Care Management for Low-Risk Patients with Heart Failure

A Randomized, Controlled Trial

19 October 2004 | Volume 141 Issue 8 | Pages 606-613

Background: Nurse care management programs for patients with chronic illness have been shown to be safe and effective.

Objective: To determine whether a telephone-mediated nurse care management program for heart failure reduced the rate of rehospitalization for heart failure and for all causes over a 1-year period.

Design: Randomized, controlled trial of usual care with nurse management versus usual care alone in patients hospitalized for heart failure from May 1998 through October 2001.

Setting: 5 northern California hospitals in a large health maintenance organization.

Patients: Of 2786 patients screened, 462 met clinical criteria for heart failure and were randomly assigned (228 to intervention and 234 to usual care).

Intervention: Nurse care management provided structured telephone surveillance and treatment for heart failure and coordination of patients' care with primary care physicians.

Measurements: Time to first rehospitalization for heart failure or for any cause and time to a combined end point of first rehospitalization, emergency department visit, or death.

Results: At 1 year, half of the patients had been rehospitalized at least once and 11% had died. Only one third of rehospitalizations were for heart failure. The rate of first rehospitalization for heart failure was similar in both groups (proportional hazard, 0.85 [95% CI, 0.46 to 1.57]). The rate of all-cause rehospitalization was similar (proportional hazard, 0.98 [CI, 0.76 to 1.27]).

Limitations: The findings of this study, conducted in a single health care system, may not be generalizable to other health care systems. The overall effect of the intervention was minor.

Conclusions: Among patients with heart failure at low risk on the basis of sociodemographic and medical attributes, nurse care management did not statistically significantly reduce rehospitalizations for heart failure or for any cause. Such programs may be less effective for patients at low risk than those at high risk.

Editors' Notes Context Case management by nurses improves outcomes for patients with heart failure, but studies have targeted patients at high risk for poor outcomes because of sociodemographic or clinical factors. Whether such programs benefit low-risk patients with heart failure is unknown. Contribution Among 462 patients in 1 staff-model health maintenance organization who were hospitalized with heart failure, those randomly assigned to nurse care management had rates of rehospitalization and death similar to rates in those who received usual care. Implications Care management for heart failure may offer limited benefit for patients with clinical and sociodemographic characteristics that put them at low risk for hospitalization or death. –The Editors

 

Author and Article Information

From Stanford University School of Medicine, Stanford, California, and Kaiser Permanente Medical Care Program of Northern California, Oakland, California.

Acknowledgments: The authors thank Lynda Fisher for her meticulous collection and management of study data and Lisa Schultz for her careful preparation of the manuscript. They also thank the following research nurses for their excellent clinical contributions to the study: Linda Balanesi, RN; Louise Barrier, RN; Susan Boyce, RN; Polly Chiang-McDonald; Catherine Burger, RN; Danielle Jennings, RN, MSN; Yeuen Kim, MD; Sarah Lamb, RN, MS; Jacqueline McGrath, RN; Patricia Pearson-LeVeau, RN; Bridget Pinson, RN; and Alice Sabalvaro, RN, BSN.

Grant Support: By the National Heart, Lung, and Blood Institute, Bethesda, Maryland, grant HL56950 ("Efficacy of a Heart Failure Management System").

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Robert F. DeBusk, MD, Stanford University School of Medicine, 780 Welch Road, #106, Stanford, CA 94304-5735; e-mail, debusk{at}stanford.edu.

Current Author Addresses: Drs. DeBusk, Cher, and West, Ms. Houston Miller, and Ms. Parker: Stanford University School of Medicine, 780 Welch Road, #106, Stanford, CA 94304-5735.

Dr. Bandura: Stanford University, Psychology Building 420, Room 134, Stanford, CA 94305.

Dr. Chmura Kraemer: PBS building #C305, Stanford, CA 94305.

Dr. Fowler: Stanford University Hospital, CVRB Sec Floor South, Stanford, CA 94305.

Dr. Greenwald: 555 Castro Street, Mountain View, CA 94041.

Read all Rapid Responses

CHF Disease Management

Ariel Linden, et al.

Annals Online, 19 Nov 2004 [Full text]

Care Management for Heart Failure

Robert F. DeBusk, et al.

Annals Online, 17 Dec 2004 [Full text]