title: Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Extending the Horizon in Chronic Heart Failure: Effects of Multidisciplinary, Home-Based Intervention Relative to Usual Care Randomised controlled trial of specialist nurse intervention in heart failure Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain. Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. 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High Rates of Sustained Smoking Cessation in Women Hospitalized With Cardiovascular Disease: The Women’s Initiative for Nonsmoking (WINS) Cost‐effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. Patients with heart failure in primary health care: effects of a nurse-led intervention on health-related quality of life and depression. A Randomised Controlled Trial to Evaluate a Nurse-Led Programme of Support and Lifestyle Management for Patients Awaiting Cardiac Surgery: ‘Fit for Surgery: Fit for Life’ Study Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme Effect of behavioral management on quality of life in mild heart failure: a randomized controlled trial. Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. Added value of a physician-and-nurse-directed heart failure clinic: results from the Deventer–Alkmaar heart failure study A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care. Effectiveness of three models for comprehensive cardiovascular disease risk reduction. Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. Clinical trial of an Internet-based case management system for secondary prevention of heart disease. 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Self-Efficacy Intervention Effect on Physical Activity in Older Adults Telehome monitoring in patients with cardiac disease who are at high risk of readmission. Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care Self-care and quality of life in patients with advanced heart failure: the effect of a supportive educational intervention. The Effect of Education and Counselling on Knowledge, Attitudes and Beliefs about Responses to Acute Myocardial Infarction Symptoms Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease
abstract: BACKGROUND Case management is believed to promote continuity of care and decrease hospitalization rates , although few controlled trials have tested this approach . OBJECTIVE To assess the effectiveness of a st and ardized telephonic case-management intervention in decreasing re source use in patients with chronic heart failure . METHODS A r and omized controlled clinical trial was used to assess the effect of telephonic case management on re source use .  Patients were identified at hospitalization and assigned to receive 6 months of intervention ( n = 130 ) or usual care ( n = 228 ) based on the group to which their physician was r and omized .  Hospitalization rates , readmission rates , hospital days , days to first rehospitalization , multiple readmissions , emergency department visits , inpatient costs , outpatient re source use , and patient satisfaction were measured at 3 and 6 months . RESULTS The heart failure hospitalization rate was 45.7 % lower in the intervention group at 3 months ( P = .03 ) and 47.8 % lower at 6 months ( P = .01 ) . Heart failure hospital days ( P = .03 ) and multiple readmissions ( P = .03 ) were significantly lower in the intervention group at 6 months . Inpatient heart failure costs were 45.5 % lower at 6 months ( P = .04 ) . A cost saving was realized even after intervention costs were deducted . There was no evidence of cost shifting to the outpatient setting . Patient satisfaction with care was higher in the intervention group . CONCLUSIONS The reduction in hospitalizations , costs , and other re source use achieved using st and ardized telephonic case management in the early months after a heart failure admission is greater than that usually achieved with pharmaceutical therapy and comparable with other disease management approaches Background — The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown . Methods and Results — The effects of a nurse-led , multidisciplinary , home-based intervention ( HBI ) in a typically elderly cohort of patients with chronic heart failure initially r and omized to either HBI ( n=149 ) or usual postdischarge care ( UC ) ( n=148 ) after a short-term hospitalization were studied for up to 10 years of follow-up ( minimum 7.5 years of follow-up ) . Study end points were all-cause mortality , event-free survival ( event was defined as death or unplanned hospitalization ) , recurrent hospital stay , and cost per life-year gained . Median survival in the HBI cohort was almost twice that of UC ( 40 versus 22 months ; P<0.001 ) , with fewer deaths overall ( HBI , 77 % versus 89 % ; adjusted relative risk , 0.74 ; 95 % CI , 0.53 to 0.80 ; P<0.001 ) . HBI was associated with prolonged event-free survival ( median , 7 versus 4 months ; P<0.01 ) . HBI patients had more unplanned readmissions ( 560 versus 550 ) but took 7 years to overtake UC ; the rates of readmission ( 2.04±3.23 versus 3.66±7.62 admissions ; P<0.05 ) and related hospital stay ( 14.8±23.0 versus 28.4±53.4 days per patient per year ; P<0.05 ) were significantly lower in the HBI group . HBI was associated with 120 more life-years per 100 patients treated compared with UC ( 405 versus 285 years ) at a cost of $ 1729 per additional life-year gained when we accounted for healthcare costs including the HBI . Conclusions — In altering the natural history of chronic heart failure relative to UC ( via prolonged survival and reduced frequency of recurrent hospitalization  ) , HBI is a remarkably cost- and time-effective strategy over the longer term Abstract Objectives : To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure . Design : R and omised controlled trial . Setting : Acute medical admissions unit in a teaching hospital . Participants : 165 patients admitted with heart failure due to left ventricular systolic dysfunction . The intervention started before discharge and continued thereafter with home visits for up to 1 year . Main outcome measures : Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure . Results : 31 patients ( 37 % ) in the intervention group died or were readmitted with heart failure compared with 45 ( 53 % ) in the usual care group ( hazard ratio=0.61 , 95 % confidence interval 0.33 to 0.96).Compared with usual care , patients in the intervention group had fewer readmissions for any reason ( 86 v 114 , P=0.018 ) , fewer admissions for heart failure ( 19 v 45 , P<0.001 ) and spent fewer days in hospital for heart failure ( mean 3.43 v 7.46 days , P=0.0051 ) . Conclusions : Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure . What is already known on this topic Studies have suggested that nurse intervention may reduce readmission in patients with heart failure What this study adds Home based intervention from nurses reduces readmissions for worsening heart failure Regular contact to review treatment and patient education are likely to contribute to this Cardiac pain arising from chronic stable angina ( CSA ) is a cardinal symptom of coronary artery disease and has a major negative impact on health-related quality of life ( HRQL ) , including pain , poor general health status , and inability to self-manage . Current secondary prevention approaches lack adequate scope to address CSA as a multidimensional ischemic and persistent pain problem . This trial evaluated the impact of a low-cost six-week angina psychoeducation program , entitled The Chronic Angina Self-Management Program ( CASMP ) , on HRQL , self-efficacy , and re source fulness to self-manage anginal pain . One hundred thirty participants were r and omized to the CASMP or three-month wait-list usual care ; 117 completed the study . Measures were taken at baseline and three months . General HRQL was measured using the Medical Outcomes Study 36-Item Short Form and the disease-specific Seattle Angina Question naire ( SAQ ) . Self-efficacy and re source fulness were measured using the Self-Efficacy Scale and the Self-Control Schedule , respectively . The mean age of participants was 68 years , 80 % were male . Analysis of variance of change scores yielded significant improvements in treatment group physical functioning [ F=11.75(1,114 ) , P<0.001 ] and general health [ F=10.94(1,114 ) , P=0.001 ] aspects of generic HRQL . Angina frequency [ F=5.57(1,115 ) , P=0.02 ] , angina stability [ F=7.37(1,115 ) , P=0.001 ] , and self-efficacy to manage disease [ F=8.45(1,115 ) , P=0.004 ] were also significantly improved at three months . The CASMP did not impact re source fulness . These data indicate that the CASMP was effective for improving physical functioning , general health , anginal pain symptoms , and self-efficacy to manage pain at three months and provide a basis for long-term evaluation of the program BACKGROUND Disease management programs ( DMPs ) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status . Evaluations of cardiac DMPs delivered by home health nurses are required . METHODS Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes . Patients who agreed were r and omly assigned to participate in a DMP or to receive usual care .  The DMP included 6 home visits by a cardiac-trained nurse , a st and ardized nurses ' checklist , referral criteria for specialty care , communication with the family physician and patient education . We measured readmission days per 1000 follow-up days for angina , congestive heart failure ( CHF ) and chronic obstructive pulmonary disease ( COPD ) ; all-cause readmission days ; and provincial cl aims for emergency department visits , physician visits , diagnostic or therapeutic services and laboratory services . RESULTS We screened 715 consecutive patients admitted with elevated cardiac markers between August 1999 and August 2000 . Of those screened 71 DMP and 75 usual care patients met the diagnostic criteria for myocardial infa rct ion , were eligible for visits from a home health nurse and consented to participate in the study . Readmission days for angina , CHF and COPD per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( incidence density ratio [ IDR ] = 1.59 , 95 % confidence interval [ CI ] 1.27 - 2.00 , p < 0.001 ) . All-cause readmission days per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( IDR = 1.53 , 95 % CI 1.37 - 1.71 , p < 0.001 ) . The difference in emergency department encounters per 1000 follow-up days was significant ( IDR = 2.08 , 95 % CI 1.56 - 2.77 , p < 0.001 ) . During the first 25 days after discharge , there were significantly fewer provincial cl aims su bmi tted for DMP patients than for usual care patients for emergency department visits ( p = 0.007 ) , diagnostic or therapeutic services ( p = 0.012 ) and laboratory services ( p = 0.007 ) . INTERPRETATION The results provide evidence that an appropriately developed and implemented community-based inner-city DMP delivered by home health nurses has a positive impact on patient outcomes OBJECTIVES We sought to identify whether home telemonitoring ( HTM ) improves outcomes compared with nurse telephone support ( NTS ) and usual care ( UC ) for patients with heart failure who are at high risk of hospitalization or death . BACKGROUND Heart failure is associated with a high rate of hospitalization and poor prognosis . Telemonitoring could help implement and maintain effective therapy and detect worsening heart failure and its cause promptly to prevent medical crises . METHODS Patients with a recent admission for heart failure and left ventricular ejection fraction ( LVEF ) < 40 % were assigned r and omly to HTM , NTS , or UC in a 2:2:1 ratio . HTM consisted of twice-daily patient self-measurement of weight , blood pressure , heart rate , and rhythm with automated devices linked to a cardiology center . The NTS consisted of specialist nurses who were available to patients by telephone . Primary care physicians delivered UC . The primary end point was days dead or hospitalized with NTS versus HTM at 240 days . RESULTS Of 426 patients r and omly assigned , 48 % were aged > 70 years , mean LVEF was 25 % ( SD , 8) and median plasma N-terminal pro-brain natriuretic peptide was 3,070 pg/ml ( interquartile range 1,285 to 6,749 pg/ml ) . During 240 days of follow-up , 19.5 % , 15.9 % , and 12.7 % of days were lost as the result of death or hospitalization for UC , NTS , and HTM , respectively ( no significant difference ) . The number of admissions and mortality were similar among patients r and omly assigned to NTS or HTM , but the mean duration of admissions was reduced by 6 days ( 95 % confidence interval 1 to 11 ) with HTM . Patients r and omly assigned to receive UC had higher one-year mortality ( 45 % ) than patients assigned to receive NTS ( 27 % ) or HTM ( 29 % ) ( p = 0.032 ) . CONCLUSIONS Further investigation and refinement of the application of HTM are warranted because it may be a valuable role for the management of selected patients with heart failure Objectives : To evaluate the effects of nurse-led secondary prevention clinics for coronary heart disease ( CHD ) in primary care on total mortality and coronary event rates after 10 years . Design : Follow-up of a r and omised controlled trial by review of national data sets . Setting : Stratified r and om sample of 19 general practice s in northeast Scotl and . Participants : Original study cohort of 1343 patients , aged < 80 years , with a working diagnosis of CHD , but without dementia or terminal illness and not housebound . Intervention : Nurse-led secondary prevention clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow-up for 1 year , Main outcome measures : Total mortality and coronary events ( non-fatal myocardial infa rct ions ( MIs ) and coronary deaths ) . Results : Mean ( SD ) follow-up was at 10.2 ( 0.19 ) years . No significant differences in total mortality or coronary events were found at 10 years . 