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The current situation related to non-invasive specialistic outpatient activity in Cardiology based on exams and not on problem solving highlights:
a) a continuous growth in demand for services that seems out of control.
b) a high percentage of inappropriate health service (some as high as 60%), demand dropped from the clinical context and services that are often not used to give a full meaning to the diagnostic pathway.
c) a continuous supply of isolated exams that does not consider the real overall need of the patient.
d) a constant discontinuity of the patient’s pathway with continuous postponements.
e) a growing situation of discomfort for both patients and operators.
f) an organization that, mainly based on examinations, does not respond to the real needs of both the patient and health operators.
The above make it difficult to understand a cohesive and complete pathway for the patient with cardiovascular pathology and the possibility of an “alliance” between Cardiologist (Card) and General Practitioner (GP). The image is that of diagnostic-therapeutic pathways inevitably based on interruptions, repeated examinations, time dilation and delays, fragmentation and discomfort for patients.
The health directions, that put the patient at the center, highlight the strong and decisive desire to promote a general reorganization of the territorial ambulatory activity, greater integration between the specialists and a more efficient articulation and synergy among the different skills. This will be possible not only with regard to the management of chronicity but also and above all for the management of patients with important cardiovascular risk factors that constitute a significant percentage of the adult population and that are one of the causes of an increase in health needs, given the associated complications, with consequent absorption of resources.
It is calculated, in fact, that at territorial level Arterial Hypertension is present in 30% of the adult population, Diabetes in 5%, Dyslipidemia (not of food origin) in 22% and the presence of more risk factors in 15% of cases [1-3]. Furthermore, it is estimated
that cardiovascular complications occur in approximately 45% of
cases, cerebrovascular complications in 30% of cases, peripheral
arterial ones in 15% of cases and nephrovascular cases in 20%
of cases while mortality is approximately equal to 20% of cases.
From the Italian register IN-CHF, approximately 39.4% of patients
with ischemic heart disease and 15.8% of patients with arterial
hypertension evolved into heart failure , about 55.3% had a
history of repeated hospitalizations and an approximately 30%
patients had a prevalence of associated diseases. The prevalence
of heart failure is estimated at around 1% -3% of the general
population and about 10% in patients over 75 years . On the
basis of the literature data, an appropriate assessment of the
patients and an adequate intervention on those with hypertension
determine a reduction of complications ranging between 13%
and 30% depending on the pathology considered and a reduction
in mortality of 13% -18%.
In the light of the above, an intervention that aims to adequately
frame this patient population, treats it from a pharmacological
point of view and plans its controls could lead to a reduction in
the occurrence of complications and a lower consumption of
The general objectives of the experimentation are to
offer the patient with chronic degenerative pathology or with
cardiovascular risk factors such as arterial hypertension,
diabetes, dyslipidemia, multifactor, adequate responses through
the definition of an adequate therapeutic diagnostic path based
on the problem-based approach [6,7] and which provides for the
supply of cardiovascular services possibly in the same structure
and in a short time and to guarantee the completeness of its
diagnostic-therapeutic pathways, avoiding dispersion, duplication
and inconvenience. The modality is that of not booking single
examinations but offering the possibility to problem solving,
through a diagnosis, clinical classification and related therapeutic
proposal in short times and with completed pathways.
In detail, COSS activity had the following objectives:
a) to Intercept the cardiology requests of GP.
b) to transform the needs of cardiological exams into
c) to manage in a complete manner, as far as possible, the
therapeutic diagnostic path of the patient.
d) to manage target pathologies with multi-specialist
collaboration and with GP.
e) to best manage the patients’ needs in respect of
effectiveness, efficiency, quality, appropriateness and equity.
f) to increase the Customer satisfaction through the
enhancement of interpersonal relationships.
g) to better manage the care processes through path
rationalization, lower costs and less information asymmetries.
h) to create a filter in the structure that allowed reducing
the number of accesses to the hospital and restoring its
original mission to it.
i) to modulate the waiting list by improving the
j) to improve the health status of patients through
adequate management of the disease.
The term one-stop-shop appeared first in the USA between the
end of 1920 and the beginning of 1930 to identify that center able
to offer more services in the same place, to satisfy the customer by
offering all the services he needed. The principle was everything
for that particular sector, achieved with just one stop, to save time
and money. Today this model is applied in the commercial sector
by creating shops, where it is possible to find everything that the
customer needs both in a specific sector and in several sectors but
also in the services’ sector where the customer gets everything
from a single branch unlike before it was obtained through the
passage of several branches.
