Congestive Heart Failure (CHF) is a common chronic condition and a leading cause of death, disability, andhospital costs in the elderly. Proven-effective treatments for CHF can reduce the burden of disease andprolong survival, but these treatments are under-utilized. Patient self-management can also improvefunctioning and survival, but patients are often unaware of ways to detect and prevent worsening of thecondition, and are therefore unprepared to intervene or seek help to stop the progression of disease. Healthplans and other providers are increasingly employing nurse-based disease management (DM) to overcomethese barriers. To test the effectiveness of nurse management, we recently conducted two randomizedcontrolled trials of nurse management versus usual care: One was conducted by investigators at Mount SinaiSchool of Medicine (MSSM) in East and Central Harlem, New York; the other by investigators for theKaiser/Stanford Heart Failure Care Management (KSHFC) study in California. The nurses in each trialfollowed similar protocols that instructed them to work with the clinicians to optimize drug therapy accordingto evidence-based guidelines, and to counsel patients on diet and self-monitoring of symptoms on regularlyscheduledtelephone calls. Although the interventions were similar, baseline patient characteristics weredifferent and the two trials yielded disparate results. The MSSM trial enrolled younger, lower socioeconomicstatus minority patients, and those in the nurse arm maintained a significantly higher level of physicalfunctioning and were hospitalized fewer times than those in the control group. The KSHFC participants werepredominantly middle-class white patients, and there was no difference in functioning or hospitalizationsbetween treatment arms.The purpose of the proposed study is to reanalyze data from these trials to explore why one DM trial workedand the other did not, and more generally, to explore what aspects of complex DM protocols contribute totheir success.
The specific aims are 1) to investigate how differences in patient characteristics at baselinecontributed to the disparate results of the two trials, and 2) to discover which of the nurses' activitiescontributed most to maintaining patients' physical functioning and reducing hospitalizations. .
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