254 patients in the intervention group and 277 patients in the control group had died : cumulative death rates were 38 % and 41 % , respectively ( p = 0.177 ) . 196 coronary events occurred in the intervention group and 195 in the control group : cumulative event rates were 29.1 % and 29.1 % , respectively ( p = 0.994 ) . When Kaplan – Meier survival analysis , adjusted for age , sex and general practice , was used , proportional hazard ratios were 0.88 ( 0.74 to 1.04 ) for total mortality and 0.96 ( 0.79 to 1.18 ) for coronary death or non-fatal MI . No significant differences in the distribution of cause of death classifications was found at either 4 or 10 years . Conclusions : After 10 years , differences between groups were no longer significant . Total mortality survival curves for the intervention and control groups had not converged , but the coronary event survival curves had . Possibly , therefore , the earlier that secondary prevention is optimised , the less likely a subsequent coronary event is to prove fatal OBJECTIVES We sought to determine whether a multidisciplinary outpatient management program decreases  chronic heart failure ( CHF )  hospital readmissions and mortality over a six-month period . BACKGROUND Hospital admission for CHF is an important problem amenable to improved outpatient management . METHODS Two hundred patients hospitalized with CHF at increased risk of hospital readmission were r and omized to a multidisciplinary program or usual care . A study cardiologist and a CHF nurse evaluated each patient and made recommendations to the patient 's primary physician before r and omization . The intervention team consisted of a cardiologist , a CHF nurse , a telephone nurse coordinator and the patient 's primary physician . Contact with the patient was on a prespecified schedule . The CHF nurse followed an algorithm to adjust medications . Patients in the nonintervention group were followed as usual . The primary outcome was the composite of the number of CHF hospital admissions and deaths over six months , compared by using a log transformation t test by intention-to-treat analysis . RESULTS The median age of the study patients was 63.5 years , and 39.5 % were women . There were 43 CHF hospital admissions and 7 deaths in the intervention group , as compared with 59 CHF hospital admissions and 13 deaths in the nonintervention group ( p = 0.09 ) . The quality -of-life score , percentage of patients on target vasodilator therapy and percentage of patients compliant with diet recommendations were significantly better in the intervention group . Cost per patient , in 1998 U.S. dollars , was similar in both groups . CONCLUSIONS This study demonstrates that a six-month , multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF AIM To assess the feasibility and impact of specialist care in patients with newly diagnosed heart failure in primary and secondary care . METHODS Patients with suspected heart failure referred for open access echocardiography to a hospital-based echocardiography service were assessed from June 2002 through to June 2003 . Patients with confirmed left ventricular systolic dysfunction ( LVSD ) were r and omised to specialist care ( cardiology registrar and heart failure nurses ) or referred back to their general practitioner ( GP ) . R and omisation was stratified for age and sex and both groups were comparable . All patients were followed up for a minimum of 3 months post r and omisation with a mean follow-up time of 10+/-3 months . Specialist care was provided both in the community and in hospital . The primary endpoint was prescription of optimum heart failure medication and secondary endpoint was a composite endpoint of all cause mortality and /or hospital admission . RESULTS 386 patients were screened ; mean age -72+/-10 years . 113 ( 29 % ) had confirmed LVSD on echocardiography and were r and omised to specialist or primary care . The prescription of ACE-inhibitors ( 85 % vs. 64 % ) and beta blockers ( 50 % vs. 2 % ) was higher in patients r and omised to specialist care . No significant differences were noted in mortality or hospitalisation . CONCLUSION Specialist heart failure care results in higher rates of optimal prescribing , in primary and secondary care Context People with chronic conditions may need tailored , practical help for managing their conditions . Contribution This 12-month trial of assistance with managing systolic- dysfunction heart failure r and omly assigned 406 ethnically diverse adults from Harlem , New York , to usual care or nurse management .  Nurses counseled nurse management patients about sodium intake , fluid buildup , medication adherence , and self-management of symptoms ; served as a bridge between patients and physicians ; and regularly called patients to discuss problems . Compared with usual care patients , nurse management patients had fewer hospitalizations and better functioning . Implication s Nurse management can improve some outcomes in ethnically diverse patients with systolic-dysfunction heart failure in ambulatory practice s. The Editors Heart failure disproportionately affects black and elderly people and is a leading cause of hospitalization among people 65 years of age or older ( 1 , 2 ) . Although effective therapies can improve functioning and survival in patients with systolic dysfunction , many patients may not be receiving the full benefit of existing knowledge ( 35 ) . Patients play a critical role in managing a chronic condition , such as heart failure . Patients may not realize that specific symptoms are related to heart failure or that adhering to medications and diet can reduce symptoms and life-threatening episodes ( 6 ) . Evidence -based guidelines for systolic dysfunction recommend that physicians not only offer patients effective therapies but also teach them the importance of adherence and self-monitoring ( 3 , 4 ) . Clinicians have fallen short in prescribing angiotensin-converting enzyme inhibitors and -blockers for patients with systolic dysfunction ( 5 , 7 , 8) . When prescribed , the doses have often been lower than those proven to convey greater benefits ( 3 , 9 ) . Clinicians have also documented counseling only a fraction of patients with heart failure about self-management ( 10 , 11 ) . System-related factors may also influence patients ' ability to obtain quality care ( 12 , 13 ) . Systematic review s of clinical behavior change have suggested that interventions targeted to specific problems are more likely to be successful ( 14 , 15 ) . On the basis of shortfalls identified in patient self-management and clinical care in Harlem , New York , a predominately nonwhite area , we tailored a nurse management intervention to address documented problems and evaluated its effectiveness in a r and omized , controlled trial . Our trial among primarily minority patients addresses important gaps in the literature . We targeted problems documented among patients with heart failure in Harlem , enrolled patients from ambulatory care practice s , r and omly assigned patients to either nurse management or usual care , and evaluated the patients ' subsequent health-related outcomes . We hypothesized that patients in the  focused nurse management program  would have fewer hospitalizations and report better functioning than patients in usual care . Methods Development of the Intervention During interviews with patients with heart failure at Mount Sinai Hospital , New York , New York , patients reported inadequate underst and ing of heart failure and their role in managing it ( 6 ) . Less than half of patients followed a very-low-salt diet , and only about one quarter weighed themselves daily . Regarding clinical management , medical records noted prescriptions for an angiotensin-converting enzyme inhibitor or hydralazinedinitrate combination in 82 % of 322 consecutive black patients with documented systolic dysfunction who were scheduled for visits at the general medicine clinic at Harlem Hospital from February 1995 through February 1997 . The prescribed doses , however , equaled or exceeded those found to be efficacious in clinical trials in only 26 % of these patients ( 3 ) . In design ing a nurse management intervention to address these problems , we built on a Stanford University program that evaluated primarily privately insured patients at Kaiser Permanente in northern California ( 16 , 17 ) . We adapted their question naire on the frequency of foods eaten to incorporate those that are common among African-American and Hispanic people in Harlem . Setting s and Recruitment All 4 hospitals in Harlem , the area 's major providers , collaborated in the trial : 1 large private academic medical center ( 1171 beds ) , 2 medium-sized municipal hospitals ( 286 beds and 363 beds ) , and 1 smaller private community hospital ( 200 beds ) . In 2000 , these hospitals had 521 , 267 , 218 , and 168 discharges for the heart failure diagnosis-related group ( code 127 ) , respectively . All are not-for-profit institutions . The trial had the following inclusion criteria : adults 18 years of age or older ; systolic dysfunction documented on a cardiac test ( echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization ) ; English- language or Spanish- language speakers ; community-dwelling at enrollment ; and current patient in a general medicine , geriatrics , or cardiology clinic or office at a participating site . Exclusion criteria were medical conditions that prevented interaction with the nurse , including blindness , deafness , or cognitive impairment ; medical conditions requiring individualized management that might differ from st and ard protocol , namely pregnancy , renal dialysis , or terminal illness ; or procedures that corrected systolic dysfunction , such as heart transplantation . Of the 216 clinicians ( 209 physicians and 7 physicians ' assistants or nurse practitioners ) in participating practice s , 1 clinician declined permission to recruit his patients . The institutional review boards for each site approved the study . We identified patients with International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) , and diagnosis-related group codes on outpatient or inpatient billings for heart failure , March 1999 through February 2001 , who had at least 1 clinician visit to a participating practice and impaired systolic dysfunction . We defined impaired systolic dysfunction as a left ventricular ejection fraction less than 0.40 or moderately or severely reduced systolic dysfunction on echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization . We obtained clinicians ' permission to recruit specific patients and sent each approved patient a letter from the site 's physician coordinator . Bilingual recruiters telephoned eligible patients or approached them at scheduled clinician appointments . The recruiter confirmed each patient 's eligibility , obtained written informed consent to participate in the study , conducted the baseline survey , and telephoned the project manager for the treatment group assignment . The recruiter conveyed the assignment to the patient and , for each nurse management patient , scheduled the in-person appointment with a nurse . We provided telephone service for 3 patients who did not have it so we could telephone patients in both treatment groups every 3 months for data on end points and so nurse management patients could participate in the intervention . R and omization and Treatment Groups The project 's statistician used a computer-generated , r and om-number sequence without blocking or stratification to central ly determine r and omization assignments and concealed treatment group assignments in sealed , opaque envelopes . Usual care patients received federal consumer guidelines for managing systolic dysfunction but no other intervention ( 18 ) . In the nurse management intervention , 1 of 3 trained registered nurses met once with each patient ( Table 1 ) . In counseling the patient , the nurse stressed the relationship among sodium intake ; fluid buildup ; and symptoms , such as shortness of breath . Nurses mailed patients the reports from the food-frequency question naire after each administration . The nurse also served as a bridge between the patient and the clinician ( Table 1 ) . A local clinical advisory committee implemented national evidence -based guidelines , and a committee of key clinicians from participating sites approved the protocol ( 3 , 4 ) . Nurses contacted patients ' clinicians to discuss specific medications and arranged any prescription changes and examinations ordered ( Table 1 ) . An internist monitored the nurses ' work , initially in weekly and then in biweekly meetings , and a cardiologist provided oversight and substituted for the internist at regular meetings , as necessary . Table 1 . Components of Nurse Management * One nurse who was bilingual in English and Spanish delivered the intervention primarily at the 2 municipal hospitals , a second bilingual nurse delivered the intervention primarily at the small community hospital , and the second and a third English- language speaking nurse delivered the intervention primarily at the academic center . All 3 nurses covered each other , especially for the follow-up telephone calls . Outcomes and Measurement To measure hospitalizations , we used billing data from the 4 participating hospitals . At quarterly telephone surveys , interviewers who were blinded to treatment assignment asked patients about hospitalizations at nonparticipating hospitals ; however , we present the analysis of billing data because they measure hospitalizations independent of possibly socially acceptable responses or survey nonresponse of the patients . For functional status , we used the generic Short Form-12 ( SF-12 ) physical component score and the condition-specific Minnesota Living with Heart Failure ( MLHF ) Question naire , with both scales administered at the quarterly interviews . We measured deaths recorded in the National Death Index plus deaths reported by patients ' families for patients with no subsequent billings . Since both nurse management and usual care involved only services delivered in routine practice , the study did not monitor adverse effects . As required by the Background . The growing number of patients with congestive heart failure has increased both the pressure on hospital re sources and the need for community management of the condition . Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines ’ recommendations for coordination and education . Positive outcomes have been reported from trials evaluating multiple interventions , enhanced hospital discharge , and follow-up through the addition of a case management role . The question remains if similar gains could be achieved working with usual hospital and community nurses . Methods . A 12-week , prospect i ve , r and omized controlled trial was conducted of the effect of transitional care on health-related quality of life ( disease-specific and generic measures ) , rates of readmission , and emergency room use .  The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge . Results . At 6 weeks after hospital discharge , the overall Minnesota Living with Heart Failure Question naire ( MLHFQ ) score was better among the Transitional Care patients ( 27.2 ± 19.1 SD ) than among the Usual Care patients ( 37.5 ± 20.3 SD;P = 0.002 ) . Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ ’s Physical Dimension and Emotional Dimension subscales . Differences in generic quality life , as assessed by the SF-36 Physical component , Mental Component , and General Health subscales , were not significantly different between the Transition and Usual Care groups . At 12 weeks postdischarge , 31 % of the Usual Care patients had been readmitted compared with 23 % of the Transitional Care patients ( P = 0.26 ) , and 46 % of the Usual Care group visited the emergency department compared with 29 % in the Transitional Care group ( & khgr;2 = 4.86 , df 1 , P = 0.03 ) . Conclusions . There were significant improvements in health-related quality of life ( HRQL ) associated with Transitional Care and less use of emergency rooms BACKGROUND Outcomes related to chronic heart failure ( HF ) remain relatively poor , despite advances in pharmacological therapy and medical and nursing care . Experts agree that outpatient care may be among the factors that affect HF outcomes . We hypothesized that the method by which outpatient care is delivered may affect outcomes in this patient population . METHODS A prospect i ve , r and omized design was used to compare HF outcomes from 216 patients r and omized to 1 of 2 home health care delivery methods for 3 months after discharge . Care was delivered by the home nurse visit ( HNV ) or the nurse telemanagement ( NTM ) method . In the latter , patients used transtelephonic home monitoring devices to measure their weight , blood pressure , heart rate , and oxygen saturation . These data were transmitted daily to a secure Internet site . An advanced- practice nurse worked collaboratively with a cardiologist and subsequently treated patients via the telephone . Both delivery methods used the same HF-specific clinical guidelines to direct care . Outcomes include HF readmissions and length of stay , anxiety , depression , self-efficacy , and quality of life . Data were primarily tested using a 2-group analysis of variance ( ANOVA ) . We used a repeated- measures ANOVA to conduct preintervention-postintervention analyses . RESULTS After 3 months , patients in the  NTM group ( n = 108 ; mean + /- SD age , 62.9 + /- 13.2 years ; 83 % African American ; 64 % female ) had fewer HF readmissions ( 13 vs 24 ; P</=.001 ) with shorter lengths of stay ( 49.5 vs 105.0 days ; P</=.001 ) compared with the HNV group ( n = 108 ; mean + /- SD age , 63.2 + /- 12.6 years ; 89 % African American ; 62 % female ) . Hospitalization charges at 3 months were less in the NTM group compared with the HNV group ( $ 65 023 vs $ 177 365 ; P</=.02 ) . At 6 and 12 months , cumulative readmission charges in the NTM group were also less ( $ 223 638 vs $ 500 343 [ P<.03 ] and $ 541 378 vs $ 677 710 [ P</=.16 ] , respectively ) compared with the HNV group . Quality of life was significantly improved for both groups when we compared postintervention and preintervention scores . CONCLUSION The adaptation of state-of-the-art computerized technology to closely monitor patients with HF with advanced- practice nurse care under the guidance of a cardiologist significantly improves HF management while reducing the cost of care BACKGROUND Despite national efforts to improve cholesterol management for patients with coronary artery disease , many patients are not reaching recommended cholesterol target levels . We sought to determine whether a nurse-based educational intervention , design ed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein ( LDL ) cholesterol target levels and encourage partnership with physicians , could increase adherence with National Cholesterol Education Program target levels ( LDL cholesterol level < or = 100 mg/dL ) . METHODS Patients hospitalized with confirmed coronary artery disease were r and omized to undergo a  nurse-based educational intervention ( 375 patients ) or usual care ( 381 patients ) for a 12-month period after hospitalization . The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization . The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels . RESULTS The groups were similar at baseline in demographic and clinical characteristics , percent at LDL cholesterol target level ( 43.9 % and 41.1 % , respectively ) , and percent with knowledge of LDL cholesterol target levels ( both 5 % ) . The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention ( 70.2 % ) and usual care group ( 67.4 % , P = .46 ) . At the conclusion of the trial , patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group ( 19.6 % and 6.7 % , respectively , P = .001 ) , but this was not associated with improved cholesterol management . CONCLUSIONS Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization . Although the intervention improved patient knowledge of LDL cholesterol target levels , overall rates of LDL cholesterol knowledge remained low , and it was not associated with improved cholesterol management BACKGROUND Heart failure is a common and important cause of morbidity and mortality . Disease management offers promise in reducing the need for hospitalization and improving quality of life for heart failure patients , but experimental data on the efficacy of such programs are limited . METHODS AND RESULTS A total of 151 patients hospitalized with heart failure were r and omized to usual care or scheduled telephone calls by specially trained nurses promoting self-management and guideline -based therapy as prescribed by primary physicians . Nurses also screened patients for heart failure exacerbations , which they managed with supplemental diuretics or by contacting the primary physician for instructions . Outcomes included time to hospital encounter , mortality , number and cost of hospitalizations , functional status , and satisfaction with care . Intervention patients had a longer time to encounter ( hazard ratio [ HR ] = 0.67 ; 95 % confidence interval [ CI ] 0.47 - 0.96 ; P = .029 ) , hospital readmission ( HR = 0.67 ; CI 0.46 - 0.99 ; P = .045 ) , and heart failure-specific readmission ( HR = 0.62 ; CI 0.38 - 1.03 ; P = .063 ) . The number of admissions , hospital days , and hospital costs were significantly lower during the first 6 months after intervention but not at 1 year . The intervention had little effect on functional status , mortality , and satisfaction with care . CONCLUSION A nurse-administered , telephone-based disease management program delayed subsequent health care encounters , but had minimal impact on other outcomes Objective : To evaluate the effects of a nurse based outpatient management programme for elderly patients discharged with heart failure from a university hospital . Design : Patients with heart failure ( New York Heart Association class II – IV ) and left ventricular systolic dysfunction aged 60 years or more were r and omly assigned to follow up within the management programme or to conventional follow up , usually in primary care . Of the 208 participants , 58 % were men , mean age was 75 years , and mean ejection fraction 34 % . All patients were scheduled for three observational study visits at six month intervals . The primary end point was quality of life ( QoL ) and secondary end points were hospitalisation and mortality . Results : More patients achieved target doses of angiotensin converting enzyme ( ACE ) inhibitors in the intervention group than in the control group ( 82 % v 69 % , 88 % v 69 % , and 88 % v 74 % of recommended target doses at 6 , 12 , and 18 months of follow up , respectively , p < 0.05 for all ) . Patients with initial low QoL had a poor prognosis . After a mean 1122 days of follow up , 82 % of all patients had been readmitted . There were on average 4.7 readmissions per patient and 66 % were due to non-cardiac diagnoses . There were no differences in QoL or health care consumption between the two study groups during follow up . Conclusion : A nurse based management programme is more effective than follow up in primary care in optimising medication for elderly patients with heart failure . However , such a programme does not seem to have a favourable influence on QoL or readmission rate during long term follow up Background —Although interventions combining patient education and postdischarge management have demonstrated benefits in patients with chronic heart failure , the benefit attributable to patient education alone is not known . We hypothesized that a patient discharge education program would improve clinical outcomes in patients with chronic heart failure . Methods and Results —We conducted a r and omized , controlled trial of 223 systolic heart failure patients and compared the effects of a 1-hour , one-on-one teaching session with a nurse educator to the st and ard discharge process . Subjects were contacted by telephone at 30 , 90 , and 180 days to collect information about clinical events , symptoms , and self-care practice s. The primary end point of the study was the total number of days hospitalized or dead in the 180-day follow-up period . Subjects r and omized to receive the teaching  session  ( n=107 ) had fewer days hospitalized or dead in the follow-up period ( 0 and 10 days , median and 75th percentiles ) than did controls ( n=116 , 4 and 19 days ; P=0.009 ) . Patients receiving the education intervention had a lower risk of rehospitalization or death ( relative risk , 0.65 ; 95 % confidence interval , 0.45 to 0.93 ; P=0.018 ) . Costs of care , including the cost of the intervention , were lower in patients receiving the education intervention than in control subjects by $ 2823 per patient ( P=0.035 ) . Conclusions —The addition of a 1-hour , nurse educator – delivered teaching session at the time of hospital discharge result ed in improved clinical outcomes , increased self-care measure adherence , and reduced cost of care in patients with systolic heart failure Background Smoking is an important risk factor for cardiovascular disease ( CVD ) , and quitting is highly beneficial . Yet , less than 30 % of CVD patients stop smoking . Relapse-prevention strategies seem most effective when initiated during the exacerbation of the disease . Objective A nurse-delivered inpatient smoking cessation program based on the Transtheoretical Model with telephone follow-up tailored to levels of readiness to quit smoking was evaluated on smoking abstinence and progress to ulterior stages of change . Method Participants ( N = 168 ) were r and omly assigned by cohorts to inpatient counseling with telephone follow-up , inpatient counseling , and usual care . The inpatient intervention consisted of a 1-hr counseling session , and the telephone follow-up included 6 calls during the first 2 months after discharge . The nursing intervention was tailored to the individual 's stage of change . End points at 2 and 6 months included actual and continuous smoking cessation rates ( biochemical markers ) and increased motivation ( progress to ulterior stages of change ) . Results Assuming that surviving patients lost to follow-up were smokers , the 6-month smoking abstinence rate was 41.5 % in the inpatient counseling with telephone follow-up group , compared with 30.2 % and 20 % in the inpatient counseling and usual care groups , respectively ( p = .05 ) . Progress to ulterior stages of change was 43.3 % , 32.1 % , and 18.2 % , respectively ( p = .02 ) . Stage of change at baseline and intervention predicted smoking status at 6 months . Discussion This tailored smoking cessation program with telephone follow-up significantly increased smoking cessation at 6 months , and progression to ulterior stages of change . The telephone follow-up was an important adjunct . It is , therefore , recommended to include such comprehensive smoking cessation programs within hospital setting s for individuals with CVD BACKGROUND Few studies have examined the potential benefits of specialist nurse-led programs of care involving home and clinic-based follow-up to optimise the post-discharge management of chronic heart failure ( CHF ) . OBJECTIVE To determine the effectiveness of a hybrid program of clinic plus home-based intervention ( C+HBI ) in reducing recurrent hospitalisation in CHF patients . METHODS CHF patients with evidence of left ventricular systolic dysfunction admitted to two hospitals in Northern Engl and were assigned to a C+HBI lasting 6 months post-discharge ( n=58 ) or to usual , post-discharge care ( UC : n=48 ) via a cluster r and omization protocol . The co- primary endpoints were death or unplanned readmission ( event-free survival ) and rate of recurrent , all-cause readmission within 6 months of hospital discharge . RESULTS During