Randomized, Controlled Trial to Improve Self-Care in Patients With Heart Failure Living in Rural Areas

[Preventive care for geriatric patients in general medicine]

BACKGROUND

Recognizing functional deficits early and counteracting them with a multimodal treatment concept is one of the most important tasks of general practitioners, who are usually the primary medical contact for geriatric patients.

AIM

Illustration of strategies for a biopsychosocial assessment of geriatric patients and for the creation of individually adapted prevention concepts in general practice.

MATERIAL AND METHODS

Literature research on the theoretical background of the most important prevention approaches for geriatric patients as well as considerations on their relevance and implementation in daily practice.

RESULTS

For geriatric patients prevention measures should be implemented simultaneously on all four prevention levels. The main objective is promoting physical and mental exercise. The risks of immobility, depression, cognitive decline, malnutrition and, last but not least, polypharmacy are of particular importance.

CONCLUSION

Geriatric patients represent a very heterogeneous group. In order to be able to take individual preventive action, a multidimensional assessment of key factors for maintaining functionality and relative health is required, even though chronic conditions may already exist.

Hospital-Based Electrocardiographic Monitoring: The Good, the Not So Good, and Untapped Potential

Continuous electrocardiographic (ECG) monitoring was first introduced into hospitals in the 1960s, initially into critical care, as bedside monitors, and eventually into step-down units with telemetry capabilities. Although the initial use was rather simplistic (ie, heart rate and rhythm assessment), the capabilities of these devices and associated physiologic (vital sign) monitors have expanded considerably. Current bedside monitors now include sophisticated ECG software designed to identify myocardial ischemia (ie, ST-segment monitoring), QT-interval prolongation, and a myriad of other cardiac arrhythmia types. Physiologic monitoring has had similar advances from noninvasive assessment of core vital signs (blood pressure, respiratory rate, oxygen saturation) to invasive monitoring including arterial blood pressure, temperature, central venous pressure, intracranial pressure, carbon dioxide, and many others. The benefit of these monitoring devices is that continuous and real-time information is displayed and can be configured to alarm to alert nurses to a change in a patient's condition. I think it is fair to say that critical and high-acuity care nurses see these devices as having a positive impact in patient care. However, this enthusiasm has been somewhat dampened in the past decade by research highlighting the shortcomings and unanticipated consequences of these devices, namely alarm and alert fatigue. In this article, which is associated with the American Association of Critical-Care Nurses' Distinguished Research Lecture, I describe my 36-year journey from a clinical nurse to nurse scientist and the trajectory of my program of research focused primarily on ECG and physiologic monitoring. Specifically, I discuss the good, the not so good, and the untapped potential of these monitoring systems in clinical care. I also describe my experiences with community-based research in patients with acute coronary syndrome and/or heart failure.

Longitudinal Relationships Between Heart Failure Self-care and All-Cause Hospital Readmissions

BACKGROUND

Many patients with heart failure (HF) are repeatedly hospitalized. Heart failure self-care may reduce readmission rates. Hospitalizations may also affect self-care.

OBJECTIVE

The purpose of this secondary analysis was to test the hypotheses that better HF self-care is associated with a lower rate of all-cause readmissions and that readmissions motivate patients to improve their self-care.

METHODS

This was a prospective cohort study of patients with HF (N = 400) who were enrolled during a stay at an urban teaching hospital between 2014 and 2016. The Self-Care of Heart Failure Index v6.2 was administered during the hospital stay, along with other questionnaires, and repeated at 6-month intervals after discharge. All-cause readmissions and deaths were ascertained for 24 months.

RESULTS

A total of 333 (83.3%) were readmitted at least once, and 117 (29.3%) of the patients died during the follow-up period. A total of 1581 readmissions were ascertained. Higher Self-Care of Heart Failure Index Maintenance scores predicted more rather than fewer readmissions (adjusted hazard ratio, 1.09; 95% confidence interval, 1.01-1.17; P < .01). Conversely, more readmissions predicted higher Maintenance scores (b = 0.29; 95% confidence interval, 0.02-0.56; P < .05).

CONCLUSIONS

These findings do not support the hypothesis that HF self-care maintenance or management helps to reduce the rate of all-cause readmissions, but they do suggest that the experience of multiple readmissions may help to motivate improvements in HF self-care.

Mediators of the Association Between Cognitive Function and Self-care Behaviors in Patients Hospitalized With an Exacerbation of Heart Failure

BACKGROUND

Patients with heart failure (HF) must engage in self-care, yet their self-care is often poor. Cognitive function commonly is impaired in HF and is associated with poor self-care. Heart failure knowledge and self-care confidence also are needed to preform self-care. Few investigators have examined mediators of the association of cognitive function with self-care.

