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Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities: A Randomized Trial

Jane E. Sisk, PhD; Paul L. Hebert, PhD; Carol R. Horowitz, MD, MPH; Mary Ann McLaughlin, MD, MPH; Jason J. Wang, PhD; and Mark R. Chassin, MD, MPP, MPH
[+] Article, Author, and Disclosure Information

From Mount Sinai School of Medicine, New York, New York.

Acknowledgments: The authors thank the nurses who performed the intervention (Wanda Garcia, Adaga Catano, and Gema Richards), the project managers for the study (Aimee Quijano and Leah Tuzzio), the abstractors of cardiac test results (Meredith Reh and Van Hong Nguyen), the survey expert at Gfk NOP (previously RoperASW) for guidance in survey design and patient interviewing (Tim Nanneman), and the analyst who prepared the graphics (Jodi Casabianca). They also thank the key clinicians who supported planning and implementation at the participating hospitals—Aubrey Clarke at Harlem Hospital Center; Elliott Perla at Metropolitan Hospital Center; Valentin Fuster, Thomas McGinn, Elizabeth Clark, Marrick Kukin, and Catherine Halliday at Mount Sinai Medical Center; and Linda Williams at North General Hospital—and Nancy Houston Miller, who shared the materials developed for Stanford University's Kaiser Permanente study and helped train the nurses.

Grant Support: By the Agency for Healthcare Research and Quality (R01 HS 10402).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jane E. Sisk, PhD, Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Room 3418, 3311 Toledo Road, Hyattsville, MD 20782; e-mail, jsisk@cdc.gov.

Current Author Addresses: Dr. Sisk: Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Room 3418, 3311 Toledo Road, Hyattsville, MD 20782.

Drs. Hebert, Horowitz, McLaughlin, Wang, and Chassin: Department of Health Policy, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029.

Ann Intern Med. 2006;145(4):273-283. doi:10.7326/0003-4819-145-4-200608150-00007
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The 406 patients recruited and randomly assigned to nurse management (n = 203) or usual care (control group) (n = 203) constituted 64% of those who were reached, alive, and eligible (Figure 1). Table 2 contains patients' baseline characteristics. The 127 nurse management and 127 usual care patients who were followed for 6 months after the intervention were similar at baseline. According to billing data before enrollment, 4 usual care patients and 1 nurse management patient had received an implantable cardioverter defibrillator and no patient in either group had received cardiac resynchronization therapy.

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Figure 1.
Study flow diagram.

*Of the 203 patients assigned to each trial group at baseline, as part of the original randomization process, the first 127 patients in each group were randomly assigned to receive a follow-up survey at 15 months and at 18 months.

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Figure 2.
Short Form-12 (SF-12) physical component score (top) and the Minnesota Living with Heart Failure (MLHF) Questionnaire functioning score (bottom) for all patients over the 12-month intervention period and for the subset of patients who were followed for 18 months, by usual care versus nurse management.
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Literacy and Heart Failure Self-Care
Posted on September 1, 2006
Michael P Pignone
University of North Carolina
Conflict of Interest: None Declared

Dear Editor,

Sisk and colleagues found that a nurse-led intervention reduced hospital admissions for patients with systolic heart failure recruited from ambulatory clinics in Harlem, New York. (1)We recently reported similar findings with a self-management program in a population of ambulatory patients with heart failure (both systolic and diastolic dysfunction) recruited from an academic internal medicine practice in North Carolina.(2) Incidence of hospitalizations was reduced by 47%.

Our population included a high proportion of patients with low educational attainment (an average of 9.5 years of schooling), and high rates of inadequate literacy (41%). In our study, patients with low literacy appeared to derive similar or greater benefit from the intervention than patients with adequate literacy, although our sample size was too small to test formally for an interaction.

Sisk and colleagues reported that 29.8% of participants had inadequate literacy.(1) It would be interesting to know if they found a similar reduction in the risk of hospitalization among those with inadequate literacy, compared to their patients with adequate literacy.


1. Sisk JE, Hebert PL, Horowitz CR, McLaughlin MA, Wang JJ, Chassin MR. Effects of nurse management on the quality of heart failure care in minority communities: a randomized trial. Ann Intern Med. 2006 Aug 15;145(4):273-83.

2. DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL, Sueta CA, Pignone MP. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. 2006 Mar 13;6:30.

Conflict of Interest:

Drs. Pignone and DeWalt have received funding from Pfizer, Inc for literacy-related research.

Posted on November 16, 2006
Jane E Sisk
Mount Sinai School of Medicine and National Center for Health Statistics, U.S. Centers for Disease C
Conflict of Interest: None Declared

We appreciated the thoughtful comments of Dr. Pigone and Mr. DeWalt. In our trial we measured patients' health literacy, however, not general literacy.(1) In preliminary analyses, we found no evidence that low health literacy was correlated with the effectiveness of nurse management in terms of either of our primary outcomes of physical functioning or all- cause hospitalization. Specifically, we measured physical function using the Short Form 12 Physical Component Score (SF12 PCS), which we administered at baseline and every three months through the end of the intervention at 12 months. We estimated a linear regression of the change in SF12 PCS on treatment assignment (nurse versus usual care), an indicator for inadequate health literacy, and the interaction between inadequate literacy and treatment assignment. Although the coefficient on treatment assignment was significant indicating a positive effect of nurse management, the coefficient on the interaction term between nurse management and inadequate literacy (p>0.2) provided little evidence that the nurse intervention was more effective for patients with inadequate health literacy at baseline. Alternative specifications of this modeling--including models with additional control variables for socio-demographic factors, and longitudinal models that made use of intervening data points at 3, 6, and 9 months--yielded similar null findings regarding health literacy. Regarding all-cause hospitalizations, we estimated Poisson regression models with total hospitalizations over the 12-month study as a function of treatment assignment, inadequate literacy at baseline, and the interaction of these two variables. The coefficient on the interaction term was not significant (p>0.2).

These null findings regarding health literacy are particularly vexing because they tend to discount a potential reason why our intervention succeeded where similar interventions have not. Continued research on why disease management works in some populations but not others is clearly needed, and is a focus of our continuing efforts.

Paul L Hebert, Ph.D. Mount Sinai School of Medicine New York, NY 10025

Jane E. Sisk, Ph.D. Mount Sinai School of Medicine and National Centers for Health Statistics, U.S. Centers for Disease Control and Prevention Hyattsville, MD 20817


1. Sisk JE, Hebert PL, Horowitz CR, McLaughlin MA, Wang JJ, Chassin MR. Effects of nurse management on the quality of heart failure care in minority communities. Ann Intern Med. 2006.145:273-283.

Conflict of Interest:

None declared

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Summary for Patients

The Effect of Nurse Managers on Heart Failure Complications in a Minority Community

The summary below is from the full report titled “Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities. A Randomized Trial.” It is in the 15 August 2006 issue of Annals of Internal Medicine (volume 145, pages 273-283). The authors are J.E. Sisk, P.L. Hebert, C.R. Horowitz, M.A. McLaughlin, J.J. Wang, and M.R. Chassin.


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