This is the first study to evaluate the impact of a nurse-led HFP in the Middle East. Our study found that there was a 2.5-fold decrease in mortality in the HFP group compared with the UC group over a median of 15 months.
Our findings are comparable with those of previous studies evaluating the impact of nurse-led HF interventions on mortality.6,9,23–25 These studies demonstrated mortality reductions of 16% to 36%. Several studies found no difference in mortality between UC and nurse-led follow-up.26–30 The authors in these studies noted several limitations. Jaarsma et al,27 in their randomized controlled trial of 1023 patients in 17 centers over 18 months, showed no benefit. All groups had more visits than planned, potentially explaining the negative outcome. Access to cardiology visits in the study setting sharply contrasts with real-world practice, whereby timely appointments with cardiologists are frequently not available.
Often, studies are criticized for their selectivity and small sample sizes, thus not reflecting the HF population. We tried to replicate a real sample as we enrolled 87% of patients admitted with HF and the flexible selection criteria used ensured a realistic picture of Saudi patients. Both patient groups had equal and free access to care as clinic visits, medications, and hospitalization. This reduced bias in regard to choice of follow-up. Conversely, most studies with negative outcomes have small sample sizes of 200 or less,26,28–30 which may explain their inability to detect a difference.
The percentage of women in the total population of our study was low (33%), consistent with other HF studies.6,9,23,24,27 Although the average age was younger than reported in previous studies, the rate of comorbidities was higher. For example, in the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH),27 26% to 30% of patients had diabetes, compared with 63% in our study. Comorbidity impacts both clinical management and patient self-care, increasing risk of readmission, symptom burden, and mortality.31–33 The high incidence of diabetes in our population, combined with our focus on managing the patient not just the disease, guided us to incorporate diabetes management in the NS training program providing comprehensive care.
Globally, HFP settings are diverse and have been adapted to local healthcare environments.22,34,35 In our center, the NS spends, on average, a total of 90 minutes per patient with HF during their hospitalization. Ledwidge and colleagues36 demonstrated the clinical and cost-benefit value of a specialist HF nurse within a multidiscipline team and noted the importance of direct inpatient contact time of 85 minutes per patient. This sharply contrasts with most studies, including the COACH,27 where patients were randomized at the time of discharge and few details were provided regarding the impatient component of care. The intrinsic benefit of enrolling patients during the inpatient phase adds clinical and psychological benefit and should be a mandatory component of care.22,37
Despite efforts from the American Heart Association, American College of Cardiology, and Heart Failure Society of America to “Get With the Guidelines,” studies such as the EuroHeart Failure Survey38 continue to demonstrate poor prescriber adherence of evidence-based HF therapies. Our study demonstrated improved prescriber adherence at the time of discharge (Table 3). More patients in the HFP group received ACEI or angiotensin receptor blocker (97% vs 88%; P = .0001) and BB therapy (90% vs 79%; P = .002) as compared with the UC group. This can be attributed to the fact that patients were enrolled into the HFP while still in the hospital, with NS assuming their care at that point. This inpatient phase is a critical component in our model of care and other successful programs,39 as the role of the NS is focused intensively on the predischarge education including adoption of evidenced-based HF medical therapy. This contrasts with the COACH,27 which had lower prescription rates of ACEI or angiotensin receptor blocker (≤85%) and BB (≤70%).
Finally, electronic data collection and reporting systems are an essential component of contemporary HFPs. These systems facilitate continuous assessment, audit, and intensify staff adherence to evidence-based guidelines and recommendations.12,21,40 For example, in our program, the NS must provide reason(s) why a given patient is not following evidence-based therapy. Clinic protocols and performance indicators41 are embedded in the reporting system and periodic reports provide summaries for audit.
Although this is the first study to support the hypothesis that a nurse-led HFP in Saudi Arabia is effective, 1 major limitation is that the study is retrospective and patients were not randomized. In addition, the sample size was small, a single center venue was used, and there were significant differences in baseline patient characteristics.
At the time of the study, those refusing enrolment in the HFP did not receive any inpatient education from the NS, which may have influenced prescriber adherence to evidence-based medications and improved outcomes. After this study, additional staff were allocated to ensure that all patients admitted with HF are seen by the NS.
We did not have detailed medication and serial follow-up data on the UC group, thereby limiting our outcome comparison of both groups only to mortality. We failed to measure any biomarkers such as brain natriuretic peptide and troponin levels, both of which have documented prognostic value in this patient population.
The 29% dropout rate in the HFP group may have influenced the reported outcomes. One major factor contributing to dropout related to travel distance, heavy traffic, and difficulties in hospital parking. This problem could be overcome by a telephone-based follow-up system, the efficacy of which has been questioned.22,28
This study enhances our understanding of patients with HF in Saudi Arabia and provides the first evidence supporting the hypothesis that a nurse-led HFP reduces all-cause mortality. The highly varied implementation, populations, and settings of HFPs challenged the authors in finding appropriate comparison studies, further stressing the need for future prospective, randomized regional research on this model of care.
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