Multidisciplinary Management Program Research Articles

Rola edukacji zdrowotnej u chorych z niewydolnością serca

According to European Society of Cardiology guidelines, the goal of heart failure (HF) management is to provide an effective system of care through the whole patient’s journey including hospital and ambulatory pathway. Strategies based on patients’ education, psychosocial support and monitoring should be considered as a fundamental part of multidisciplinary disease management programs and may lead to a reduction in mortality and morbidity and improvement in the quality of life. In this article, we focus on patient’s education strategies by describing different models: “one-to-one” strategies, multidisciplinary care management programs, activation of the family members, pharmaceutical care, and end-stage HF advance care planning. Furthermore, we explain the problem of health literacy among HF patients and describe actionable advice on how medical professionals can effectively improve patients’ comprehension and knowledge on disease management and the ability for self-care. Lastly, we review the latest evidence on outcomes obtained by HF education.

Prevalence of co-morbidities in a specialist weight management programme prior to bariatric surgery

Objective: There is limited evidence on the prevalence of patients’ obesity-related co-morbidities and the effectiveness of specialist multidisciplinary weight management (Tier 3) programmes prior to bariatric surgery. We therefore evaluate and report the prevalence of co-morbidities in patients attending a Tier 3 service within the National Health Service.Methods: This was a prospective observational study of consecutive patients who attended the Tier 3 service at the East Midlands Bariatric Metabolic Institute throughout 2017.Results: 430 patients attended the service over the study observation period. Twelve patients (2.8%) were excluded from our analysis due to incomplete data. 70.8% of patients were women, mean age at baseline was 46.4 years, mean±SD weight and body mass index at baseline were 137.8±29.2 kg and 48.0±8.6 kg/m2, respectively. The most common co-morbidities recorded at baseline were type 2 diabetes mellitus (31.1%), hypertension (31.1%), depression (26.1%), obstructive sleep apnoea (23.2%) and osteoarthritis (15.6%). Significant weight loss was observed at the 3-month and 6-month follow-up points, but not at the 9- or 12-month follow-up points. 22.5% of patients achieved weight loss of ≥5%.Conclusion: The prevalence of co-morbidities within this Tier 3 service was high. While specialised weight management services may achieve moderate weight loss through a multidisciplinary intervention, future evaluation of clinical outcomes of specialist weight services should also include co-morbidity outcomes.

2404-PUB: Evaluating a Multidisciplinary Chronic Illness Management Program for Children and Adolescents

Objective: Among youth with type 1 diabetes mellitus (T1DM), older adolescents have demonstrated decreased compliance to treatment adherence, resulting in unfavorable disease control. Poor disease management established in this population can continue into adulthood, perpetuating the health and economic burden to the individual and society. This study aims to evaluate the effectiveness and sustainability of an inpatient multidisciplinary approach to treating children and adolescents with T1DM. Methods: Patients with a diagnosis of T1DM admitted to the Chronic Illness Management Program (CIMP) between 1/1/2016 and 12/31/2017 were eligible for inclusion. Data related to physiological and psychosocial outcomes were compared between admission and discharge. Outpatient providers were contacted following a patient’s discharge from the CIMP for A1C and health care utilization data. Results: During the 2-year study period, 57 inpatient admissions of children and adolescents with T1DM were included in the analysis sample. On average, there was a significant (p < 0.0001) reduction in A1C values from admission (11.1%) to discharge (9.1%). Patients improved significantly (p < 0.01) in all psychosocial outcome measures during their inpatient stay. While patient’s A1C values increased 3 months after discharge, they still sustained clinically significant improvements from admission values. Among outpatient providers successfully contacted, none reported any patient hospitalizations or diabetic ketoacidosis episodes in the 3 months following discharge from the CIMP. Conclusion: The inpatient setting allows for an intensive multidisciplinary treatment model for T1DM management that demonstrates sustainable clinical improvements post discharge. This program model should be considered for adolescents who have been unable to successfully manage their T1DM with outpatient treatment alone. Evaluation of successful long-term management after the CIMP is currently underway. Disclosure C.M. Marchetta: None. R. Maruyama: None. C.R. O'Reilly: None.

Malignant and Benign Phenotypes of Multimorbidity in Heart Failure: Implications for Clinical Practice.

