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Vol. 72. Issue 9.
Pages 779-781 (September 2019)
Scientific letter
DOI: 10.1016/j.rec.2018.09.015
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Improving Medical Attention Through an Integral Care Model for Patients With Ischemic Heart Disease or Atrial Fibrillation
Mejorar la atención médica mediante un modelo integrado de asistencia para pacientes con cardiopatía isquémica o fibrilación auricular
Román Freixa-Pamiasa,b,
Corresponding author
, Pedro Blanch Gràciaa, Maria Lluïsa Rodríguez Latrec, Luca Basilea,d, Pilar Sánchez Chameroa, Josep Lupónb,e,f
a Servicio de Cardiología, Hospital de Sant Joan Despí Moisès Broggi, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain
b Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
c Servicio de Atención Primaria Baix Llobregat, Institut Català de la Salut, Barcelona, Spain
d Agència de Salut Pública de Catalunya, Generalitat de Catalunya, Barcelona, Spain
e Servicio de Cardiología e Insuficiencia Cardíaca, Instituto de Investigación en Ciencias de la Salud y Hospital Universitario Germans Trias i Pujol, Badalona. Barcelona, Spain
f Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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Tables (2)
Table 1. Incidence/prevalence and Lipid Parameters of Patients With Chronic Ischemic Heart Disease According to Care Model
Table 2. Incidence/prevalence of AF and Antithrombotic treatment According to Çare Model
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To the Editor,

Recently, substantial discrepancies have been detected between clinical guideline recommendations and the actual treatment prescribed1 to patients with ischemic heart disease (IHD) or atrial fibrillation (AF). In this study, we assessed the impact of a change from a classic model of care coordination between primary care (PC) and cardiology to a more integrated model in the region covered by Hospital Moisès Broggi (Barcelona, Spain), on target low-density lipoprotein cholesterol (LDL-C) levels in patients with IHD and on the degree of anticoagulation in patients with AF.

This was an ecological study of aggregate data by center, which involved a retrospective analysis of the characteristics of the patients who received care at the centers where the new integrated model was implemented (426 377 patients; 19 PC centers) and those who received care at centers where the classic model (105 936 patients; 6 PC centers) at one time point before (2013) and one time point after (2017) the introduction of the integrated care model. In the classic model, the patients are seen by a cardiologist in the hospital outpatient cardiology clinic, for their first and subsequent follow-up visits. In the integrated model, a cardiologist goes once a week to the PC centers, where they hold in-person or virtual consultations and joint sessions (our group has analyzed these data in a study that is pending publication).

At the study start, 32.0% and 32.5% of the patients with IHD in the integrated care and classic care models, respectively, were women. The mean age was 72.7±11.6 and 71.8±12.1 years. In the areas where the new model was implemented, there was a higher intensity of lipid-lowering therapy, and the mean LDL-C value decreased (from 92.7 to 85.3mg/dL) significantly compared with the classic group (87.8 to 87.1mg/dL). This translated to a higher percentage of LDL-C target levels being met (from 20.8% to 34.1% [relative increase of 63.9%] and from 27.1% to 31.2% [relative increase of 15.1%]; P <0.001) (Table 1).

Table 1.

Incidence/prevalence and Lipid Parameters of Patients With Chronic Ischemic Heart Disease According to Care Model

  Integrated care  Classic model  P 
Patients with ischemic heart disease, n
2013  9150  2878 
2014  9281  2924 
2015  9548  2988 
2016  10 122  2996 
2017  10 380  3099 
New cases of patients with ischemic heart disease, n (%)NS
2013  669 (7.3)  213 (7.4) 
2014  614 (6.6)  208 (7.1) 
2015  653 (6.8)  174 (5.8) 
2016  670 (6.6)  154 (5.2) 
2017  673 (6.5)  214 (6.9) 
Patients with at least 1 LDL-C measurement, %NS
2013  55.9  55.4 
2014  57.7  56.8 
2015  62.2  59.6 
2016  62.3  46.7 
2017  60.7  61.2 
Lipid-lowering therapy. %*
Low-intensity statins      <.001 
2014  55.3     
2016  36.3     
High-intensity statinsNS
2014  37.7   
2016  42.3  NA 
2016  17.3   
Mean LDL-C (mg/dL).001
2013  92.7  87.8 
2014  89.1  87.9 
2015  89.6  86.8 
2016  86.8  85.5 
2017  85.3  87.1 
Patients with LDL-C <70 mg/dL, %.001
2013  20.8  27.1 
2014  24.7  25.7 
2015  25.1  28.9 
2016  29.6  33.5 
2017  34.1  31.2 

LDL-C, low density lipoprotein cholesterol; NA, not available; NS, not significant.


Data on lipid-lowering therapy in the group of patients treated under the traditional model of care were not available. The comparisons of lipid-lowering therapies were performed between 2014 and 2016 with a sample of 300 patients treated under the integrated care model.

