Published online before print May 19, 2003, doi: 10.1161/01.CIR.0000070952.08969.5B
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(Circulation. 2003;107:2799.)
© 2003 American Heart Association, Inc.
Clinical Investigation and Reports |
Improving Guideline Adherence
A Randomized Trial Evaluating Strategies to Increase ß-Blocker Use in Heart Failure
From the Cardiology Division, San Francisco VA Medical Center (M.A., E.C.P., B.M.M.); Departments of Medicine (M.A., M.G.S., D.V.O., B.M.M.) and Epidemiology and Biostatistics (M.G.S.) and Cardiovascular Research Institute (B.M.M.), University of California, San Francisco; Cardiology Division, Palo Alto VA Medical Center (P.A.H.); and California Pacific Medical Center Research Institute (W.S.B.), San Francisco, Calif.
Correspondence to Barry M. Massie, MD, Cardiology Division (111C), San Francisco VAMC, 4150 Clement St, San Francisco, CA 94121. E-mail barry.massie{at}med.va.gov
Background— The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of ß-blockers for heart failure patients.
Methods and Results— This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction ≤45% and no contraindications to ß-blockers. Patients’ primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating ß-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate ß-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on ß-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target ß-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.
Conclusions— The use of a nurse facilitator was a successful approach for implementing a ß-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.
Key Words: heart failure • drugs • trials
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