The impact of different patterns of multimorbidity in heart failure (HF) on health outcomes is unknown. The aim of this study was to test the hypothesis that, independent of the extent of comorbidity, there are distinctive phenotypes of multimorbidity that convey an increased risk for premature mortality in patients hospitalized with HF. We analyzed the clinical profile and health outcomes of 787 patients hospitalized with HF participating in a multidisciplinary HF management program with a minimum 12-month follow-up. A Classification and Regression Tree model was applied to explore the distinctive combinations of 10 most prevalent concurrent conditions (other than coronary artery disease and hypertension) associated with 12-month all-cause mortality. Mean (SD) age was 74 (12) years (59% men), and 65% had left ventricular systolic dysfunction. Most patients (88%) had 3 or more comorbid conditions, with a mean of 4.3 concurrent conditions in addition to HF. A total of 248 patients (32%) died (median, 663 [IQR, 492-910] days), including 142 deaths (18%) within 12 months. Patients with concurrent dysrhythmia, anemia, and respiratory disease experienced significantly higher 12-month all-cause mortality than those without these conditions (36.1% vs 3.6%, respectively; hazard ratio, 6.1 [95% confidence interval, 2.0-19.1]). Overall, this "malignant" phenotype of multimorbidity was associated with not only a markedly increased risk of all-cause mortality but also more unplanned readmissions, longer inpatient stays, and highest costs in the short (30-day) and longer terms when compared with more "benign" phenotypes of multimorbidity. We found a differential pattern of health outcomes according to pattern of comorbidity present in older patients hospitalized with HF and exposed to postdischarge, multidisciplinary management.

Role and efficacy of cardiac rehabilitation in patients with heart failure.

Despite improvements in treatments, the prognosis of heart failure remains poor. Elderly patients with heart failure are burdened with multiple co-morbidities and polypharmacy. Multidisciplinary disease-management programs are recommended as standard care for patients at high risk of hospitalization. Cardiac rehabilitation is defined a coordinated multidimensional intervention that integrates the basic elements in multidisciplinary management programs with a continuing program of physical activity and exercise training. Cardiac rehabilitation services can be provided on an inpatient or outpatient basis according to the clinical characteristics and severity of the disease. Data support the usefulness of inpatient cardiac rehabilitation interventions soon after hospitalization for acute decompensated heart failure as a "transition care service" to overcome the particularly high risk "vulnerable" phase. Although in the elderly, physical activity is conditioned by the general clinical conditions, the presence of comorbidities and frailty, several data underscore the importance of improving exercise capacity in the elderly vulnerable patient.

Comprehensive osteoarthritis management programme: a multi-disciplinary non-surgical management programme for Chinese patient with osteoarthritis of knee

Comprehensive osteoarthritis management programme: a multi-disciplinary non-surgical management programme for Chinese patient with osteoarthritis of knee

Favourable prognosis of trigeminal neuralgia when enrolled in a multidisciplinary management program - a two-year prospective real-life study

BackgroundPrognosis of medically treated trigeminal neuralgia patients is assumed to be poor, but the evidence is lacking. Thus, prospective real-life studies of medical management of trigeminal neuralgia are warranted.MethodsThis was an observational study. Patients were consecutively enrolled in a structured management program at a specialist centre for facial pain. Optimisation of medical treatment, physiotherapy, psychotherapy, and advice from trained nurses, were parts of the program. Medically intractable patients were referred for neurosurgery. Data-collection was prospective using standardised schemes and patient surveys. The aim was to describe the two-year outcome of medical treatment at the specialist centre. The primary outcome was a 50% reduction in the overall burden of pain according to a Numerical Rating Scale (NRS) after two years.ResultsA total of 186 primary TN patients were enrolled in the program of which 103 patients remained medically managed and completed the two-year follow-up. Fifty patients were treated surgically within the first two years of follow-up. Half of the medically managed patients (53 (51%)), had more than a 50% reduction in the overall burden of pain over the two-year period. The overall burden of pain on NRS decreased from mean 5.34 to 3.00, p < 0.01. There was no significant association between primary outcome and sex, depression and/or anxiety, concomitant persistent pain, or neurovascular contact with morphological changes of the trigeminal nerve.ConclusionsPatients with trigeminal neuralgia improve over a two-year period when enrolled in a structured medical management program. Optimisation of drug treatment, continuous advice and education and support by the multidisciplinary team, referral of the medically intractable patients for surgery or the natural history of the disease, can be some of the reasons for the improvement. The favourable prognosis provides hope and optimism for medically managed TN patients.Trial registrationCurrent study was observational, and patients were offered standard clinical care and laboratory workups according to current American Academy of Neurology and European Federation of Neurological Societies treatment guidelines. The study has been registered at ClincalTrials.gov. ID: NCT03838393.

