A general practice nurse intervention for heart failure patients
Contact - Dr. Ffion Lloyd-Williams, ffionlw@liv.ac.uk, 0151 794 5118 or Prof. Frances Mair, fm46c@clinmed.gla.ac.uk
Academic Lead
Professor Frances Mair
Researchers
- Susan Beaton
- Pauline Goldstein
- Ffion Lloyd-Williams
Project Status
Completed, September 2004
Collaborating Institutions
Mersey R&D Consortium/University of Liverpool
Funding
- NHS Executive North West £103293
- MPCRDC £84k
- CTC NHS Trust £5000
Aim
This randomised controlled trial aimed to examine whether a general practice based nurse intervention would improve the diagnosis and management of heart failure patients in the community in a cost effective manner.
Primary outcome measures included:
1. Echocardiography utilisation. 2. Angiotensin Converting Enzyme (ACE) inhibitor use. 3. Beta Blocker use. 4. Readmission rates (for congestive heart failure (CHF) and all other causes).
Secondary outcome measures included:
1. duration of hospitalisations. 2. quality of life (assessed in a subgroup of 40 patients from the intervention group and 40 patients from the control group). 3. mortality. 4. cost-effectiveness.
Method
Eight general practices were randomised into the control group (n = 4) or intervention group (n = 4). Databases of heart failure patients were constructed in all participating practices. Heart failure guidelines were developed and disseminated within all the practices. Practice nurses (n = 4) providing the heart failure clinics received training and the clinics were delivered for a 12-14 month period (February 2002 to March 2003). Two quality of life questionnaires were administered at patients' homes at baseline (prior to clinics commencement) and at 12 month follow up. Data from patients' medical and computerised records were collected on a three monthly basis for the duration of the clinics, with a final data collection in May 2003. Semi-structured face to face interviews were conducted with the nurses providing the clinics and a sub-sample of patients attending the clinics.
Results
- 235 patients consented to take part, 115 intervention, 120 usual care. 142 (60.4%) male; 93 (39.6%) female. Mean age 73.7 years (range 44.9-91.1 years). Mean Jarman score 8.4 (SD 17.7). The intervention practices demonstrated a significant increase in the proportion of patients receiving an echo during the trial amongst those with none recorded at baseline, when compared to the control group, intervention group (81.5% (22/27) vs. control group 7.7% (2/26); (diff. 74%; CI (95%) 44% to 100%, p=0.018). There was some suggestion that patients in the intervention arm were more likely to be on an appropriate dosage of Angiotensin Converting Enzyme (ACE) inhibitor (diff. 18%, 95% CI -2 - 39%, p=0.093). There was a non significant trend towards reduction in the proportion of patients in the intervention arm admitted to hospital during the trial of 11% (CI (95%) -39% to 17%, p=0.31).
- Nurses felt the self-care advice provided had empowered patients to manage their condition. Explaining why a medication had been prescribed, and how it controlled heart failure was felt to increase compliance.
Although communication was deemed good, some patients were reticent about asking questions. Patients seemed to be confused about the purpose and outcome of investigations. Patients were knowledgeable about their prescribed heart failure medications, but some did not recall having discussed their medications. Also medication inserts led some patients to question their prescription. Furthermore, many patients suggested they had problems adhering to or remembering the advice given.
Conclusions
- This pilot project indicates positive effects of non specialist practice nurse-led heart failure clinics in primary care, particularly in relation to the use of appropriate diagnostic tests and improved patient management. It highlights the need for further research in this area to substantiate these findings.
- P ractical benefits are gained when attending a nurse-led heart failure clinic in primary care. However, patients and health care providers may have quite divergent views about such a service and its benefits, emphasising the potential value of consumer involvement and feedback when developing and delivering such services.
Published Papers
1) Lloyd-Williams F, Beaton S, Goldstein P, Mair F, May C, Capewell S. Patients' and nurses' views of nurse-led heart failure clinics in general practice: a qualitative study. Chronic Illness 2005; 1: 39-47.
2) Lloyd-Williams F, Mair F , Sheils C, Hanratty B, Goldstein P, Beaton S, Capewell S, Lye M, Mcdonald R, Roberts C, Connelly D. Why Are Patients in Clinical Trials of Heart Failure Not Like Those We See in Everyday Practice? Journal of Clinical Epidemiology 2003; 56(12):1157-1162.
1) FS. Mair, F. Lloyd-Williams, C. Shiels, R. McDonald, S. Beaton, P. Goldstein, C. Roberts, A. Haycox. The economic costs of heart failure: a community perspective. European Heart Journal. Abstract Suppl. Aug/ Sept 2004; 25: Abstract No. 3811; 663.
2) F. Lloyd-Williams, FS. Mair, C. Roberts, C. Shiels, S. Beaton, P. Goldstein, S. Capewell, DT. Connelly. A pilot cluster randomised controlled trial of nurse-led heart failure clinics in primary care. European Heart Journal. Abstract Suppl. Aug/ Sept 2004; 25: Abstract No. P3270; 545.
3) Beaton S, Lloyd-Williams F, Mair F, McDonald R, Sheils C, McQuillan S, Blair A, Goldstein P, Hanratty B, Evans M, Lye M, Bundred P, Capewell S, Connolly D. Meeting NSF requirements: Are the necessary resources available? Heart failure databases in Primary Care. Heart. 2002; 87 (suppl 2): 10.
