Outcome measurement: self-management in heart failure

Allowing for unemployment in productivity measurement

The labour productivity index is a mainstay measure for comparing countries' relative economic performance, but the Covid-19 pandemic could expose some of its inherent limitations: it focuses on people in work and ignores unemployment, and it is not standardised. In theory, a country's index value could increase, even though its GDP might fall, because of significant increased unemployment in low-productivity sectors such as tourism and retail. It follows that the index value could fall when these sectors recover. Also, high-performing countries could see their index value fall because of the pandemic's impact in high-value sectors, such as demand for oil.Consequently, a wider perspective of productivity is necessary. This paper, therefore, proposes a complementary index which adjusts labour productivity for levels of unemployment-the social labour productivity index (SLPI)-and recommends that the labour productivity index itself should be standardised. The relationship between employment and productivity is complex. For example, the UK's economic performance, involving comparatively low labour productivity and low unemployment, has been deemed a 'productivity puzzle'. A literature review discusses this relationship, but it is clear that econometric worldwide evaluation requires very large data sets, that are unlikely to be routinely available in practice to monitor international performance. By contrast, data sets on national productivity are small and already available, although they contain little or no data on causal factors. SLPI values were calculated for differing levels of unemployment and relative labour productivity for newly employed workers for countries where data was available; with patterns over the period 1986-2016 established for the G7 countries, Portugal, Ireland, Greece, and Spain. There were marked variations between the two indices for countries with high unemployment. The SLPI presents a practicable measure which can be utilised quickly in these unprecedented times. Using available data to compare countries' GDP with their total workforce, it arguably provides a better measure of their overall economic and social health. Sensitivity analyses varying assumptions can model differing potential scenarios to sit alongside GDP and labour productivity index predictions.

Patients with heart failure as co-designers of an educational website: implications for medical education

OBJECTIVES

To identify the learning needs of patients with heart failure between outpatients follow-up visits from their perspective and to ascertain what they emphasize as being important in the design of an educational website for them.

METHODS

We conducted a two-step qualitative study at Aarhus University Hospital, Denmark. Twenty patients with heart failure participated either in focus group interviews, diary writing, or video-recorded design sessions. Data on learning needs were collected in step 1 and analyses, therefore, helped develop the preliminary prototypes of a website. In step 2, patients worked on the prototypes in video-recorded design sessions, employing a think-aloud method. The interviews were transcribed and a content analysis was performed on the text and video data.

RESULTS

Patients' learning needs were multifaceted, driven by anxiety, arising from, and often influenced by, such daily situations and contexts as the medical condition, medication, challenges in daily life, and where to get support and how to manage their self-care. They emphasized different ways of adapting the design to the patient group to enable interaction with peers and professionals and specific interface issues.

CONCLUSIONS

This study provided insights into the different learning needs of patients with heart failure, how managing daily situations is the starting point for these needs and how emotions play a part in patients' learning. Moreover, it showed how patient co-designers proved to be useful for understanding how to design a website that supports patients' learning: insights, which may become important in designing online learning tools for patients.

Does improvement in self-management skills predict improvement in quality of life and depressive symptoms? A prospective study in patients with heart failure up to one year after self-management education

Background

Heart failure (HF) patient education aims to foster patients’ self-management skills. These are assumed to bring about, in turn, improvements in distal outcomes such as quality of life. The purpose of this study was to test the hypothesis that change in self-reported self-management skills observed after participation in self-management education predicts changes in physical and mental quality of life and depressive symptoms up to one year thereafter.

Methods

The sample comprised 342 patients with chronic heart failure, treated in inpatient rehabilitation clinics, who received a heart failure self-management education program. Latent change modelling was used to analyze relationships between both short-term (during inpatient rehabilitation) and intermediate-term (after six months) changes in self-reported self-management skills and both intermediate-term and long-term (after twelve months) changes in physical and mental quality of life and depressive symptoms.

Results

Short-term changes in self-reported self-management skills predicted intermediate-term changes in mental quality of life and long-term changes in physical quality of life. Intermediate-term changes in self-reported self-management skills predicted long-term changes in all outcomes.

Conclusions

These findings support the assumption that improvements in self-management skills may foster improvements in distal outcomes.

Educating Nurses and Patients to Manage Heart Failure

Patient education is an important component in the management of patients with heart failure and nurses are increasingly involved in this area. This paper reviews the literature on education to patients with heart failure and the education and training for heart failure nurses. Patients with heart failure need education in order to adapt to their chronic syndrome and perform self-care. The education process often starts during the hospital admission, but must continue in the outpatient setting. Nurses need to be skilled in assessing the requirements and level of the education given to the individual. Computer-based education has been found to be a preferred and effective compliment to the education provided by health care professionals. The effect of new materials and methods needs to be evaluated in order to improve the overall effectiveness of the education provided. The patient with heart failure should have an active role in this development and evaluation. The heart failure nurse needs to be experienced in cardiac care, have an ability to work independently in order to be delegated responsibilities such as drug titration and patient assessment. This requires optimal experience, training and education for advanced practice. In order to develop and evaluate the education of patients with heart failure and the overall effectiveness of heart failure nurses in this regard, national and international collaborations are needed.