Applied in the health care or health service provision field, the
one-stop-service model must be read as an offer point organization
where the customer/patient finds his or her health needs partially
or completely satisfied through the provision of a service whose
level (performance, type, routes, mode) is defined in advance. This
provides for the completeness of the diagnostic-therapeutic path,
when possible, without further displacements or postponements
in the area of specialist availability (presence of the specialist,
type of diagnostics). Compared to the original model, what one
intends to apply to the health service presupposes the taking in
charge of the patient/customer to guarantee the continuity of the
path even when the latter must be continued outside the center or
inside the hospital structure.
This model was used to outline the COSS (Cardiology One-
Stop-Service) as a point of non-invasive cardiological offer and
as an organizational modality able to offer the patient all the
basic services he needs within the same day and without further
accesses. To this end, through the COSS, it is intended to implement
a form of Outpatient Health Care Center or Community Medicine
able to manage non-invasive diagnostic therapeutic pathways,
especially for chronic degenerative diseases more frequent
outside the hospital place in health facilities open-day (daytime
opening) and with one-stop-shop mode (all for health in a single
stop). The COSS represents a specialist outpatient health sector
within a possible organization more extended to the medical field
(MOSS - Medical one stop service) which aims to offer broader
outpatient polyspecialistic basic services.
Important cardiovascular risk factors and the level of the same
risk have been requirements both as first access and as control and patients more generally with cardiovascular pathology in
the first evaluation or with chronic degenerative that needed
a new instrumental clinical assessment. The target population
being evaluated in this project was represented by patients with
the first detection of main risk factors and metabolic syndrome,
by patients with associated risk factors, by patients in followup
not adequately controlled by therapy or with onset of new
cardiovascular problems to evaluate.
Approach for problems according to which the prescriber put
a problem and the cardiologist tried to solve the problem using
what was needed, taking charge of the patient’s diagnostic path
until its conclusion, including the therapeutic proposal. The flow
is shown below:
a) Patient presents a cardiovascular problem (risk factors,
first visit, etc.)
b) GP identifies the patient’s need (known/suspected
cardiovascular) and put the problem to Card
c) Card takes care of the diagnostic path of his competence
to solve the problem and sends the patient back to the GP once
the path is closed.
Communication and information transfer deficits are frequent
and have a negative influence on the path and management of the
patient’s illness, on the relationship with GP and on the correct
use of health facilities . This collaboration aimed at a direct
connection between the Policlinic and GP, in such a way that there
was the possibility of interacting each other directly and easily on
particular clinical situations and, for some types of first visits, of
putting problems and not asking examinations (on which need
the Card would have decided). This was achieved through project
presentation meetings, founding principles, organizational
methods and objectives. In the initial phase the immediate offer
in the outpatient structure was a visit, EKG and cardiac and
vascular echocardiography; other instrumental investigations
and specialist consultations have been initiated by the Card. An
annual training program for GP was defined and implemented on
the appropriate use of non-invasive diagnostics and the correct
use of the information obtained.
The aim of this collaboration agreement was to reduce the
discomforts of patients and to guarantee them adequate and
appropriate answers within a reasonable time. Moreover, in
respect of the professionalism and the respective competences, it
had the purpose to:
a) Promote the management of the patient’s pathway
b) Guarantee the completeness of the health and diagnostic
pathway until the therapeutic proposal.
c) Promote the prescription of exams within the
anamnestic and clinical process (and not out of this context),
whenever possible, or in any case within a reasonable period
of time with clinical needs and preferably in the same place.
d) Ensure constant communication and continued
exchange of information between professionals on the clinical
status of the patient.
e) Promote professional growth and the definition of paths.
The activity was carried out in a hospital external
structure (policlinic) in close collaboration with the Hospital’s
Cardiovascular Department using a separate booking agenda.
The activities carried out within the Policlinic concerned the visit,
EKG, Echocardiography, Vascular ultrasound, endocrinological
and ophthalmology counseling. Other diagnostic investigations
or specialistic consultations have been requested directly by the
Card through a preferential pathway and sent to the Hospital’s
Cardiovascular Department. The final classification was carried
out by the Card who took charge of the patient.
The following decisional points have been considered:
a) Closure of the pathway based on the visit only + EKG.
b) Need for ECOCG and / or Vascular Ultrasound. In this
case the Card performed exams within the visit and closed the
c) Need for other non-invasive or invasive instrumental
cardiological examinations, or other specialist consultations.
In this case the Card made the prescription and booking,
followed the pathway, closed this after the results of
examinations/consultations, with a final report to be sent to
d) Need for other non-cardiological instrumental tests. In
this case the Card made the proposal in the final report to the
GP (he will decide whether to proceed or not).
