiouracil administration, intravenous (IV) dexamethasone 2 mg every 6 hours, and oral propranolol 20 mg every 6 hours. The patient was discharged from the hospital after presented favorable improvement. Conclusion: This case demonstrates that the stage of the disease determines the management of Grave's disease during pregnancy, and that multidisciplinary involvement could improve the success and reduce the patient mortality.

PS-P11-7: DIABETES AND HYPERTENSION SELF-MANAGEMENT: CHALLENGES AND SOLUTIONS FROM SOUTH AFRICAN PATIENTS AND HEALTH CARE PROVIDERS: A QUALITATIVE STUDY

Objective: This study aimed to unravel experiences, identify barriers to self management of diabetes and hypertension and solicit solutions for enhancing chronic disease self management from patients and their healthcare providers. Design and Methods: This was a qualitative study which collected data from eight in-depth interviews conducted with healthcare providers and four focus group discussions among patients with type 2 diabetes and hypertension receiving chronic disease care from two health facilities in a large peri-urban Township in Cape Town, South Africa. The Self Management framework described by Lorig and Holman, based on work done by Corbin and Strauss was used to analyse the data Results: Patients experienced challenges across all three self management tasks of behavioural or medical management, role management and emotional management. Main challenges included poor patient self-control towards lifestyle modification, sub-optimal patient-provider and family partnerships and post-diagnosis grief-reactions by patients. Barriers experienced were stigma, socio-economic and cultural influences, provider-patient communication gaps, disconnect between facility-based services and patients lived experiences and inadequate community care services. Patients suggested empowering community-based solutions to strengthen their disease self-management including dedicated multidisciplinary chronic disease management services, counselling services, strengthened family support, patient buddy system, patient-led community projects and advocacy. Providers suggested contextualised communication using audio-visual technologies and patient-centred provider consultations. Conclusions: Patients experienced several barriers to self-management of their chronic disease. Community-based dedicated multidisciplinary chronic disease healthcare teams, chronic disease counselling services, patient-driven projects towards healthy lifestyle and diet, and advocacy are needed to improve patient self-management. This will contribute towards SDG 3

The Nephrotoxicity of Drugs Used in Causal Oncological Therapies.

In recent years, a dynamic development of oncology has been observed, resulting from the increasingly frequent occurrence of neoplasms and therefore, increasing population of patients. The most effective form of therapy for cancer patients is complex multidisciplinary specialized disease management, including nephro-oncology care. Different forms of renal function impairment are frequently diagnosed in cancer patients. They are caused by different co-morbidities existing before starting the oncologic treatment as well as the direct undesirable effects of this therapy which may cause temporary or irreversible damage of the urinary system-especially kidneys. According to different therapeutic programs, in such cases the degree of renal damage is often crucial for the possibility of further anti-cancer treatment. Medical personnel responsible for delivering care to oncology patients should be properly educated on current methods of prevention and treatment of renal complications resulting from anti-cancer therapy. The development of oncologic medicines design, including especially immuno-oncological agents, obliges us to learn new patomechanisms determining potential adverse effects, including renal complications. This publication is focused on the most important undesirable nephrotoxic effects of the frequently used anti-cancer drugs.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care.

Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care. Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period. After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05). Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

