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Impact of a Nurse-Led Heart Failure Program on All-Cause Mortality

Bdeir, Bassam MD; Conboy, Tara RN, BSN, MSc; Mukhtar, Abdulmajid MD; Omer, Hafez MD; Odeh, Raed RGN, BSN; Farah, Iyad RGN, MS; Al-Khateeb, May RGN; Tayiem, Alaa RGN; Dosari, Alhanouf BSc; Al Mallah, Mouaz MD, MSc, FACC, FAHA, FESC

The Journal of Cardiovascular Nursing: March/April 2015 - Volume 30 - Issue 2 - p E7–E14
doi: 10.1097/JCN.0000000000000133
ARTICLES: ONLINE ONLY
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Background: Nurse-led heart failure programs (HFPs) have been shown to reduce readmissions and improve medication adherence rates. However, their impact on survival is not well demonstrated.

Objective: The purpose of this study was to evaluate the impact of a nurse-led HFP on all-cause mortality.

Methods: This retrospective review included 413 consecutive patients who were admitted with heart failure exacerbations in 2008 and 2009. All patients were invited to attend a nurse-led HFP; 199 (48%) patients agreed and were compared with the 214 (52%) who chose usual care. Patients were followed for all-cause mortality, which was confirmed by the national death index. Independent predictors of outcomes were identified using multivariable Cox regression.

Results: Patients followed in the HFP were younger, more often men with lower ejection fraction, blood urea nitrogen, and systolic blood pressure. After a median follow-up of 15 months (range, 6–30 months), a total of 55 patients died: 14 in the HFP group (7%) compared with 41 patients (19%) in the usual care group. Participation in the HFP was independently associated with reduction in all-cause mortality (hazard ratio, 0.4; 95% confidence interval, 0.2–0.8; P = .008).

Conclusions: Our nurse-led HFP was independently associated with improved survival among patients with decompensated heart failure. Further research is required to confirm this finding.

Bassam Bdeir, MD Consultant Cardiologist and Division Head, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Tara Conboy, RN, BSN, MSc Nurse Supervisor, Cardiovascular Disease Management Program, Cardiac Sciences, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Abdulmajid Mukhtar, MD Consultant, Adult Cardiology Division, Cardiac Sciences, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Hafez Omer, MD Consultant, Adult Cardiology Division, Cardiac Sciences, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Raed Odeh, RGN, BSN Nurse Specialist, Cardiovascular Disease Management Program, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Iyad Farah, RGN, MS Nurse Specialist, Cardiovascular Disease Management Program, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

May Al-Khateeb, RGN Nurse Specialist, Cardiovascular Disease Management Program, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Alaa Tayiem, RGN Nurse Specialist, Cardiovascular Disease Management Program, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Alhanouf Dosari, BSc Coordinator, Clinical Departments, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Mouaz Al Mallah, MD, MSc, FACC, FAHA, FESC Section Head, Advance Cardiac Imaging Disease Management Program, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

The authors have no funding or conflicts of interest to disclose.

Correspondence Bassam Bdeir, MD, Cardiac Clinics, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, National Guard Health Affairs, Department Mail Code 1413, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia (bassambdeir@yahoo.com).

Heart failure (HF) is a growing global public health problem associated with a high expenditure and significant morbidity and mortality.1,2 The incidence and prevalence of HF are increasing as the population ages and individuals survive the cardiovascular precursors of HF.2 Despite multiple effective proven therapies, HF mortality remains high. In a recent study among geriatric outpatients, 3-year survival in patients with newly diagnosed HF was 44%.3 Estimates of HF prevalence and outcome from the Gulf region are comparable with those in the West.4,5 The traditional acute care–driven healthcare model is powerless to cope with the HF epidemic, and this has led innovative approaches to manage HF such as nurse-led HF clinics and telephone-based disease management programs.6–11

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Background and Significance

The European Society of Cardiology guidelines advocate the implementation of nurse-led HF programs (HFPs) to achieve optimal management of HF.12 Although these programs have demonstrated effectiveness in improving patients’ survival, reducing hospital admissions, and enhancing the patients’ overall quality of life,9,11,13–15 the data regarding their efficacy are limited to developed countries. The Middle Eastern population is known to have a high prevalence of multiple risk factors that predispose to HF, including diabetes mellitus and hypertension.16–18 Data concentrating on acute coronary syndrome from the Gulf region have shown that cardiac patients in this region are younger and have a higher mortality compared with Western patients.19 Whereas the body of evidence about the efficacy of nurse-led HFPs in developed countries has been demonstrated, this has not been studied in the Middle East.

