Despite established clinical practice guidelines, wide variations exist in the care of chronic heart failure (CHF) patients in Veterans Health Administration. Previous randomized, controlled studies have suggested that a nurse case management model may improve the outcomes of care for patients with CHF. However, these studies involved selected groups of patients (i.e., those who agreed to participate in randomized trials) in selected settings (i.e., tertiary care facilities); so, the findings are not likely to be indicative of the true effectiveness of case management in a large population of CHF patients.
This study will evaluate the impact of a nurse practitioner case management model compared with usual care in patients with congestive heart failure (CHF). Outcomes include health-related quality of life, patient satisfaction, compliance with medication guidelines, mortality, readmissions, bed days of care, outpatient visits, emergency room visits, and pharmacy costs.
All patients who are hospitalized with a primary diagnosis of CHF during months 4 through 15 of the study in the northern half of VISN 11 (Ann Arbor, Detroit, Saginaw, and Battle Creek) will participate in a case management program, in which they will receive care from nurse practitioners who will be supported by practice guidelines, treatment algorithms, and guidance from cardiologists at the VA Ann Arbor Health Care System. Patients in the southern half of the VISN (Indianapolis and Danville) will make up the comparison group and will receive usual care for CHF patients.
All study participants will complete baseline and one and two year follow-up questionnaires on health related quality of life, including the SF-36V and the Minnesota Living With Heart Failure Questionnaire. Patient satisfaction will be assessed using the VA National Ambulatory Care Survey. Additional data on the use of health care resources over the two years following each patient’s index hospitalization will be collected from the Patient Treatment File (PTF) and the Outpatient Census (OPC) File. Data on compliance with medication guidelines will be obtained from the VISN 11 pharmacy database. Multivariate analyses will be used, with the main study outcomes as dependent variables and intervention vs. comparison group membership as independent variables, controlling for baseline differences between intervention and comparison groups. Additional analyses will compare the study outcomes for patients served by primary versus tertiary sites.
Semi-structured interviews will be conducted with participating providers at the beginning, middle, and end of the study, to determine satisfaction with the program, as well as specific components that were perceived to help or hinder its effectiveness.
Patient enrollment for this quasi-experimental study ended February 9, 2004, with a total of 969 enrolled, including 459 in the intervention group (VAMCs with nurse case management in the northern part of VISN 11) and 510 in the control group (VAMCs without nurse case management in the southern part of VISN 11).
The last of the two-year follow-up surveys were distributed in February 2006, with follow-up of non-respondents completed in spring 2006. Data analysis should be completed by fall 2007.
Sample size was 782 at 1-year following enrollment (after excluding deaths) and 692 at 2 years. Using logistic regression, control patients were 1.9 and 3.2 times (p<0.05) as likely as intervention patients to have an admission for any reason and for an admission for CHF (respectively) within year 1. There were no significant differences between the 2 groups in year 2.
Using Poisson regression to analyze bed days of care for patients with admissions, intervention patients had significantly fewer bed days of care for any admission (total N=322, B=0.40) in year 1. In year 2 intervention patients who had a CHF admission had more days of care (total N=55, B=0.29). The intervention group had more outpatient visits than the control group in both years (Poisson regression, B=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 use of outpatient visits. These results are consistent with results from RCTs of NP case management in highly select groups of CHF patients in tertiary facilities. However, this study demonstrates potential effectiveness of the intervention in both primary and tertiary care hospitals, with a more inclusive sample of patients.
The study will evaluate whether a nurse practitioner case management model implemented for all CHF patients in a network of VA medical centers, including both tertiary and primary care facilities, improves health outcomes and reduces resource utilization.
- Subramanian U, Hopp F, Mitchinson A, Lowery J. Impact of provider self-management education, patient self-efficacy, and health status on patient adherence in heart failure in a Veterans Administration population. Congestive Heart Failure (Greenwich, Conn.). 2008 Jan 1; 14(1):6-11.
- Subramanian U, Sutherland J, Hopp F, Lowery J, Doebbeling B. Patient self-efficacy, provider self-management counseling and health status among patients with chronic heart failure. Journal of general internal medicine. 2005 Oct 1; 20(Supplement 1):70.
- Subramanian U, Weinberger M, Fihn SD, Tierney WM. Diagnostic challenges defining heart failure when using echocardiograms. The American journal of cardiology. 2003 Apr 15; 91(8):1015-7, A8.
- Subramanian U, Weinberger M, Eckert GJ, L'Italien GJ, Lapuerta P, Tierney W. Geographic variation in health care utilization and outcomes in veterans with acute myocardial infarction. Journal of general internal medicine. 2002 Aug 1; 17(8):604-11.
- Subramanian, Welsh, Lowery JC. Effect of nurse practitioner CHF case management on resource utilization. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 19; Pittsburgh, PA.
- Subramanian, Welsh, Lowery. Effect of Nurse Practitioner CHF Case Management on Resource Utilization. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
- Lowery JC, Stemmer KS, Zak CK, Welsh DW. Effect of nurse practitioner CHF case management on resource utilization. Poster session presented at: Heart Failure Society of America Annual Scientific Meeting; 2007 Sep 17; Washington, DC.
- Subramanian U, Sutherland J, Lowery J, Doebbeling BN. Patient self-efficacy, provider self-management counseling and health status among patient with chronic heart failure. Paper presented at: Society of General Internal Medicine Annual Meeting; 2005 May 1; New Orleans, LA.
- Hopp F, Chan P, Vaitkevicius P, Subramanian U, Lowery J. Veterans with Heart Failure: The Relationship Between CHF Symptoms and Depression. Paper presented at: American Geriatrics Society Annual Meeting; 2004 Mar 18; Las Vegas, NV.
- Subramanian U, Hopp FP, Austin K, Kim HM, Lowery J. Development of a case-mix adjustment model for CHF patients. Paper presented at: Society of General Internal Medicine Midwest Regional Annual Meeting; 2003 Sep 19; Chicago, IL.