At baseline, 50.9% and 54.3% of the patients with AF were women, and the mean age was 80.3±10.5 and 79.2±11.1 years. In the integrated care centers, the percentage of patients on anticoagulant therapy increased significantly (from 69.3% to 80.2% [relative increase of 15.7%]; P <0.001), unlike in the classic model (from 74.8% to 75.4% [relative increase of 0.8%]; P=NS; P <0.001 between groups). Similarly, while there was a marked decrease in use of antiplatelets in the integrated model group, in the classic model this reduction was smaller (relative decrease of 55.3% vs 31.0%; P <0.001). Although the prescription of direct-acting anticoagulants increased in both groups, the increase was larger in the patients receiving care under the new model (from 7.9% to 36.6% and 4.1% to 18.4%; P <0.001). Both groups had a similar increase in international normalized ratio (INR) monitoring carried out in PC, with no differences regarding good INR control, defined as time in therapeutic range ≥ 60%. No significant differences were found between the 2 groups in the CHA2DS2-VASc score (Table 2).

Table 2.

Incidence/prevalence of AF and Antithrombotic treatment According to Çare Model

  Integrated care  Classic model  P 
Patients with AF, n
2013  7356  2098 
2014  7627  2211 
2015  7952  2554 
2016  8799  2272 
2017  9056  2671 
New cases of patients with AF, n (%)NS
2013  993 (13.5)  323 (15.4) 
2014  1031 (13.5)  317 (14.3) 
2015  1083 (13.6)  299 (11.7) 
2016  1066 (12.1)  236 (10.4) 
2017  1163 (12.8)  311 (11.6) 
Antithrombotic treatment (none/antiplatelet/anticoagulant), %<.001
2013  8.8/21.9/69.3  7.8/17.4/74.8 
2014  9.8/17.4/72.8  8.6/14.3/77.1 
2015  9.0/14.5/76.5  13.2/14.6/72.2 
2016  11.9/13.0/75.1  7.2/11.8/81.0 
2017  10.0/9.8/80.2  12.6/12.0/75.4 
Patients with known CHA2DS2-VASc score, n (mean CHA2DS2-VASc)
2017  974 (3.2)  200 (3.4)  NS 
Patients with CHA2DS2-VASc=0, n (%)
2017  49 (5.0)  6 (3.0)  NS 
Patients on anticoagulation with CHA2DS2-VASc=0, n (%)
2017  16 (32.7)  4 (66.7)  NS 
Type of anticoagulant therapy (VKA/DAOA), %<.001
2013  92.1/7.9  95.9/4.1 
2014  84.9/15.1  94.8/5.2 
2015  78.0/22.0  92.0/8.0 
2016  71.7/28.3  89.7/10.3 
2017  63.4/36.6  81.6/18.4 
Patients on VKA and good INR control, %NS
2013  59.8  59.3 
2014  59.4  59.3 
2015  57.4  58.7 
2016  57.5  58.1 
2017  57.4  59.4 
INR monitoring in primary care, %NS
2013  58.4  35.7 
2014  67.7  47.0 
2015  74.7  58.3 
2016  87.5  62.4 
2017  88.7  59.2 

AF, atrial fibrillation; DAOA, direct-acting oral anticoagulants; INR, international normalized ratio; VKA, vitamin K antagonist.

While LDL-C control has improved over the past decade in Spain, more than 70% of patients on secondary prevention still do not meet target levels, suggesting that, despite treatment intensification, treatment is insufficient.2 Our results show that there was a similar increase in the 2 groups in the number of LDL-C measurements, which would suggest a greater awareness of achieving LDL-C targets. However, the integrated model was associated with a higher intensity of lipid-lowering therapy (greater use of high-potency statins and above all combined treatment), which would explain the greater reduction in LDL-C and consequently the higher proportion of patients meeting targets. Thus, an integrated care model can help to improve LDL-C control in secondary prevention. Unfortunately, the figures are still very poor,2 indicating that greater effort is needed.

Most patients with AF should be on anticoagulant therapy. However, previous studies have shown that up to one-third of patients at high risk are not anticoagulated in practice,3 a figure that is similar to that found in 2013 in both groups. Our data indicate that, although there is still a percentage of patients that are not on anticoagulation, integrated care could substantially reduce these levels. Approximately 40% to 45% of the patients had poor INR control, independently of the type of care received, a finding similar to previously-reported figures,4 suggesting that additional measures are required. Direct-acting anticoagulants are particularly indicated for patients with poor INR control. In Spain they are clearly underused. Our data suggest that the integrated care model could help to detect these patients and optimize the prescription of these anticoagulants.

In conclusion, our data show that PC-cardiology integrated care can improve LDL-C control in secondary prevention and optimize anticoagulant therapy in patients with AF, which could ultimately improve health outcomes.


The authors thank the Cardiology-Primary Care Integrated Care working group for the Hospital Moisès Broggi region.

Content Ed Net, Madrid, provided editorial assistance in writing this article.

J. Hernández-Afonso, M. Facenda-Lorenzo, M. Rodríguez-Esteban, et al.
New model of integration between primary health care and specialized cardiology care.
Rev Esp Cardiol., 70 (2017), pp. 873-875
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Trends in risk factors and treatments in patients with stable ischemic heart disease seen at cardiology clinics between 2006 and 2014.
Rev Esp Cardiol., 69 (2016), pp. 401-407
V. Barrios, C. Escobar, A. Calderón, et al.
Uso del tratamiento antitrombótico según la escala CHA2DS2-VASc en los pacientes con fibrilación auricular en atención primaria.
Rev Esp Cardiol., 67 (2014), pp. 150-151
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Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA.
Rev Esp Cardiol., 68 (2015), pp. 769-776
Copyright © 2018. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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