Heart Failure: Increasing Role of Advanced Practice Nurses in Heart Failure Management

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September 21, 2007 By Grendel Burrell [1]

Washington, DC: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a validated, disease specific quality of life instrument which is easy to administer, sensitive to clinical change (a 5 point change is clinically significant), prognostically important, and can identify high-risk patients (1,2).

The economic burden of heart failure (HF) on the US health care system is well recognized and large (AHA 2007 Heart and Stroke Statistical Update), and HF management programs reduce hospital readmissions, lower costs, and improve functional status compared to conventional care (3,4,5). A group of nurses and physicians described their efforts to evaluate the KCCQ as a tool for quantifying the impact of an Advanced Practice Nurses (APN) led clinic of patients’ outcomes in a “real world” HF population in the Kansas City area at HFSA 2007 in Washington, DC

The poster presentation by Felicia Menefee, RC, BC, ANP, John Spertus, MD, MPH, et al attempted to quantify the benefits of this management program overseen by Advanced Practice Nurses. 124 patients with NYHA class II-IV newly referred to a large private cardiology practice were included. Data was collected retrospectively through a review of the patients’ medical records. Demographics, coexisting conditions, LVEF, type of cardiomyopathy, baseline meds, and utilization of devices were all collected. KCCQ was used to assess health status at the initial visit and at three moths. Change in HF health status between baseline and 3-minth follow up was assessed. The Student’s t-test was utilized to compare KCCQ scores, and a multivariable linear regression analysis was performed to evaluate predictors of change in KCCQ scores.

At the initial visit, 89% of patients were taking beta-blockers, 69% were on ACE inhibitors, 66% were taking a diuretic, and 11% were taking hydralazine. 31% of patients were taking an aldosterone inhibitor, 19% on ARB, and 28% of patients were on digoxin. 13% of patients were prescribed nitrates. 57% of patients had a diagnosis of ischemic cardiomyopathy. 72% of patients had hypertension and 81% were dyslipidemic. 37% of patients were diabetic with <20% having COPD. 18% of patients had an ICD, and 19% had a CRT-D device at the baseline visit.

At baseline, only 8.9% of patients were assessed to have poor to very poor HF health by the KCCQ score (0-25). 26.6% of patients had moderate to poor HF health, while 34.7% scored in the range of moderate to good HF health. 29.8% of patients scored in the good to excellent HF health (>75-100) range.

Over the three-month period of care in the heart failure clinic managed by Advanced Practice Nurses, 35% of patients had a moderate to large improvement in KCCQ scores. 15% of patients experienced a small to moderate improvement. The mean KCCQ scores improved from 60.6 +/- 23.6 to 67.4 +/-23.8 (p<0.0005). 50% of patients improved more than 5 points on the KCCQ overall summary score, a clinically significant improvement over the 3-month follow up period. Lower KCCQW score at the initial visit was an important predictor of improvement with a mean 3.4+/- 0.7 point improvement for every ten points of lower baseline KCCQ score.

Study results are limited by the small sample size at a single center, and the possibilities of caretakers influencing responses cannot be excluded. Finally the study did not determine which component of the APN HF clinic had the greatest impact on the improvements.

Throughout the HFSA 2007 meeting, attendees commented on the need to find creative solutions to the management of the burgeoning numbers of HF patients. Patients with numerous drugs and resynchronization and/or ICD devices require multidisciplinary approaches, coordinated care and visits, and excellent communication between patients, families, and caregivers. The model presented by Menefee et al may provide one approach to improving care of these complex patients.

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