Session number: 1076
Abstract title: Interventions to Improve Beta-Blocker Utilization in Heart Failure
Author(s):
MG Shlipak -
San Francisco VAMC
MN Ansari - San Francisco VAMC
PA Heidenreich - Palo Alto VAMC
BM Massie - San Francisco VAMC
Objectives: Clinical practice guidelines are designed to translate medical research and
expert opinion into recommendations for everyday practice; however their
ability to affect clinician behavior has been limited. We evaluated
interventions for implementing a new practice guideline, which advocates
beta-blockers (BBs) for patients with heart failure (HF).
Methods: This study was a clinical trial that randomized providers at the San Francisco
VA Medical Center to one of 3 groups on 2/1/00: 1) Control: provider education
(n= 25 providers, 51 patients); 2) Alert: computerized reminders to providers
and letters advocating BBs to patients (n=24 providers, 64 patients); and
3) Nurse Management:supervised nurse practitioner to initiate and titrate BBs
with provider consent(n=25 providers, 54 patients). The primary outcome was the
proportion of pts identified as appropriate BB candidates who were initiated and
maintained on BBs after 1 year of intervention or at the study endpoint on
4/16/01. Secondary outcomes included hospitalizations and adverse events.
Inclusion criteria for pts were an ICD-9 HF diagnosis, EF=45% and clinical
evidence of HF. Exclusions included prior intolerance to BBs, BB use at target
dose, lack of primary care at the VA, HR<60, SBP<90, severe COPD, asthma,
diabetes with hypoglycemic events, and terminal comorbidities.
Results: Characteristics of providers (specialty, training level) and patients (age, EF,
HF etiology, comorbidities) were similar in the 3 intervention arms. Providers
assigned to the Nurse Management arm initiated and maintained BBs in 61% of
candidate patients compared with 29% (p<.01) in the Control group and 12%
(p<.001) in the Alert group. The Nurse Management group also had the highest
proportion of patients reaching target BB doses (43% vs. 1.5% and 10%, p<0.001
for both) compared to the Alert and Control arms. There was no difference in
adverse events (ER visits, hospitalizations, or deaths) during follow-up.
Conclusions: The use of a nurse manager was a successful and safe approach for implementing
a BB guideline in HF patients.
Impact statement: The implementation of complex treatment algorithms in the primary care setting,
such as the use of BB's in the treatment of HF, can be facilitated through the
use of specialty nurse managers.