Evolution and Outcomes of a Canadian Pediatric Bariatric Surgery Program

PurposeAn interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery. MethodsThis was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded. ResultsThirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1–17.4) years and at time of surgery was 17.4 (range, 13.6–18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal. ConclusionsAdolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding. Level of EvidenceIII.

Multidisciplinary Management of Collegiate Sports-Related Concussions.

Collegiate varsity athletes are at risk for sustaining a sports-related concussion, which can negatively impact performance during academic, social, work, and athletic endeavors. Because of the complex nature of concussions and high rates of underreporting by athletes, concussion education, identification, and postinjury care require a collaborative, multidisciplinary approach. Therefore, the purpose of this paper is to describe the specific responsibilities of the team members along with the established pre- and postconcussion procedures of one of the oldest university-based multidisciplinary concussion management programs that is coordinated by speech-language pathology. The authors provide a theoretical review of current best practices for the multidisciplinary team along with a discussion of baseline and postconcussion neurocognitive assessment and management procedures directly involving speech-language pathology. Included is a case example illustrating the postinjury procedures utilized by the team. Management of the complex sequelae of sports-related concussion for the varsity collegiate athlete necessitates implementation of a multidisciplinary, collaborative approach. Speech-language pathologists' training in the assessment and treatment of brain injury provides the team with an objective perspective in the evaluation and postinjury management of the injured student athlete. While our understanding of concussions has improved greatly over the past two decades, researchers and clinicians on the front lines of care recognize that continued voids exist in our knowledge, with the need to continually explore new methods to identify and manage the complex immediate and potentially long-term ramifications of concussion.

Transfusion Strategy the Impact of Oxygen Delivery

Cardiac surgery is associated with high risk of perioperative blood loss leading to hemodynamic instability, which frequently warrants fluid replacement, pharmacological therapy or transfusion. Regardless of an association of as little as 1-2 blood units with a dramatic increase in morbidity and mortality, transfusion is still widely administered. Despite recent guidelines there is still little consensus on blood transfusion thresholds and the implementation of multidisciplinary patient blood management programs, has not led to convincing effects as RBC transfusion is still a frequent option in cardiac surgery.

Cost-effectiveness of a primary care multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) over lifetime.

The multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) was found to be cost-saving in comparison with usual primary care over 5 years' follow-up. This study aimed to estimate the cost-effectiveness of RAMP-DM over lifetime. We built a Discrete Event Simulation model to evaluate the cost-effectiveness of RAMP-DM over lifespan from public health service provider's perspective. Transition probabilities among disease states were extrapolated from a cohort of 17,140 propensity score matched participants in RAMP-DM and those under usual primary care over 5-year's follow-up. The mortality of patients with specific DM-related complications was estimated from a cohort of 206,238 patients with diabetes. Health preference and direct medical costs of DM patients referred to our previous studies among Chinese DM patients. RAMP-DM individuals gained 0.745 QALYs and cost US$1404 less than those under usual care. The probabilistic sensitivity analysis found that RAMP-DM had 86.0% chance of being cost-saving compared to usual care under the assumptions and estimates used in the model. The probability of RAMP-DM being cost-effective compared to usual care would be over 99%, when the willingness to pay threshold is HK$20,000 (US$ 2564) or higher. RAMP-DM added to usual primary care was cost-saving in managing people with diabetes over lifetime. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

Hepcidin as a potential predictor for preoperative anemia treatment with intravenous iron-A retrospective pilot study.