study follow-up , more UC patients had an unplanned readmission for any cause ( 44 % vs. 22 % : P=0.019 , OR 1.95 95 % CI 1.10 - 3.48 ) whilst 7 ( 15 % ) versus 5 ( 9 % ) UC and C+HBI patients , respectively , died ( P = NS ) . Overall , 15 ( 26 % ) C+HBI versus 21 ( 44 % ) UC patients experienced a primary endpoint . C+HBI was associated with a non-significant , 45 % reduction in the risk of death or readmission when adjusting for potential confounders ( RR 0.55 , 95 % CI 0.28 - 1.08 : P=0.08 ) . Overall , C+HBI patients accumulated significantly fewer unplanned readmissions ( 15 vs. 45 : P<0.01 ) and days of recurrent hospital stay ( 108 vs. 459 days : P<0.01 ) . C+HBI was also associated with greater uptake of beta-blocker therapy ( 56 % vs. 18 % : P<0.001 ) and adherence to Na restrictions ( P<0.05 ) during 6-month follow-up . CONCLUSION This is the first r and omised study to specifically examine the impact of a hybrid , C+HBI program of care on hospital utilisation in patients with CHF . Its beneficial effects on recurrent readmission and event-free survival are consistent with those applying either a home or clinic-based approach Background Providing information is an important part of st and ard care and treatment for acute myocardial infa rct ion in patients . Evidence exists indicating that acute myocardial infa rct ion patients experience an information gap in the period immediately after discharge from the hospital . The aim of this study was to assess the short-term effects of a nurse-led telephone follow-up intervention to provide information and support to patients with acute myocardial infa rct ion after their discharge from hospital . Design and method A prospect i ve r and omized , controlled trial with a 6-month follow-up was conducted . A total of 288 patients were allocated to either an intervention group ( n = 156 ) or a control group ( n = 132 ) . The latter received routine post-discharge care . The primary endpoint measured at 3 and 6 months after discharge was the health-related quality of life using the 36-item Short Form Health Survey . Secondary endpoints included smoking and exercise habits . Results In both groups , health-related quality of life improved significantly over time on most subscales . A statistically significant difference in favour of the intervention group was found on the 36-item Short Form Health Survey Physical Health Component Summary Scale ( P=0.034 ) after 6 months . No difference was found between the groups on the Mental Health Component Summary Scale . We found a significant difference with respect to frequency of physical activity in favour of the intervention group after 6 months ( P=0.004 ) . More participants in the intervention group than the control group had ceased smoking at the 6-month follow-up ( P=0.055 ) . Conclusion A nurse-led systematic telephone follow-up intervention significantly improved the physical dimension of health-related quality of life in patients in the intervention group compared with usual care patients . Participation in this intervention also seemed to promote health behaviour change in patients after acute myocardial infa rct ion Background —Several trials support the usefulness of disease management ( DM ) for improving clinical outcomes in heart failure ( HF ) . Most of these studies are limited by small sample size ; absence of concurrent , r and omized controls ; limited follow-up ; restriction to urban academic centers ; and low baseline use of effective medications . Methods and Results —We performed a prospect i ve , r and omized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy . During a 90-day follow-up , patients r and omized to DM experienced fewer hospitalizations for HF [ primary end point , 0.55±0.15 per patient-year alive versus 1.14±0.22 per patient-year alive in control subjects ; relative risk ( RR ) , 0.48 , P=0.027 ] . Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF ( 4.3±0.4 versus 7.8±0.6 days hospitalized per patient-year ; RR , 0.54 ; P<0.001 ) , cardiovascular hospitalizations ( 0.81±0.19 versus 1.43±0.24 per patient-year alive ; RR , 0.57 ; P=0.043 ) , and days in hospital per patient-year alive for cardiovascular cause ( RR , 0.64 ; P<0.001 ) . Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days . On long-term ( mean , 283 days ) follow-up , there was substantial attrition of the 3-month gain in outcomes , with sustained significant reduction only in days in hospital for cardiac cause . Conclusions —In a population with high background use of st and ard HF therapy  , a DM intervention , uniformly delivered across varied clinical sites , produced significant short-term improvement in HF-related clinical outcomes . Longer-term benefit likely requires more active chronic intervention , even among patients who appear clinical ly stable BACKGROUND The aim of this study was to determine the effects of a home-based exercise program on clinical outcomes .  Exercise training improves exercise capacity in patients with heart failure ( HF ) but the long-term effects on clinical outcomes remain unknown . METHODS We r and omized 173 patients with systolic HF to control ( n = 87 ) or home-based exercise ( n = 86 ) . The primary end point was a composite of all-cause hospitalizations , emergency department admissions , urgent transplantation , and death at 12 months . Functional performance ( as assessed by cardiopulmonary exercise testing and the 6-minute walk test ) , quality of life , and psychological states were measured at baseline , 3 months , and 6 months . RESULTS There was no significant difference between experimental and control groups in the combined clinical end point at 12 months and in functional status , quality of life , or psychological states over 6 months . Patients in the exercise group had a lower incidence of multiple ( 2 or more ) hospitalizations compared with the control group : 12.8 % versus 26.6 % , respectively ( P = .018 ) . CONCLUSIONS A home-based walking program that incorporated aerobic and resistance exercise did not result in improved clinical outcomes at 1-year follow-up in this cohort of patients with systolic HF . However , the exercise program result ed in reduced rehospitalization rates Objective : To determine if a disease management programme for patients with coronary heart disease and heart failure represents an efficient use of health services re sources . Methods : We carried out an economic evaluation alongside a cluster r and omised control trial of 1163 patients with coronary heart disease and chronic heart failure in 20 primary care practice s in the United Kingdom . Practice s were r and omised to either a control group , where patients received st and ard general practice care , or an intervention group where patients had access to a specialist nurse-led disease management programme . We estimated costs in both groups for coronary heart disease-related re source use . The main outcome measure used in the economic evaluation was quality adjusted life years ( QALY ) measured using the EuroQol . Results : The disease management programme was associated with an increase in the QALY measured of 0.03 per year and an increase in the total NHS costs of £ 425 ( € 540 ) , of this only £ 83 was directly associated with the provision of the nurse clinics . The clinics generated additional QALY at an incremental cost of £ 13 158 per QALY compared to the control group . Conclusions : The use of a nurse-led disease management programme is associated with increased costs in other coronary heart disease-related services as well as for the costs of the clinics . They are also associated with improvements in health . Even in the short term these disease management programmes may represent a cost-effective service , as additional QALY are generated at an acceptable extra cost OBJECTIVE The purpose of this study was to test the effect of a post-discharge telephone counseling intervention on women 's psychosocial adjustment following a cardiac event . DESIGN The study was a prospect i ve , r and omized , controlled trial . PATIENTS Women ( n = 196 ) were recruited from 4 hospitals in Sydney , Australia , who were hospitalized for coronary artery disease : myocardial infa rct ion , coronary artery bypass grafts , coronary angioplasty , or stable angina . Women were r and omized to usual care ( n = 103 ) or telephone counseling ( n = 93 ) and were 67 years of age ( range 34 - 92 ) . The majority had not completed high school ( 92 % ) and were not employed ( 84 % ) . OUTCOMES Psychosocial adjustment was measured by the Psychosocial Adjustment to Illness Scale and the Hospital Anxiety and Depression Scale the day before hospital discharge and 12 weeks postdischarge . INTERVENTION Individualized information and support , was design ed to promote self-managed recovery and psychosocial adjustment , and began with an evaluation during admission and was followed up by telephone counseling at 1 , 2 , 3 , and 6 weeks after discharge . RESULTS The intervention had no effect on psychosocial adjustment ( F[1,182 ] = 0.06 , P = .8 ) , anxiety ( F[1,182 ] = 0.15 , P = .69 ) or depression ( F[1,182 ] = 0.11 , P = .74 ) at 12 weeks after discharge . Women made significant improvements during the 12 weeks on mean scores for psychosocial adjustment ( F[1,182 ] = 58.37 , P = .00 ) , anxiety ( F [ 1,182 ] = 74.58 , P = .00 ) and depression ( F[1,182 ] = 14.11 , P = .00 ) . The predictors of poor psychosocial outcomes for women included being less than 55 years of age , being unemployed or retired , having poor psychosocial adjustment to illness at baseline , having readmission , or experiencing a stressful , personal event during follow-up . CONCLUSIONS Women at risk for poor outcomes following hospitalization for a cardiac event can be identified ( ie , women less than 55 years of age , unemployed or retired , poorly adjusted to their cardiac illness , or readmitted to hospital within 12 weeks of a previous cardiac admission ) , but an effective intervention to enhance psychosocial outcomes remains to be established Background —Although men hospitalized with cardiovascular disease ( CVD ) show high smoking-cessation rates , similar data for women are lacking . We tested the efficacy of  smoking-cessation intervention in women hospitalized for CVD . Methods and Results —In this r and omized controlled trial conducted from 1996 to 2001 , 277 women diagnosed with CVD ( mean age 61±10 years ) were r and omly assigned within 1 of 12 San Francisco Bay Area hospitals to a  usual-care group ( UG ; n=135 ) or intervention group  ( IG ; n=142 ) . Baseline histories were obtained , and interviews to ascertain self-reported smoking status occurred at 6 , 12 , 24 , and 30 months after hospitalization . The UG received strong physician ’s advice , a self-help pamphlet , and a list of community re sources . The IG received strong physician ’s advice and a nurse-managed cognitive behavioral relapse-prevention intervention at bedside , with telephone contact at intervals after discharge . The groups were similar demographically and had smoked cigarettes for a median of 38 ( IG ) or 40 ( UG ) years . Time to resumption of continuous smoking was assessed by Kaplan-Meier analysis , and risk differences between groups were determined . Time smoke-free was significantly greater for the IG than the UG ( P = 0.038 ) . Point prevalence for nonsmoking at the interviews was somewhat greater for the IG than the UG ( P > 0.15 at all times ) . Conclusions —Cognitive behavioral intervention result ed in longer average times to resumption of smoking , but in these 2 groups of older women with limited social and financial re sources , long-term success rates were similar . Systematic identification of smokers and even the brief intervention afforded the UG yielded a high smoking-cessation rate over time Purpose : To evaluate the cost‐effectiveness of case management by a nurse practitioner ( NP ) to lower blood lipids in patients with coronary heart disease ( CHD ) from a managed care perspective . Data sources : A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention from an NP for 1 year after discharge in addition to their usual care ( NURS ) or to receive usual care ( EUC ) enhanced with feedback on lipids to their primary provider and /or cardiologist . A cost‐effectiveness ratio was calculated using incremental costs of the NURS group per unit change and percent change in low‐density lipoprotein cholesterol ( LDL‐C ) for 1 year at 2004 values . Conclusions : The annual incremental cost‐effectiveness of NP case management was $ 26.03 per mg/dL and $ 39.05 per percent reduction in LDL‐C. When costs of NURS care for the second 6 months of management were compared to the first 6 months of management , nursing salary costs were lower as patients were established on cholesterol management regimens , but the reduction in costs was offset by the increase in incremental costs of drug treatment as the NP titrated the patient to higher drug dosages that were more costly . Implication s for practice : The findings suggest that case management by an NP is a cost‐effective approach for a managed care organization to consider in improving the care of patients with cardiovascular disease BACKGROUND There are approximately 1.8 million patients with angina in the United Kingdom , many of whom report a poor quality of life , including raised levels of anxiety and depression . AIM To evaluate the effect of a cognitive behavioural disease management programme , the Angina Plan , on psychological adjustment in patients newly diagnosed with angina pectoris . DESIGN OF STUDY R and omised controlled trial . SETTING Patients from GP practice s in a Northern UK city ( York ) between April 1999 and May 2000 . METHOD Recruited patients were r and omised to receive the Angina Plan or to a routine , practice nurse-led secondary prevention educational session . RESULTS Twenty of the 25 practice s invited to join the study supplied