916-P: Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care

Purpose: Primary care practices manage most patients with diabetes, and face significant operational, regulatory, and reimbursement pressures to improve care quality. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team registered nurses and pharmacists to improve diabetes care. Methods: Utilizing a retrospective, interrupted time series design, we evaluated the EPCD model’s impact on a composite publicly reported quality measure of diabetes care (D5) , including indicators of glycemic control, blood pressure control, low-density lipoprotein, tobacco use, and aspirin use. We compared three groups of practices (32 total) that care for adults (age 18-75 years) with diabetes: staff clinician (physician and Advanced Practice Provider) practices with access to EPCD (5761 patients) , resident physician practices with access to EPCD (1887 patients) , and staff clinician practices without access EPCD (10,079 patients) . The primary outcome was a comparison of the pre-implementation trend (7 months) to the post-implementation trend (months) in the three groups for the percentage meeting the D5. Results: There was a positive difference in pre to post-implementation trends for patients meeting the D5 in the staff clinician practices in the EPCD group (Pre IRR 0.995, Post IRR 1.005; P= 0.01) . There was no difference in the trend for the trainee physician practices with access to EPCD (Pre IRR 0.999, Post IRR 1.011; P= 0.14) , and a significant negative trend in the staff clinician practices without access to EPCD (Pre IRR 1.001, Post IRR 0.994; P= 0.05) . Conclusion: The EPCD model significantly improved diabetes care quality. Further study of proactive, multidisciplinary chronic disease management led by care team nurses integrating clinical pharmacists is warranted. Disclosure J.Herges: None. J.Matulis: None. M.Kessler: None. L.L.Ruehmann: None. K.Mara: None. R.G.Mccoy: Consultant; Emmi. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

Towards Equitable Surgical Management of Inflammatory Bowel Disease: A Systematic Review of Disparities in Surgery for Inflammatory Bowel Disease

Existing evidence for disparities in inflammatory bowel disease is fragmented and heterogenous. Underlying mechanisms for differences in outcomes based on race and socioeconomic status remain undefined. We performed a systematic review of the literature to examine disparities in surgery for inflammatory bowel disease in the United States. Electronic databases were searched from 2000 through June 11, 2021, to identify studies addressing disparities in surgical treatment for adults with inflammatory bowel disease. Eligible English-language publications comparing the use or outcomes of surgery by racial/ethnic, socioeconomic, geographic, and/or institutional factors were included. Studies were grouped according to whether outcomes of surgery were reported or surgery itself was the relevant end point (utilization). Quality was assessed using the Newcastle-Ottawa Scale for observational studies. Forty-five studies were included. Twenty-four reported surgical outcomes and 21addressed utilization. Race/ethnicity was considered in 96% of studies, socioeconomic status in 44%, geographic factors in 27%, and hospital/surgeon factors in 22%. Although study populations and end points were heterogeneous, Black and Hispanic patients were less likely to undergo abdominal surgery when hospitalized; they were more likely to have a complication when they did have surgery. Differences based on race were correlated with socioeconomic factors but frequently remained significant after adjustments for insurance and baseline health. Surgical disparities based on sociologic and structural factors reflect unidentified differences in multidisciplinary disease management. A broad, multidimensional approach to disparities research with more granular and diverse data sources is needed to improve health care quality and equity for inflammatory bowel disease.

Update on oncoplastic techniques in breast conserving surgery: algorithms for predictable results and custom-made reconstructions.

Breast cancer surgery is going to be a relevant specialty involved in the multidisciplinary disease management, finalized to guarantee high performances on mortality reduction together with a quality-of-life improvement. The intellectual architecture of this field is characterized by its inclination to respect, sharing, empathy and scientific knowledge that can make it a high model of medical culture. In this context, oncoplastic breast conserving surgery is identified by special aesthetic sensitivities, as well as creativity and innovation. Knowing how to reshape the gland and fill the gaps, planning the targeted exeresis design, while anticipating the final outcome, respecting symmetries and ensuring first of all oncological safety, are the new skills that are required to the breast surgeon. Several tecniques could provide a refined surgical treatment but always challenging according to anatomical findings and patient expectations, as a systematic process of self-critical reflection, with the purpose to optimize criteria for improving therapeutic results.

Impact of primary care involvement and setting on multidisciplinary heart failure management: a systematic review and meta-analysis.