OBJECTIVES

The aim of this study was to determine whether HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance and management among patients with HF.

METHODS

This was a cross-sectional observational study of 164 patients with HF. Cognitive function was assessed using the Montreal Cognitive Assessment. Self-care maintenance and self-care management behaviors and self-care confidence were measured using the Self-care of Heart Failure Index. Heart failure knowledge was measured using the Dutch Heart Failure Knowledge Scale. We conducted 2 parallel mediation analyses using the PROCESS macro in SPSS, one for self-care maintenance and one for self-care management.

RESULTS

Cognitive function was indirectly associated with self-care maintenance through HF knowledge (indirect effect, 0.54; 95% confidence interval, 0.10-1.02) and self-care confidence (indirect effect, 0.26; 95% confidence interval, 0.04-0.54). Those with better cognitive function had more HF knowledge and self-care confidence. Better cognitive function was not directly associated with self-care management but indirectly associated with better self-care management through higher self-care confidence (indirect effect, 0.50; 95% confidence interval, 0.04-1.05).

CONCLUSIONS

Both HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance, and only self-care confidence mediated the association between cognitive function and self-care management. Interventions targeting HF knowledge and self-care confidence may improve self-care even for those with lower cognitive function and need to be developed and tested.

Impact of nurse-led education on the prognosis of heart failure patients: A systematic review and meta-analysis

AIM

To perform a meta-analysis of randomized controlled trials to investigate the effect of nurse-led education on death, readmission, and quality of life in patients with heart failure.

BACKGROUND

The evidence of the effectiveness of nurse-led education in heart failure patients from randomized controlled trials is limited, and the results are inconsistent. Therefore, the impact of nurse-led education remains poorly understood, and more rigorous studies are needed.

INTRODUCTION

Heart failure is a syndrome associated with high morbidity, mortality, and hospital readmission. Authorities advocate nurse-led education to raise awareness of disease progression and treatment planning, as this could improve patients' prognosis.

METHODS

PubMed, Embase, and the Cochrane Library were searched up to May 2022 to retrieve relevant studies. The primary outcomes were readmission rate (all-cause or HF-related) and all-cause mortality. The secondary outcome was quality of life, evaluated by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), EuroQol-5D (EQ-5D), and visual analog scale for quality of life.

RESULTS

Although there was no significant association between the nursing intervention and all-cause readmissions [RR (95% CI) = 0.91 (0.79, 1.06), P = 0.231], the nursing intervention decreased HF-related readmission by 25% [RR (95% CI) = 0.75 (0.58, 0.99), P = 0.039]. The e nursing intervention reduced all-cause readmission or mortality as a composite endpoint by 13% [RR (95% CI) = 0.87 (0.76, 0.99), P = 0.029]. In the subgroup analysis, we found that home nursing visits reduced HF-related readmissions [RR (95% CI) = 0.56 (0.37, 0.84), P = 0.005]. In addition, the nursing intervention improved the quality of life in MLHFQ and EQ-5D [standardized mean differences (SMD) (95% CI) = 3.38 (1.10, 5.66), 7.12 (2.54, 11.71), respectively].

DISCUSSION

The outcome variation between studies may be due to reporting methods, comorbidities, and medication management education. Patient outcomes and quality of life may also vary between different educational approaches. Limitations of this meta-analysis stem from the incomplete reporting of information from the original studies, the small sample size, and the inclusion of English language literature only.

CONCLUSION

Nurse-led education programs significantly impact HF-related readmission rates, all-cause readmission, and mortality rates in patients with HF.

IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICIES

The results suggest stakeholders should allocate resources to develop nurse-led education programs for HF 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.

Treatment of depression and inadequate self-care in patients with heart failure: One-year outcomes of a randomized controlled trial

OBJECTIVE

Both depression and inadequate self-care are common in patients with heart failure. This secondary analysis examines the one-year outcomes of a randomized controlled trial of a sequential approach to treating these problems.

METHODS

Patients with heart failure and major depression were randomly assigned to usual care (n = 70) or to cognitive behavior therapy (n = 69). All patients received a heart failure self-care intervention starting 8 weeks after randomization. Patient-reported outcomes were assessed at Weeks 8, 16, 32, and 52. Data on hospital admissions and deaths were also obtained.

RESULTS

One year after randomization, Beck Depression Inventory (BDI-II) scores were - 4.9 (95% C.I., -8.9 to -0.9; p < .05) points lower in the cognitive therapy than the usual care arm, and Kansas City Cardiomyopathy scores were 8.3 (95% C.I., 1.9 to 14.7; p < .05) points higher. There were no differences on the Self-Care of Heart Failure Index or in hospitalizations or deaths.

