Outcomes of nurse practitioner-led care in patients with cardiovascular disease: A systematic review and meta-analysis.

AIM: To assess randomized controlled trials evaluating the impact of nurse practitioner-led cardiovascular care. BACKGROUND: Systematic review of nurse practitioner-led care in patients with cardiovascular disease has not been completed. DESIGN: Systematic review and meta-analysis. DATA SOURCES: The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, Web of Science, Scopus and ProQuest were systematically searched for studies published between January 2007 - June 2017. REVIEW METHODS: Cochrane methodology was used for risk of bias, data extraction and meta-analysis. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Out of 605 articles, five articles met the inclusion criteria. There was no statistical difference between nurse practitioner-led care and usual care for 30-day readmissions, health-related quality of life and length of stay. A 12% reduction in Framingham risk score was identified. CONCLUSION: There are a few randomized control trials assessing nurse practitioner-led cardiovascular care. IMPACT: Low to moderate quality evidence was identified with no statistically significant associated outcomes of care. Nurse practitioner roles need to be supported to conduct and publish high-quality research.

Measuring the effect of nurse practitioner (NP)-led care on health-related quality of life in adult patients with atrial fibrillation: study protocol for a randomized controlled trial.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity, mortality, and healthcare resource use. The prevalence of AF is increasing with a growing and aging population, and timely access to care for these patients is a concern. Nontraditional models of care delivery, such as nurse practitioner (NP)-led clinics, may improve access to care and quality of care, but they require formal assessment. The objective of this study is to assess the effect of NP-led care on the health-related quality of life (HRQoL) of adult patients with AF. METHODS/DESIGN: We plan a randomized controlled trial comparing NP-led care vs. standard care. Inclusion criteria are ≥18 years of age, documented nonvalvular AF, willingness to give informed consent, and capacity to complete questionnaires. Patients referred for electrophysiological intervention who are clinically unstable or unable to attend follow-up visits will not be eligible to participate. Patients will be asked for verbal consent during the initial triage phone call from the nurse. Randomization will occur via a secure website. The intervention includes an NP consult, including medical history, physical examination, patient teaching, treatment plan, and follow-up at 3 and 6 months. The control arm involves usual cardiologist consultation with follow-up determined by the cardiologist's practice pattern. The primary outcome will be the difference in change in Atrial Fibrillation Effect on Quality of Life Survey scores at 6 months between groups. Secondary outcomes will include difference in change of EQ-5D scores at 6 months between groups, difference in composite outcomes of death resulting from cardiovascular cause, hospitalizations and emergency department visits between groups, and satisfaction with NP-led care measured by the Consultant Satisfaction Questionnaire. A sample size of 70 per group will ensure adequate power despite a potential 10% loss to follow-up. DISCUSSION: Our study will determine the effect of NP-led AF care on HRQoL in patients with AF, as well as measure its impact on relevant outcomes such as death, hospitalization, and emergency department visits. Our findings may have implications for delivery of care to patients with AF. TRIAL REGISTRATION: ClincalTrials.gov, NCT02745236 . Registered on 16 April 2016.

Impact of Electrical Cardioversion on Quality of Life for the Treatment of Atrial Fibrillation.

BACKGROUND: Despite being a common intervention to restore sinus rhythm in patients with atrial fibrillation (AF), limited data exist on the impact of electrical cardioversion on quality of life (QoL) outcomes in clinical practice. METHODS: This was a prospective cohort study of consecutive patients with AF referred for outpatient electrical cardioversion at 2 hospitals in Edmonton from 2013-2014. Baseline demographics, clinical characteristics, medications, and procedure details were obtained. QoL was assessed at baseline and at 3 months using the global Short-Form Health Survey (SF-36) and the Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire. RESULTS: One hundred patients underwent electrical cardioversion and completed follow-up. The median age was 62 years (interquartile range, 56-68 years) and 80% were men; the majority had nonparoxysmal AF (90%) with a mean left ventricular ejection fraction of 50.0% (± 12.4). At baseline, scores were lower than those reported from healthy individuals across all domains of the SF-36. The overall mean AFEQT score was 55.6 ± 24.4, and the domain-specific scores were as follows: symptoms, 66.2 ± 26.6; daily activities, 48.5 ± 29.5; treatment concerns, 57.6 ± 25.8; and treatment satisfaction, 56.7 ± 26.1. There were significant improvements in the vast majority of the SF-36 and AFEQT domains for the 51 patients who maintained sinus rhythm at 3 months. Patients who were in AF by 3 months demonstrated improvements in the AFEQT treatment concern score (P = 0.02) and SF-36 emotional role value (P < 0.01) compared with baseline values, which may be the result of treatment expectations related to cardioversion. CONCLUSIONS: There are significant QoL benefits for patients who maintain sinus rhythm after electrical cardioversion.

Cardiac EASE (Ensuring Access and Speedy Evaluation) - the impact of a single-point-of-entry multidisciplinary outpatient cardiology consultation program on wait times in Canada.

