Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities

A Randomized Trial

15 August 2006 | Volume 145 Issue 4 | Pages 273-283

Background: Despite therapies proven effective for heart failure with systolic dysfunction, the condition continues to cause substantial hospitalization, disability, and death, especially among African- American and other nonwhite populations.

Objective: To compare the effects of a nurse-led intervention focused on specific management problems versus usual care among ethnically diverse patients with systolic dysfunction in ambulatory care practices.

Design: Randomized effectiveness trial conducted from September 2000 to September 2002.

Setting: The 4 hospitals in Harlem, New York.

Patients: 406 adults (45.8% were non-Hispanic black adults, 32.5% were Hispanic adults, 46.3% were women, and 36.7% were 65 years of age) who met eligibility criteria: systolic dysfunction, English- or Spanish-language speakers, community-dwelling patients, and ambulatory care practice patients.

Intervention: During a 12-month intervention, bilingual nurses counseled patients on diet, medication adherence, and self-management of symptoms through an initial visit and regularly scheduled follow-up telephone calls and facilitated evidence-based changes to medications in discussions with patients' clinicians.

Measurements: Hospitalizations (in 406 of 406 patients during follow-up) and self-reported functioning (in 286 of 406 patients during follow-up) at 12 months.

Results: At 12 months, nurse management patients had had fewer hospitalizations (143 hospitalizations vs. 180 hospitalizations; adjusted difference, –0.13 hospitalization/person-year [95% CI, –0.25 to –0.001 hospitalization/person-year]) than usual care patients. They also had better functioning: The Short Form-12 physical component score was 39.9 versus 36.3, respectively (difference, 3.6 [CI, 1.2 to 6.1]), and the Minnesota Living with Heart Failure Questionnaire score was 38.6 versus 47.3, respectively (difference, –8.8 [CI, –15.3 to –2.2]). Through 12 months, 22 deaths occurred in each group and percentages of patients who were hospitalized at least once were similar in each group (30.5% of nurse management patients vs. 36.5% of control patients; adjusted difference, –7.1 percentage points [CI, –16.9 to 2.6 percentage points]).

Limitations: Three nurses at 4 hospitals delivered interventions in this modest-sized trial, and 75% of the participants were from 1 site. It is not clear which aspects of the complex intervention accounted for the results.

Conclusions: Nurse management can improve functioning and modestly lower hospitalizations in ethnically diverse ambulatory care patients who have heart failure with systolic dysfunction. Sustaining improved functioning may require continuing nurse contact.

Editors' Notes Context People with chronic conditions may need tailored, practical help for managing their conditions. Contribution This 12-month trial of assistance with managing systolic- dysfunction heart failure randomly assigned 406 ethnically diverse adults from Harlem, New York, to usual care or nurse management. Nurses counseled nurse management patients about sodium intake, fluid buildup, medication adherence, and self-management of symptoms; served as a bridge between patients and physicians; and regularly called patients to discuss problems. Compared with usual care patients, nurse management patients had fewer hospitalizations and better functioning. Implications Nurse management can improve some outcomes in ethnically diverse patients with systolic-dysfunction heart failure in ambulatory practices. —The Editors

 

Author and Article Information

From Mount Sinai School of Medicine, New York, New York.

Acknowledgments: The authors thank the nurses who performed the intervention (Wanda Garcia, Adaga Catano, and Gema Richards), the project managers for the study (Aimee Quijano and Leah Tuzzio), the abstractors of cardiac test results (Meredith Reh and Van Hong Nguyen), the survey expert at Gfk NOP (previously RoperASW) for guidance in survey design and patient interviewing (Tim Nanneman), and the analyst who prepared the graphics (Jodi Casabianca). They also thank the key clinicians who supported planning and implementation at the participating hospitals—Aubrey Clarke at Harlem Hospital Center; Elliott Perla at Metropolitan Hospital Center; Valentin Fuster, Thomas McGinn, Elizabeth Clark, Marrick Kukin, and Catherine Halliday at Mount Sinai Medical Center; and Linda Williams at North General Hospital—and Nancy Houston Miller, who shared the materials developed for Stanford University's Kaiser Permanente study and helped train the nurses.

Grant Support: By the Agency for Healthcare Research and Quality (R01 HS 10402).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jane E. Sisk, PhD, Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Room 3418, 3311 Toledo Road, Hyattsville, MD 20782; e-mail, jsisk{at}cdc.gov.

Current Author Addresses: Dr. Sisk: Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Room 3418, 3311 Toledo Road, Hyattsville, MD 20782.

Drs. Hebert, Horowitz, McLaughlin, Wang, and Chassin: Department of Health Policy, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029.

Read all Rapid Responses

Literacy and Heart Failure Self-Care

Michael P Pignone, et al.

Annals Online, 5 Sep 2006 [Full text]

IN RESPONSE

Jane E Sisk, et al.

Annals Online, 22 Nov 2006 [Full text]