CONGRESS ABSTRACT

Background: Nurse-led outpatient care pathways have shown promise in improving outcomes and reducing hospitalizations. 1 This study evaluates the effectiveness of a nurse-led outpatient care pathway in the management of heart failure (HF).   Purpose: Optimization of pharmacological and non-pharmacological therapy. Therapeutic education and promotion of treatment adherence. Prevention of readmissions and hospitalizations. Improvement of health-related quality of life (HRQoL), measured through Patient-Reported Outcome Measures (PROMs). Evaluation of patient experience through Patient-Reported Experience Measures (PREMs). Method: Multidimensional assessment at discharge: Clinical evaluation (history, physical examination, ECG, echocardiogram). Risk assessment (estimation of short-term mortality risk using the MAGGIC risk score and NT-proBNP dosage). Assessment of HF severity (NYHA classification). Assessment of care and educational needs (BRASS scale). A personalized care pathway was developed for each patient: Optimization of pharmacological therapy. Therapeutic education on pathology, therapy, lifestyle, self-management. Clinical monitoring (scheduled nursing visits, vital signs monitoring, clinical status assessment using the ANAI+C scale, telephone follow-up). Psychological support and counseling. Results: Implementation of the pathway led to: Risk stratification and early identification of patients at high risk of readmission. Significant reduction in 30-day readmission rates and short-term mortality. Improvement or maintenance of NYHA functional class in most patients. Maintenance or improvement of left ventricular ejection fraction. Significant improvement in HRQoL, measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ). The pathway positively impacted fatigue, dyspnea, and limitations in daily activities. High patient satisfaction with the care received, assessed through PREMs. Conclusions: The nurse-led outpatient pathway represents an effective care model for improving clinical outcomes and quality of life in patients with HF. The use of PROMs and PREMs allowed for the evaluation of the pathway's effectiveness not only in terms of improving clinical parameters but also from the patient's perspective.