patients ' names ; 142 patients attended an assessment clinic and were r and omised There were no significant differences in any baseline measures . At the six month post-treatment follow-up , 130 ( 91 % ) patients were reassessed . When compared with the educational session patients ( using analysis of covariance adjusted for baseline scores in an intention-to-treat analysis ) Angina Plan patients showed a greater reduction in anxiety ( P = 0.05 ) and depression ( P = 0.01 ) , the frequency of angina ( reduced by three episodes per week , versus a reduction of 0.4 per week , P = 0.016 ) the use of glyceryl trinitrate  ( reduced by 4.19 fewer doses per week versus a reduction of 0.59 per week , P = 0.018 ) , and physical limitations ( P<0.001 : Seattle Angina Question naire ) . They were also more likely to report having changed their diet ( 41 versus 21 , P<0.001 ) and increased their daily walking ( 30 versus 2 , P<0.001 ) . There was no significant difference between the groups on the other sub-scales of the Seattle Angina Question naire or in any of the medical variables measured . CONCLUSION The Angina Plan appears to improve the psychological , symptomatic , and functional status of patients newly diagnosed with angina AIMS To determine the effects of a nurse-led intervention design ed to improve self-management of patients with heart failure in a primary health care setting regarding health-related quality of life and depression . METHODS Patients at eight primary health care centres were screened by the Diagnosis Related Groups registry for the diagnosis of heart failure and eligibility for a cluster r and omised study . A total of 153 patients were included ( n=78 in the intervention group , 54 % males , mean age 79 years , 59 % in New York Heart Association class III-IV ) . The intervention involved patient and family education about heart failure and self-management and monthly telephone follow-up during 12 months by a primary health care nurse . RESULTS The effects of the nurse-led intervention were limited . Significant differences were found in the physical dimension measured by the SF-36 health survey , and in depression measured by the Zung Self-rating Depression Scale . In comparison within groups at the 3 and 12-month follow-up , the intervention group significantly maintained their health-related quality of life measured by the SF-36 health survey , and their experience of depression measured by the Zung Self-rating Depression Scale to a greater extent than in the control group , especially among women . CONCLUSION A nurse-led intervention directed toward patients with heart failure in a primary health care setting result ed in limited effects between the groups , although the physical and mental status were retained during 12 months of follow-up to a greater extent than in the control group Background : The ‘ Fit For Surgery ’ programme was based on previous studies suggesting improvement in risk factors contributing to coronary disease while patients wait for cardiac surgery . Aim : To evaluate our nurse-led programme in a r and omised controlled trial with 188 patients . Methods : Patients listed for coronary artery bypass surgery with at least one poorly controlled risk factor were r and omised to st and ard care or the intervention which provided lifestyle counselling and preparation for surgery at monthly intervals . Primary outcome measurements were anxiety , blood pressure , cholesterol , length of stay and body mass index . Costs of the intervention were also collected . Results : For both groups blood pressure and total cholesterol improved ( Blood pressure mm Hg ( Control − 9.11 ( CI − 4.89 , − 13.33 ) ; Intervention − 13.02 ( CI − 8.76 , − U17.29 ) both p < 0.01 ) ; total cholesterol ( Control − 0.20 ( CI − 0.03 , − 0.37 ) p = 0.02 , Intervention − 0.18 ( CI − 0.02 , − 0.34 ) p = 0.03 ) . However there were no significant differences between the groups . Cost minimization analysis showed that the total costs were less in the intervention group due to fewer admissions ( total costs £ 10,754 ( 3746 ) v £ 13,047 ( 5835 ) , CI − 3743 , − 843 ; p = 0.002 ) . Conclusions : The nurse-led programme did not appear to reduce risk factors prior to coronary artery bypass surgery . However , the intervention appears to reduce overall healthcare utilization Objective Heart failure ( HF ) is a major health problem result ing in a high financial burden for the healthcare system . Many previous HF management programmes reduced adverse clinical outcomes and costs , but they usually involved several professional figures as well as huge investments , requiring re sources and budgets not often available in our healthcare system . We evaluated the effects of our HF management programme , which included patient education and regular outpatient contact with the HF team , on re-hospitalisation and death , optimising the few re sources already available at our hospital . Methods Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were r and omised to the intervention group ( nurse-led education programme , facilitated telephone communication and follow-up visits with an internist at 15 days , 1 and 6 months ) or to the usual care group ( follow-up by their primary care physician ) . The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period . Results There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group ( P = NS ) . Fourteen patients ( 14 % ) in the intervention group and eight patients ( 8 % ) in the control group died during the study period ( P = NS ) . Unplanned outpatient visits were less frequent in the intervention group than in the control group ( 39 [ 28 % ] versus 99 [ 72 % ] , P < 0.001 ) . Conclusions The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status . More intense follow-up monitoring and more re sources are needed to achieve better results There has been a lack of research regarding nonpharmacologic interventions in heart failure . The objective was to determine the effect of behavioral management on health related quality of life ( HRQL ) in patients with heart failure . Participants ( N = 116 ) were r and omly assigned to one of two groups : usual care for heart failure ( n = 58 ) and the 15-week behavioral management program ( n = 58 ) . Outcomes included exercise performance ( 6-min walk ) , physical and mental functioning ( SF-36 ) , general health perceptions ( SF-36 ) , and disease specific HRQL ( Minnesota Living with Heart Failure Question naire-MLHF ) . Outcomes were assessed at baseline , 4 , 10 and 16 months . Participants were mostly male ( 95 % ) and Caucasian ( 75 % ) , with a mean age of 67 years ( S.D. = 10 ) . Intervention patients showed significantly improved self-reported disease specific HRQL ( MLHF physical dimension scores ) over time compared to control patients . There were no group differences in exercise performance , physical functioning , mental functioning or general health perceptions BACKGROUND Disease management is effective in the general population , but it has not been tested prospect ively in a sample of solely Hispanics with heart failure ( HF ) . We tested the effectiveness of telephone case management in decreasing hospitalizations and improving health-related quality of life ( HRQL ) and depression in Hispanics of Mexican origin with HF . METHODS AND RESULTS Hospitalized Hispanics with chronic HF ( n = 134 ) were enrolled and r and omized to intervention ( n = 69 ) or usual care ( n = 65 ) . The sample was elderly ( 72 + /- 11 years ) , New York Heart Association class III/IV ( 81.3 % ) , and poorly educated ( 78.4 % less than high school education ) . Most ( 55 % ) were unacculturated into US society . Bilingual/bicultural Mexican-American registered nurses provided 6 months of st and ardized telephone case management . Data on hospitalizations were collected from automated systems at 1 , 3 , and 6 months after the index hospital discharge . Health-related quality of life and depression were measured by self-report at enrollment , 3 , and 6 months . Intention to treat analysis was used . No significant group differences were found in HF hospitalizations , the primary outcome variable ( usual care : 0.49 + /- 0.81 [ CI 0.25 - 0.73 ] ; intervention : 0.55 + /- 1.1 [ CI 0.32 - 0.78 ] at 6 months ) . No significant group differences were found in HF readmission rate , HF days in the hospital , HF cost of care , all-cause hospitalizations or cost , mortality , HRQL , or depression . CONCLUSION These results have important implication s because of the current widespread enthusiasm for disease management . Although disease management is effective in the mainstream HF patient population , in Hispanics this ill , elderly , and poorly educated , a different approach may be needed Aim : To determine whether an intensive intervention at a heart failure ( HF ) clinic by a combination of a clinician and a cardiovascular nurse , both trained in HF , reduces the incidence of hospitalisation for worsening HF and /or all-cause mortality ( primary end point ) and improves functional status ( including left ventricular ejection fraction , New York Heart Association ( NYHA ) class and quality of life ) in patients with NYHA class III or IV . Setting : Two regional teaching hospitals in The Netherl and s. Methods : 240 patients were r and omly allocated to the 1-year intervention  ( n = 118 ) or usual care ( n = 122 ) . The intervention consisted of 9 scheduled patient contacts — at day 3 by telephone , and at weeks 1 , 3 , 5 , 7 and at months 3 , 6 , 9 and 12 by a visit — to a combined , intensive physician- and -nurse-directed HF outpatient clinic , starting within a week after hospital discharge from the hospital or referral from the outpatient clinic . Verbal and written comprehensive education , optimisation of treatment , easy access to the clinic , recommendations for exercise and rest , and advice for symptom monitoring and self-care were provided . Usual care included outpatient visits initialised by individual cardiologists in the cardiology departments involved and applying the guidelines of the European Society of Cardiology . Results : During the 12-month study period , the number of admissions for worsening HF and /or all-cause deaths in the intervention group was lower than in the control group ( 23 vs 47 ; relative risk ( RR ) 0.49 ; 95 % confidence interval ( CI ) 0.30 to 0.81 ; p = 0.001 ) . There was an improvement in left ventricular ejection fraction ( LVEF ) in the intervention group ( plus 2.6 % ) compared with the usual care group ( minus 3.1 % ; p = 0.004 ) . Patients in the intervention group were hospitalised for a total of 359 days compared with 644 days for those in the usual care group . Beneficial effects were also observed on NYHA classification , prescription of spironolactone , maximally reached dose of β-blockers , quality of life , self-care behaviour and healthcare costs . Conclusion : A heart failure clinic involving an intensive intervention by both a clinician and a cardiovascular nurse substantially reduces hospitalisations for worsening HF and /or all-cause mortality and improves functional status , while decreasing healthcare costs , even in a country with a primary -care-based healthcare system AIM The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu , China . BACKGROUND Epidemiological studies indicate a dose- , level- and duration -dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality . Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes . DESIGN METHODS A r and omized controlled trial was conducted . Coronary heart disease patients ( n = 167 ) who met the sampling criteria in two tertiary medical centres in Chengdu , south-west China , were r and omly assigned to either an intervention group ( the cardiac rehabilitation programme ) or control group ( the routine care ) . The change of health behaviours ( walking performance , step II diet adherence , medication adherence , smoking cessation ) and physiological risk parameters ( serum lipids , blood pressure , body weight ) were assessed to evaluate the programme effect . RESULTS Patients in the intervention group demonstrated a significantly better performance in walking , step II diet adherence , medication adherence ; a significantly greater reduction in serum lipids including triglyceride , total cholesterol , low-density lipoprotein ; and significantly better control of systolic and diastolic blood pressure at three months . The majority of these positive impacts were maintained at six months . The effect of the programme on smoking cessation , body weight , serum high-density lipoprotein , was not confirmed . CONCLUSIONS A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients . Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease . RELEVANCE TO CLINICAL PRACTICE This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients . Furthermore , the hospital-home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care BACKGROUND The long-term effects of disease management programmes for coronary heart disease on health status are unknown . In a r and omized trial of nurse-led secondary prevention clinics , we found significantly improved health status at 1 year . Participants were followed-up again at 4 years to determine if improvements had been sustained . OBJECTIVE Our aim was to evaluate the effects on health of  nurse-led clinics for the secondary prevention of coronary heart disease in primary care . METHODS A total of 1343 patients with coronary heart disease were r and omized to nurse-led secondary prevention clinics or usual care  , with follow-up at 1 and 4 years by review of medical case notes and national data sets , and postal question naires . The study involved a stratified , r and om sample of 19 general practice s in north-east Scotl and .  