BACKGROUND: Universal access to health care is valued in Canada but increasing wait times for services (eg, cardiology consultation) raise safety questions. Observations suggest that deficiencies in the process of care contribute to wait times. Consequently, an outpatient clinic was designed for Ensuring Access and Speedy Evaluation (Cardiac EASE) in a university group practice, providing cardiac consultative services for northern Alberta. Cardiac EASE has two components: a single-point-ofentry intake service (prospective testing using physician-approved algorithms and previsit triage) and a multidisciplinary clinic (staffed by cardiologists, nurse practitioners and doctoral-trained pharmacists). OBJECTIVES: It was hypothesized that Cardiac EASE would reduce the time to initial consultation and a definitive diagnosis, and also increase the referral capacity. METHODS: The primary and secondary outcomes were time from referral to initial consultation, and time to achieve a definitive diagnosis and management plan, respectively. A conventionally managed historical control group (three-month pre-EASE period in 2003) was compared with the EASE group (2004 to 2006). The conventional referral mechanism continued concurrently with EASE. RESULTS: A comparison between pre-EASE (n=311) and EASE (n=3096) revealed no difference in the mean (+/- SD) age (60+/-16 years), sex (55% and 52% men, respectively) or reason for referral, including chest pain (31% and 40%, respectively) and arrhythmia (27% and 29%, respectively). Cardiac EASE reduced the time to initial cardiac consultation (from 71+/-45 days to 33+/-19 days) and time to a definitive diagnosis (from 120+/-86 days to 51+/-58 days) (P<0.0001). The annual number of new referrals increased from 1512 in 2002 to 2574 in 2006 due to growth in the Cardiac EASE clinic. The number of patients seen through the conventional referral mechanism and their wait times remained constant during the study period. CONCLUSIONS: Cardiac EASE reduced wait times, increased capacity and shortened time to achieve a diagnosis. The EASE model could shorten wait times for consultative services in Canada.

Cardiac EASE (Ensuring Access and Speedy Evaluation)--design of a single point of entry and a multidisciplinary team to reduce waiting times in the Canadian health care system.

Out-patient cardiac consultation in academic group practices often lacks a coordinated intake process, making it difficult to perform prospective testing or to direct undifferentiated consultations to the cardiologist with the shortest waiting list. We created a programmatic approach, with a single point of entry to improve the efficiency of cardiology consultation, without departing from the Canada Health Act. The purpose of this paper is to describe the design of Cardiac EASE.

A commentary on access to cardiovascular services: nursing roles and initiatives.

The Canadian Council of Cardiovascular Nurses (CCCN) applauds the work done by the Canadian Cardiovascular Society in setting benchmarks for wait times. The Canadian Cardiovascular Society is to be commended for developing the benchmark documents, as well as for establishing strategies for systematic dissemination to increase awareness, advocacy and implementation of the benchmarks across Canada. Quality nursing care, as defined within the CCCN framework, includes working with health teams to ensure that patients have timely access to specialized personnel, tests and procedures as required to prevent disease, promote health, address acute and episodic interventions, and to provide rehabilitative and palliative services, depending on patient need. To extend the access to care discussion, the CCCN suggests that further engagement of all stakeholders, especially clients/patients, is needed to find solutions to wait times and define benchmarks. In addition, preventing heart disease and promoting 'health care' should be recognized and acted on as central to reducing wait times for cardiovascular care. Finally, access to cardiovascular services will be more efficient when the first point of care is broadened to include nurses and other health care professionals. Nurses occupy creative, cost-effective roles directly aimed at reducing wait times and improving care while patients wait. The expanded role of interprofessional education and health care teams, as well as the inclusion of patients and families in program improvement, are solutions that the CCCN suggests may contribute to improved access to cardiovascular care and a sustainable health care system in Canada.

Cardiovascular nurse practitioner practice: results of a Canada-wide survey.

Despite an increase in the number of nurse practitioners (NPs) practising within the realm of cardiovascular care, roles and responsibilities of cardiovascular NPs in similar areas appear to be vast and variable. With the recent changes in certification and regulation of the NP role by the Canadian Nurses Association, there has been an attempt to standardize patient care practices. In the spring of 2005, the University of Alberta Hospital-based cardiovascular NPs conducted a national survey. This survey was the first formalized attempt to gather information on the practice patterns of cardiovascular NPs and determine if similarities in roles, responsibilities, manpower and patient workload existed across Canada. A survey was mailed out to all centres that were known to have cardiovascular NPs in their employ. An impressive response rate of 63% was obtained. As predicted, survey results reveal that roles and responsibilities of cardiovascular NPs are diverse and unique. One hundred per cent of respondents were Masters-prepared with 88% of cardiovascular NPs practising in a ward and/or outpatient setting. However, reporting structure, patient workload, clinical, educational, administrative, and research responsibilities were more diversified. The results of the survey may facilitate a better understanding of the NP role within the health care setting and in cardiovascular care. In turn, the findings may provide a basis by which to establish a template for developing future NP roles or enhancing existing NP roles in cardiovascular centres across Canada.