Preoperative anemia occurs in about one third of patients who undergo elective surgery and is associated with an impaired outcome. Therefore, screening of preoperative anemia was established in the context of a multidisciplinary Patient Blood Management (PBM) program at the University Hospital of Muenster, Germany. Anemic patients without contraindications were treated with intravenous (IV) iron (ferric carboxymaltose) to increase their hemoglobin (Hgb) levels and hence to treat anemia prior to surgery. Interestingly, we detected a large variability in the response of Hgb levels after IV iron administration. Systemic iron homeostasis is mainly regulated by the hepatic hormone hepcidin, which regulates the cell surface expression of the sole known iron exporter ferroportin. The objective of this retrospective pilot study was to analyze the potential of hepcidin to predict the response of anemic patients to preoperative IV iron treatment measured as increase in Hgb.Serum samples of non-anemic (n = 48), untreated anemic (n = 64) and anemic patients treated with IV iron (n = 79), in total 191 patients, were collected between October 2014 until June 2016. Serum hepcidin levels were determined and data were analyzed retrospectively.The analysis revealed at first a correlation between serum hepcidin levels and the parameters of the iron status. Second, patients treated with IV iron showed a noticeably higher increase in their delta Hgb level between PBM consultation and surgery (0.45g/dl [0.05, 1.05] compared to patients without IV iron (0.1g/dl [-0.48, 0.73], *p = 0.03). Patients were then grouped into ‘non-responders’, defined as delta Hgb <0.6g/dl and ‘responders’, with delta Hgb ≥0.6g/dl between the day of IV iron treatment and the day of surgery. Within normal ranges and clinically unapparent, a statistically noticeable difference between responders and non-responders was found for CRP and leukocytes. Serum hepcidin levels were higher in the group of non-responders (10.6ng/ml [3.93, 34.77]) compared to responders (2.1ng/ml [0.25, 7.97], *p = 0.04).To conclude, the data of this retrospective pilot study indicate that hepcidin might be a promising biomarker to predict a patient`s responsiveness to IV iron in preoperative anemia treatment. Prospective studies have to investigate serum hepcidin levels as a biomarker to guide physician`s decision on IV iron substitution.

Obesity: when is specialist referral needed?

Obesity is a chronic progressive condition affecting 27% of the UK adult population. Obesity underlies much of primary care workload: 44% of type 2 diabetes (T2D) cases, 23% of ischaemic heart disease, and 41% of certain cancers are attributable to excess BMI.1 Worryingly, the number of adults with severe obesity, which significantly reduces life expectancy, has doubled to approximately 2.6 million over the past decade. Obesity and related illnesses lead to significant healthcare costs, estimated at £6.1 billion per year in the UK, with additional societal costs of £27 billion from reduced productivity secondary to obesity-related ill-health.2 Obesity is a complex issue with no single or simple solution. Preventing incident obesity is crucial but for those people already affected we need to provide optimal, evidence-based care. Multidisciplinary weight management programmes that encompass changes in diet, behaviour, and physical activity need to be established and readily accessible across the UK. Prescription medications and bariatric surgery where indicated should be seen as adjuncts to facilitate such programmes rather than standalone alternatives. Bariatric surgery offers the most effective method for substantial and sustained weight loss, while significantly improving obesity-associated comorbidities and improving quality of life. Responsibility for commissioning bariatric surgery was devolved from NHS England to clinical commissioning groups (CCGs) in April 2017 with the primary aim of increasing consistency in obesity care pathways nationwide. However, commissioning of medical weight management services (Tier 3) across the UK is variable and, in some areas, absent, while less than 1% of people who fulfil National Institute for Health and Care Excellence (NICE) eligibility criteria for bariatric surgery (Tier 4) are able to access it. Greater awareness of the evidence supporting bariatric surgery health outcomes and the NHS weight management …

Construct validity of the Heart Failure Screening Tool (Heart-FaST) to identify heart failure patients at risk of poor self-care: Rasch analysis.

The aim of this study was to psychometrically evaluate the Heart Failure Screening Tool (Heart-FaST) via: (1) examination of internal construct validity; (2) testing of scale function in accordance with design; and (3) recommendation for change/s, if items are not well adjusted, to improve psychometric credential. Self-care is vital to the management of heart failure. The Heart-FaST may provide a prospective assessment of risk, regarding the likelihood that patients with heart failure will engage in self-care. Psychometric validation of the Heart-FaST using Rasch analysis. The Heart-FaST was administered to 135 patients (median age=68, IQR=59-78years; 105 males) enrolled in a multidisciplinary heart failure management program. The Heart-FaST is a nurse-administered tool for screening patients with HF at risk of poor self-care. A Rasch analysis of responses was conducted which tested data against Rasch model expectations, including whether items serve as unbiased, non-redundant indicators of risk and measure a single construct and that rating scales operate as intended. The results showed that data met Rasch model expectations after rescoring or deleting items due to poor discrimination, disordered thresholds, differential item functioning, or response dependence. There was no evidence of multidimensionality which supports the use of total scores from Heart-FaST as indicators of risk. Aggregate scores from this modified screening tool rank heart failure patients according to their "risk of poor self-care" demonstrating that the Heart-FaST items constitute a meaningful scale to identify heart failure patients at risk of poor engagement in heart failure self-care.