Multidisciplinary disease management programmes (DMPs) are a cornerstone of modern guideline‐recommended care for heart failure (HF). Few programmes are community initiated or involve primary care professionals, despite the importance of home‐based care for HF. We compared the outcomes of different multidisciplinary HF DMPs in relation to their recruitment setting and involvement of primary care health professionals. We conducted a systematic review and meta‐analysis of randomized controlled trials published in MEDLINE, Embase, and Cochrane between 2000 and 2020 using Cochrane Collaboration methodology. Our meta‐analysis included 19 randomized controlled trials (7577 patients), classified according to recruitment setting and involvement of primary care professionals. Thirteen studies recruited in the hospital (n = 5243 patients) and six in the community (n = 2334 patients). Only six studies involved primary care professionals (n = 3427 patients), with two of these recruited in the community (n = 225 patients). Multidisciplinary HF DMPs that recruited in the community had no significant effect on all‐cause and HF readmissions nor on mortality, irrespective of primary care involvement. Studies that recruited in the hospital demonstrated a significant reduction in mortality (relative risk 0.87, 95% confidence interval [CI] [0.76, 0.98]), HF readmissions (0.70, 95% CI [0.54, 0.89]), and all‐cause readmissions (0.72, 95% CI [0.60, 0.87]). However, the difference in effect size between recruitment setting and involvement of primary care was not significant in a meta‐regression analysis. Multidisciplinary HF DMPs that recruit in the community have no significant effect on mortality or hospital readmissions, unlike DMPs that recruit in the hospital, although the difference in effect size was not significant in a meta‐regression analysis. Only six multidisciplinary studies involved primary care professionals. Given demographic evolutions and the importance of integrated home‐based care for patients with HF, future multidisciplinary HF DMPs should consider integrating primary care professionals and evaluating the effectiveness of this model.

Implementation of a Disease Management Program in Adult Patients With Heart Failure.

Approximately 5.7 million people in the United States are diagnosed and living with heart failure (HF), with projected prevalence rates to increase 46% by 2030. Heart failure leads hospital admissions in the United States for individuals 65 years or older, with many acute exacerbation admissions resulting from a lack of medication management, poor patient treatment plan adherence, and lack of appropriate follow-up within the health care system. In 2017, the 30-day HF readmission rate at the facility of implementation was 27%, 3% higher than the national average and, more specifically, 18.5% for the cardiac care unit (CCU). The aim of this study was to develop an HF disease management program to reduce 30-day readmission rates for HF patients through the implementation of a structured program including self-care education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. The implementation of the disease management program took place at a major military treatment facility in the continental United States. The facility is a teaching facility housing a 272-bed multispecialty hospital and an ambulatory complex. The implementation took place on the CCU, the primary unit for cardiac admissions, with approximately 30 admissions a month for a primary diagnosis of HF. In August 2018, a multidisciplinary disease management program was implemented to include patient education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. Data were collected and analyzed for 90 days and compared with retrospective data from 2017. Participants in the disease management program had a statistically significant improvement (p < .001) in the hospital readmission rate. The overall 30-day readmission rate decreased from 27% to 10.2% during the implementation period, a decrease of 38%. Ninety-three percent of the patients completed the self-care education, and telephone follow-up was successfully achieved with 96% of these patients. Only 4 patients in the HF disease management program experienced readmission within 30 days. Patients and caregivers reported increased satisfaction with their care due to the disease management program and increased follow-up with care. The findings of this innovation suggest that a multidisciplinary disease management program can reduce avoidable 30-day readmissions. The program improved patient follow-up and decreased follow-up appointment no-shows. Multiple participants expressed increased patient satisfaction. The program supports the need for coordinated, interdisciplinary disease management to improve the quality of life of those affected by HF and improve the use of resources to reduce the overall health care burden. Case management is critical to the organized care of HF patients due to the complex, individualized care to achieve optimum patient outcomes.

Case study of the integration of electronic patient-reported outcomes as standard of care in a head and neck oncology practice: Obstacles and opportunities.

