Inpatient initiation of beta-blockade plus nurse management in vulnerable heart failure patients: a randomized study.

BACKGROUND: Predischarge beta-blocker initiation in hospitalized patients with heart failure due to reduced left ventricular ejection fraction (LVEF) is safe and improves adherence; improved outcomes with this approach have not been demonstrated in a randomized trial. This study compared 6-month rehospitalization rates among patients assigned to predischarge beta-blockade coupled with postdischarge nurse management (intervention) versus usual care. METHODS AND RESULTS: We randomized 64 patients with an LVEF

Comprehensive coronary artery disease care in a safety-net hospital: results of Get With The Guidelines quality improvement initiative.

BACKGROUND: Adherence to published coronary artery disease (CAD) guidelines is suboptimal, particularly among minorities and the poor. While hospital-based quality-improvement programs may increase the use of evidence-based therapies, little data exist regarding the impact of such programs in sociodemographically disadvantaged (vulnerable) populations. Vulnerable patients in the United States are cared for primarily within the safety-net health system, which comprises urban public hospitals and outpatient community health centers. Denver Health is an example of an integrated system that encompasses both types of facilities. OBJECTIVE: To assess evidence-based medication use in CAD patients after initiation of an inpatient quality-improvement program at Denver Health. METHODS: We reviewed the medical records of 499 patients with angiographically proven CAD who were hospitalized between July 1998 and December 2002. Patients were prospectively identified through a multidisciplinary intervention led by a nurse manager, and their records were input retrospectively into the American Heart Association's Get With The Guidelines patient management tool. The association's program, which recommends initiating 4 cardioprotective drug classes while patients are hospitalized, was started 2 years into the observation period (August 2000). Treatment rates were compared over the ensuing years. We evaluated temporal trends in discharge use of 4 drugs: (1) betablockers, (2) angiotensin-converting enzyme inhibitors (ACEIs), (3) hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), and (4) aspirin. We calculated the proportion of eligible patients (no documented contraindication) who were prescribed each drug category as well as the proportion who received all 4 drug categories, our principal composite outcome. If any one drug was absent, the composite criterion was considered unmet. RESULTS: We observed progressive improvement in discharge use of the 4- drug composite: 18% in 1998-1999 (95% confidence interval [CI], 12%-25%), 50% in 2000 (95% CI, 37%-63%), 62% (95% CI, 54%-70%) in 2001, and 72% (65%-79%) in 2002 (P <0.001 for between-year differences). Among eligible patients discharged in 2002, 90% received beta-blockers, 91% received ACEIs, 86% received statins, and 93% received aspirin. CONCLUSIONS: Implementation of a multidisciplinary program led by a nurse manager was associated with increased CAD guideline compliance among sociodemographically disadvantaged patients. This compliance exceeded national averages. Achievement of the composite measure of use of all 4 recommended drug categories at discharge improved from 18% in 1998-1999 to 72% in 2002.

Impact of a cardiac risk reduction program in vulnerable patients hospitalized with coronary artery disease.

STUDY OBJECTIVE: To increase the use of guideline-based pharmacotherapy in vulnerable patients (ethnic minorities and the poor) with coronary artery disease (CAD) through a nurse-based quality-improvement program. DESIGN: Retrospective program evaluation. SETTING: Inner-city hospital in Denver, Colorado. PATIENTS: One hundred fifty-one consecutive patients hospitalized with a CAD-related diagnosis. INTERVENTION: A nurse-management program was initiated for patients with angiographically documented CAD, and rates of guideline-based care were compared with rates for historic controls. The intervention consisted of two key elements: patient counseling with language-appropriate education materials and direct physician education regarding the importance of cardioprotective drugs. The 151 patients in the intervention group were compared with 125 historic control patients hospitalized before the program was begun. Multivariable logistic regression analysis was used to assess differences in care with regard to ethnicity, education level, and insurance status, and to adjust for different baseline characteristics. MEASUREMENTS AND MAIN RESULTS: At hospital discharge, patients in the intervention group were more likely to receive statins (71% vs 52%, p=0.001) and angiotensin-converting enzyme inhibitors (79% vs 51%, p<0.001) compared with controls. These differences remained after adjusting for ethnicity, education level, insurance status, and baseline clinical characteristics. Also, a trend was noted toward greater use of aspirin (92% vs 86%, p=0.13) and beta-blockers (79% vs 73%, p=0.24) in the intervention group compared with controls. Patients in the intervention group were more likely to receive counseling for smoking cessation. CONCLUSION: An inpatient nurse-management program improved the quality of care for patients with CAD regardless of sociodemographic status. Properly designed disease-management initiatives can be effective for disadvantaged patients, who often obtain health care through emergency and inpatient services.