Conference Presentations
Lloyd-Williams F, Mair FS, Roberts C, Shiels C, Beaton S, Goldstein P, Capewell S. Nurse-Led Heart Failure Clinics in Family Practice. WONCA, Florida, USA, October, 2004. (Oral Presentation)
Mair FS , Lloyd-Williams F, Shiels C, McDonald R, Beaton S, Goldstein P, Roberts C, Haycox A. Primary health care resource use by a cohort of heart failure patients. WONCA, Florida, USA, October 2004. (Oral Presentation)
Lloyd-Williams F , Mair FS, Beaton S, Goldstein P, Capewell S, Connelly DT. An education program for delivering heart failure (HF) clinics in family practice: The nurses' perspective. WONCA, Florida, USA, October 2004. (Oral Presentation)
Lloyd-Williams F, Mair F, Beaton S, Goldstein P, May C. Patients' and nurses' views of nurse-led heart failure clinics in general practice: a qualitative study. NAPCRG, Florida, USA, October 2004. (Oral Presentation)
Mair F, Lloyd-Williams F, Sheils C, McDonald R, Beaton S, Goldstein P, Roberts C, Capewell S, Connelly DT. Beta blocker prescribing in family practice: experience from a nurse-led heart failure clinic. NAPCRG, Florida, USA, October 2004. (Oral Presentation)
Mair FS, Lloyd-Williams F, Shiels C, McDonald R, Beaton S, Goldstein P, Roberts C, Haycox A. The economic costs of heart failure: a community perspective. ESC Congress, Munich, Germany, September 2004. (Oral Presentation)
Lloyd-Williams F, Mair FS, Roberts C, Shiels C, Beaton S, Goldstein P, Capewell S, Connelly DT. A pilot cluster randomised controlled trial of nurse-led heart failure clinics in primary care. ESC Congress, Munich, Germany, September 2004. (E-Poster Presentation)
Lloyd-Williams F, Mair FS, Roberts C, Shiels C, Beaton S, Goldstein P, Capewell S. Results From A pilot Cluster Randomised Controlled Trial Of Practice Nurse-led Heart Failure (HF) Clinics In Primary Care. Society of Academic Primary Care, Glasgow, UK. July 2004. (Oral Presentation)
Lloyd-Williams F, Mair FS, Shiels C, McDonald R, Beaton S, Goldstein P, Haycox A. The economic costs of heart failure. Society of Academic Primary Care, Glasgow, UK. July 2004 (Oral Poster Presentation)
Lloyd-Williams F. Beaton S. Mair FS. Shiels C. Goldstein P. Hanratty B. Lye M. Connelly D. Roberts C. Haycox A. Capewell S.Developing a general practice nurse intervention for heart failure patients: What lessons can we learn from the early stages? UK Federation of Primary Care Research Networks Conference, Birmingham, UK. November 2003.(Oral Presentation)
Lloyd-Williams F. Beaton S. Mair FS. Shiels C. Goldstein P. Hanratty B. Lye M. Connelly D. Haycox A. Capewell S. An education programme for delivering heart failure clinics in primary care: the nurses' perspective. UK Federation of Primary Care Research Networks Conference, Birmingham, UK. November 2003.(Oral Presentation)
Lloyd-Williams F , Beaton S, Mair FS, Shiels C, Goldstein P, Hanratty B, Lye M, Connelly D, Roberts C, Haycox A, Capewell S. A General Practice Nurse Intervention for Heart Failure Patients. CVD North West R&D Network Conference. Manchester UK. May 2003 (Oral Presentation).
Lloyd-Williams F , Beaton S, Mair FS, Shiels C, Goldstein P, Hanratty B, Lye M, Connelly D, Roberts C, Haycox A, Capewell S. Recruiting heart failure patients to clinical trials: The experience of a randomised controlled trial in primary care. Society for Social Medicine Annual Scientific Meeting. Liverpool, UK. September 2002 (Poster Presentation)
Lloyd-Williams F , Beaton S, Mair FS, Shiels C, Goldstein P, Hanratty B, Lye M, Connelly D, Roberts C, Haycox A, Capewell S. The Problem of Recruitment to Clinical Trials in Primary Care - experience from a randomised controlled trial of heart failure patients. Society of Academic Primary Care Annual Conference. Birmingham, UK. July 2002 (Oral Presentation)
Lloyd-Williams F, Beaton S, Mair FS, Shiels C, Goldstein P, Hanratty B, Lye M, Connelly D, Roberts C, Haycox A, Capewell S.1. Chronic Heart Failure: Evidence Indicates Inequalities in Management. British Cardiac Society Annual Scientific Conference. Leeds, UK. May 2002 (Oral Presentation)
Lloyd-Williams F, Beaton S, Mair FS, Shiels C, Goldstein P, Hanratty B, Lye M, Connelly D, Roberts C, Haycox A, Capewell S. Meeting NSF Requirements: Are the necessary resources available? British Cardiac Society Annual Scientific Conference. Leeds, UK. May 2002 (Oral Presentation)
Reports
1) Mair F. Lloyd-Williams F. Beaton S. Goldstein P. Roberts C. McDonald R. Shiels C. Connelly D. Capewell S. Haycox A. A General Practice Nurse Intervention for Heart Failure Patients. Report submitted to Health Research and Development North West, December 2004. Grant: RDO/28/2/15.