CONCLUSIONS

The superiority of cognitive behavior therapy relative to usual care for major depression in patients with heart failure persisted for at least one year. Cognitive behavior therapy did not increase patients' ability to benefit from a heart failure self-care intervention, but it did improve HF-related quality of life during the follow-up period.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02997865.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions

BACKGROUND

Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.

METHODS

Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.

ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).

INFORMATION SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020.

OUTCOME MEASURES

Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate.

DATA SYNTHESIS

We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.

RESULTS

We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%).

CONCLUSIONS

KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

The Effectiveness of Self-Management Strategies in Patients With Heart Failure: A Narrative Review

Heart failure (HF) is a common condition with high morbidity and mortality. Self-management strategies for heart failure can be effective in improving patients' quality of life and reducing mortality and hospitalization for heart failure. These self-management strategies are also cost-effective. A complex interplay between various factors related to patients, therapy, healthcare, and socioeconomic factors influences the effectiveness of self-management strategies. The primary aim of this study is to determine the effectiveness of self-management strategies in patients with heart failure in reducing mortality, hospitalization for heart failure, and healthcare cost savings at six months and one year. The secondary aim is to determine adherence to self-management strategies in patients with HF. The current study is a narrative review of studies evaluating the effectiveness of self-management strategies in heart failure. A literature search was done in PubMed, Embase, Google Scholar, ScienceDirect, and the Cochrane Library for studies published in the English language between 2012 and 2022. Descriptive statistics were used to summarize the characteristics of studies and interventions. We calculated odds ratios, risk ratios, or mean differences to calculate the effect of self-management strategies on mortality, hospitalization for HF, and healthcare costs between patient groups. We included a total of 30 studies in our narrative review: eight cross-sectional studies and 22 randomized controlled trials. These studies showed a significant effect of self-management strategies on mortality at six- and 12-month follow-ups. Studies on the effectiveness of self-management strategies on hospitalization for heart failure showed benefits at six and 12 months. Self-management strategies are cost-effective and feasible with improved disability-adjusted life years (DALY). One study showed higher costs associated with self-management strategies and only a slight decrease in DALY. Overall, adherence to self-management strategies was inadequate in these studies. Novel and innovative self-management interventions improve therapy adherence. There was a lack of uniformity in using tools to assess self-management across studies. There was a lack of ethnic diversity in the individual studies, limiting the generalization of these studies' findings. Our review showed that self-management strategies are beneficial for heart failure-related hospitalization, reduce mortality and hospitalization for heart failure, and are cost-effective. The use of innovative approaches like smartphone applications improves adherence.

A multicomponent complex intervention for supportive follow-up of persons with chronic heart failure: a randomized controlled pilot study (the UTILE project)

BACKGROUND

Heart failure (HF) is a progressive disease associated with a high burden of symptoms, high morbidity and mortality, and low quality of life (QoL). This study aimed to evaluate the feasibility and potential outcomes of a novel multicomponent complex intervention, to inform a future full-scale randomized controlled trial (RCT) in Switzerland.

METHODS

We conducted a pilot RCT at a secondary care hospital for people with HF hospitalized due to decompensated HF or with a history of HF decompensation over the past 6 months. We randomized 1:1; usual care for the control (CG) and intervention group (IG) who received the intervention as well as usual care. Feasibility measures included patient recruitment rate, study nurse time, study attrition, the number and duration of consultations, intervention acceptability and intervention fidelity. Patient-reported outcomes included HF-specific self-care and HF-related health status (KCCQ-12) at 3 months follow-up. Clinical outcomes were all-cause mortality, hospitalization and days spent in hospital.

RESULTS

We recruited 60 persons with HF (age mean = 75.7 years, ± 8.9) over a 62-week period, requiring 1011 h of study nurse time. Recruitment rate was 46.15%; study attrition rate was 31.7%. Follow-up included 2.14 (mean, ± 0.97) visits per patient lasting a total of 166.96 min (mean, ± 72.55), and 3.1 (mean, ± 1.7) additional telephone contacts. Intervention acceptability was high. Mean intervention fidelity was 0.71. We found a 20-point difference in mean self-care management change from baseline to 3 months in favour of the IG (Cohens' d = 0.59). Small effect sizes for KCCQ-12 variables; less IG participants worsened in health status compared to CG participants. Five deaths occurred (IG = 3, CG = 2). There were 13 (IG) and 18 (CG) all-cause hospital admissions; participants spent 8.90 (median, IQR = 9.70, IG) and 15.38 (median, IQR = 18.41, CG) days in hospital. A subsequent full-scale effectiveness trial would require 304 (for a mono-centric trial) and 751 participants (for a ten-centre trial) for HF-related QoL (effect size = 0.3; power = 0.80, alpha = 0.05).

