Outpatient Cardiology Practices With Advanced Practice Nurses and Physician Assistants Provide Similar Delivery of Recommended Therapies (Findings from IMPROVE HF)

National guidelines recommend a team model of care to facilitate adherence to evidencebased 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 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 2.0 APN and PA staffing had similar adherence to the 7 guideline-recommended HF therapies. After adjustment, staffing with 2 APNs or PAs was associated with greater conformity with 2 of 7 measures (implantable cardioverter-defibrillator therapy and delivery of HF education, p 0.01 for both) and similar conformity to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy,
-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, 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. © 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;105:1773–1779) National heart failure (HF) guidelines recommend a team model of care for all patients who are at high risk for hospital admission or who have clinical deterioration as a means to provide education, manage chronic symptoms, and facilitate the implementation of evidence-based practices.1 In American studies, a team model of care most often involved nurse-led clinics that were carried out by nurses with advanced practice nurse (APN) credentials;2–5 however, physician assistant (PA) services have also been used in managing ambulatory patients with HF.6 In American nurse-managed clinics, emphasis was placed on reporting patient functioning7 and hospitalization rates2,7 and financial outcomes.2– 4 Relatively little is known about the effectiveness of HF-devoted APNs and PAs on the delivery of recommended HF therapies in outpatient cardiology practices beyond artificial research settings, in which APNs and PAs are more likely to be highly trained and experienced in managing HF and in which they work closely with cardiologists who are also HF specialty trained. Thus, the objective of this study was to examine the influence of APN and PA staffing on the delivery of guideline-recommended therapies for patients with HF in outpatient cardiology practices. Methods The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) is a aNursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; bUniversity of California, Los Angeles, Medical Center, Los Angeles, California; cBaylor University Medical Center, Dallas, Texas; dUniversity of South Florida College of Medicine, Tampa, Florida; eCampbell University School of Pharmacy, Research Triangle Park, North Carolina; fDuke University Medical Center, Durham, North Carolina; gNorthwestern University, Feinberg School of Medicine, Chicago, Illinois; h Scripps Clinic, La Jolla, California; iOutcome Sciences, Inc., Boston, Massachusetts; jUniversity of Maryland, Baltimore, Maryland; kUniversity of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and lThe Care Group, LLC, Indianapolis, Indiana. Manuscript received November 10, 2009; revised manuscript received and accepted January 20, 2010. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) and this study are sponsored by Medtronic, Inc., Minneapolis, Minnesota. *Corresponding author: Tel: ; fax: . E-mail address: (N.M. Albert). /10/$ – see front matter © 2010 Elsevier Inc. All rights reserved.