Randomised controlled trial of specialist nurse intervention in heart failure

Blue, Lynda; Lang, Elanor; McMurray, John J.V.; Davie, Andrew; McDonagh, Theresa A.; Murdoch, David R.; Petrie, Mark C.; Connolly, Eugene; Norrie, John; Round, Caroline E; Ford, Ian; Morrison, Caroline

doi:10.1136/bmj.323.7315.715

Cited by 485 publications

(425 citation statements)

References 10 publications

(18 reference statements)

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“…Many of the programs which have shown improvements in patient outcomes have required substantial investments in multi-disciplinary staff time which may prove to be unsustainable and infeasible in practices withlimited resources (Naylor, Brooten, & Jones, 1994;Rich, Beckham, & Wittenberg, 1995;Foranow et al, 1997;Hunt et al, 2002). Newer, less cumbersome programs involving nurse or pharmacist management have shown decreases in hospitalizations and improved quality of life (Blue et al, 2001;Krumholz et al, 2002;Varma, McElnay, Hughes, Passmore, & Varma, 1999;West et al, 1997), but withthe exception of one study (Stewart & Horowitz, 2002), there has been no clear improvement in survival. The modest success of interventions points to the need for a fundamental reexamination of how CHF patients understand and manage their physical conditions.…”

Section: Introductionmentioning

confidence: 99%

A story of maladies, misconceptions and mishaps: effective management of heart failure

Horowitz¹,

Rein²,

Leventhal³

2004

Social Science & Medicine

240

283

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Congestive heart failure (CHF) is a common chronic disease with effective therapy, yet interventions to improve outcomes have met with limited success. Though problems in selfmanagement are suspected causes for deterioration, few efforts have been made to understand how self-management could be improved to enhance the lives of affected patients. We conducted semistructured interviews of 19 patients with CHF treated at an urban United States hospital to elucidate their knowledge and beliefs about CHF and to understand what underlies their self-care routines. A comparison of the themes generated from these interviews with the common-sense model for self-management of illness threats, clarifies how patients' perceptions and understanding of CHF affected their behaviors. Patients had an acute model of CHF. They did not connect chronic symptoms with a chronic disease, CHF, and did not recognize that these symptoms worsened over time from their baseline of moderate, chronic distress, to a severe state that required urgent care. As a consequence, they often did not manage symptoms on a routine basis and did not, therefore, prevent or minimize exacerbations. When they worsened, many patients reported barriers to reaching their physicians and most reported seeking care primarily in an emergency room.These in depth responses elucidate how the interplay between acute and chronic models of a chronic illness effect self-management behaviors. These factors play a previously not understood role in patient's efforts to understand and manage the ever-present but symptomatically variable chronic illness that is CHF. These new concepts illustrate the tools that may be needed to effectively manage this serious and disabling illness, and suggest possible ways to enhance the self-management process and ultimately improve patients' lives.

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Section: Introductionmentioning

confidence: 99%

A story of maladies, misconceptions and mishaps: effective management of heart failure

Horowitz¹,

Rein²,

Leventhal³

2004

Social Science & Medicine

240

283

View full text Add to dashboard Cite

show abstract

“…In seven studies, a reduction in the readmission rate, irrespective of cause [1,2,[7][8][9]11,13] was observed, and a reduction of readmissions for heart failure was demonstrated in five studies [1,4,6,11,12]. A statistically significant decrease in the number of days spent in hospital was reported in five studies [1,4,7,8,14].…”

Section: Randomised Studies Of Heart Failure Management Programmesmentioning

confidence: 90%

“…Five studies showed a statistically significant reduction in the combined endpoint of readmissions and/or mortality, irrespective of the reason [5,[7][8][9]14], and two studies reported a statistically significant reduction in the combined endpoint of readmission rates for heart failure and/or death [11,12].…”

Section: Randomised Studies Of Heart Failure Management Programmesmentioning

confidence: 95%

“…Since this publication, many more relevant publications of randomised controlled trials have been reported. In Table 1, the characteristics of most of these trials are reported [1,[3][4][5][6][7][8][9][10][11][12][13][14][16][17][18][19][20][21][22][23]. All trials are designed as prospective, randomised, controlled trials, thus minimising the possibility of bias.…”

