Optimal left ventricular assist device (LVAD) functioning and preservation of right ventricular (RV) function are major survival determinants in destination therapy (DT)-LVAD recipients. Currently, the indication for routine pump speed optimization in stable patients and its effect on RV function at follow-up remain underexplored. Hemodynamically stable patients (N = 17, age 61 [interquartile range {IQR} 51-66] years; 13 [77%] male) underwent a routine speed ramp test. Echocardiographic images were obtained at incremental speed settings to determine optimal pump speed. In 8 patients (47%), LVAD speed could be optimized. In these patients, RV fractional area change (26% [IQR 23-31] to 35% [IQR 27-45], p = 0.04) and RV longitudinal peak systolic strain (-13% [IQR -16 to -9] to -17% [IQR -18 to -11], p = 0.02) at 3 months follow-up improved without RV dilatation. Furthermore, N-terminal pro-brain natriuretic peptide level decreased (3,162 [IQR 1,336-4,487] ng/L to 2,294 [IQR 1,157-3,810] ng/L, p = 0.02). No significant follow-up changes were found in patients without indication for speed adjustment. In conclusion, routine evaluation of optimal LVAD speed reveals the potential of speed optimization in a substantial proportion of stable LVAD-DT patients and can improve RV function.

Aims Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain. Methods and results Financial data of patients without a cardiac history from 4 hospitals (January 2012-October 2018), who were registered with the national diagnostic code ‘No cardiac pathology’ (ICD-10 Z13.6), ‘Chest wall syndrome’ (ICD-10 R07.4) or ‘stable angina pectoris’ (ICD-10 I20.9) were extracted. In total, 74.091 patients were included for analysis and divided into the following final diagnosis groups: No cardiac pathology: N = 19.688 (age 53±18), 46% male), Chest wall syndrome: N = 40.858 (age 56±15), 45% male), and stable angina pectoris: N = 13.545 (age 67±11), 61% male). A total of approximately €142,7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was €1.97, €8.13, and €10.7 million respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years follow up ≥ 95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischemic free survival. Conclusion The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain is high. We should define what we as society find acceptable as ‘assurance costs’ with an increasing pressure on the healthcare system and costs.

Purpose Integrated care models have shown to deliver efficient healthcare, but implementation has proven to be difficult. The Support Consultation is an integrated care model, which enables full integration by bundled payment, insurer involvement, predefined care pathways and strengthening of primary care. The purpose of this paper is to provide an indication of the improvements in healthcare delivery after implementation of this proposed model and to create a base for extension to similar interfaces between primary and secondary care. Design/methodology/approach A retrospective study was used to compare the effect on the number of referred patients with non-acute cardiac complaints and the cost effectiveness before and after implementation of the Support Consultation. Patients who previously would have been referred to the cardiologist were now discussed between general practitioner and cardiologist in a primary care setting. Findings The first consecutive 100 patients (age 55±16 years, male 48 percent), discussed in the Support Consultation, were analyzed. Implementation of the Support Consultation resulted in a net costs (program costs and referral costs) reduction of 61 percent compared with usual care. All involved parties were positive about the program. Research limitations/implications The Support Consultation has the ability to provide more effective healthcare delivery and to reduce net costs. The setting of the current study can be used as example for other specialties in countries with a similar healthcare system. Originality/value This study provides the potential cost savings after implementation of an integrated care model, based on real-life data.

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