Nurse Care Management for Low-Risk Patients with Heart Failure

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The summary below is from the full report titled "Care Management for Low-Risk Patients with Heart Failure. A Randomized, Controlled Trial." It is in the 19 October 2004 issue of Annals of Internal Medicine (volume 141, pages 606-613). The authors are R.F. DeBusk, N. Houston Miller, K.M. Parker, A. Bandura, H. Chmura Kraemer, D.J. Cher, J.A. West, M.B. Fowler, and G. Greenwald.

What is the problem and what is known about it so far?

In heart failure, the heart does not pump blood as well as it should and fluid builds up in the lungs. The symptoms of heart failure include difficulty breathing, decreased ability to exercise, and leg swelling. Although many drugs help patients with heart failure, there is no cure. The condition is disabling and even fatal for many patients. Patients with heart failure often require hospitalization to receive adequate treatment. Even with the best hospital treatment, however, many patients get worse after discharge and are rehospitalized. Research shows that patients who are older, who have more severe heart failure, or who cannot easily see a health care provider are at high risk for rehospitalization. Special treatment programs can prevent readmission for many of these high-risk patients. Whether special treatment programs also benefit patients who are at low risk and are less likely to need readmission is not clear.

Why did the researchers do this particular study?

To see whether special treatment programs that benefit patients at high risk for rehospitalization apply to those at lower risk.

Who was studied?

462 patients with new or worsening heart failure admitted to 5 hospitals affiliated with a large health maintenance organization (HMO) in northern California.

How was the study done?

The researchers assigned patients at random to either usual health care or a special nurse care management program. The special program provided patients with information about heart failure and used nurses to supervise patients' symptoms, treatment, and progress by telephone after they left the hospital. The researchers then measured the number, cause, and timing of emergency department visits and hospitalizations over the next 12 months.

What did the researchers find?

Half of all patients were rehospitalized at least once within a year, mostly for illnesses other than heart failure. Patients who received usual care and those in the special treatment program had the same number, cause, and timing of emergency department visits and hospitalizations.

What are the limitations of the study?

Nurse managers for patients in the special treatment program were not available at night and on weekends, when many emergency department visits and hospitalizations occurred. Patients in both groups received intensive drug treatment for heart failure and had frequent follow-up visits with their physicians; this reduces the benefits of the special treatment program. Since the study occurred in a large HMO, the results may not apply to patients in other health care settings.

What are the implications of the study?

Special nurse care management programs that benefit patients at high risk for rehospitalization may not apply to those at lower risk.