Improving Heart Failure Care in Minority Communities

Congestive heart failure (CHF) disproportionately afflicts Black and elderly people, and is
a leading cause of hospitalization > 65 years. Although effective therapies can improve
functioning and survival in patients with systolic dysfunction, many may not be receiving
the full benefit of existing knowledge, including counseling on self-management and
appropriate doses of medications. Patients play a critical role in managing a chronic
condition such as CHF, but may not have the skills to do so. Clinicians may not provide
counseling or medications consistent with evidence-based guidelines.

Systematic reviews of clinical-behavior change have suggested that interventions targeted to
specific problems are more likely to be successful. Based on shortfalls identified in
patient self-management and clinical care in Harlem, a predominately non-white area in
northern Manhattan, we tailored a nurse-management intervention to address the problems
documented, and evaluated its effectiveness in a randomized controlled trial. This trial
among primarily-minority patients addresses important gaps in this literature: the study
targeted problems documented among CHF patients in Harlem, enrolled patients from ambulatory
practices, randomly assigned patients between nurse-management and usual care, and evaluated
their subsequent health-related outcomes. Hypothesis: the nurse-management program would
result in nurse patients' having fewer hospitalizations and reporting better functioning.

Inclusion Criteria:

- • adults >18 years,

- systolic dysfunction documented on a cardiac test (echocardiography,
radionuclide ventriculography, myocardial stress sestamibi/thallium testing, or
left-heart catheterization),

- English- or Spanish-speaking,

- community-dwelling at enrollment, and

- current patient in a general medicine, geriatrics, or cardiology clinic or
office at a participating site.

Exclusion Criteria:

- • medical conditions that prevented a patient's interacting with the nurse, including
blindness, deafness, and cognitive impairment;

- medical conditions that required individualized management that might differ
from standard protocol, namely pregnancy, renal dialysis, and terminal illness;
and

- procedures that corrected systolic dysfunction, such as heart transplantation.