Feasibility of a group-based self-management program among congestive heart failure patients

OBJECTIVE

This study assessed the feasibility of the Chronic Disease Self-Management Program (CDSMP) among patients with congestive heart failure (CHF). The program emphasizes patients' central role and responsibility in managing their illness.

METHODS

Patients were randomly assigned to the program, which was led by a cardiac nurse specialist and a CHF patient. Data on performance according to protocol, adherence, and opinion about the program were collected among 186 patients and 18 leaders.

RESULTS

Eighty percent of the group sessions were carried out largely according to protocol. Three fourths of the patients attended at least 4 of the 6 sessions. Female sex and lower New York Heart Association classification predicted good attendance.

CONCLUSION

Directly after the program and at 12-month follow-up, approximately three fourths of the patients stated that they had benefited from the program. Recommendations mainly concerned spending more time on several program topics and specifying patient-selection criteria in more detail. The program was considered feasible.

Self-management behaviours for patients with chronic obstructive pulmonary disease: a qualitative study

AIM

This paper is a report of a study to explore the self-management behaviours of patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Chronic obstructive pulmonary disease is a major cause of chronic morbidity and mortality throughout the world. A patient-centred perspective calls for the investigation of self-management behaviours as means to develop self-management programmes and enhance quality of life for patients with COPD.

METHOD

The participants were a convenience sample of 18 patients with COPD of various severities. Interview data were collected in the thoracic ward, outpatient department and pulmonary rehabilitation unit of a medical centre in Taiwan from November 2006 to April 2007.

FINDINGS

Participants demonstrated the ability to choose suitable disease management behaviours to prevent symptoms and complications. Five themes of disease management behaviours were identified: symptom management, activity and exercise implementation, environmental control, emotional adaptation and maintaining a healthy lifestyle.

CONCLUSION

Participants are experts on their lives and, as such, they adopt appropriate disease control behaviours, based on their experience and knowledge, as well as integrate the illness and its symptoms into their lives. With the worldwide increase in migration, an understanding of the cultural factors that influence patients' perspectives on self-management behaviours is necessary and can contribute to the development of an evidence-based programme for disease self-management with COPD.

Medication adherence self-report instruments: implications for practice and research

BACKGROUND

After an acute cardiac event, adhering to recommendations for pharmacologic therapy is important in achieving optimal health outcomes. Considering the impressive evidence base for cardiovascular pharmacotherapy, strategies for promoting adherence are less well developed. Furthermore, accessing reliable, valid, and cost-effective mechanisms of monitoring adherence in the research and clinical settings is challenging.

AIM

The aim of this article was to review published self-report measures assessing and monitoring medication adherence in cardiovascular disease and provide recommendations for research into medication adherence.

METHODS

The electronic databases CINAHL, Medline, and Science Direct were searched using the key search terms medication adherence and/or compliance, cardiovascular, self-report measures, and questionnaires. The World Wide Web was searched using the Google and Google Scholar search engines, and reference lists of retrieved documents were reviewed. The search strategy was verified by a health librarian. Instruments were included if they specifically addressed medication adherence as a discrete construct rather than a disease-specific or a generic health status measurement.

FINDINGS

Despite of the problems with medication adherence identified in the literature, only 7 instruments met the search criteria. There was limited use of instruments across studies and settings to enable comparison across populations and extensive psychometric evaluation.

CONCLUSIONS

Medication adherence is a complex, multifaceted construct dependent on a range of physical, social, economic, and psychological considerations. In spite of the importance of adherence in ensuring optimal cardiovascular outcomes, conceptual underpinnings and methods of assessing medication adherence require further discussion and debate.

Therapeutic enhancement: nursing intervention category for patients diagnosed with Readiness for Therapeutic Regimen Management

AIMS

To present a new nursing intervention category called therapeutic enhancement.

BACKGROUND

Fewer than half of North Americans follow their physician's recommendations for diet and exercise, even when such are crucial to their health or recovery. It is imperative that nurses consider new ways to promote healthy behaviours. Therapeutic enhancement is intended to provide such a fresh approach. Traditional intervention techniques focusing on education, contracts, social support and more frequent interaction with physicians appear not to be effective when used alone. Successful strategies have been multidisciplinary; and have included interventions by professional nurses who assist patients to understand their disease and the disease process and that helps them to develop disease-management and self-management skills. Therapeutic enhancement incorporates The Stages of Change Theory, Commitment to Health Theory, Motivational Interviewing techniques and instrumentation specifically designed for process evaluation of health-promoting interventions.