On an experimental basis, the COSS project was implemented
in 2010 for a period of 10 months with about two weekly sessions
(total accesses 38, total approximately 130 hours, total number of
patients visited 400) and in 2013-2014 for a period of 10 months
with approximately four weekly sessions (total accesses around
150, total approximately 700 hours, total number of patients
The results have been as follows:
The total number of patients was 2400 (female 55%, male 45%,
aged 14 to 92 years old, first access 67%, known cardiovascular
patients 33%). The concordance between the diagnostic suspect
put by prescriber and final diagnosis made by Card was 75%, in all
of these no therapeutical modification has been made. The need
of echo examination within the visit was 25%. New pathologies
detected were ischemic heart disease in 5%, heart failure 3%,
others 2% (A-V block, pericardial effusion, pleural effusion, mitral valve insufficiency due to chordal rupture, atrial fibrillation);
additional exams performed in one-stop-service modality
were 35%, additional exams performed within the hospital
cardiovascular department were 7% (coronary angiography,
effort test, electrophysiology), extra cardiovascular examinations
recommended were 10% (neurology, gastroenterology,
rheumatology). Anxiety was the main symptom of patient
presentation (80%), palpitation was present in 12% and chest
pain in 16%; in 15% of the latter it was typical (11% in known
cardiovascular patients and in 5% confirmed by specific tests,
whereas in 84% chest pain was due to anxiety, gastroesophageal
reflux, osteomuscular origin. In summary data have highlighted
a) The diagnostic question has been often generic (control),
did not put the clinical problem but rather defined the
diagnosis (arterial hypertension), often it was discordant with
what the patient reported (generic chest pain vs. palpitation
or effort dyspnea due to obesity or anxiety), sometimes it did
not correspond to a condition for which the consultation was
b) The clinical-diagnostic pathway of the patient was
often disorganized and did not give the Card the opportunity
to assess appropriately the patient’s clinical situation (for
ex: cardiological consultation before other instrumental or
hematochemical tests requested by the GP).
c) In 75% of cases, the cardiological examination with
EKG neither added any information, nor it modified the
therapy; further, there was not the need to request additional
examinations to close the pathway, considering the clinical
stability of the patient, which in most cases presented
asymptomatic (in this case the cardiological consultation
made was not necessary but, however, the correct setting of
the GP was confirmed)
d) In a fair percentage of cases with chest pain a correct
medical history, visit and clinical and instrumental
classification led to a non-cardiac diagnosis of pain. In 5% of
cases a new coronary artery disease has been demonstrated
e) In six cases emergency hospitalization was required for
acute symptoms (dyspnea or angor) which had appeared a
few days before and treated with non-specific therapy. The
clinical and instrumental framework allowed the immediate
diagnosis of myocardial infarction in the subacute phase, heart
failure, pericardial effusion, pleural effusion, atrioventricular
block, rupture of mitral cord tendons; in other cases,
hospitalization has been scheduled (for specific exams or
electrical cardioversion for atrial fibrillation).
f) An ECHOCG was necessary in one fourth of the patients
visited, giving the possibility of completing the patient’s
diagnostic path in the same session. In 5% of patients a Carotid
vascular Echo was necessary. Comparing the data with those
related to the patients with direct access for single exams, the
number of ECHOCGs was reduced of 60%.
g) The presence of the endocrinologist and ophthalmologist
in the same external structure allowed specific contextual
counseling (fundus, diabetes, dysthyroidism) giving the
possibility of integrating the skills and completeness of the
Usually, it is difficult to control the Demand due to the fact
that the health need does not arise spontaneously but is often
generated or self-generated. The Demand is often formed by a
myriad of examinations and services put often outside a sequential
and integrated path. The Offer is often limited or in any case not
proportionate to the Demand to such an extent as to represent
a funnel with continuous dispersions and chokes to the regular
flow. The flood of requests for services often unhooked from the
logical and appropriate process of diagnosis and care creates a
continuous imbalance with penalization of those who really have
the need compared to those who do not have a real one.
In the light of the above, a change of approach to the problem
is necessary evaluating innovative ways that can facilitate a
significant improvement in an articulated way. To do this we must
strive to get out of the performance logic, proposing a different
way of seeing both demand and offer.
The demand generated by the need for health should no
longer be put as a demand for services but as a problem, that is,
the perceived need for health in itself generates a problem that
must be put as such for its resolution, in compliance with the
principle of the patient at the center.
The solution of a health problem (closely related to the
satisfaction of the health need presented by the patient) is the
final result of a simple or complex articulated process that as
such presents different phases and levels of activity configuring
the real clinical-diagnostic pathway. In this context, each phase
of the process can be conclusive or prelude to the next one and
every health worker (GP or Card) will have the responsibility to
close the phase of the path that competes with him only when he
considers that the patient’s health need is sufficiently satisfied.
