Improving Guideline Adherence

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 β-blockers for heart failure patients.Methods and Results— This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction ≤45% and no contraindications to β-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 β-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate β-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on β-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 β-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 β-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.