Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure.
BACKGROUND
The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of beta-blockers for heart failure patients.


RESULTS
This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction < or =45% and no contraindications to beta-blockers. Patients' primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating beta-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate beta-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on beta-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target beta-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.


CONCLUSIONS
The use of a nurse facilitator was a successful approach for implementing a beta-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.
Ansari
Maria
M
Cardiology Division, San Francisco VA Medical Center, 4150 Clement St, San Francisco, Calif 94121, USA.
Shlipak
Michael G
MG
Heidenreich
Paul A
PA
Van Ostaeyen
Denise
D
Pohl
Elizabeth C
EC
Browner
Warren S
WS
Massie
Barry M
BM
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D015331:Cohort Studies; D004363:Drug Utilization / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000193:education / Q000592:standards; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D033181:Information Dissemination; D009722:Nurse Practitioners / Q000592:standards; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010353:Patient Education as Topic / Q000379:methods / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D017010:Reminder Systems
D000319:Adrenergic beta-Antagonists