Patient-reported outcomes (PROs) allow for the direct measurement of functional and psychosocial effects related to treatment. However, technological barriers, survey fatigue, and clinician adoption have hindered the meaningful integration of PROs into clinical care. The objective of the authors was to develop an electronic PROs (ePROs) program that meets a range of clinical needs across a head and neck multidisciplinary disease management team. The authors developed the ePROs module using literature review and stakeholder input in collaboration with health informatics. They designed an ePROs platform that was integrated as the standard of care for personalized survey delivery by diagnosis across the disease management team. Tableau software was used to create dashboards for data visualization and monitoring at the clinical enterprise, disease subsite, and patient levels. All patients who were treated for head and neck cancer were eligible for ePROs assessment as part of the standard of care. A descriptive analysis of ePROs program implementation is presented herein. The Head and Neck Service at Memorial Sloan Kettering Cancer Center has integrated ePROs into clinical care. Surveys are delivered via the patient portal at the time of diagnosis and longitudinally through care. From August 1, 2018, to February 1, 2020, a total of 4154 patients completed ePROs surveys. The average patient participation rate was 69%, with a median time for completion of 5 minutes. Integration of the head and neck ePROs program as part of clinical care is feasible and could be used to assess value and counsel patients in the future. Continued qualitative assessments of stakeholders and workflow will refine content and enhance the health informatics platform. Patients with head and neck cancer experience significant changes in their quality of life after treatment. Measuring and integrating patient-reported outcomes as a part of clinical care have been challenging given the multimodal treatment options, vast subsites, and unique domains affected. The authors present a case study of the successful integration of electronic patient-reported outcomes into a high-volume head and neck cancer practice.

Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana.

The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.

Heart failure disease management programs in Austria 2019 : Asystematic survey of the Heart Failure Working Group and the Working Group for Cardiological Assistance and Care Personnel of the Austrian Society of Cardiology.

SummaryHeart failure (HF) is common and is associated with high morbidity, mortality and high health expenditure. A multidisciplinary disease management plan (DMP) can reduce morbidity and mortality, save costs and improve the quality of life. In Austria, three HF-specific DMPs are currently in a project phase and four established DMPs are active. Although programs are widely heterogeneous with respect to their intervention type, they pursue the same interventional goal by supporting seamless care between inpatient and community care settings with a multidisciplinary team. This survey presents a systematic survey of the HF-specific DMPs in Austria. Disparities between programs are highlighted and discussed. The nationwide establishment of HF-specific DMPs that integrate primary care and cardiology services including a regulation of the remuneration of stakeholders and program infrastructure is needed to decrease the burden of HF for both the individual and society.

Clinical Impact of Multidisciplinary Outpatient Care on Outcomes of Patients with COPD.

PurposeHeterogeneous nature of Chronic Obstructive Pulmonary Disease (COPD) must be comprehensively addressed. It is unclear if integrative multidisciplinary disease management (IMDM) can optimize clinical outcomes of patients with COPD.MethodsA single-center, retrospective cohort observational study with a historical intervention was conducted in a clinic specialized for COPD care. Patients with a confirmed diagnosis of COPD were administered IMDM with measurement of BODE score on initial and follow-up visits. Primary outcomes were dynamic changes in BODE quartiles after receiving IMDM.ResultsOf 124 patients, 21% were misdiagnosed with COPD. Patients with a confirmed diagnosis of COPD were 50% female, median age 64 years (IQR 57–70), 43% actively smoking and initial visit median BODE quartile 2 (IQR 1–3). Three subgroups were identified based on the changes in BODE quartiles: worsened (21%), unchanged (55%) and improved (24%). At baseline, mMRC (median [IQR]) was higher in improved subgroup vs worsened and unchanged subgroup (3 [3, 4] vs 2 [1, 2] vs 2 [1, 3], p value 0.002) respectively. Drop in all components of BODE score was noted in worsened group, but significant improvement in mMRC with preservation of spirometry values was noted in the improved group. The incidence of smoking cigarettes changed from 39% to 26% during follow-up.ConclusionOur study demonstrates that IMDM can be potentially effective in a subgroup of COPD patients. In others precipitous drop in lung function, activity tolerance, and subjective symptoms seems inevitable with worsening BODE quartiles.