Health status was measured by the SF-36 question naire , chest pain by the angina TyPE specification and anxiety and depression by the hospital anxiety and depression scale . RESULTS At 1 year , there were significant improvements in five of eight SF-36 domains ( all functioning scales , pain and general health ) in patients r and omized to clinics . Role limitations attributed to physical problems improved the most [ adjusted difference 8.52 , 95 % confidence interval ( CI ) 4.16 - 12.9 ] . At 4 years , the intervention group scored higher than control in all domains , but differences were no longer significant . At 1 year , fewer patients in the intervention group reported worsening chest pain ( odds ratio 0.59 , 95 % C1 0.37 - 0.94 ) . At 4 years , there were no significant differences between the proportion of intervention or control group patients who reported chest pain in the last week or who reported worsening chest pain . No significant effects were observed on anxiety or depression at 1 or 4 years . CONCLUSION We have demonstrated previously a significantly greater survival in attendees at nurse-led secondary prevention clinics . Despite this , improvements in health status achieved in the first year of the study were reduced at 4 years . The case for nurse-led clinics remains strong , but further research is required on ways to optimize current health status Cost and accessibility contribute to low participation rates in phase 2 cardiac rehabilitation programs in the United States . In this study , we compared the clinical effectiveness of 2 less costly and potentially more accessible approaches to cardiovascular risk reduction with that of a contemporary phase 2 cardiac rehabilitation program . Low- or moderate-risk patients ( n = 155 ) with coronary artery disease ( CAD ) were r and omly assigned to 12 weeks of participation in a  contemporary phase 2 cardiac rehabilitation program ( n = 52 ) , a physician supervised , nurse-case-managed cardiovascular risk reduction program ( n = 54 ) , or a community-based cardiovascular risk reduction program administered by exercise physiologists guided by a computerized participant management system based on national clinical guidelines ( n = 49 ) . In all , 142 patients ( 91.6 % ) completed testing at baseline and after 12 weeks of intervention . For patients with abnormal ( i.e. , not at the goal level ) baseline values , statistically significant ( p < or = 0.05 ) improvements were observed with all 3 interventions for multiple CAD risk factors . No statistically significant risk factor differences were observed among the 3 programs . For patients with a baseline maximal oxygen uptake < 7 metabolic equivalents , cardiorespiratory fitness increased to a greater degree in patients in the cardiac rehabilitation program and the community-based program versus the physician-supervised , nurse- case-managed program . These data have important implication s for cost containment and increasing accessibility to clinical ly effective comprehensive cardiovascular risk reduction services in low- or moderate-risk patients with CAD BACKGROUND Both r and omized and nonr and omized controlled studies have linked congestive heart failure ( CHF ) case management ( CM ) to decreased readmissions and improved outcomes in mostly homogeneous setting s. The objective of this r and omized controlled trial was to test the effect of CHF CM on the 90-day readmission rate in a more heterogeneous setting . METHODS A total of 287 patients admitted to the hospital with the primary or secondary diagnosis of CHF , left ventricular dysfunction of less than 40 % , or radiologic evidence of pulmonary edema for which they underwent diuresis were r and omized . The intervention consisted of 4 major components : early discharge planning , patient and family CHF education , 12 weeks of telephone follow-up , and promotion of optimal CHF medications . RESULTS The 90-day readmission rates were equal for the CM and usual care groups ( 37 % ) . Total inpatient and outpatient median costs and readmission median cost were reduced 14 % and 26 % , respectively , for the intervention group . Patients in the CM group were more likely to be taking CHF medication at target doses , but dosages did not increase significantly throughout 12 weeks . Although both groups took their medications as prescribed equally well , the rest of the adherence to treatment plan was significantly better in the CM group . Subgroup analysis of patients who lived locally and saw a cardiologist showed a significant decrease in CHF readmissions for the intervention group ( P = .03 ) . CONCLUSIONS These results suggest several limitations to the generalizability of the CHF CM-improved outcome link in a heterogeneous setting . One explanation is that the lack of coordinated system supports and varied accessibility to care in an extended , nonnetworked physician setting limits the effectiveness of the CM OBJECTIVES To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses ( APNs ) to elders hospitalized with heart failure . DESIGN R and omized , controlled trial with follow-up through 52 weeks postindex hospital discharge . SETTING Six Philadelphia academic and community hospitals . PARTICIPANTS Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure . INTERVENTION A 3-month APN-directed discharge planning and home follow-up protocol . MEASUREMENTS Time to first rehospitalization or death , number of rehospitalizations , quality of life , functional status , costs , and satisfaction with care . RESULTS Mean age of patients ( control n=121 ; intervention n=118 ) enrolled was 76 ; 43 % were male , and 36 % were African American .  Time to first readmission or death was longer in intervention patients ( log rank chi(2)=5.0 , P=.026 ; Cox regression incidence density ratio=1.65 , 95 % confidence interval=1.13 - 2.40 ) . At 52 weeks , intervention group patients had fewer readmissions ( 104 vs 162 , P=.047 ) and lower mean total costs ( $ 7,636 vs $ 12,481 , P=.002 ) . For intervention patients , only short-term improvements were demonstrated in overall quality of life ( 12 weeks , P<.05 ) , physical dimension of quality of life ( 2 weeks , P<.01 ; 12 weeks , P<.05 ) and patient satisfaction ( assessed at 2 and 6 weeks , P<.001 ) . CONCLUSION A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death , reduced total number of rehospitalizations , and decreased healthcare costs , thus demonstrating great promise for improving clinical and economic outcomes PURPOSE Despite demonstrated benefits of cardiac rehabilitation and risk factor reduction , only 11 % to 38 % of eligible patients with cardiovascular disease ( CVD ) participate in cardiac rehabilitation programs .  Women and older adults are particularly less likely to participate in cardiac rehabilitation . In an effort to broaden access to cardiac rehabilitation , the authors developed an alternative Internet-based program that allows nurse case managers to provide risk factor management training , risk factor education , and monitoring services to patients with CVD . METHODS The evaluation consisted of a r and omized , clinical trial involving 104 patients with CVD , 53 of whom used the program as a special intervention ( SI ) for 6 months and 51 of whom received usual care ( UC ) .  RESULTS The results indicate that fewer cardiovascular events occurred among the SI subjects ( 15.7 % ) than among the UC subjects ( 4.1 % ) ( P = .053 ) , result ing in a gross cost savings of $ 1418 US dollars per patient . With a projected program cost of $ 453 USD per patient , the return on investment is estimated at 213 % . More weight loss occurred in the SI group ( -3.68 pounds ) than in the UC group ( + .47 pounds ) ( P = .003 ) . The differences between the two groups in terms of blood pressure , lipid levels , depression scores , minutes of exercise , and dietary habits were not statistically significant . CONCLUSION An Internet-based case management system could be used as a cost-effective intervention for patients with CVD , either independently or in conjunction with traditional cardiac rehabilitation BACKGROUND Heart failure ( HF ) disease management programs are widely implemented , but data about their effect on outcome have been inconsistent . METHODS The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure ( COACH ) was a multicenter , r and omized , controlled trial in which 1023 patients were enrolled after hospitalization because of HF . Patients were assigned to 1 of 3 groups : a control group ( follow-up by a cardiologist ) and 2 intervention groups with additional basic or intensive support by a nurse specializing in management of patients with HF .  Patients were studied for 18 months . Primary end points were time to death or rehospitalization because of HF and the number of days lost to death or hospitalization . RESULTS Mean patient age was 71 years ; 38 % were women ; and 50 % of patients had mild HF and 50 % had moderate to severe HF . During the study , 411 patients ( 40 % ) were readmitted because of HF or died  from  any cause : 42 % in the control group , and 41 % and 38 % in the basic and intensive support groups , respectively ( hazard ratio , 0.96 and 0.93 , respectively ; P = .73 and P = .52 , respectively ) . The number of days lost to death or hospitalization was 39 960 in the control group , 33 731 days for the basic intervention group ( P = .81 ) , and 34 268 for the intensive support group ( P = .49 ) . All-cause mortality occurred in 29 % of patients in the control group , and there was a trend toward lower mortality in the intervention groups combined ( hazard ratio , 0.85 ; 95 % confidence interval , 0.66 - 1.08 ; P = .18 ) . There were slightly more hospitalizations in the 2 intervention groups ( basic intervention group , P = .89 ; and intensive support group , P = .60 ) . CONCLUSIONS Neither moderate nor intensive disease management by a nurse specializing in management of patients with HF reduced the combined end points of death and hospitalization because of HF compared with st and ard follow-up . There was a nonsignificant , potentially relevant reduction in mortality , accompanied by a slight increase in the number of short hospitalizations in both intervention groups . Clinical Trial Registry http://trialregister.nl Identifier : NCT 98675639 Background : After the cardiovascular events of myocardial infa rct ion ( MI ) and coronary artery bypass surgery ( CABS ) , unpartnered older adults are a vulnerable group that may benefit from interventions to improve health outcomes . The purpose of this analysis is to determine if a community-based collaborative peer advisor/advanced practice nurse intervention increased participation in cardiac rehabilitation programs and reduced hospital readmissions after MI and CABS and determine whether the type of cardiovascular event influenced rehospitalization . Subjects and Methods : This study was a r and omized clinical trial that enrolled 247 unpartnered older adults who were single , widowed , or divorced . Subjects were r and omized into 4 groups : st and ard of care group for MI and for CABS and st and ard of care plus the treatment groups for MI and for CABS , for 12 weeks after discharge . There were 163 women/84 men , with a mean age of 76.4 years , who were admitted for MI ( n = 93 ) or CABS ( n = 154 ) and who were enrolled from 5 academic medical centers . The treatment consisted of a community-based intervention of a home visit within 72 hours and telephone calls at 2 , 6 , and 10 weeks from an advanced practice nurse and 12 weekly telephone calls from a peer advisor .  Participation in a cardiac rehabilitation program and rehospitalizations were collected at 6 weeks and 3 , 6 , and 12 months by telephone interview . Results and Conclusions : There were significantly more participants in cardiac rehabilitation programs after 3 months in the treatment group , and this increase was seen up to 1 year after MI and CABS . There were no statistical differences , although there were fewer rehospitalizations between 3 and 6 months after MI and CABS in the treatment group compared with the st and ard of care group . Overall , the evidence from this study suggests that a community-based collaborative peer advisor/advanced practice nurse intervention can play a role in promoting active participation in cardiac rehabilitation programs and fewer rehospitalizations in unpartnered older adults after MI and CAGS AIM The aim of this trial was to prospect ively evaluate the effect of follow-up at a nurse-led heart failure clinic on mortality , morbidity and self-care behaviour for patients hospitalised due to heart failure for 12 months after discharge . METHODS A total of 106 patients were r and omly assigned to either follow-up at a nurse-led heart failure clinic or to usual care . The nurse-led heart failure clinic was staffed by specially educated and experienced cardiac nurses , delegated the responsibility for making protocol -led changes in medications . The first follow-up visit was 2 - 3 weeks after discharge . During the visit the nurse evaluated the heart failure status and the treatment , gave education about heart failure and social support to the patient and his family . RESULTS There were fewer patients with events ( death or admission ) after 12 months in the intervention group compared to the control group ( 29 vs 40 , p=0.03 ) and fewer deaths after 12 months ( 7 vs 20 , p=0.005 ) . The intervention group had fewer admissions ( 33 vs 56 , p=0.047 ) and days in hospital ( 350 vs 592 , p=0.045 ) during the first 3 months . After 12 months the intervention was associated with a 55 % decrease in admissions/patient/month ( 0.18 vs 0.40 , p=0.06 ) and fewer days in hospital/patient/month ( 1.4 vs 3.9 , p=0.02 ) . The intervention group had significantly higher self-care scores at 3 and 12 months compared to the control group ( p=0.02 and p=0.01 ) . CONCLUSIONS Follow up after hospitalisation at a nurse-led heart failure clinic can improve survival and self-care behaviour in patients with heart failure as well as reduce the number of events , readmissions and days in hospital The effects of a nurse-managed secondary prevention program for patients after acute cardiac events were examined . Special interest was given to gender-specific results . The design was a prospect i ve , r and omized , controlled trial involving 343 patients following 3 weeks of inpatient cardiac rehabilitation , r and omly assigned to either of two study groups . Patients in the treatment group were contacted monthly by phone over 1 year . The main goals of the intervention were the reduction of behavioural coronary risk factors and enhancing quality of life . The program was conducted by specially trained nurses . The control group received written information only . Primary outcome was the Framingham risk score . Follow-up examination after 12 months was completed by 297 patients . Patients in the intervention group showed lower Framingham risk scores as compared to controls . Separate analyses by sex revealed that this was mostly due to the men in the sample . Women , on the other h and , showed a significant rise of clinical ly relevant anxiety/depressiveness in the control but not in the intervention group ; in males there were no differences between study conditions . In conclusion , telephone counselling by specially trained nurses seems a cost-effective way to achieve a lasting reduction in cardiac risk factors and to maintain the effects of cardiac rehabilitation . Effekte eines von Pflegepersonal durchgefuehrten Nachsorgeprogramms fuer Koronarpatienten wurden untersucht . Besondere Aufmerksamkeit galt moeglichen Gendereffekten . Es h and elt sich um eine prospektive , r and omisierte , kontrollierte Studie . 