Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

A nurse-run program for congestive heart failure increased time to hospital readmission

ACP J Club. 1999 May-June;130:81. doi:10.7326/ACPJC-1999-130-3-081

Related Content in this Issue
• Companion Abstract and Commentary: Nurse-run clinics in primary care increased secondary prevention in coronary artrey disease

Related Content in the Archives
Correction: A nurse-run program for congestive heart failure increased time to hospital readmission


Source Citation

Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR. Cost effective management programme for heart failure reduces hospitalisation. Heart. 1998 Nov;80:442-6.


Abstract

Question

Can a nurse-run management program reduce hospitalization and health care costs 1 year after admission for congestive heart failure (CHF)?

Design

Randomized, unblinded, controlled trial with 1-year follow-up.

Setting

A university hospital in Malmö, Sweden.

Patients

206 patients aged 65 to 84 years (mean age 76 y; 53% men; 62% with moderately severe CHF, New York Heart Association functional class III) who were hospitalized for CHF. Exclusion criteria included other serious disease. Follow-up was 92%.

Intervention

96 patients were allocated to the intervention group. These patients and their families received nursing education on CHF, encouragement to adhere to medical treatment, and self-management guidelines during hospitalization and 2 weeks after discharge; had follow-up visits at an accessible, nurse-run outpatient clinic; and had outpatient visits with physicians at 1 and 4 months after discharge. 110 patients were allocated to receive routine clinical care (control group).

Main outcome measures

Number of hospitalizations and readmissions, time to readmission, length of hospital stay, health care costs, mortality, and self-reported quality of life 1 year after hospitalization for CHF.

Main results

16 patients in the intervention group withheld consent after randomization; analysis was thus based on 80 patients in the intervention group and 110 patients in the control group. At 1 year, patients in the intervention group had a longer mean time to readmission (141 vs 106 d, P < 0.05) and trends toward fewer hospitalizations per patient (0.7 vs 1.1, P = 0.08) and readmissions (39% vs 54%, P = 0.08), a shorter length of hospital stay (4.2 vs 8.2 d, P = 0.07), and lower mean annual health care costs (U.S. $2294 vs $3594/patient, P = 0.07) than those in the control group. Patients in the intervention and control groups did not differ in the 1-year mortality rate (30% vs 28%, { P = 0.8}*) or for quality of life assessed by a CHF questionnaire, the Nottingham Health Profile, and the global self-assessment questionnaire.

Conclusion

For patients discharged after hospitalization for congestive heart failure, a nurse-run management program increased the time to readmission but had no effect on the 1-year mortality rate or quality of life.

Sources of funding: Swedish Heart and Lung Foundation; Malmö University Hospital; Lund University.

For correspondence: Dr. C.M. Cline, Department of Cardiology, Malmö University Hospital, Lund University, S-205 02 Malmö, Sweden. FAX 46-40-33-6209.

* P value calculated from data in article.


Commentary

The studies by Campbell and Cline and their colleagues build on growing evidence that secondary prevention of chronic disease can be enhanced by nursing support to educate patients and help them to follow recommended treatments.

Campbell and colleagues showed that patient counseling (mean 82 min/patient-y) in nurse-run clinics improved adherence to recommended practices for patients with established CAD, especially for such outcomes as aspirin use, hypertension, and lipid management. Intervention had the greatest benefit for behavior related to lipid management. The finding of suboptimal adherence to cholesterol guidelines is consistent with various other studies that included both generalist and specialist physicians (1). Since 1994, there has been increasing evidence supporting aggressive control of dyslipidemia in patients with existing CAD, with benefits usually apparent after 1 year (2).

Lifestyle variables, in particular tobacco use, were less likely to be influenced by nurse-mediated follow-up. The persistence of smoking in 17% of patients is consistent with findings of resistance to change in other studies (3). As small-scale educational interventions are unlikely to permanently effect change in this group of persons who persistently smoked, more intensive and costly strategies (both behavioral modification and pharmaceutical) need to be considered.

Campbell and colleagues concluded that nurse-run clinics reduced the risk for recurrent CAD. They did not measure cardiovascular events or mortality but suggested that these outcomes could be reduced by up to 1 third. Because of the high risk for patients with established CAD, the benefit of such improvement in multiple risk factors, even of smaller magnitude, is likely to result in clinically important decreases in subsequent CAD events. The presence of multiple risk factors, especially in patients with existing disease, demands a more aggressive treatment approach by all providers.

Cline and colleagues followed an elderly group of patients with CHF, initially identified during hospital admission. Nurse-run education sessions provided > 120 minutes per patient and telephone access. The intervention group showed an increased time to first readmission and trends of reduced mean number of readmissions and days in the hospital. Survival benefits were only apparent early in this 1-year trial. Benefits of such a short-term intervention may lessen over time, given the natural progression of CHF and the nature of patient compliance; thus, additional 'booster' interventions may be useful in future evaluations.

Because of the lower number of hospitalizations in the intervention group, economic evaluation showed a trend toward a mean annual reduction of overall costs of U.S. $1300 per patient. However, because the mean cost for Swedish hospitalization was U.S. $381/day, the study likely underestimated the cost benefits in such venues as the United States.

This program may have achieved these benefits by delaying the progression of CHF. When compared with the year preceding the intervention, the number of hospital days in the study group remained stable, whereas that in the control group increased. Although greater use of angiotensin-converting enzyme (ACE) inhibitors in the intervention group than in the control group may have contributed to this effect (4), it is unlikely because treatment was started at various times during the follow-up year and treatment differences were small.

Despite the value of improved drug treatments, such as ACE inhibitors and statins, clinical practice must include much more than prescribing drugs. Providers must do more to increase patient knowledge and understanding to improve outcomes in these chronic cardiac conditions (5). Close and continuing follow-up is needed, and this is perhaps best done by skilled nursing staff, as in these studies.

Jeffrey K. Mills, MD, MSc
University of TorontoToronto, Ontario, Canada


References

1. Gotto AM Jr. Cholesterol management in theory and practice. Circulation. 1997; 96:4424-30.

2. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344: 1383-9.

3. Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ. 1994;309:993-6.

4. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995;273: 1450-6.

5. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med. 1984;100:258-68.