The patient’s need for health can be diagnostic or therapeutic.
In the first case it is necessary to talk about the diagnostic path
in the second of clinical assistance complexity. In the context of
modern medicine that aims to satisfy health needs in accordance
with the clinical-diagnostic-therapeutic process based on the
problem-based approach, the diagnostic path may be at two
levels of complexity (diagnosis carried out at the first clinical and
instrumental level and diagnosis which requires more complex
and higher level surveys); the clinical-assistential complexity of low, medium and high level implies an organization that places
the patient at the center and the active collaboration among the
different health operators for an appropriate management of the
clinical, therapeutic and care aspects. In both cases the path starts
with the patient’s problem (perceived need) for which the GP and
the Card will be involved in subsequent phases and integrated
according to a linear path with regards to the diagnosis, and
according to an active collaboration (circular path) regarding care.
The concept highlights an “exhaustive treatment process”
guided by a doctor who represents the central point of reference
for the integration and continuity of all the processes necessary
to close the path of that patient with that given need for health.
According to international literature, continuity of care can refer
to the use of information related to the patient’s clinical history to
make the most appropriate decisions (Informational continuity),
to the responsible approach to managing the patient’s health
needs (Management continuity) and to the personal relationship
between patient and doctor (Relational continuity) . It is evident
from these definitions that the continuity of care represents
three moments of a single process that foresees the information,
management and relational phases that must be coordinated and
integrated, with all the health workers involved, with the aim of
giving answers appropriate, concrete and fulfilled to the patient’s
need for health. So, the continuity of the care represents the path
and integration of care and the way in which we try to achieve our
A final aspect to be emphasized is that relating to the
dimensions of continuity of care: the first is the individual one,
relative to the individual patient and his care process, the second
is the longitudinal one, relative to the time and evolution of
the relations between patient and patient doctor, the third is
the strategic one, relative to the orientation of the diagnostictherapeutic
path and, finally, the fourth is the informative one,
relative to the past and present history of the patient and to the
identification of his problems and needs [9-34].
The data reported in the present paper highlight the validity
of a new organizational model that aims to intercept out
patients from the hospital, in polyclinical structures, needing
cardiological counseling (first visit or new problem), completing
the diagnostic therapeutic path whether this is closed at the
moment or whether it needs further instrumental investigations
or specialist advices. In this way we tried to get out of the
performance logic by reintroducing the approach to problems,
taking charge of the patient’s path and completeness, intervening
on the appropriateness of the performances and thus reducing
the number of inappropriate and often useless services and
discomfort for patients.
The organizational model, limited for now to Cardiology, may
be extended to all specialistic outpatient activities by creating
an organization that allows interaction, when necessary, among
the various specialties involved in the management of patients
with chronic degenerative pathology that represents the highest
share consistent with performance claims. From Cardiological to
Medical one stop service. The advantages linked to the filter and
the completeness of the pathway is evident. Another advantage is
the increase in appropriateness, reduction of the event occurrence
and of health consumption.
On the basis of the data and considerations reported, a
hypothesis of future work is the realization of an organizational
plan articulated on the path of the incoming and outgoing patient
to develop the territorial function of the Hospital in the outpatient
structures, placing them in continuity with the GP, with the
a) COSS - Gate on the way in to improve the appropriateness of examinations and
hospitalizations by assessing patients with cardiovascular risk
factors outside the hospital, or with cardiovascular disease in
the first assessment by closing the diagnostic therapeutic path
or planning the necessary high-level path within the hospital or
b) COSS - Gate on the way out to improve clinical care management and reduce rehospitalization
by assessing and treating patients with chronic
degenerative pathology and follow-up control of patients
discharged from the hospital.
Agenzia Sanitaria Regionale Emilia Romagna Dossier 118-2006: Linee guida per l’accesso alle prestazioni.
The Lincoln Star, Lincoln, Nebraska, July 1930.
Legge 30 novembre 1998 n. 419.
Decreto legislativo 19 giugno 1999, n. 229.
Piano Sanitario Nazionale 2003 – 2005.
Legge 31/97 Regione Lombardia per il riordino del servizio sanitario regionale.
Piano Socio sanitario Regionale 2007-2009 Regione Lombardia.
Lorenzoni R, Baldini P, Bernardi D, et al. (2002) a nome del Gruppo di Valutazione dell’Appropriatezza ANMCO-Toscana. La valutazione dell’appropriatezza dei test cardiologici non invasivi. Ital Heart J Suppl3: 607-612.