 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
Rapid Responses to:
|
|
Electronic letters published:
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif){kind=icon}
Care Management for Heart Failure
CHF Disease Management
|
|
|||
|
Robert F. DeBusk, MD Stanford University, Helena C. Kraemer, Daniel J. Cher
Send rapid response to journal:
debusk{at}stanford.edu Robert F. DeBusk, et al.
|
Dr. Linden notes that physicians’ awareness of the study may have influenced the care provided to study participants. However, any such effect was substantially mitigated by the fact that our study was conducted by an “outside” group of Stanford-based investigators without the incentive or means to provide feedback to Kaiser physicians or administrators on the quality of care provided to patients during the study. Given the nature of excluded patients, Linden’s suggestion of an analysis of changes in medication prescription rates among these subjects would be difficult to interpret. As Linden suggests, the evidence-based “baseline” care provided by Kaiser physicians for these low-risk heart failure patients might not have been amenable to improvement. However, our group has conducted a series of multi-center randomized trials in Kaiser Permanente Hospitals in which care management produced superior outcomes. (1-4) These trials focused on behaviors (exercise, smoking, diet, drug adherence) that were under the direct control of patients. As we noted in our present paper, rehospitalization is only partly influenced by patients’ adherence to medication regiments for heart failure. Indeed, most rehospitalizations in the present study were not for heart failure, but for coronary artery disease and other medical conditions. This underscores the need to address the multiple comorbidities associated with chronic diseases (5). We agree with Linden that our study was not designed to evaluate the generalizability of our findings to non-HMO settings. Regarding the value of disease management in low-risk patients treated elsewhere, our conclusions speak for themselves: “Although nurse care management did not statistically significantly reduce the rate of rehospitalization compared to the Kaiser Permanente HMO-treated group, its potential value in non-HMO settings should not be diminished.” Dr. Linden raises an interesting methodologic problem with evaluating nurse care management: such studies rely on physicians’ willingness to collaborate closely with the nurse care managers. It is our impression that physicians practicing in HMO settings are more willing to do so than those practicing in other settings. A future challenge is how to organize and conduct rigorous studies of care management for various chronic conditions outside of environments such as HMOs whose physicians place a high value on collaboration. Robert F. DeBusk, MD Daniel J. Cher, MD Helena C. Kraemer, PhD References 1. Taylor CB, Houston-Miller N, Killen JD, DeBusk RF: Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Int Med 113: 118-123, 1990. 2. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger III WE, Heller RS, Rompf J, Gee D, Kraemer HC, Bandura A, Ghandour G, Clark M, Fisher L, Taylor CB: A case management system for coronary risk factor modification following acute myocardial infarction. Annals Int Med; 120:721-729, 1994. 3. Taylor CB, Miller NH, Herman S, Smith PM, Sobel D, Fisher L, DeBusk RF. A nurse-managed smoking cessation program for hospitalized smokers. AJPH; 86:1557-1560, 1996. 4. Miller NH, Smith PM, DeBusk RF, Sobel DS, Taylor CB: Smoking cessation and hospitalized patients: results of a randomized trial. Arch Int Med 157; 409-415, 1997. 5. DeBusk RF, West JA, Miller NH, Taylor CB. Chronic Disease Management. Treating the patient with disease(s) vs treating disease(s) in the patient. Arch Intern Med 1999; 2739-2742. Stanford University School of Medicine Stanford University Conflict of Interest:None declared |
|||
|
|
|||
|
Ariel Linden, DrPH, MS Linden Consulting Group, Thomas Wilson, DrPH, PhD. Wilson Research
Send rapid response to journal:
alinden{at}lindenconsulting.org Ariel Linden, et al.
|
Contrary to popular belief, the random controlled trial (RCT) is not bias free and the paper by DeBusk et al. highlights a potential threat to validity, the “Hawthorne effect,” that is not recognized by the authors. The medical staff at the five Kaiser hospitals was informed of the study protocol. Considering that Kaiser is a “closed system” of care, we do not know if those physicians behaved differently as a result of being aware that they would be indirectly scrutinized for the care they provide One assessment that could provide insight as to whether this was an issue would be to indicate the CHF population-wide change in ACE-I and beta- blocker usage in addition to just the experimental and control groups. As it stands now, the reader is left to wonder if the Hawthorne effect in the reference group negated the potential positive effects of disease management (DM) services in the intervention group. Secondly, and potentially more importantly, telephonic-based DM is intended to guide participants toward improving control of their condition by bringing the individual and their physician in line with evidence-based practice guidelines. If in fact most individuals already adhered to self- management behaviors -- as seems evident here -- there is little gain to be expected from a DM program. For these two reasons, the “external validity” and generalizability of this study is unknown. Thus, the conclusion drawn by the authors that the benefits of disease management may not valuable to low-risk patients elsewhere is overreaching. An equally valid conclusion, with stronger “internal validity” would be: “A telephonic-based disease management strategy does not appear to work in tightly-controlled, well-managed, low risk CHF patient population.” Conflict of Interest:None declared |
|||