343 Patienten wurden nach stationaerer kardiologischer Rehabilitation auf eine von zwei Studiengruppen r and omisiert . Patienten in der Interventions gruppe wurden über ein Jahr ca . einmal i m Monat telephonisch kontaktiert . Hauptziele der Intervention waren die effektive und nachhaltige Reduktion verhaltensgebundener Risikofaktoren sowie die Verbesserung der Lebensqualitaet . Das Programm wurde von speziell dafuer fortgebildetem Pflegepersonal durchgefuehrt . Die Kontrollgruppe erhielt nur schriftliches Informations material . Primaerer Endpunkt war das globale koronare Risiko ( Framingham Score ) . Von 297 Patienten wurden komplette Date n bei der Abschlussuntersuchung nach 12 Monaten erhalten . Patienten in der Interventions gruppe zeigten niedrigere Framingham-Scores als Kontrollpatienten . Getrennte Analysen nach Geschlecht ergaben , dass dieser Effekt hauptsaechlich auf die Maenner zurueckzufuehren ist ; bei den Frauen zeigten sich keine Unterschiede zwischen den Studiengruppen . Auf der and eren Seite zeigte sich bei den Frauen in der Kontrollgruppe eine deutliche Zunahme an Angst bzw . Depressivitaet ; ein entsprechender Effekt f and sich bei den Maennern nicht . Telefonische Nachsorge durch speziell fortgebildetes Pflegepersonal scheint ein kostenguenstiger Weg zu sein , koronare Risikofaktoren zu reduzieren und die Effekte von kardiologischer Rehabilitation aufrechtzuerhalten . Se evaluaron los result ados de un programa secundario de prevención dirigido por el personal de enfermería para pacientes que han sufrido un trastorno cardiovascular agudo . Se dio una especial importancia a los result ados específicos para cada sexo . Se trata de un estudio prospect ivo , aleatorizado , comparativo , en el que participaron 343 pacientes tras 3 semanas de haber recibido rehabilitación cardiovascular , a quienes se dividieron en dos grupos , de manera aleatoria . Los pacientes del grupo que recibió tratamiento fueron contactados por teléfono una vez al mes durante 1 año . Los principales objetivos de la intervención fueron reducir los factores de riesgo de las cardiopatías arterioscleróticas relacionados con el actuar de los pacientes , y mejorar la calidad de vida de éstos . La realización del programa estuvo a cargo de un grupo de enfermeras y enfermeros especialmente entrenados para ello . El grupo de referencia recibió información sólo por escrito . Los result ados iniciales se obtuvieron aplic and o la escala de riesgo de Framingham . En las valoraciones de seguimiento , realizadas tras 12 meses , participaron 292 pacientes . Los valores en la escala de riesgo de Framingham fueron más bajos en los pacientes del grupo que recibió la intervención que en el grupo de referencia . Los análisis según el sexo revelaron que el aporte mayor a este result ado provino de los varones de la muestra . Por su parte , las mujeres del grupo de referencia presentaron un aumento importante de la ansiedad/depresión relacionada con el proceso de enfermedad , lo cual no se apreció en el grupo que recibió tratamiento . Entre los varones no se apreciaron diferencias relacionadas con las condiciones del estudio . En conclusión , el apoyo emocional por vía telefónica brindado por el personal de enfermería especialmente entrenado para ello parece ser una manera rentable de disminuir de forma perdurable los factores de riesgo para las cardiopatías arterioscleróticas , así como de perpetuar los result ados de la rehabilitación cardiovascular . Cette étude examine les effets d'un programme de prévention secondaire sous surveillance du personnel infirmier pour les patients ayant souffert d'incidents cardiaques aigus . Une attention toute particulière a été donnée aux résultats selon le sexe . L'essai était de type prospect if , r and omisé et contrôlé , avec la participation de 343 patients après 3 semaines de rééducation cardiaque dans des conditions d'hospitalisation , affectés de manière aléatoire à l'un ou l'autre des deux groupes d'étude . Les patients appartenant au groupe de traitement ont été contactés tous les mois par téléphone sur une période de 1 an . Les principaux objectifs de l'intervention étaient la réduction des facteurs comportementaux de risque coronaire et l'amélioration de la qualité de vie . Le programme était administré par des infirmiers spécialement formés . Le groupe témoin recevait simplement des informations écrites . Le principal résultat était le score de risque de Framingham .  297 patients ont subi des examens de suivi après 12 mois . Les patients appartenant au groupe d'intervention ont affiché des scores de risque de Framingham inférieurs à ceux du groupe témoin . Les analyses séparées par sexe révèlent que la différence porte principalement sur les hommes . Les femmes , par contre , affichent une augmentation significative des tendances dépressives/à l'anxiété , cliniquement pertinente dans le groupe témoin , contrairement au groupe d'intervention ; chez les hommes , on ne note aucune différence entre les conditions d'étude . En conclusion , le conseil téléphonique administré par des infirmiers spécialement formés semble constituer un mode économique et efficace pour parvenir à une réduction durable des facteurs de risques cardiaques et préserver les effets de la rééducation cardiaque OBJECTIVE To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting ( CABG ) . DESIGN R and omised controlled trial . SETTING Community , January 1997 to March 1998 . STUDY GROUPS 98 ( 75 male ) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust . Patients were r and omly assigned to  usual care ( control ; n = 49 ) or a  nurse led intervention programme  ( n = 49 ) . INTERVENTION A shared care programme consisting of health education and motivational interviews , according to individual need , was carried out monthly . Care was provided in the patients ' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic . OUTCOME MEASURES Smoking status , obesity , physical activity , anxiety and depression , general health status , and proportion of patients exceeding target values for blood pressure , plasma cholesterol , and alcohol intake . RESULTS Compared with patients who received usual care , those participating in the nurse led programme were more likely to stop smoking ( 25 % v 2 % , p = 0.001 ) and to reduce obesity ( body mass index > 30 kg/m2 ) ( 16.3 % v 8.1 % , p = 0.01 ) . Target systolic blood pressure improved by 19.8 % compared with a 10.7 % decrease in the control group ( p = 0.001 ) and target diastolic blood pressure improved by 21.5 % compared with 10.2 % in the control group ( p = 0.000 ) . However , there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values . There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 ( p = 0.005 ) to 36.1 ( p < 0.000 ) . Levels of anxiety and depression improved ( p < 0.000 ) and there was improvement in time spent being physically active ( p < 0.000 ) . CONCLUSIONS This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms This study determined the effectiveness of a self-efficacy intervention design ed to improve selfefficacy and physical activity in older adults postcardiac event . An experimental three-group design tested the intervention , with treatment groups receiving 1 of 2 supportive telephone protocol s ( theory-based self-efficacy coaching or attention control ) . Outcome variables included selfefficacy expectations for physical activity ( PA ) , self-reported PA , and PA performance ( distance walked in 6 minutes ) . The self-efficacy intervention was effective in demonstrating greater PA performance when compared to the attention control intervention , and PA self-efficacy was significantly correlated with both measures of PA . There were significant main effects of time for PA self-efficacy and distance walked , and a significant interaction effect on the distance walked because of time and treatment condition . Although the self-efficacy intervention did not show a direct effect on level of PA self-efficacy as hypothesized , there was an indirect interaction effect on distance walked and physical activity confidence Patients with chronic conditions are heavy users of the health care system . There are opportunities for significant savings and improvements to patient care if patients can be maintained in their homes . A r and omized control trial tested the impact of 3 months of telehome monitoring on hospital readmission , quality of life , and functional status in patients with heart failure or angina . The intervention consisted of video conferencing and phone line transmission of weight , blood pressure , and electrocardiograms . Telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with heart failure or angina . Patients found the technology easy to use and expressed high levels of satisfaction .  Telehealth technologies are a viable means of providing home monitoring to patients with heart disease at high risk of hospital readmission to improve their self-care abilities Context Although evidence indicates that nurse-led care management improves clinical outcomes for patients with heart failure , evidence on the economic benefits of these programs is lacking . Contribution Using data on costs from a r and omized trial of 12 months of care management versus usual care for socioeconomically disadvantaged patients with heart failure , the investigators estimated that the cost-effectiveness of case management is less than $ 20000/QALY . Caution The results might not apply to patients in less socioeconomically disadvantaged setting s. The Editors Health care administrators and policymakers are increasingly turning to nurse-led disease management to lessen the economic and health burden of chronic diseases , such as heart failure . Meta-analyses of r and omized , controlled trials ( RCTs ) suggest that nurse management can be effective at reducing rehospitalization and sometimes at improving functioning ( 1 ) . To our knowledge , however , no previous RCT has included a cost-effectiveness analysis sufficient to inform policymakers as to whether nurse management improves quality of life for patients with heart failure at a reasonable cost to society . Studies have not followed recommended cost-effectiveness guidelines or thoroughly calculated intervention costs ( 2 ) . Establishing the cost-effectiveness of nurse management for heart failure may be especially important in minority communities , which have disproportionate rates of hospitalization for heart failure ( 3 ) and shortfalls in the use of proven effective therapies ( 4 ) and in patients ' underst and ing of heart failure ( 5 ) . We aim ed to estimate the cost-effectiveness of a nurse-led disease management intervention that was conducted alongside a r and omized , controlled effectiveness trial . The trial , conducted in Harlem , New York , from 1999 to 2003 , found that patients in the nurse-managed group maintained better physical functioning , as measured by the Short Form-12 ( SF-12 ) physical component score , and had statistically significantly fewer hospitalizations than did patients in the control group ( 6 ) . Methods For the RCT , we recruited patients from outpatient clinics at the 4 hospitals serving East and Central Harlem in New York City . We r and omly assigned 406 patients to usual care ( 203 patients ) or a nurse-led program ( 203 patients ) in which patients had 1 in-person visit with a trained nurse and periodic follow-up telephone calls over 12 months ( 6 ) . The nurses stressed adherence to a low-salt diet and to medications and worked with the patient 's physician to optimize heart failure medications according to published guidelines . Primary outcomes were total hospitalizations and physical functioning as measured by the SF-12 physical component score . Trained surveyors who were blinded to treatment assignment called patients in both groups every 3 months for 18 months to administer the SF-12 and collect information on health care utilization , amount of informal care received , and patients ' estimates of their time engaged in receiving health care over the past 3 months . We measured cost-effectiveness by using the incremental cost-effectiveness ratio ( ICER ) , which is the difference in average costs between the nurse-managed and usual care groups ( CostNCostUC ) divided by the difference in mean quality -adjusted life-years ( QALYs ) ( QALYNQALYUC ) : ICER = (CostNCostUC)/(QALYNQALYUC ) QALYs We estimated QALYs for the 12-month intervention by translating the SF-12 physical and mental component scores into Health Utility Index Mark 3 ( HUI3 ) and EuroQol-5D ( EQ-5D ) quality -of-life scores by using methods described by Franks and colleagues ( 7 ) . We chose these translations over other published methods ( 810 ) because they were vali date d in African-American patients , and most of the patients in our trial were African American or Hispanic . Patients who died were assigned a quality -of-life score of 0 in subsequent periods . We calculated QALYs by connecting the 5 quality -of-life scores for each patient ( baseline and quarterly through 12 months ) by using straight lines and calculating the area of the result ing 4 trapezoids . We estimated adjusted differences in QALYs by the coefficient on treatment from a linear regression of each patient 's QALY on his or her quality -of-life score at baseline and treatment assignment ( 11 ) . Societal Costs We followed guidelines for cost-effectiveness analysis ( 2 ) to estimate costs from a societal perspective and included intervention , medical , and nonmedical costs ( Appendix Table ) . Intervention costs included all intervention material s ( for example , scales ) , telephone service for 2 patients who did not have it , patients ' transportation costs to the initial nurse meeting , nurses ' salaries and fringe benefits , physician time overseeing the nurse activities , and costs for office space and equipment used by the nurses . Appendix Table . Data Sources and Imputations for Cost Items We derived medical costs for inpatient , outpatient , and emergency department use from administrative records from the 4 hospitals that participated in the trial . For inpatient costs , we converted billed charges to costs by using the cost-to-charge ratio for each hospital ( 2 , 12 ) and converted the costs to 2001 U.S. dollars by using the Producer Price Index for general and surgical hospitals ( 13 ) . For outpatient and emergency department cl aims , we applied the 2001 Medicare fee schedule for the New York City region ( 14 ) to billed procedure codes . For medication costs , we obtained medications prescribed from patients ' charts and prices for those medications from the average prices paid by Medicaid ( 15 ) . We used quarterly patient surveys to collect information on inpatient and outpatient utilization at nonparticipating institutions ( to supplement administrative records from participating hospitals ) and information on nonmedical costs , which included nursing home stays ; patient transportation and time costs associated with medical encounters ; and costs of informal care or assistance with household chores provided by friends , family members , or paid housekeepers . Costs are reported in 2001 U.S. dollars . Because of skewed cost data and a high percentage of patients with zero costs for many cost categories , we evaluated the statistical significance of the difference in costs between nurse-managed and usual care groups by using 2-part gamma models ( 16 ) . In the first part , we estimated the probability of costs being greater than 0 by logistic regression , with treatment assignment ; age ; sex ; race ( non-Hispanic black , non-Hispanic white , or other non-Hispanic ) ; Hispanic ethnicity ; recruitment site ; education ; preference for Spanish interview ; New York Heart Association ( NYHA ) heart failure class ; and indicators for diabetes , chronic pulmonary disease , and ischemic heart disease as explanatory variables . In the second part , for patients with costs greater than zero , we modeled costs as a function of the same explanatory variables by using generalized linear models with a gamma distribution and a logarithmic link function . For nursing home costs , which had a very small probability of being greater than 0 , we calculated unadjusted differences in mean costs and bootstrapped SEs by using 500 replicates stratified by treatment . We replaced missing observations for SF-12 scores and self-reported utilization with 10 imputed values found by using imputation by chained equations ( 17 ) as implemented by the ICE comm and in Stata , version 10.0 ( StataCorp , College Station , TX ) ( 18 ) . The previously listed explanatory variables at baseline and administrative data for hospitalizations and outpatient visits at baseline and quarterly follow-up were regressors in these equations . We estimated the 2-part models described previously on each imputed data set and combined the results by using Rubin 's rules ( 19 ) . Uncertainty in the ICER We created 500 bootstrapped replicates ( 50 from each of the 10 imputations ) and plotted the corresponding cost-effectiveness acceptability curves ( 20 ) . We calculated approximate empirical CIs for the ICER by using the bootstrap percentile method ( 21 ) . To explore whether nurse management is more likely to be cost-effective for patients with varying heart failure severity , we computed separate acceptability curves according to baseline NYHA class . Sensitivity Analysis We estimated costs on the basis of national prices for all cost items . We used the national 2001 Medicare fee schedule to calculate costs for outpatient and emergency department use ( 14 ) , deflated costs for hospitalizations and self-reported medical use by the ratio of the United States to New York metropolitan area Consumer Price Index for medical care , and deflated nonmedical costs by the ratio of the United States to New York metropolitan area Consumer Price Index for urban dwellers ( 22 ) . To characterize the cost implication s from the payer 's perspective , we also calculated costs to the Medicare program on the basis of categories and proportions of societal costs that Medicare typically covers . These included intervention costs but excluded costs for nursing home stays , patient time , telephone consultations , nonphysician office visits , and informal care . We decreased payer costs by the deductible and copayment rates for Medicare beneficiaries in 2001 . We included drug costs because Medicare and most insurers now cover medications . We assumed the deductible and copayment rate of the 2006 Medicare prescription drug plan , but no coverage gap . We investigated the influence of imputing missing survey data on the results by reporting the ICER for the observed data only ( available data analysis ) for patients who responded to every quarterly telephone survey until death or 12 months ( complete case analysis ) and for a data set in which a patient 's missing observations were replaced with the mean value of that patient 's observed responses ( patient-specific imputation ) . We conducted all analyses in Stata , version 10 ( 18 ) . The Abstract Objectives : To evaluate the effects of nurse led clinics in primary care on secondary prevention , total mortality , and coronary event rates after four years . Design : Follow up of a r and omised controlled trial by postal question naires and review of case notes and national data sets . Setting : Stratified , r and om sample of 19 general practice s in north east Scotl and . Participants : 1343 patients ( 673 intervention and 670 control ) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound . Intervention : Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year . Main outcome measures : Components of secondary prevention ( aspirin , blood pressure management , lipid management , healthy diet , exercise , non-smoking ) , total mortality , and coronary events ( non-fatal myocardial infa rct ions and coronary deaths ) . Results : Mean follow up was at 4.7 years . Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year , and these were sustained after four years except for exercise . The control group , most of whom attended clinics after the initial year , caught up before final follow up , and differences between groups were no longer significant . At 4.7 years , 100 patients in the intervention group and 128 in the control group had died : cumulative death rates were 14.5 % and 18.9 % , respectively ( P=0.038 ) . 100 coronary events occurred in the intervention group and 125 in the control group : cumulative event rates were 14.2 % and 18.2 % , respectively ( P=0.052 ) . Adjusting for age , sex , general practice , and baseline secondary prevention , proportional hazard ratios were 0.75 for all deaths ( 95 % confidence intervals 0.58 to 0.98 ; P=0.036 ) and 0.76 for coronary events ( 0.58 to 1.00 ; P=0.049 ) Conclusions : Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events .  Secondary prevention clinics should be started sooner rather than later . What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease , but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary OBJECTIVE The goal of this study was to determine the effects of a supportive educational nursing intervention on self-care abilities , self-care behavior , and quality of life of patients with advanced heart failure . DESIGN The study design was an experimental , r and om assignment . SETTING The study was located at the University Hospital in Maastricht , The Netherl and s. PATIENTS The study included 179 patients ( mean age 73 years , 58 % men , New York Heart Association classification III and IV ) admitted to a university hospital with symptoms of heart failure . OUTCOME MEASURES Outcome measures included self-care abilities ( Appraisal of Self-care Agency Scale ) , self-care behavior ( Heart Failure Self-care Behavior Scale ) , 3 dimensions of quality of life ( functional capabilities , symptoms , and psychosocial adjustment to illness ) , and overall well-being ( Cantril 's ladder of life ) . INTERVENTION The intervention patients received systematic education and support by a nurse in the hospital and at home . Control patients received routine care . RESULTS Self-care abilities did not change as a result of the intervention , but the self-care behavior in the intervention group was higher than the self-care behavior in the control group during follow-up . The effect of the supportive educational intervention on quality of life was limited . The 3 dimensions of quality of life improved after hospitalization in both groups , with no differences between intervention and control group as measured at each follow-up measurement . However , there was a trend indicating differences between the 2 groups in decrease in symptom frequency and symptom distress during the 9 months of follow-up . CONCLUSION A supportive educational nursing intervention is effective in improving self-care behavior in patients with advanced ( New York Heart Association class III-IV ) heart failure ; however , a more intensive intervention is needed to show effectiveness in improving quality of life The time that elapses from the onset of symptoms of acute myocardial infa rct ion ( AMI ) to treatment has a significant effect on mortality and morbidity . This study reports the effectiveness of an education and counselling intervention on knowledge , attitudes and beliefs about AMI symptoms and the appropriate response to symptoms . The intervention was tested in a r and omised controlled trial of 200 people with a history of coronary heart disease ( CHD ) . The groups were equivalent at baseline on study outcomes , clinical history and sociodemographic characteristics with the exception of more women in the intervention group ( 38 % vs. 24 % ) . The results of repeated measures ANOVA showed that the intervention result ed in improved knowledge of CHD , AMI symptoms and the appropriate response to symptoms that was sustained to 12 months ( p = 0.02 ) . There were no differences between groups ' attitudes and beliefs over time . It is concluded that a short individual teaching and counselling intervention result ed in improved knowledge of CHD , AMI symptoms and the appropriate response to symptoms in people at risk of AMI sustained to 12 months abstract Objective To determine whether a nurse led smoking cessation intervention affects smoking cessation rates in patients admitted for coronary heart disease . Design R and omised controlled trial . Setting Cardiac ward of a general hospital , Norway . Participants 240 smokers aged under 76 years admitted for myocardial infa rct ion , unstable angina , or cardiac bypass surgery . 118 were r and omly assigned to the intervention and 122 to usual care  ( control group ) . Intervention The intervention was based on a booklet and focused on fear arousal and prevention of relapses .  The intervention was delivered by cardiac nurses without special training . The intervention was initiated in hospital , and the participants were contacted regularly for at least five months . Main outcome measure Smoking cessation rates at 12 months determined by self report and biochemical verification . Results 12 months after admission to hospital , 57 % ( n = 57/100)of patients in the intervention group and 37 % ( n = 44/118 ) in the control group had quit smoking ( absolute risk reduction 20 % , 95 % confidence interval 6 % to 33 % ) . The number needed to treat to get one additional person who would quit was 5 ( 3 to 16 ) . Assuming all dropouts relapsed at 12 months , the smoking cessation rates were 50 % in the intervention group and 37 % in the control group ( absolute risk reduction 13 % , 0 % to 26 % ) . Conclusion A smoking cessation programme delivered by cardiac nurses without special training , significantly reduced smoking rates in patients 12 months after admission to hospital for coronary heart disease
target: However , there were no consistent relationships observed between intervention characteristics and the effects of interventions .
  Most trials review ed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure .
background: OBJECTIVE This systematic review of recent r and omized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease ( CAD ) and /or heart failure .