Evaluation of a Nurse Case Management Model for Chronic Heart Failure
Evaluation of a Nurse Case Management Model for Chronic Heart Failure
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.
BACKGROUND / RATIONALE:

 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.

 OBJECTIVE(S):

 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.

 METHODS:

 Patients with CHF will be identified by review of admission/discharge logs, review of clinic
 schedules, and referrals from medical personnel. All patients 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.

 STATUS:

 All two-year follow-up questionnaires have been received and entered. Medical record
 abstraction, which includes data on severity of disease, will continue through Dec 2007. All
 interviews with medical center staff have been conducted, transcribed, and coded. We are in
 the process of pulling one-year prior and one and two-year post data on comorbidities and
 resource utilization. Analysis of survey, medical record, interview, and secondary data will
 continue through spring of 2008, when the final report will be written.
Inclusion Criteria:

 -  Patient receives all cardiology care at a VISN 11 VAMC.

 -  Must have chronic heart failure (CHF) secondary to systolic or diastolic dysfunction,
 as defined by meeting (1) or (2) below:

 1. Systolic Dysfunction, defined by a history or documentation of LVEF = 40% (or
 fractional shortening = 20%-if LVEF not documented)

 AND at least ONE of the following:

 -  Current diagnosis or history of CHF and/or

 -  Physical findings and/or symptoms of CHF within two months of enrollment
 and/or

 -  Hospitalization for CHF within 12 months OR

 2. Diastolic Dysfunction, defined by a history of documentation of LVEF > 40% (or
 fractional shortening > 20% if LVEF not documented) AND Physical findings and/or
 symptoms of CHF within two months of enrollment.

 Exclusion Criteria:

 Based on medical record data, patient does not have any co-morbidity other than CHF which,
 in the opinion of the investigator, limits life expectancy to less than six months (e.g.,
 metastatic CA, hospice care, renal failure with a creatinine above 5.0 mg/dL or on
 dialysis, HIV).