Discovering why successful nurse-based disease management program worked

充血性心力衰竭(CHF)是一种常见的慢性疾病，也是导致死亡、残疾和 老年人的住院费用。已被证明有效的CHF治疗方法可以减轻疾病负担和 延长生命，但这些治疗方法没有得到充分利用。患者的自我管理也可以改善 功能和生存，但患者往往不知道如何检测和防止病情恶化 因此，他们没有准备好进行干预或寻求帮助来阻止疾病的发展。健康状况 计划和其他提供者越来越多地使用基于护士的疾病管理(DM)来克服 这些障碍。为了检验护士管理的有效性，我们最近随机进行了两项 护士管理与常规护理的对照试验：一项是由西奈山的调查人员进行的 位于纽约哈莱姆区东部和中部的医学院(MSSM)；另一家是由 凯撒/斯坦福大学心力衰竭护理管理(KSHFC)加州研究。每项试验中的护士 遵循类似的方案，指导他们与临床医生合作，优化药物治疗 循证指导，并定期指导患者饮食和自我监测症状 电话。尽管干预措施相似，但基线患者的特征是 不同的是，这两项试验产生了截然不同的结果。MSSM试验招募了更年轻、社会经济水平较低的患者 地位少数的患者，而那些在护士臂上的人保持着明显更高的身体水平 与对照组相比，两组患者的住院次数均明显减少。KSHFC的参与者是 主要是中产阶级白人患者，在功能或住院方面没有差异 在治疗臂之间。 这项拟议研究的目的是重新分析这些试验的数据，以探索为什么一项DM试验有效 另一个没有，更广泛地说，探索复杂的DM协议的哪些方面有助于 他们的成功。具体目标是1)调查基线下患者特征的差异 对两个试验的不同结果有贡献，以及2)找出哪些护士的活动 对维持患者的身体功能和减少住院人数贡献最大。。

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