METHOD

This is a critical review of approaches that, heretofore, have not been synthesised in a single published article.

CONCLUSIONS

Based on the commonly used Stages of Change model, therapeutic enhancement is useful for patients who are at the action stage of change. Using therapeutic enhancement as well as therapeutic strategies identified in Stages of Change Theory, such as contingency management, helping relationships, counterconditioning, stimulus control and Motivational Interviewing techniques, nursing professionals can significantly increase the chances of patients moving from action to the maintenance stage of change for a specific health behaviour.

RELEVANCE TO CLINICAL PRACTICE

Using the nursing intervention category, therapeutic enhancement can increase caregivers' success in helping patients maintain healthy behaviours.

What do we know about adherence and self-care?

Despite advances in healthcare, heart failure patients continue to experience complications that could have been prevented or treated. This occurs because the only way that a therapeutic or preventive regimen can be effective, assuming that the patient's condition has been accurately diagnosed and appropriately treated, is if the patient implements self-care behaviors and adheres to the treatment regimen. However, it is widely accepted that this does not occur in many or even most instances. This article provides an overview of the current evidence related to adherence and self-care behaviors among heart failure patients and describes the state of the science on interventions developed and tested to enhance self-care maintenance in this population. Our review of literature shows that effective interventions integrate strategies that motivate, empower, and encourage patients to make informed decisions and assume responsibility for self-care. Gaps in current evidence support the need for additional research on ways to improve adherence and self-care for patients who are at an increased risk of poor adherence, including those with cognitive and functional impairments and low health literacy.

Patients' Self-Care Improvement with Nurse Education Intervention in Spain Assessed by the European Heart Failure Self-Care Behaviour Scale

The European Heart Failure Self-care Behaviour Scale (EHFScBS) has been developed for assessing patients' self-care level. We used it to assess our patients' self-care progress after a medium-term period of nurse education intervention.

Patients and method: We prospectively studied 151 patients (111 men and 40 women, mean age 65.4 ± 11.9 years). All patients were evaluated twice with the EHFScBS: during the first visit to the Unit and after 1 year of nurse educational intervention.

Results: Mean score obtained by our patients in the initial evaluation was 24.8 ± 7.6. In the second evaluation patients showed a significant ( p < 0.001) improvement in self-care behaviour (mean score 19.9 ± 5.7). Analyzing item by item of the scale, patients show improvement in all items except in four: “If I am short of breath, I take it easy”, “I take a rest during the day”, “I eat a low salt diet” and “I take my medication as prescribed”.

Conclusions: Improvement in self-care behaviour, assessed with the EHFScBS, was achieved with nurse educational intervention in patients without previous heart failure education. However, in our population, this improvement was not obtained in one important aspect such is low salt diet compliance, although punctuation in this item was quite acceptable already initially.

A telephone-delivered empowerment intervention with patients diagnosed with heart failure

BACKGROUND

Heart failure (HF) is a major public health problem. Case management by nurses using telephone follow-up has been suggested as a convenient and effective mechanism to promote the self-management of HF. Similarly, a patient empowerment approach to the management of chronic disease has been suggested as one that may nurture self-management in individuals with chronic illness.

OBJECTIVE

The purpose of this study was to examine the effects of a telephone-delivered empowerment intervention (EI) on clinically and theoretically relevant outcomes in patients with HF, including purposeful participation in goal attainment, self-management of HF, and perception of functional health. The EI was guided by Rogers' Science of Unitary Human Beings person-environment process.

METHODS

A convenience sample of men and women aged 21 years and older with a clinical diagnosis of HF was obtained from a metropolitan hospital located in the southwestern United States. The participants were randomly assigned to the control group (n = 45) or EI group (n = 45). All participants received standardized HF patient education; the intervention group also received an EI delivered through telephone follow-up calls from a registered nurse. Repeated-measures analysis of variance was used to evaluate intervention effects.

RESULTS

The telephone-delivered EI facilitated self-management of HF through self-care activities in EI group members.

CONCLUSION

The knowledge gained from this study provides a beginning understanding of strategies to enhance health care providers' ability to facilitate self-management of HF among patients diagnosed with HF.

The crucial role of patient education in heart failure

BACKGROUND

Deterioration of heart failure causes and complicates many hospital admissions in people aged over 65 years. Frequent readmissions cause an immense burden on the individual, the family and the health care system. Heart failure management programmes, in which patient education is an important component, have been shown to be effective in improving self-care and reducing readmissions.

