Telephone follow-up does not reduce rehospitalization for low-risk heart failure patients

October 18, 2004

STANFORD, Calif. - Nurse care management - a widely used system of telephone-based health instruction and follow-up designed to help patients manage their illnesses - did not lower rehospitalization rates in clinically low-risk heart failure patients, according to a new study by researchers at the Stanford University School of Medicine.

The findings, which appear in the Oct. 19 issue of Annals of Internal Medicine, are at odds with past studies that show substantial benefits to specialized care management. The authors suggest that nurse care management does not measurably improve the health of clinically low-risk heart failure patients who, like the ones in this study, are receiving comprehensive health care.

"Nurse care management holds tremendous promise for patients at higher risk or those not receiving comprehensive care, but that doesn't mean it's universally effective," said Robert F. DeBusk, MD, professor of medicine (cardiovascular medicine) and lead author of the study.

Heart failure is the leading cause of hospitalization in people age 65 or older. It is a chronic ailment in which the heart loses some of its pumping capacity, though it may keep beating normally. It differs from heart attack, in which blood flow to the heart muscle itself is restricted.

DeBusk and his team studied 462 patients receiving treatment for heart failure at five Kaiser Permanente hospitals in the San Francisco Bay area. Half of the participants received nurse care management. Nurses at Stanford phoned these patients 16 times during the yearlong study to instruct them about their condition and check that they were taking the appropriate medications. All participants received the usual follow-up care provided by their own doctor.

"The idea is that if you give patients information on how to manage their illness, they will do it," said DeBusk. That's what previous studies of nurse care management conducted by DeBusk's team have shown.

But DeBusk's latest results reveal something different: half of the patients were rehospitalized, whether they received nurse care management or not. Only one-third of rehospitalizations were for treatment of heart failure; the majority was for treatment of coronary artery disease.

DeBusk, founder and director of the Stanford Cardiac Rehabilitation Program, offered two likely reasons why these findings depart from past work: differences in patients' baseline risk and differences in overall health care they received.

Other investigators evaluated patients with more advanced heart failure. As many as 90 percent of these patients were rated Class 3 or 4 - the two highest risk levels - on the New York Heart Association severity scale. Many had been hospitalized multiple times for heart failure. In contrast, only half of the patients in DeBusk's most recent study was rated as Class 3 or 4 and only 61 percent had been hospitalized previously for heart failure.

But DeBusk believes a second, more important reason is that his study enrolled patients who were already receiving good overall care from the Kaiser Permanente Medical Care Program. More than 90 percent of Kaiser patients in both study samples received medications recommended by national guidelines.

"We were dealing with a ceiling effect," said DeBusk. "It's hard to improve on excellent care."

He added, "The lesson is that nurse care management works best for high-risk patients."

DeBusk noted that there continues to be good reason for insurers to support nurse care management, especially for older patients, those with more severe symptoms or patients with inadequate social support.

The Stanford-Kaiser collaboration was novel. DeBusk's team of nurse care managers worked directly with Kaiser physicians, by telephone, to coordinate follow-up care in each of the participating hospitals. That makes the study's results more applicable to real-world health care, said DeBusk.

The Stanford Cardiac Rehabilitation Program has collaborated with Kaiser Permanente for more than 20 years. DeBusk said it had been a fruitful relationship. "We jointly developed the basis for this program, which was adopted by Kaiser Permanente and is still operational today," he said.
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