心臟衰竭整合照護之執行成效

Effectiveness of Multidisciplinary Care in Patients with Heart Failure

目的：旨在探討心衰竭團隊在心衰竭急性後期整合照護（HF-PAC）計畫中的執行成效。材料與方法：本研究納入2020年7月至2022年12月因心衰竭住院的患者，並提供出院後六個月的跨團隊照護。評估指標包含指引導向藥物之處方率、心臟功能、營養狀態、生活品質、六個月再住院率與一年死亡率，並探討病人特徵與六個月再住院率之相關性。
結果：本研究共有93名患者完整參與HF-PAC計畫。經介入後，指引導向藥物之處方率大幅提升。患者的心臟功能、心衰竭症狀、自理能力、生活品質及營養狀態亦顯著改善。參與患者的六個月內再住院率11.8%，一年死亡率1.1%；併有慢性腎臟病的患者六個月再住院率的風險增加。
結論：HF-PAC計畫提高了醫療服務品質，達到延緩疾病惡化的最佳效果。

Objective: This study aims to explore the effectiveness of the Heart Failure Post-Acute Care (HF-PAC) program implemented by the heart failure team at Taipei Medical University Hospital. Methods: This study includes patients hospitalized for heart failure from July 2020 to December 2022, and provides six months of multidisciplinary team care after discharge. The outcomes of interest include the prescription rate of guideline-directed medical therapy, cardiac function, nutritional status, quality of life, six-month heart failure readmission rate, and one-year mortality rate. The impact of comorbidities on six-month heart failure readmission rate was also examined.
Results: A total of 93 patients fully participated in the HF-PAC program. After intervention, the prescription rate of guideline-directed medical therapy significantly increased. The patients' cardiac function, heart failure symptoms, self-care ability, quality of life, and nutritional status also significantly improved. The six-month heart failure readmission rate was 11.8%, and the one-year mortality rate was 1.1%. Chronic kidney disease was associated with higher risk of heart failure readmission.
Conclusion: The HF-PAC program has improved the quality of care, delaying disease progression and enabling patients to have a better quality of life.