The goal of this observational study is to explore the potential of implementing a telemedicine-based cross-sector collaboration model to manage patients with frequent admissions with decompensated heart failure. The main question(s) it aims to answer are:
* Characterization of conditions that make these patients vulnerable * Description of key-elements that makes possible to manage the patients with the cardio-share model
Participants are:
* Patients - will be helped to use the available telemedicine tools * General Practitioners - will be offered teleconferences with cardiologists (chat and video) on demand * Community health workers (caregivers at the patient home or in elderly home) - will be guided to assist the patients to use the available telemedicine tools Researchers will compare readmission rates (primary outcome) and quality of life of patients where the cardio-share management model is successfully implemented one year before and after the implementation.
with previous admission with decompensated heart failure in the three-month period prior to the current admission or
who have two or more admissions in the 6 months prior to the current admission.
Patients who
have refused to share their data for health-quality projects
have already ongoing telemedicine management for heart failure
Patients admitted to the University Hospital of Bispebjerg and Frederiksberg and for whom this is their reference hospital for general heart conditions.
Cohort
Prospective
Telemedicine-based cross-sector collaboration for patient management
Other interventionTelemedicine support from the hospital-based cardiology heart-failure team is provided on demand defined by the needs from Primary Care and from the patient rather than plain guideline-based targets
Days out-of-hospital
Number of days out of hospital from date of discharge for the index event until the next re-admission with acute decompensated heart failure
Number of readmissions
number of emergency readmissions after discharge from the index readmission, where there have been signs of decompensated heart failure
Quality of care - Medicines
Proportion of guideline-based target medicines for heart failure that patients actually use (based on purchased medicine prescriptions). This includes angiotensin converter enzyme inhibitors(ACEi)/angiotensin receptor blockers (ARB), Betablockers, Mineralocorticoids, Angiotensin Receptor Neprilysin inhibitors (ARNi), Selective Sodium Glucose Co-Transporter-2 inhibitors (SGLT2i), Hydralazine and Nitrates.
Symptom-based quality of care
Progression of heart failure specific patient-reported outcome measures. These include weekly to monthly collected: • Out-of-breath in daily activities • Night orthopnea • Dizziness • Feeling body fluid retention (leg swelling, increased abdominal pressure, increased intake of diuretics • Tiredness • Feeling of general worsening
Palliative care
Number of subjects with established palliative care
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