In this retrospective study, we report the results of the first nurse-led HFP in Saudi Arabia. The aim of this study was to identify the impact of a nurse-led HFP on all-cause mortality.

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Methods

Design and Samples

This study used data prospectively collected as part of routine clinical practice to examine the impact of a nurse-led HFP on all-cause mortality. The venue was a cardiac disease management program located in a tertiary cardiac center affiliated with a college of medicine and nursing in Riyadh, Saudi Arabia. Approval was obtained from the institutional review board and ethics committee.

Our nurse-led HFP was the first in the region. In accordance with European Society of Cardiology recommendations,12 the model used was based on available resources, local healthcare structure, patient population, and their requirements. We adapted the Swedish model, where the program is nurse directed, physician supervised.14 Nurses specifically trained in HF management provide comprehensive early follow-up after hospitalization with symptom evaluation, optimization of medical therapy, and intensive patient education as well as psychosocial support. This nurse specialist (NS) role was new to the region.

All patients admitted with HF were seen by an NS within the inpatient setting and were asked to enroll in the HFP. If patients were unwilling to enroll in the HFP, they were referred to the general cardiology clinic. This retrospective study included 413 consecutive patients admitted to cardiac units with a diagnosis of decompensated HF between January 1, 2008, and December 31, 2009. Exclusion criteria were kept to a minimum, namely, noneligibility for follow-up or discharge to a chronic care facility.

One important role of the NS within the inpatient cardiology team has been to bridge the gap between discharge and the first follow-up visit in the HFP. Patient education and discharge medication are a key focus. Any questions regarding change in management were discussed with the supervising HF physician. In addition, there was support from a multidisciplinary team composed of cardiac diabetic nurses, cardiac rehabilitation nurses, and dieticians who were consulted according to protocol.

The HFP followed an “open door” policy, and patients were encouraged to use this facility with the aim of preventing readmission in the early postdischarge period by improving symptoms, medication titration, and patient education. Frequency of visits ranged from 3 days to 3 months depending on the patients’ clinical status and their individual needs. Routine clinic visits were 30 to 45 minutes and included 3 main parts: assessment, adjustment of medical therapy, and education. Unscheduled, open-door visits were usually shorter and addressed the specific needs of that patient. Patients and their family members were provided with a contact number for the program, which was accessible during working hours.

Heart failure programs worldwide are heterogeneous, with varied healthcare professionals, components of care, and staff training.20 This nurse-led program was the first in this region and required substantial work to gain recognition within the institution and nationally. Nurse specialists are required to register with the Saudi Nursing Council, and their practice is defined, legitimized, and validated by the Hospital Authority using a job description and frequently updated scope of practice and competencies, reflecting the progressive nature of this role.

We adopted the European approach with intensive in-hospital training to develop specialist skills for nurses in relation to HF management. A major component in preparation of staff for this program included supervised “on the job training.” Nurses selected into the program had a bachelor of science in nursing degree and a minimum of 3 years of cardiac critical care experience.

The key functions of the NS in HF include patient and family education with a special emphasis on self-management, increased access to care, drug titration within protocol guidelines, and coordination of care within the multidisciplinary team.14,21,22 These functions have been reflected in our scope and standards of practice, which has enabled nurses to accurately define their role, accept responsibility, and obtain and maintain skills and competencies.

All NSs involved are graduates of an accredited in-house HF Disease Management Training Program, where they were expected to complete the following educational syllabus, courses, and workshops within 2 years: Diabetes Educator Course, Nurse Specialist Training Program, Heart Failure Management Program (online), Lipid Management Program (online), Foundation Course in Evidence-Based Health Care, Statistics Made Easy Course, Reflective Practice Workshop, Smoking Cessation Workshop, and Clinical Record and Reporting System Training (on-site). All the NSs successfully completed competencies reported in Table 1 and underwent professional development and evaluation (Table 2).

TABLE 1

TABLE 1

TABLE 2

TABLE 2

Evidence-based protocols, developed and approved by a multidisciplinary team including NSs and cardiologists, were implemented to increase the NS’s scope of practice and ensure that care provided was evidence based. The physician remained responsible for the patient14 and was accessible for all consultations.

All patients in the usual care (UC) group received conventional follow-up in the general cardiology clinic, where the treating physician determined their plan of care, including frequency of visitation.

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Measures

Variables included age, gender, race, diabetes mellitus, ejection fraction, New York Heart Association (NYHA) functional class, heart rate, systolic blood pressure, is chemic etiology, blood urea nitrogen (BUN), and sodium. All data were collected prospectively during the index hospital admission and HFP visits using a data-driven reporting system. Data used in this study were collected as part of routine patient care.