AIM

This paper reviews the literature on the education of patients with heart failure. The paper addresses the level of knowledge in patients with heart failure, barriers to learning, learning needs, educational methods, goals and how the effects of patient education can be evaluated.

CONCLUSION

Many patients had low levels of knowledge and lacked a clear understanding of heart failure and self-care. Educational interventions need to be designed specifically for elderly patients and need to target barriers to learning such as functional and cognitive limitations, misconceptions, low motivation and self-esteem. Health care professionals need to be skilled in assessing the requirements and level of education given to the individual. New technologies such as computer-based education and telemonitoring can be used as tools to improve the education. Patient education is an important component of heart failure care and should be provided through effective and well-evaluated strategies.

Patient-centered Needs Assessment

Determining an individual's unique perspective of an illness experience remains a challenge for clinicians, administrators, and researchers. A range of concepts and psychometric measures have been developed and evaluated to capture this information. These include patient satisfaction, quality of life, and utility measures. Needs assessment as a tool for evaluating perceptions of health status and determining patient satisfaction and treatment plans has been explored in oncology. Studies have demonstrated that a high proportion of patients have unmet needs in relation to activities of daily living, information sources, and comfort. Heart failure (HF), a condition with significant individual and societal burden, mirrors the illness of experience of cancer, as individuals process issues related to prognosis, treatment regimens, and decreased functional status. A needs-based assessment of health status, expectations, and perceptions is patient-centered and has the capacity to not only evaluate current health status but also plan and project care plans. Needs assessment is a dynamic construct rather than a point in time consistent with other assessment modalities, such as quality of life. Multidimensional needs assessment allows for planning and projection of needs, not only on an individual but also a population basis. Implicit in the exploration of needs is an expectation of level of care to be provided, from both the provider and recipient of care. In many instances a misalignment may exist between services and resources available to the individual. This article seeks to provide a theoretical justification for the development of a needs assessment instrument for patients with HF and to discuss the rationale of this method of assessment to create better alignment and resources with patients needs and expectations.

Development and testing of the European Heart Failure Self-Care Behaviour Scale

BACKGROUND

Improvement of self-care behaviour is an aim of several non-pharmacological nurse-led management programmes for patients with heart failure. These programmes are often evaluated based on their effects on readmission, costs and quality of life. It is, however, also important to know how patients changed their self-care behaviour as a result of such a programme. Therefore a comprehensive, reliable and valid measure of the self-care behaviour of HF patients is needed.

OBJECTIVES

To develop a scale measuring the behaviour that heart failure patients perform to maintain life, healthy functioning, and well-being.

METHOD

The European Heart Failure Self-Care Behaviour Scale (EHFScBS) was developed in three phases: (1) concept analysis and first construction; (2) revision of items and response and scoring format; and (3) testing of the new scale for validity and reliability.

RESULTS

The European Heart Failure Self-Care Behaviour Scale is a 12-item, self-administered questionnaire that covers items concerning self-care behaviour of patients with heart failure. Face-validity and concurrent validity was established and the internal consistency of the scale was tested using pooled data of 442 patients from two centres in Sweden, three in the Netherlands and one in Italy. Cronbachs's alpha was 0.81.

CONCLUSION

The instrument is a valid, reliable and practical scale to measure the self-reported self-care behaviour of heart failure patients. It is ready to use by investigators evaluating the outcome of heart failure management programmes that target changes in patients' self-care practices.

Heart failure management in the elderly postoperative patient

As the population ages, the elderly will account for a significant portion of surgical cases. These patients have age-related cardiovascular changes and can suffer from multiple chronic disease conditions. Congestive heart failure is a chronic condition that afflicts nearly five million Americans. It is the most common diagnosis among patients 65 years or older, with 8% to 10% of senior citizens having this chronic disease. A comprehensive understanding of the pathophysiology, assessment, and management strategies of congestive heart failure will give the orthopaedic nurse the knowledge needed to help minimize the morbidity and mortality associated with this disease.

Family caregivers need support with heart failure patients

Millions of family members are serving as caregivers for patients with heart failure and the numbers will continue to rise. It appears that caregivers desire to be involved in the patient's care even when the caregiving tasks average 8 hours per day. Burden, stress, and depression have been found to be significantly associated with the caregiving role in this population. Decreasing any negative aspects of caregiving should be a priority. Alarmingly, caregivers have reported being ignored or made to feel like an outsider by health care providers. Nurses are in a pivotal position to improve patient and caregiver outcomes by including the family caregivers of heart failure patients in all aspects of care and in promoting the well being of the caregiver. This article will highlight the importance of social support on patient and caregiver outcomes, and second, review studies on family caregiving among heart failure patients. Recommendations for nursing practice and further research will be discussed.