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、残疾和死亡的主要原因。 老年人的住院费用。经证实有效的CHF治疗可以减轻疾病负担， 延长生存期，但这些治疗方法未得到充分利用。患者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恶化的 因此，他们没有准备好进行干预或寻求帮助以阻止疾病的进展。健康 计划和其他提供者越来越多地采用以护士为基础的疾病管理（DM），以克服 这些障碍。为了测试护士管理的有效性，我们最近进行了两次随机 护士管理与常规护理的对照试验：一项是由西奈山的研究人员进行的， 医学院（MSSM）在东部和中部哈莱姆，纽约;另一个由研究人员为 加州的Kaiser/斯坦福大学心力衰竭护理管理（KSHFC）研究。每次试验中的护士 遵循类似的方案，指导他们与临床医生合作，根据 以证据为基础的指南，并建议患者定期饮食和自我监测症状 电话。虽然干预措施相似，但基线患者特征 两个试验的结果不同。MSSM试验招募了更年轻、社会经济地位更低的人， 地位少数的病人，和那些在护士手臂保持了显着较高的水平，身体 功能正常，住院次数少于对照组。KSHFC的参与者是 主要是中产阶级白色患者，在功能或住院方面没有差异 治疗臂之间。 这项研究的目的是重新分析这些试验的数据，以探讨为什么一项DM试验有效 另一个没有，更普遍的是，探索复杂DM协议的哪些方面有助于 他们的成功具体目标是：1）研究基线时患者特征的差异 导致了两项试验的不同结果，2）发现护士的哪些活动 对维持病人的身体机能和减少住院治疗的贡献最大。.

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. .