198 Multidisciplinary Medication Therapy Management (MTM) Program Impact On 30-Day Hospital Readmissions

198 Multidisciplinary Medication Therapy Management (MTM) Program Impact On 30-Day Hospital Readmissions

A Specialized Medical Management Program to Address Post-operative Weight Regain in Bariatric Patients.

Although bariatric surgery results in massive weight loss, weight regain over time up to as much as 25% is not uncommon. Weight regain in this population often leads to long-term weight loss failure and non-compliance in clinical follow-up and program recommendations. We analyzed early weight outcomes at 3 and 6months of 48 bariatric patients referred to an individualized, multidisciplinary medical management program at the Center for Obesity Medicine (COM) to address weight regain in 2015 and compared to a group of matched non-bariatric patients. The medical management center, under the direction of a medical obesity specialist and complementary to the surgical program and multidisciplinary team, addressed weight regain with intensive lifestyle (diet, activity, anti-stress therapy, behavioral counseling, sleep) and with medical intervention (one or more anti-obesity medications). According to early findings, the average percentage post-operative weight regain of patients entering the weight management program was 20% above nadir and time since surgery averaged 6years (range = 1 to 20years) with a mean weight loss of - 2.3kg after 3months and - 4.4kg at 6months into the program. Individuals most successful with weight loss were those treated with anorexigenic pharmaceuticals. Weight and percent weight loss were significantly greater for the non-surgical than the surgical patients at 3 and 6months (p < 0.05). A medically supervised weight management program complementary to surgery is beneficial for the treatment of weight regain and may prove important in assisting the surgical patient achieve long-term weight loss success.

Evaluation of a multidisciplinary rehabilitation programme for elderly patients with hip fracture: A prospective cohort study.

To investigate the effectiveness and cost of an 18-month multi-disciplinary Comprehensive Fragility Fracture Management Program (CFFMP) for fragility hip fracture patients. Prospective cohort study. Elderly patients with hip fracture were recruited at their first postoperative follow-up in 2 district hospitals. The intervention group comprised patients from the hospital undergoing CFFMP, and the control group comprised patients from another hospital undergoing conventional care. CFFMP provided geri-orthopaedic co-management, physician consultations, group-exercise and vibration-therapy. Timed-up-and-go test (TUG), Elderly Mobility Scale (EMS), Berg Balance Scale (BBS) and fall risk screening (FS) were used to assess functional performance. Incidences of falls and secondary fractures, the cost of the programme and related healthcare resources were recorded. A total of 76 patients were included in the intervention group (mean age 77.9 years ((standard deviation; SD) 6.1) ) and 77 in the control group (79.9 (SD 7.2)), respectively. The re-fracture rate in the control group (10.39%) was significantly higher than in the intervention group (1.32%) (p = 0.034). The intervention group improved significantly in TUG, EMS and FS after a 1-year programme. The overall healthcare costs per patient in the intervention and control groups were US$22,450 and US$25,313, respectively. Multi-disciplinary CFFMP is effective, with reduced overall cost, reduced length of hospital stay and reduced secondary fracture rate. The rehabilitation community service favours rehabilitation and improved quality of life of hip fracture patients.

Five-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Diabetes-Related Complications and Health Service Uses-A Population-Based and Propensity-Matched Cohort Study.

To evaluate the 5-year effectiveness of a multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes. A 5-year prospective cohort study was conducted with 121,584 Chinese primary care patients with type 2 DM who were recruited between August 2009 and June 2011. Missing data were dealt with multiple imputations. After excluding patients with prior diabetes mellitus (DM)-related complications and one-to-one propensity score matching on all patient characteristics, 26,718 RAMP-DM participants and 26,718 matched usual care patients were followed up for a median time of 4.5 years. The effect of RAMP-DM on nine DM-related complications and all-cause mortality were evaluated using Cox regressions. The first incidence for each event was used for all models. Health service use was analyzed using negative binomial regressions. Subgroup analyses on different patient characteristics were performed. The cumulative incidence of all events (DM-related complications and all-cause mortality) was 23.2% in the RAMP-DM group and 43.6% in the usual care group. RAMP-DM led to significantly greater reductions in cardiovascular disease (CVD) risk by 56.6% (95% CI 54.5, 58.6), microvascular complications by 11.9% (95% CI 7.0, 16.6), mortality by 66.1% (95% CI 64.3, 67.9), specialist attendance by 35.0% (95% CI 33.6, 36.4), emergency attendance by 41.2% (95% CI 39.8, 42.5), and hospitalizations by 58.5% (95% CI 57.2, 59.7). Patients with low baseline CVD risks benefitted the most from RAMP-DM, which decreased CVD and mortality risk by 60.4% (95% CI 51.8, 67.5) and 83.6% (95% CI 79.3, 87.0), respectively. This naturalistic study highlighted the importance of early optimal DM control and risk factor management by risk stratification and multidisciplinary, protocol-driven, chronic disease model care to delay disease progression and prevent complications.

Kinesiophobia, functional disability and physical deconditioning evaluation in chronic low back pain

Chronic low back pain, which represents only 5 to 10% of the cases, is the cause of high health and social costs. Non-specific chronic low back pain has negative effects for physical activities and patient psychology. The aim of this study was to evaluate kinesiophobia, functional abilities and physical deconditioning in a population with chronic low back pain. The Tampa Scale of Kinesiophobia (TSK) Arabic version was used to evaluate pain beliefs and fear of movement/(re) injury. To evaluate functional abilities, we used both Oswestry Disability index (ODI) and Visual Analog Scale (VAS) of functional discomfort. Pain intensity was measured in calculating VAS of pain intensity. In order to assess endurance-responses, the following tests were used: Sorensen and Shirado tests. In addition, we studied relations between Kinesiophobia, Pain Intensity, Functional Disabilities and Endurance tests. To verify the significance of the correlations between the different variables, we used the Spearman correlation coefficient. The significance level was set at 5% ( P < 0.05). A total of 50 patients with non-specific chronic low back pain were recruited from Department of Physical Medicine and Functional Rehabilitation, Habib Bourguiba University Hospital of Sfax, Tunisia. The average Kinesiophobia score was high in our patients (48.5 ± 10.2). The mean Oswestry index was 34.4 ± 12.5%, whereas the functional VAS was 5.86 ± 2.13. High positive correlation was founded between global score of TSK and ODI ( r = 0.6, P < 0.001). Moreover, TSK was significantly correlated with VAS of functional discomfort ( r = 0.7, P < 0.001) and VAS of pain intensity ( r = 0.46, P = 0.001). About endurance variables, TSK showed negative correlations according Shirado test ( r = −0.51, P < 0.001) and Sorensen test ( r = −0.39, P = 0.004) on a moderate to low level. Given these results, Kinesiophobia presents a real problem in chronic low back pain patients since it has been significantly correlated with functional abilities and physical deconditioning. We intend to propose multidisciplinary therapeutic management programs. These programs will rely on psychological education and cognitive-behavioral therapies that allow patients to change their erroneous beliefs and to promote functional recovery.

Cost-Effectiveness of Multidisciplinary Management Program and Exercise Training Program in Heart Failure

Heart failure causes significant health and financial burdens for patients and society. Multidisciplinary management program (MMP) and exercise training program (ETP) have been reported as cost-effective in improving health outcomes, yet no study has compared the 2 programs. We constructed a Markov model to simulate life year (LY) gained and total costs in usual care (UC), MMP, and ETP. The probability of transitions between states and healthcare costs were extracted from previous literature. We calculated the incremental cost-effectiveness ratio (ICER) over a 10-year horizon. Model robustness was assessed through 1-way and probabilistic sensitivity analyses. The expected LY for patients treated with UC, MMP, and ETP was 7.6, 8.2, and 8.4 years, respectively. From a societal perspective, the expected cost of MMP was $20,695, slightly higher than the cost of UC ($20,092). The cost of ETP was much higher ($48,378) because of its high implementation expense and the wage loss it incurred. The ICER of MMP versus UC was $976 per LY gained, and the ICER of ETP versus MMP was $165,702 per LY gained. The results indicated that, under current cost-effectiveness threshold, MMP is cost-effective compared with UC, and ETP is not cost-effective compared with MMP. However, ETP is cost-effective compared with MMP from a healthcare payer's perspective.