At the time of the patient visit, the history and physical clinic reports were generated. These reports were automatically sent to the electronic record. The process of reporting involved audit by the supervising physician for the history and physical examination as well as the final clinic reports. Detailed data about the postdischarge treatment of the UC group were not available.

The primary endpoint was all-cause mortality. Death was ascertained through hospital mortality records and Saudi Civil Authority database.

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Statistical Analysis

Group comparisons were conducted for baseline characteristics, comorbidities, and laboratory investigations between the 2 groups using Pearson χ2/Fischer exact test for categorical variables and Student t test for continuous variables. Continuous variables are described as mean ± standard deviation. A P value of ≤.05 was considered statistically significant. Kaplan-Maier survival curves were constructed, and the curves for the HFP and UC groups were compared using log rank testing. Univariate Cox proportional hazard regression models were used to identify univariate predictors of all-cause mortality. Then, multivariate Cox proportional hazard regression models were used to identify independent predictors of follow-up events.

Selection of variables for entry consideration was based on both univariate statistical significance and clinical judgment. Variables were chosen in a stepwise forward selection manner with entry and retention set at a significance level of .05. Variables included in the model were age, gender, race, diabetes mellitus, ejection fraction, NYHA functional class, heart rate, systolic blood pressure, ischemic etiology, BUN, and sodium. Care was given to examination of assumptions, including proportional hazards, linearity, and additively, as well as avoidance of model overfitting by maintaining events-covariate ratio of at least 5:1. Incremental and global χ2 values were reported at every step. All analyses were performed using SPSS v. 18.0 (SPSS Inc, Chicago, Illinois).

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Results

Patient Characteristics

A total of 413 patients who were admitted to the cardiac center with decompensated HF between January 1, 2008, and December 31, 2009, were enrolled. Of these, 199 (48%) agreed to be followed up in the nurse-led HFP group. The remaining 214 (52%) who refused (UC group) were followed up by general cardiology.

Baseline characteristics for both groups are shown in Table 3. Patients in the HFP group were younger and more likely to be men. They had a lower left ventricular ejection fraction, BUN, and systolic blood pressure. There were no significant differences in the prevalence of hypertension, diabetes mellitus, and ischemic cardiomyopathy or in the NYHA functional class. The HFP patients were more likely to be discharged on β-blocker (BB) and angiotensin-converting enzyme inhibitors (ACEIs).

TABLE 3

TABLE 3

After a median follow-up of 15 months (range, 6–30 months), 55 patients died: 14 (7%) from the HFP group compared with 41 (19%) from the UC group. Kaplan-Meier survival curves are shown in Figure 1 and demonstrate an early and sustained decrease in all-cause mortality among the nurse-led HFP patients (P < .0001).

FIGURE 1

FIGURE 1

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Univariate Predictors of Death

The univariate predictors of mortality identified using univariate Cox proportional hazard analysis are shown in Table 4. Age, systolic blood pressure, NYHA functional class, BUN, sodium, taking prescribed ACEI and BB, and being followed up in the HFP were identified as predictors of all-cause mortality.

TABLE 4

TABLE 4

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Independent Predicators of Survival

Using multivariate Cox proportional analysis, we constructed multiple nested models for the prediction of all-cause mortality. The initial clinical model, which included age, gender, race, diabetes, ejection fraction, NYHA class, heart rate, systolic blood pressure, ischemic etiology, BUN, and sodium yielded a model global χ2 score of 56 (Figure 2). Adding BB and ACEI to the model added incremental prognostic value (model global χ2 score increased to 90; P < .0001). Participation in the nurse-led HFP added further incremental prognostic value and improved the χ2 value to 95.4, which was highly statistically significant (P < .0001). The final independent predictors of all-cause mortality in this cohort are shown in Table 5. Participation in the HFP was independently associated with a 2.5-fold reduction in all-cause mortality (hazard ratio, 0.4; 95% confidence interval, 0.2–0.8; P = .008).

TABLE 5

TABLE 5

FIGURE 2

FIGURE 2

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Discussion

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.

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Limitations

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

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Conclusions and Implications

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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What’s New and Important

  • This model of nurse-led HF care is associated with reduced mortality in Saudi patients with HF.
  • The active role of the inpatient NS in a nurse-led HFP is associated with enhanced prescriber adherence.
  • Challenges associated with attending clinic, which included distance to travel, heavy traffic, and difficulties in hospital parking, were identified as factors that led to a 29% dropout. This finding emphasizes the need for further research into the applicability of telephone-based follow-up in the Saudi population.
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Keywords:

disease management; heart failure; medication adherence; mortality; nurse-led clinics; nursing

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