on May 19, 2003
Published online before print May 19, 2003, doi: 10.1161/01.CIR.0000070952.08969.5B
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Submitted on December 17, 2002
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. * To whom correspondence should be addressed. 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 Methods and Results--This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction Conclusions--The use of a nurse facilitator was a successful approach for implementing a
Revised on March 17, 2003
Accepted on March 17, 2003
Improving Guideline Adherence. A Randomized Trial Evaluating Strategies to Increase
Maria Ansari MD, 
-Blocker Use in Heart Failure
-blockers for heart failure patients.
45% and no contraindications to -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 -blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate -blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on -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 -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.-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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