Paul Revere of Medicine
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Jul 27, 2004
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I had to pick myself off the floor after reading this. :laugh:

Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation

Aims: The management of patients with atrial fibrillation (AF) is often inadequate due to deficient adherence to the guidelines. A nurse-led AF clinic providing integrated chronic care to improve guideline adherence and activate patients in their role, may effectively reduce morbidity and mortality but such care has not been tested in a large randomized trial. Therefore, we performed a randomized clinical trial to compare the AF clinic with routine clinical care in patients with AF.

Methods and results: We randomly assigned 712 patients with AF to nurse-led care and usual care. Nurse-led care consisted of guidelines based, software supported integrated chronic care supervised by a cardiologist. The primary endpoint was a composite of cardiovascular hospitalization and cardiovascular death. Duration of follow-up was at least 12 months. Adherence to guideline recommendations was significantly better in the nurse-led care group. After a mean of 22 months, the primary endpoint occurred in 14.3% of 356 patients of the nurse-led care group compared with 20.8% of 356 patients receiving usual care [hazard ratio: 0.65; 95% confidence interval (CI) 0.45–0.93; P= 0.017]. Cardiovascular death occurred in 1.1% in the nurse-led care vs. 3.9% in the usual care group (hazard ratio: 0.28; 95% CI: 0.09–0.85; P= 0.025). Cardiovascular hospitalization amounted (13.5 vs. 19.1%, respectively, hazard ratio: 0.66; 95% CI: 0.46–0.96, P= 0.029).

Conclusion: Nurse-led care of patients with AF is superior to usual care provided by a cardiologist in terms of cardiovascular hospitalizations and cardiovascular mortality.


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Wouldn't get too riled up..

First off, not sure how guideline based AF mgt is - so would be curious to look at their endpoints. Figure the main thing would be anticoagulation compliance which unfortunately internal medicine physicians (and even Cardiologists) do a fairly poor job of adhering too.

So, anytime you have a dedicated specialized clinic (HTN clinic, DMII clinic) I'm sure you'll tackle those individual goals targets much easier (A1c, BP goals) than just a general practice.

Those types of models (similar to some VA programs) might be the wave of the future. Obviously the criticism is that it often burdens the patient (which could be a good thing) but it really fractionalizes care adding a lot of chefs to the kitchen and a lot of unqualified chefs that can't manage anything but the one thing they were taught (this is where the NP come in)...

Again - agree this is more propaganda for NP's that some might run with but obviously a pretty flawed approach in trying to show their supposed superiority (though the avg layman wouldn't catch that)... Do think their conclusion is totally inappropriate.. If they want to show superiority get RN-led care vs. MD-led care both in "specialized AF clinics" or conclude that patients in specialized AF clinics have higher guideline based compliance than traditional practices.

Trifling Jester

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Jun 22, 2003
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We don't get to see the full pdf, text, so I won't comment on study design. But if this was pre-Pradaxa then I doubt it's still relevant.

-The Trifling Jester
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The "nurse-led care" was still supervised by a cardiologist and in a dedicated clinic...

and so I basically agree with supp-2 above


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nurses (supervised by MDs) who adhere strictly to guidelines (cookbook) that are probably written by committees paneled by MDs.

i want to see the methodology, obviously.


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This just shows that patients with a fib (some had CHF too) who are seen/followed more frequently do better. Duh. It doesn't mean nurses are "better" than us but maybe that collaboration can be a good thing...I think nurses and docs collaborating for things like management of AF, HTN, CHF can be a good thing. Some patients just need to be seen more often than the doc alone can do...
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