Challenges Facing Nurse-Led Disease Management for Heart Failure

Abstract

The positive results of several randomized controlled trials of nurse-led disease management (DM) for heart failure have led to considerable growth in the use of DM programs in such patients. However, many aspects of the protocols used in randomized trials of DM for heart failure have differed, and there are still significant gaps in our knowledge of what makes DM work and for whom. Four important unresolved issues are: (i) what components of multifaceted DM protocols for heart failure are effective; (ii) whether a face-to-face meeting with the nurse is necessary for successful DM; (iii) what type of patients benefit from DM; and (iv) who should provide and pay for nurse-led DM. Our understanding of why nurse-led DM works would be enhanced if researchers systematically described each component of the intervention, measured the patient or clinician behavior that each component was designed to modify, and reported the trial’s success or failure at achieving that modification. Almost all randomized trials to-date have recruited hospitalized patients at relatively high risk of decompensation and have provided them with face-to-face contact with the DM team. More research is needed to document the effectiveness of DM protocols that use purely telephonic contact with patients, and those that recruit lower-risk patients from ambulatory settings. Finally, instead of assessing whether DM reduces costs or yields an adequate return on investment, more emphasis should be placed on cost-effectiveness research, which assesses whether DM improves patient health-related quality of life for a reasonable cost. Research along these lines will fill the gaps in our knowledge regarding the utility of DM for heart failure, and will contribute to making nurse-led DM for heart failure more effective, efficient, and commonplace.