Mechanism of engaging self-management behavior in rural heart failure patients

Digital Health Interventions for Heart Failure Management in Underserved Rural Areas of the United States: A Systematic Review of Randomized Trials

BACKGROUND

Heart failure disproportionately affects individuals residing in rural areas, leading to worse health outcomes. Digital health interventions have been proposed as a promising approach for improving heart failure management. This systematic review aims to identify randomized trials of digital health interventions for individuals living in underserved rural areas with heart failure.

METHODS AND RESULTS

We conducted a systematic review by searching 6 databases (CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed; 2000-2023). A total of 30 426 articles were identified and screened. Inclusion criteria consisted of digital health randomized trials that were conducted in underserved rural areas of the United States based on the US Census Bureau's classification. Two independent reviewers screened the studies using the National Heart, Lung, and Blood Institute tool to evaluate the risk of bias. The review included 5 trials from 6 US states, involving 870 participants (42.9% female). Each of the 5 studies employed telemedicine, 2 studies used remote monitoring, and 1 study used mobile health technology. The studies reported improvement in self-care behaviors in 4 trials, increased knowledge in 2, and decreased cardiovascular mortality in 1 study. However, 3 trials revealed no change or an increase in health care resource use, 2 showed no change in cardiac biomarkers, and 2 demonstrated an increase in anxiety.

CONCLUSIONS

The results suggest that digital health interventions have the potential to enhance self-care and knowledge of patients with heart failure living in underserved rural areas. However, further research is necessary to evaluate their impact on clinical outcomes, biomarkers, and health care resource use.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022366923.

Mechanisms and Effects of Health Coaching in Patients With Early-Stage Chronic Kidney Disease: A Randomized Controlled Trial

PURPOSE

To examine the effects of health coaching on self-management and quality of life (QOL) in patients with chronic kidney disease (CKD) and to evaluate whether self-efficacy and patient activation mediate the effect of health coaching on self-management and QOL.

DESIGN AND METHODS

A single-center, parallel-group, randomized controlled trial. A total of 108 patients with stages 1 to 3a CKD participated in the study. Participants were randomly assigned to a health-coaching intervention group or a usual care control group. Participants' QOL (World Health Organization Quality of Life Scale), self-management (CKD Self-Management instrument), patient activation (Patient Activation Measure), and self-efficacy (CKD Self-Efficacy instrument) were measured at baseline, immediately after, and 6 weeks after the intervention.

FINDINGS

Health coaching improved QOL, self-management, patient activation, and self-efficacy at postintervention and at 12 weeks' follow-up. Health coaching had a significant indirect effect on QOL through improvements in patient activation. Health coaching exerted a significant indirect effect on self-management through improvements in self-efficacy and patient activation.

CONCLUSIONS

The findings demonstrated that health coaching can effectively improve QOL and self-management. A health-coaching intervention can raise self-efficacy and activation levels through which self-management and QOL further improve.

CLINICAL RELEVANCE

Health-coaching strategies can be used to assist patients with early-stage CKD in reaching their health goals and becoming activated in self-management of their diseases.

Role of Digital Games in Self-Management of Cardiovascular Diseases: A Scoping Review

OBJECTIVE

Examine research on the use of digital games to improve self-management (SM) behaviors in patients diagnosed with cardiovascular diagnoses of hypertension, coronary artery disease, heart failure, or myocardial infarction.

MATERIALS AND METHODS

For this scoping review, the CINAHL, PubMed, and Web of Science databases were searched for studies published from January 1, 2008 to December 20, 2017 using terms relevant to digital games and cardiovascular diseases (CVDs).

RESULTS

Eight articles met the inclusion/exclusion criteria, seven of which presented studies with participants 50 years or older. Five of the eight studies assessed physical activity. Only two studies included a control group. Digital games significantly improved exercise capacity and energy expenditure but did not affect quality of life, self-efficacy, anxiety, or depression. Digital games were found enjoyable by 79%-93% of participants, including those with lower education or age; however, barriers to game use included being tired or bored, lack of interest in digital games, poor perception of fitness through games, sensor limitations, conflicts with daily life routine, and preferences for group exercise. Average adherence ranged from 70% to 100% over 2 weeks to 6 months of study duration, with higher adherence rates in studies that included human contact through supervision or social support.

CONCLUSION

Paucity of studies about digital games for CVD SM behaviors precludes the need to undertake a full systematic review. Future studies examining digital games should include larger sample sizes, longer durations, game-design guided by behavioral change theoretical frameworks, and CVD SM behaviors in addition to physical activity behaviors.

The Impact of Self-management Knowledge and Support on the Relationships Among Self-efficacy, Patient Activation, and Self-management in Rural Patients With Heart Failure

BACKGROUND

Self-management (SM) is an essential component of heart failure (HF) management. The mechanisms to improve SM behaviors are unclear.

OBJECTIVE

The objective of this study is to examine whether patient activation mediates the effect of self-efficacy on SM behaviors in rural HF patients.

METHODS

A secondary analysis was conducted using data collected from a randomized controlled trial aimed to improve SM behaviors. The main variables included were SM knowledge, self-efficacy, patient activation, and SM behaviors.

