Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA.
Am J Cardiol. 2010 Jun 15;105(12):1773-9. doi: 10.1016/j.amjcard.2010.01.360. Epub 2010 May 4.
National guidelines recommend a team model of care to facilitate adherence to evidence-based practices; however, previous studies suggesting benefit may have limited generalizability. The aim of this study was to examine the influence of advanced practice nurse (APN) and physician assistant (PA) staffing on the delivery of guideline-recommended therapies for outpatients with heart failure (HF). The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic HF and left ventricular ejection fractions < or =35%. Adherence to guideline-recommended HF therapies was recorded, and the presence of APN and PA staffing was assessed by survey. Multivariate models identified contributions to the delivery of guideline-recommended HF therapies. Of cardiology outpatient practices, 66.0% had APNs and PAs. Practices with 0, >0 to <2, and > or =2.0 APN and PA staffing had similar adherence to the 7 guideline-recommended HF therapies. After adjustment, staffing with > or =2 APNs or PAs was associated with greater conformity with 2 of 7 measures (implantable cardioverter-defibrillator therapy and delivery of HF education, p < or =0.01 for both) and similar conformity to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, beta-blocker therapy, aldosterone antagonist therapy, anticoagulation for atrial fibrillation, and cardiac resynchronization therapy. In conclusion, staffing with APNs and PAs varied in cardiology outpatient practices. Compared to no APNs or PAs, > or =2.0 APNs or PAs per cardiology practice was associated with the greater use of implantable cardioverter-defibrillator therapy and delivery of HF education and equivalent use of drug and cardiac resynchronization therapies.
国家指南建议采用团队护理模式，以促进循证实践的实施；然而，以前的研究表明，这种模式可能具有一定的局限性。本研究旨在探讨高级执业护士（APN）和医师助理（PA）的人员配备对心力衰竭（HF）门诊患者推荐疗法实施的影响。改善HF 门诊治疗中证据应用的注册研究（IMPROVE HF）是一项前瞻性队列研究，共纳入 167 个心内科诊所，以描述 15381 例慢性 HF 和左心室射血分数<或=35%患者的门诊管理情况。记录了推荐 HF 疗法的实施情况，并通过问卷调查评估了 APN 和 PA 人员配备情况。多变量模型确定了对推荐 HF 疗法实施的影响因素。在接受调查的心内科门诊中，66.0%的诊所配备了 APN 和 PA。有 0、0 至<2、和≥2 名 APN 和 PA 的诊所，其 7 项推荐 HF 疗法的实施率相似。经调整后，≥2 名 APN 或 PA 的人员配备与 2 项（植入式心脏复律除颤器治疗和 HF 教育，p<或=0.01）和相似的血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂治疗、β受体阻滞剂治疗、醛固酮拮抗剂治疗、心房颤动抗凝治疗和心脏再同步治疗的实施标准更为一致。总之，APN 和 PA 的人员配备在心血管门诊实践中存在差异。与没有 APN 或 PA 相比，每所心内科诊所配备≥2 名 APN 或 PA 与植入式心脏复律除颤器治疗和 HF 教育的应用更为广泛，与药物和心脏再同步治疗的应用相当。
