Key Factors for Optimal Care Models for Heart Failure: An Integrative and Multidisciplinary Approach

[Resumen] Introducción y objetivos. La insuficiencia cardiaca (IC) supone un reto para los sistemas sanitarios que se puede responder a través del desarrollo de modelos integrales de atención. Un grupo multidisciplinar de expertos reflexionó sobre los factores clave para avanzar en el desarrollo de este tipo de modelos, planteando una hoja de ruta dirigida a todos los agentes (administraciones, gestores y profesionales sanitarios). Métodos. Se conformó un panel Delphi multidisciplinar integrado por un comité asesor de 15 expertos y un panel adicional de 31 expertos. A través de una revisión bibliográfica sistemática y entrevistas individuales semiestructuradas se realizó un diagnóstico e identificación de retos y áreas de mejora a lo largo del proceso asistencial. El panel Delphi consensuó y priorizó los factores clave con la metodología Delphi Rand/UCLA, valorando su adecuación y necesidad. Resultados. Tras 2 rondas de valoración Delphi se consensuó una propuesta de 7 retos y 75 factores clave para el desarrollo de modelos integrados para la IC. Los 25 factores clave considerados altamente prioritarios se relacionan con la necesidad de una mayor coordinación y planificación a nivel de gestión sanitaria, el abordaje integral durante la hospitalización y la implantación de medidas de continuidad y coordinación asistencial, garantizando que se cubren las necesidades específicas de diferentes perfiles de pacientes. Conclusiones. La propuesta y priorización de acciones para avanzar en modelos de atención integral a la IC debe surgir de reflexiones multidisciplinares y multinivel que incluyan la visión de los pacientes y cuidadores.[Abstract] Introduction and objectives. Heart failure (HF) is a challenge for health systems that can be responded through the development of comprehensive care models. A multidisciplinary group of experts reflected on the key factors that could facilitate the development of this type of models, proposing a roadmap aimed at all agents (politicians, managers, administrators, and health professional). Methods. A multidisciplinary Delphi panel was formed, made up of an advisory committee of 15 experts and an additional panel of 31 experts. After a systematic bibliographic review and semi-structured individual interviews, a diagnosis and identification of challenges and areas for improvement were made throughout the healthcare process. The Delphi panel agreed and prioritized the key factors applying Delphi Rand/UCLA methodology, assessing their appropriateness and need. Results. After 2 rounds of Delphi assessment, a proposal of 7 challenges and 75 key factors was agreed upon for the development of integrated models for HF. The 25 key factors considered high priority are related to the need for greater coordination and planning at the health management level, the comprehensive approach during hospitalization and the implementation of measures of continuity and care coordination, ensuring that the specific needs of different patient profiles. Conclusions. The proposal and prioritization of actions to advance in models of comprehensive care for HF must arise from multidisciplinary and multilevel reflections that include the vision of patients and caregivers.El proyecto MAIC ha sido financiado por Boehringer Ingelheim Españ

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio