When the results of the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) were published in February, many nurses likely found them discouraging. The multicenter, randomized trial by Jaarsma and colleagues followed 1,023 patients with heart failure for 18 months to evaluate whether a nurse-led management program altered outcomes. The conclusion: neither of the nursing interventions studied reduced rates of death and hospitalization from heart failure significantly more than usual follow-up did.
These are daunting findings, given the scope of the problem. Heart failure afflicts 5.3 million people in this country; 660,000 new cases are diagnosed annually, and 40-year-olds have a one-in-five lifetime risk of developing heart failure.
Of the COACH participants (the mean age was 71 years, and 38% were female), half had been hospitalized with mild heart failure and half with moderate-to-severe heart failure; they were randomized to one of three groups.
* The control group received standard care by a cardiologist, including an outpatient visit within two months of discharge and every six months thereafter, for a total of four scheduled visits.
* The basic support group was allotted nine outpatient visits with the nurse specialist, in addition to standard care.
* The intensive support group was scheduled for 18 outpatient visits with the nurse specialist, two home visits, and two multidisciplinary advice sessions, in addition to standard care.
Both intervention groups also received telephone calls and written materials from the nurse specialist. All groups received more care than the protocol allotted: the control group (as a whole) had 33% more visits to their cardiologist, and the basic and intensive support groups (as wholes), respectively, had 40% and 10% more visits and telephone calls than planned.
In 18 months, 42% of the controls, 41% of the basic support group, and 38% of the intensive support group had died or were hospitalized because of heart failure. The total days lost to either death or hospitalization from any cause were also comparable. The researchers found a "nonsignificant but potentially clinically relevant 15% decrease in all-cause mortality," as well as slightly more (and shorter) hospitalizations, in both intervention groups compared with controls.
Why did the nurse-led program have "no effect" on rates of death and hospitalization because of heart failure? Perhaps standard care had been better than they'd assumed, the researchers wrote, making further improvement difficult. Also, all patients received more visits than called for, which might have improved results. They said that it was unlikely that the nursing interventions simply weren't good enough, given the efforts of "specially educated and experienced workers" to develop them.
The COACH researchers say that the decrease in overall mortality rates, though not statistically significant, shows that the nursing interventions "may have been successful in preventing progression of the disease." They also concluded that the study's findings "should not lead to abandoning the concept of disease management programs for heart failure; rather, they must lead to more precise definitions of how such programs should be implemented."
That conclusion is supported by at least one recent study, in which an intervention by an NP, a physician, and a community health worker did yield marked benefits. Dennison and colleagues studied less- and more-intensive interventions among 309 underserved urban black men who had hypertension over a five-year period. (Hypertension is a leading risk factor for heart failure.) Both groups received education. The more-intensive intervention also involved NP visits every one to three months, free medication, and social services referrals. The less-intensive intervention group received a list of community resources. Both groups demonstrated "significantly improved blood pressure control," with greater benefits evident in the more-intensive group. This difference wasn't seen at the five-year point.
Martha Hill, principal investigator of the hypertension study, told AJN that the COACH was "a very rigorous project with a very high bar: the combined end point of mortality and hospitalization. Many studies have shown nurse-led programs to be effective in reducing hospitalizations and ED visits among people with heart failure. The COACH findings suggest that we would benefit from learning how to better tailor interventions."
Sylvia Foley, senior editor
NewsCAPS
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