Clinical Courses of Elderly Patients with Heart Failure Managed by Local Partnership Clinical Pathway and Multidisciplinary Care

Heart failure (HF) is the most critical issue in the medical and long-term care for the elderly because HF is an economic and social burden due to its high prevalence and poor prognosis. General practitioners (GPs) have recently managed patients with chronic HF (CHF) in collaboration with hospital cardiologists. However, little is known about how to collaborate and its outcomes.We have operated a local partnership program using clinical pathway (LPCP) for CHF to facilitate medical and nursing care teamwork in the local community since June 2009. The hospital's multidisciplinary teams evaluate and share patient information periodically. Among 500 patients with available follow-up data as of December 2020, we defined patients who withdrew from the LPCP for reasons other than death as path-dropout (n = 164) and the remaining as path-continue patients (n = 336). The Kaplan-Meier method considering time co-variability of path-dropout, showed a significantly higher hazard ratio of all-cause death in the path-dropout group than in the path-continue group (HR: 5.09; 95% CI: 3.54-7.30, P < 0.001).LPCP provides integrated disease management for CHF by cardiologists and multidisciplinary professionals in the hospital collaborating with local GPs and home care teams. A multivariate analysis identified LPCP as the most important independent predictor of clinical outcome. LPCP may work as an observational tool to distinguish HF patient clinical outcomes.