West J A, Miller N H, Parker K M, Senneca D, Ghandour G, Clark M, Greenwald G, Heller R S, Fowler M B, DeBusk R F
Department of Medicine, Veterans Affairs Palo Alto Health Care System, California, USA.
Am J Cardiol. 1997 Jan 1;79(1):58-63. doi: 10.1016/s0002-9149(96)00676-5.
The effectiveness of heart failure management in clinical practice is limited by physicians' suboptimal utilization of effective medications, patients' poor adherence to dietary sodium limitation and optimal drug therapy, and the lack of systematic monitoring of patients after hospitalization. The present study evaluated the feasibility and safety of MULTIFIT, a physician-supervised, nurse-mediated, home-based system for heart failure management that implements consensus guidelines for pharmacologic and dietary therapy using a nurse manager to enhance dietary and pharmacologic adherence and to monitor clinical status by frequent telephone contact. Fifty-one patients with the clinical diagnosis of heart failure were followed for 138 +/- 44 days. Daily dietary sodium intake fell by 38%, from 3,393 to 2,088 mg (p = 0.0001); average daily medication doses increased significantly (lisinopril: 17 to 23 mg, p <0.001; hydralazine: 140 to 252 mg, p = 0.01). Functional status and exercise capacity improved significantly (p = 0.01). Compared with the 6 months before enrollment and normalized for variable follow-up, the frequency of general medical and cardiology visits declined by 23% and 31%, respectively (both p <0.03); emergency room visits for heart failure and for all causes declined 67% and 53%, respectively (both p <0.001). Hospitalization rates for heart failure and for all causes declined 87% and 74%, respectively (p = 0.001), compared with the year before enrollment. The MULTIFIT system enhanced the effectiveness of pharmacologic and dietary therapy for heart failure in clinical practice, improving clinical outcomes and reducing medical resource utilization.
在临床实践中，心力衰竭管理的有效性受到多种因素限制，包括医生对有效药物的使用不够优化、患者对饮食中钠限制和最佳药物治疗的依从性差，以及住院后对患者缺乏系统监测。本研究评估了MULTIFIT的可行性和安全性，MULTIFIT是一种由医生监督、护士介导的居家心力衰竭管理系统，该系统采用护士经理通过频繁电话联系来加强饮食和药物依从性并监测临床状况，从而实施药物和饮食治疗的共识指南。51例临床诊断为心力衰竭的患者接受了138±44天的随访。每日饮食钠摄入量下降了38%，从3393毫克降至2088毫克（p = 0.0001）；平均每日药物剂量显著增加（赖诺普利：从17毫克增至23毫克，p <0.001；肼屈嗪：从140毫克增至252毫克，p = 0.01）。功能状态和运动能力显著改善（p = 0.01）。与入组前6个月相比，并对不同随访时间进行标准化后，普通内科和心脏病科就诊频率分别下降了23%和31%（均p <0.03）；因心力衰竭和所有原因的急诊就诊次数分别下降了67%和53%（均p <0.001）。与入组前一年相比，心力衰竭和所有原因的住院率分别下降了87%和74%（p = 0.001）。MULTIFIT系统提高了临床实践中药物和饮食治疗心力衰竭的有效性，改善了临床结局并减少了医疗资源的使用。