RESULTS

Mediation analysis showed patient activation mediated the effect of self-efficacy on SM. Both self-efficacy and patient activation were significantly related to SM behaviors, respectively (r = 0.46, P < .001; β = .48, P = .001). However, self-efficacy was no longer directly related to SM behaviors when patient activation was entered into the final model (β = .17, P = .248). Self-management knowledge and support were significant moderators. In patients with high levels of SM knowledge, patient activation did not mediate the effect of self-efficacy on SM behaviors (β = .15, P = .47). When SM support was entered in the path model, patient activation was not a significant mediator between self-efficacy and SM behavior at high (β = .27, P = .27) or low (β = .27, P = .25) levels of SM support.

CONCLUSIONS

Study findings suggest that targeted SM support for high-risk HF patients with low SM knowledge and support may be useful. In addition, strategies to increase patient activation may improve HF patients' SM confidence.

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

OBJECTIVE

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

METHODS

A 3-group randomized controlled pilot study was conducted. The intervention group received 1 home visit, weekly (month 1), and biweekly (months 2 and 3) telephone calls. The attention group received telephone calls starting at week 2, following a similar pattern. The control group received usual care only. The Self-care of Heart Failure Index, was administered at baseline, 5, 9, and 13 weeks. Linear mixed modeling examined intervention effect on study outcomes.

RESULTS

A total of 66 participants completed the study. The participants were mean age 61 years; 54.2% male; 56% Non-Caucasian; and 43.9% New York Heart Association HF Class II. Significant treatment-by-time interaction effects were noted for self-care maintenance (F=4.813; p=0.010) and self-care confidence (F=4.469; p=0.014). There was no significant treatment-by-time interaction effect on self-care management.

CONCLUSIONS

Coping partnership interventions that strengthen support and social problem- solving may improve self-care maintenance and confidence in individuals with HF.

PRACTICE IMPLICATIONS

Clinicians should consider including these components in HF patient education and clinical follow-up.

Agreement between Heart Failure Patients and Their Primary Caregivers on Symptom Assessment

BACKGROUND

To decrease the readmission rate of heart failure (HF) patients, patients and their caregivers (CGs) should participate in symptoms assessment. This study aimed to assess the agreement between HF patients and their CGs on symptoms assessment.

METHODS

Using a correlational design, 100 HF patients with their CGs (100 dyads) were recruited from Department of Cardiology, Iranshahr, during August-December 2014. Data were collected using modified Heart Failure Symptom Survey (HFSS).Pearson and intra-class correlation coefficients (ICC) were used to analyze the degree of agreement within HF dyads, using SPSS16. The level of significance was set at 0.05.

RESULTS

The most frequent and severe symptom assessed equally by partners was shortness of breath (SOB). Dyads had a good agreement on assessment of extremity swelling (r=0.87, P≤0.01, ICC=0.861 CI: 0.798-0.901), SOB at rest (r=0.83, P≤0.01, ICC=0.775, CI: 0.680-0.845), SOB with activity (r=0.81, P≤0.01, ICC=0.795 CI: 0.711-0.858), and feeling depressed (r=0.77, P≤0.01, ICC=0.769, CI: 0.675-0.838). 28.6% of HF dyad had a good, 50% had a moderate, and 21.4 % had a poor agreement in assessment of HF symptoms.

CONCLUSION

Most of the HF dyad members did not agree with each other on the assessment of symptoms. Knowledge, skills and ability of each dyad in HF symptoms assessment should be included in the patients' discharge planning and nurses must modify their misunderstanding or inability.

Effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the PATCH randomized controlled trial

BACKGROUND

Heart failure (HF) patients discharged from rural hospitals have higher 30-day readmission rates. Self-management (SM) reduces readmissions, but adherence to SM guidelines is low in the rural HF population. We tested a home-based intervention to enhance patient activation and lead to improved SM adherence.

METHODS

In this two-group, repeated measures randomized control trial, the main outcomes were patient reported and clinical outcomes associated with SM adherence, and all-cause readmission at 30, 90 and 180 days.

RESULTS

The study included 100 HF patients discharged from a rural critical access hospital. The intervention group received a 12-week SM training and coaching program delivered by telephone and tailored on subjects' activation levels. At α = .10, the PATCH intervention showed significantly greater improvement compared to usual care in patient-reported SM adherence: weighing themselves, following a low-sodium diet, taking prescribed medication, and exercising daily (all p < .0005) at 3 and 6 months after discharge. In contrast, groups did not differ in physical activity assessed by actigraphy or in clinical biomarkers. Contrary to expectation, the 30-day readmission rate was significantly higher (p = .088) in the intervention group (19.6 %) than in the control group (6.1 %), with no differences at 90 or 180 days.

CONCLUSION

It is feasible to conduct a randomized controlled trial in HF patients discharged from rural critical access hospitals. Significantly higher patient-reported SM adherence was not accompanied by lower clinical biomarkers or readmission rates. Further research is needed to understand mechanisms that influence outcomes and healthcare utilization in this population.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov; NCT01964053 .