Subramanian U (Indianapolis Center of Excellence (COE)), Welsh D
(Ann Arbor COE), Lowery J
(Ann Arbor COE)
This quasi-experimental study evaluated the effect of a chronic heart failure (CHF) case management model run by nurse practioners (NPs) in a sample of VA medical centers to test the hypothesis that compared with patients receiving usual care, those receiving case management would have less resource utilization in terms of admissions, bed days of care, and outpatient visits.
CHF patients in 2 tertiary and 2 primary facilities were recruited to receive the NP model (intervention) CHF care. CHF patients in 1 tertiary and 1 primary facility made up the control group and received usual primary and cardiology care. Logistic regression was used to compare any and CHF-specific hospital admission, and Poisson regression models were used to compare bed days of care for those with any admission, and outpatient visits. All outcomes were measured at 1 and 2 years following enrollment. Independent variables included group status (intervention vs. control), baseline resource use one year prior to enrollment, and comorbidity count.
969 patients were enrolled (458 intervention, 511 control). Excluding deaths, sample size was 788 at 1 year following enrollment and 698 at 2 years. Control patients were 1.7 and 3.0 times as likely as intervention patients to have an admission for any reason, and for CHF respectively, within year 1. There were no significant differences between the 2 groups in year 2. Intervention patients had significantly fewer bed days of care for any admission (total N=316, ß=-0.39) in year 1. In year 2, intervention patients who had a CHF admission had more days of care (total N=54, ß=0.39). The intervention group had more outpatient visits than controls in both years (Poisson regression, ß=0.14 year 1, 0.09 year 2).
It appears that the intervention had the desired effect of reducing admissions and bed days of care in the short-term, but possibly at a cost of increased outpatient visits.
These results are consistent with results from RCTs of NP case management in highly select groups of CHF patients in tertiary facilities. This study demonstrates the potential effectiveness of the intervention in both primary and tertiary care hospitals, with a more inclusive sample of patients.