Which Patients with Congestive Heart Failure (CHF) Benefit Most from Nurse-based Disease Management?
- Presenter:
Chair: TBA; Discussant: TBA Tue June 6, 2006 10:45-12:15 Room 225
Rationale: Several recently conducted randomized controlled trials (RCT) have demonstrated the benefits of a nurse-based disease management programs for patients with CHF. Most, although not all, trials have found that patients randomized to a nurse management program have fewer subsequent hospitalizations than patients in usual care. However, no studies have addressed whether the benefits of nurse management are limited to patients with certain clinical or socio-demographic characteristics. If this is true, administrators and policy makers may improve the cost effectiveness of nurse management by targeting patients most likely to benefit.
Objective: The objective of this paper is to reanalyze data from a successful RCT of nurse management for CHF to assess which patients benefited most from nurse-based disease management.
Methods: In the RCT, 406 patients with CHF from the four hospitals serving East and Central Harlem in New York City were randomized to nurse management (n=203) or usual care (n=203). Nurse managers gave patients information on CHF and tools designed to improve self-management, and worked with patients’ clinicians to optimize drug therapy. The outcome for this reanalysis was physical functioning as measured by the Short Form 12 (SF-12) questionnaire, which was measured at baseline and every 3 months for 1 year. We estimated the benefit of nurse management for each patient in the treatment group by estimating a random effects linear regression of SF-12 scores on time and patient characteristics at baseline for patients in the control group. We then used parameters from this model to estimate what functioning would have been for each patient in the nurse group if he/she had not received the intervention. The difference in actually and expected functioning for patients in the treatment group was then regressed on baseline patient characteristics to find characteristics of patients who benefited more than others.
Results: 406 patients provided 1693 follow-up observations. The patients were diverse in terms of age (59.4±13.7), race/ethnicity (46% black, 32% Hispanic, 15% White), education (46% < high school degree), and health literacy (28.9% inadequate). Nurse patients maintained better SF-12 functioning scores than control patients throughout the study (difference at 12 months +4.0, 95% C.I. (2.2, 5.9)). Preliminary results, suggest that Black patients (+4.1 ; p=0.021) and Hispanic (+5.9; p=0.005) benefited more than white Non-Hispanic patients. Patients age 40-59 faired better than patients age <40 (p<0.001). We found little evidence that patients with low health literacy skills, those who had been recently hospitalized, or those with more severe heart failure at baseline benefited more from nurse management.
Conclusion: Although these results are preliminary, they suggest that re-analyses of data from nurse management RCT may help to target patients with CHF who are most likely to benefit from nurse management programs.
