Impact of Nurse Practitioners on Implementation of Evidence Based Therapy: Results of the St. Paul Heart Clinic (SPHC) Heart Failure Database

Background: Implementation of evidence based therapies has been challenging outside of controlled clinical trials. We utilized nurse practitioners, in combination with physician visits, to maximize medication initiation/titration, instruction for standard heart failure (HF) education (e.g. dietary sodium restriction and daily weights) and referral for device therapy in the outpatient setting.Methods: SPHC is an independent cardiology practice with 36 physicians and 3 nurse practitioners with specialty interest in HF. All patients (pts) who had at least one outpatient visit coded for either HF or cardiomyopathy over a 24 month period were entered into a database that tracks clinical outcomes and utilization of medications, devices and HF education.Results: Among 2,302 pts, there were 1,482 with a LVEF<45%. Pts seen by a HF-NP (n=677) were similar to those not seen by a HF-NP (n=805)in terms of age (70 vs. 71), male predominance (69 vs. 68%) and etiology. However, pts seen by a HF-NP had a lower EF (27 vs. 30%) and a higher frequency of co-morbidities, such as AF (39 vs. 36%), renal insufficiency (26 vs. 17%), COPD (19 vs. 13%) and non-compliance (10 vs. 5%) Utilization of ACE (85.0 vs. 85.0%) and BB (91.2 vs. 85.1%)was high with or without HF-NP. However, pts seen by a HF-NP were much more likely to receive instruction on sodium restriction (86.1 vs. 19.9%), daily weights (77.7 vs. 15.3%), smoking cessation (92 vs. 50.4%) and an exercise program than pts without a NP visit. Device therapy (CRT and ICD) was used in 63.7% of pts with a HF-NP visit compared to only 46% of pts without a HF-NP. Further, pts seen by a NP had a higher survival rate (86.1 vs. 82.4%) and a lower lost to follow up rate (1.5 vs. 4.1%) over 1300 days of follow up.Conclusion: These data demonstrate that compliance with evidence based therapy is enhanced by a team approach that utilizes concomitant visits with nurse practitioners. Pts seen by HF-NP have higher rates of education and device therapy which may be due to greater accessibility and to a focus on education. The use of nurse practitioners is a simple method to enhance the achievement of HF quality goals for a cardiology practice. Background: Implementation of evidence based therapies has been challenging outside of controlled clinical trials. We utilized nurse practitioners, in combination with physician visits, to maximize medication initiation/titration, instruction for standard heart failure (HF) education (e.g. dietary sodium restriction and daily weights) and referral for device therapy in the outpatient setting. Methods: SPHC is an independent cardiology practice with 36 physicians and 3 nurse practitioners with specialty interest in HF. All patients (pts) who had at least one outpatient visit coded for either HF or cardiomyopathy over a 24 month period were entered into a database that tracks clinical outcomes and utilization of medications, devices and HF education. Results: Among 2,302 pts, there were 1,482 with a LVEF<45%. Pts seen by a HF-NP (n=677) were similar to those not seen by a HF-NP (n=805)in terms of age (70 vs. 71), male predominance (69 vs. 68%) and etiology. However, pts seen by a HF-NP had a lower EF (27 vs. 30%) and a higher frequency of co-morbidities, such as AF (39 vs. 36%), renal insufficiency (26 vs. 17%), COPD (19 vs. 13%) and non-compliance (10 vs. 5%) Utilization of ACE (85.0 vs. 85.0%) and BB (91.2 vs. 85.1%)was high with or without HF-NP. However, pts seen by a HF-NP were much more likely to receive instruction on sodium restriction (86.1 vs. 19.9%), daily weights (77.7 vs. 15.3%), smoking cessation (92 vs. 50.4%) and an exercise program than pts without a NP visit. Device therapy (CRT and ICD) was used in 63.7% of pts with a HF-NP visit compared to only 46% of pts without a HF-NP. Further, pts seen by a NP had a higher survival rate (86.1 vs. 82.4%) and a lower lost to follow up rate (1.5 vs. 4.1%) over 1300 days of follow up. Conclusion: These data demonstrate that compliance with evidence based therapy is enhanced by a team approach that utilizes concomitant visits with nurse practitioners. Pts seen by HF-NP have higher rates of education and device therapy which may be due to greater accessibility and to a focus on education. The use of nurse practitioners is a simple method to enhance the achievement of HF quality goals for a cardiology practice.