Randomised controlled trial of specialist nurse intervention in heart failure
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7315.715 (Published 29 September 2001) Cite this as: BMJ 2001;323:715
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Sir,
Blue and colleagues (1) state that specialist nursing intervention reduces
the rate of readmission to hospital in patients with chronic heart
failure. Although we accept this conclusion from the data presented,
there are several points we feel should be raised.
Firstly, we note that both primary and secondary end-points include
death from all causes. We agree that these are valid end-points.
However, given that this was a heart failure study, we wondered why
specific heart failure mortality was not included as a primary end-point.
Failing this, did the authors consider discussing the inclusion of
definite non-cardiac deaths, and would their exclusion have increased the
accuracy of this study?
Another primary end-point was hospital readmission for heart failure,
emergency or elective. The intervention offered involved increased
patient contact and patient education. Given this, it might be expected
that patients in the intervention group would have been better able to
recognise deterioration in their health early enough to anticipate the
need for admission. A higher rate of elective over emergency admissions
might therefore have been achieved. Assuming that elective admissions are
preferable to emergency ones, it would have been interesting to see an
analysis of whether this difference was in fact achieved. If it was, it
may lend weight to any conclusions concerning the benefits of repeated
nursing intervention.
Thirdly, we suggest that hospital readmission alone is not a
sufficient indicator of improved outcome from the patients’ perspective.
We feel that an assessment of quality of life between the two groups in
the study would have been a relevant and useful measure.
Finally, the authors refer to a similar study conducted by Stewart
et.al (2), with the similar finding that nursing intervention reduced
hospital readmission. The studies differ in that the work described by
Stewart et.al concerned a single intervention with a six month follow-up,
while Blue and colleagues’ work is based on repeated interventions over a
period of one year. Blue and colleagues have demonstrated that the
beneficial effect of nursing intervention may be extended to one year.
However, there is no comparison of results from the two studies from which
to draw the conclusion that repeated interventions confer any greater
benefit in terms of readmission. Given that repeated interventions over a
year would inevitably be more expensive, such a comparison would be
necessary in making a case for longer-term nurse intervention when
assessing cost-effectiveness of service delivery. Such a comparison would
also be necessary in justifying the adoption of any therapeutic strategy
in the present climate of evidence based medicine.
Ewan Hunter, Yenandeenee Desha, Jennifer Pond and Stephanie How Yaw
4th year medical students
Department of Epidemiology and Public Health, The Medical School,
University of Newcastle-upon-Tyne, Newcastle NE2 4HH, UK
1 Blue, L. et.al.. Randomised controlled trial of specialist nurse
intervention in heart failure. BMJ 2001; 323: 715-718
2 Stewart, S. et.al. Effects of a multi-disciplinary, home-based
intervention on unplanned readmissions and survival among patients with
chronic congestive heart failure: a randomised controlled study. Lancet
1999; 354: 1077-1083
Competing interests: No competing interests
Specialist nurse intervention in heart failure
Sir,
The important article by Blue et al (1) underlines the clinical value
of a cohesive strategy for the management of heart failure patients. The
reduction in events, notably rehospitalisations, is supported by
observations from other centres, including our own (2). However, it is our
opinion that to be absolutely sure that this intervention explains the
difference in rehospitalisation rates, all other important variables must
be standardised within the two groups. It appears from table 2 that
patients from the intervention group were discharged from hospital on a
higher dose of angiotensin converting enzyme inhibitor than the usual care
group. It has been well demonstrated that high-dose ACEI therapy is
associated with a lower risk of hospitalisation following discharge than
low-dose treatment (3).
Therefore, while we agree with the authors conclusion that nurse-led
intervention reduces morbidity in heart failure patients, we feel the data
provided leaves unanswered the impact of final dose of angiotensin
converting enzyme inhibitor at discharge.
Finally, this study included only patients with heart failure and
reduced systolic function, in spite of the fact that as many as 30-40% of
patients presenting with clinical manifestations of heart failure have
normal systolic function (4). 51% of eligible patients were excluded for
this reason. However, recent data suggest the morbidity of the two types
of heart failure is similar (5). Intervention that primarily influences
morbidity, as described in this study, may be even more important in
patients with preserved systolic function heart failure, given that our
knowledge of which therapies influence prognosis and morbidity in this
condition is lacking,
Yours sincerely,
Dr. Enda Ryan M.R.C.P.I.,
Cardiology Registrar,
St. Vincent’s University Hospital,
Dublin 4, Ireland.
Dr. K. McDonald M.D., F.R.C.P.I.,
Consultant Cardiologist,
St. Vincent’s University Hospital,
Dublin 4, Ireland.
References:
1) “Randomised controlled trial of specialist nurse intervention in heart
failure”.
L Blue et al. BMJ Vol 323, 29 Sept 2001, p715-718
2) “Elimination of early rehospitalization in a randomised controlled
trial of multidisciplinary care in a high-risk, elderly heart failure
population: the potential contribution of specialist care, clinical
stability and optimal angiotensin converting enzyme inhibitor dose at
discharge”.
Ken McDonald et al. European Journal of Heart Failure Vol 3 (2)
2001 p209-215.
3) “ Comparative effects of low and high doses of the angiotensin
converting enzyme inhibitor, lisinopril, on morbidity and mortality in
chronic heart failure. ATLAS Study group.”
M Packer et al Circulation 1999 Dec 7; 100(23): 2312-8.
4) “Heart failure with normal systolic function”.
Kessler KM Arch Intern Med 1988; 148: 2109-2111.
5) “Congestive heart failure with preserved systolic function in a state-
wide sample of community hospitals”. Dauterman KW et al.
Journal of Cardiac Failure Vol 7 No. 3 2001.
Competing interests: No competing interests