Section: Randomised Studies Of Heart Failure Management Programmesmentioning

confidence: 99%

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Heart failure programmes in countries with a primary care‐based health care system. Are additional trials necessary? Design of the DEAL‐HF study

Porte

Lok

Wijngaarden

et al. 2005

European J of Heart Fail

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Background: Several randomised studies of heart failure (HF) management programmes in the United States, Australia and Europe have shown a considerable reduction in hospitalisation rates for HF. In this article, a comprehensive review of these studies will be provided and their applicability to countries, with a primary care-based healthcare system, will be discussed. In addition, the design of the DeventerAlkmaar HF Project (DEAL-HF), a randomised study of the effect of a nurse and physician-directed intervention over 1 year in The Netherlands, will also be presented. Aim: To discuss the applicability of the results of available studies on heart failure management programmes to countries with well-structured primary care facilities and to determine whether additional trials should be conducted in these countries. Methods: We performed a literature search in PubMed. In a review of the available studies, essential methodological aspects, in particular, the population involved, the sample size, follow-up period, setting, type of intervention, and the outcome parameters, are discussed critically. Also, the applicability of these studies to countries with a primary care-based healthcare system and easy access to medical care is evaluated. Conclusion: Applicability of the results of the available studies on the efficacy of heart failure management programmes to countries with a primary care-based health care system is doubtful. An efficacy trial in a country with a well-established primary care-based healthcare system, such as The Netherlands, is due to report soon (DEAL-HF).

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“…Further, nurses are the health professionals most closely involved, according to the meta‐review of 15 meta‐analyses by Savard et al 9 A considerable number of these meta‐analyses mentioned dose titration by HF nurses. In the clinical trials included, nurses titrated ACEIs, ARBs, BBs, K, diuretics, MRAs, and digoxin,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 assessed the dose reached,13, 14, 19, 20 and initiated treatment following a protocol 10, 12, 14, 15, 17. Hardly any similar research has been conducted in Spain.…”

Section: Introductionmentioning

confidence: 99%

Design of a multicentre randomized controlled trial to assess the safety and efficacy of dose titration by specialized nurses in patients with heart failure. ETIFIC study protocol

et al. 2017

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AimsHeart failure (HF) is associated with many hospital admissions and relatively high mortality, rates decreasing with administration of beta‐blockers (BBs), angiotensin‐converting‐enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists. The effect is dose dependent, suboptimal doses being common in clinical practice. The 2012 European guidelines recommend close monitoring and dose titration by HF nurses. Our main aim is to compare BB doses achieved by patients after 4 months in intervention (HF nurse‐managed) and control (cardiologist‐managed) groups. Secondary aims include comparing doses of the other aforementioned drugs achieved after 4 months, adverse events, and outcomes at 6 months in the two groups.MethodsWe have designed a multicentre (20 hospitals) non‐inferiority randomized controlled trial, including patients with new‐onset HF, left ventricular ejection fraction ≤40%, and New York Heart Association class II–III, with no contraindications to BBs. We will also conduct qualitative analysis to explore potential barriers to and facilitators of dose titration by HF nurses. In the intervention group, HF nurses will implement titration as prescribed by cardiologists, following a protocol. In controls, cardiologists will both prescribe and titrate doses. The study variables are doses of each of the drugs after 4 months relative to the target dose (%), New York Heart Association class, left ventricular ejection fraction, N‐terminal pro B‐type natriuretic peptide levels, 6 min walk distance, comorbidities, renal function, readmissions, mortality, quality of life, and psychosocial characteristics.ConclusionsThe trial seeks to assess whether titration by HF nurses of drugs recommended in practice guidelines is safe and not inferior to direct management by cardiologists. The results could have an impact on clinical practice.

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Randomised controlled trial of specialist nurse intervention in heart failure

Cited by 485 publications

References 10 publications

A story of maladies, misconceptions and mishaps: effective management of heart failure

A story of maladies, misconceptions and mishaps: effective management of heart failure

Heart failure programmes in countries with a primary care‐based health care system. Are additional trials necessary? Design of the DEAL‐HF study

Design of a multicentre randomized controlled trial to assess the safety and efficacy of dose titration by specialized nurses in patients with heart failure. ETIFIC study protocol

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