Nurse-Led Clinics for Heart Failure in Sweden—Doing the Right Thing?

Although the pharmacological treatment of heart failure has improved considerably in the wake of landmark clinical trials over the past years, it has not had the same dramatic impact on heart failure outcomes in the community as could be inferred from these trials. To some extent this is due to poor application of the lessons learnt from clinical trials, which in turn may relate to inadequate strategies for the management of heart failure patients 1. In an effort to address this problem, different management programs have been developed aimed at improving outcomes for heart failure patients. In Sweden nurse-led, outpatient clinics have found widespread acceptance and have been established in a majority of hospitals and are being started in the primary care setting 2. Nurse-led clinics for the management of heart failure are often compared in contrast with multidisciplinary management strategies. However, the difference in these approaches may be more semantic than actual. When reviewing the literature one finds that in both approaches nurses most often play a major role in the intervention and indeed the similarities in the different management strategies are more predominant than the differences. The most relevant approach to evaluating nurse-led or nurse-based management programs is to study the content not the nomenclature. From this given perspective it is then reasonable to ask if the rapid establishment of nurse-led heart failure clinics is in the interest of patients with regard to outcomes and the community from the perspective of resource utilisation and health economics. Is the widespread use in Sweden ‘doing the right thing’? In a landmark study Rich et al. evaluated the effect of a nurse-directed, multidisciplinary intervention in which a cardiovascular nurse provided patient education, dietary instruction, home visits and telephone contact for patients who were followed-up for 90 days after hospital discharge 3. This intervention resulted in a trend towards increased survival without readmission, a reduction in readmission and improved quality of life. We have reported that patient education on heart failure and self-management, with follow-up at a nurse directed outpatient clinic reduces health care costs and the need for readmission up to 1 year following discharge 4. In the management program reported by Stewart et al. patients assigned to the intervention group received a structured home visit by a qualified cardiac nurse 7–14 days after discharge 5. During this visit the nurse assessed the patient's clinical progress since discharge, did a physical examination, and assessed the patient's adherence to the prescribed treatment regimen, understanding of the disease process, fluid and sodium intake, current amount of physical activity, extent of psychosocial support, and use of available community-based resources. On the basis of this comprehensive home assessment the nurse could initiate a number of actions aimed at improving adherence and treatment. This intervention resulted in a reduction in unplanned readmission plus out-of-hospital death. More recently Blue et al. reported a 39% reduction in death or readmission at 1 year following a specialist nurse intervention 6; Doughty et al. reported improved quality of life, reduction in multiple readmission and bed days following an intervention in which a nurse appeared to play a central role in patient education and follow-up 7; Krumholz et al. reported that a formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with heart failure 8. The intervention was based on patient education by an experienced cardiac nurse; Kasper et al. reported that a 6-month, multidisciplinary approach to chronic heart failure management resulted in improvement in important clinical outcomes at a similar cost in recently hospitalised high-risk patients 9. The intervention was largely based on efforts of heart failure nurses who assisted patients and helped implement the therapeutic plan designed by cardiologists. There are very little data to suggest that nurse-led interventions in heart failure are ineffective or detrimental. Ekman et al. reported from Gothenburg in Sweden results of a structured-care programme based on a nurse-monitored, outpatient clinic, run in co-operation with doctors who were responsible for optimal pharmacological treatment 10. Patients included were 65 or older, had a Boston criteria score of at least 8 and New York Heart Association class III or IV at the last hospitalisation. In this study there were no differences in outcomes between patients assigned to conventional care and those assigned to the nurse-monitored, outpatient-care program. A number of points have been raised regarding the strategy employed in managing patients in this trial 11. Also, a relatively large number of patients in the intervention group were not followed up by the heart failure nurse. Furthermore, it seems reasonable to suspect that increased access to health care could in fact lead to increased utilisation in heart failure patients as some data suggest 12. The paucity of neutral and negative data could of course represent the unwillingness of researchers to report negative results or a publication bias. Whatever the background to the overwhelmingly positive published results of nurse-led interventions in heart failure the question remains, will widespread clinical application of these management strategies in Sweden result in similar benefits. What reason is there for scepticism? Firstly, far from all nurses in Swedish heart failure clinics have received formal training and heart failure is not an officially recognised speciality for nurses in Sweden. Secondly, not all heart failure clinics are the responsibility of cardiologists as is the case in the clinical trials. Thirdly, the management programs from published trials are not strictly adhered to when applied in clinical practice. Finally, no data for follow-up beyond 1 year have been presented and therefore the long term efficacy of nurse-led heart failure management is unproven. These facts do not imply that the clinical utilisation of nurse-led clinics may be counter productive, but does call for rigorous and systematic continuing evaluation of the quality of care provided, which is not the case at present. Quality of care should ideally be evaluated on a national level to allow for regional comparisons and a local level in order to facilitate improvements 13. Formal training programs for heart failure nurses need to be established and preferably heart failure should be officially recognised as a nursing speciality. Given these prerequisites, the widespread dissemination of nurse-led clinics in Sweden should lead to measurable improvement in the care of chronic heart failure patients in terms of morbidity and costs.