An intensive follow-up in subjects with cardiometabolic high-risk

Abstract

Addressing chronic problems requires a model of care that promotes selfmanagementof the disease and facilitates adherence to treatment. Objectives: This project wasdesigned to enhance patient?s clinical and functional outcomes through a ComprehensiveModel to be implemented in our health system and to evaluate the results. Methods: differentpopulation stratification tools were tested and designed to classify subjects according todifferent variables. We have developed a program to detect and screen cardiometabolic risk byintegrating most of the Chronic Care Model recommendations through in-house developedmanagement software (MoviHealth ). Results: From the results, 1317 subjects were evaluated(27% of the whole population) during the first year of follow-up which significantly improvedfor all variables along the follow-up period. The blood pressure of the hypertensive populationin 2010 and 2015 showed the importance of enrollment of subjects and the optimization of theblood pressure control. The result of HbA1c observed in 2010 decreased progressively to7.1 1.4% in 2015, and dyslipidemia levels improved gradually. The number of cardiovascularevents requiring hospitalization decreased significantly (48%), from 1.9 events per 100subjects in 2011 to 0.98 in 2015. Conclusion: Our program has combined strategies for theprevention and control of non-communicable diseases, incorporating interventions to controlrisk factors and to reduce morbidity and mortality. It also had improvements in life quality,accessibility to health-care services, and the promotion of self-care.