CONCLUSION

We found the intervention, research methods and outcomes were feasible and acceptable. We propose increasing intervention fidelity strategies for a full-scale trial.

TRIAL REGISTRATION

ISRCTN10151805 , retrospectively registered 04/10/2019.

The association between comorbidities and self-care of heart failure: a cross-sectional study

BACKGROUND

Because heart failure (HF) is a debilitating chronic cardiac condition and increases with age, most patients with HF experience a broad range of coexisting chronic morbidities. Comorbidities present challenges for patients with HF to successfully perform self-care, but it is unknown what types and number of comorbidities influence HF patients' self-care. The purpose of this study was to explore whether the number of cardiovascular and non-cardiovascular conditions are associated with HF self-care.

METHODS

Secondary data analysis was performed with 590 patients with HF. The number of cardiovascular and non-cardiovascular conditions was calculated using the list of conditions in the Charlson Comorbidity Index. Self-care was measured with the European HF self-care behavior scale. Multivariable linear regression was performed to explore the relationship between the types and number of comorbidities and self-care.

RESULTS

Univariate analysis revealed that a greater number of non-cardiovascular comorbidities was associated with poorer HF self-care(β=-0.103), but not of more cardiovascular comorbidities. In the multivariate analysis, this relationship disappeared after adjusting for covariates. Perceived control and depressive symptoms were associated with HF self-care.

CONCLUSION

The significant relationship between the number of non-cardiovascular comorbidities and HF self-care was not independent of perceived control and depressive symptoms. This result suggests a possible mediating effect of perceived control and depressive symptoms on the relationship between HF self-care and the number and type of comorbidities.

Heart Failure Knowledge, Symptom Perception, and Symptom Management in Patients With Heart Failure

BACKGROUND

Prevention of heart failure (HF) exacerbations requires that patients carefully self-manage their condition. Symptom perception is a key component in self-care for patients with HF that involves monitoring for HF symptoms and recognizing symptom changes. Heart failure knowledge is a prerequisite for better symptom perception and symptom management. However, the relationships among HF knowledge, symptom perception, and symptom management remain unclear.

OBJECTIVE

The aim of this study was to explore the inter-relationships among HF knowledge, symptom monitoring, symptom recognition, and symptom response in patients with HF.

METHOD

We included 185 patients with HF in this study. Heart failure knowledge was measured using the Dutch HF Knowledge Scale. Symptom monitoring, symptom recognition, and symptom response were measured using the Self-care of HF Index. Structural equation modeling was used for data analyses.

RESULTS

Heart failure knowledge was associated with symptom monitoring (β = .357, P < .001). Symptom monitoring was directly associated with both symptom recognition (β = .371, P < .001) and symptom response (β = .499, P < .001). Symptom recognition was directly associated with symptom response (β = .274, P < .001). Heart failure knowledge was not directly associated with symptom recognition, nor with symptom response. Heart failure knowledge was indirectly associated with symptom recognition and symptom response through symptom monitoring.

CONCLUSION

Symptom monitoring is associated with both symptom recognition and symptom response and is a mediator between HF knowledge and symptom recognition and between HF knowledge and symptom response. This finding suggests that it is important for clinicians not just to increase patients' HF knowledge but also to enhance their skills of symptom monitoring and symptom recognition and promote symptom monitoring among patients to improve symptom response in self-care.

Association of psychological distress with reasons for delay in seeking medical care in rural patients with worsening heart failure symptoms

BACKGROUND

The impact of depressive symptoms and anxiety on rural patients' decisions to seek care for worsening heart failure (HF) symptoms remains unknown. The purposes of this study were (1) to describe rural patients' reasons for delay in seeking care for HF, and (2) to determine whether depressive symptoms or anxiety was associated with patients' reasons for delay in seeking medical care for worsening symptoms.

METHODS

A total of 611 rural HF patients were included. Data on reasons for patient delay in seeking medical care (The Reasons for Delay Questionnaire), depressive symptoms (PHQ-9), and anxiety (BSI-ANX) were collected. Statistical analyses included chi-square and multiple regression.

RESULTS

A total of 85.4% of patients reported at least 1 reason for delay. Patients with higher levels of depressive symptoms were more likely to cite embarrassment, problems with transportation, and financial concerns as a reason for delay. Patients with anxiety not only cited nonsymptom-related reasons but also reported symptom-related reasons for delay in seeking care (ie, symptoms seemed vague, not sure of symptoms, symptoms didn't seem to be serious enough, and symptoms were different from the last episode). In multiple regression, patients with greater depressive symptoms and anxiety had a greater number of reasons for delay in seeking care (P = .003 and P = .023, respectively).

CONCLUSIONS

Our findings suggest that enhancement of patients' symptom appraisal abilities and improvement in psychological distress may result in a reduction in delay in seeking medical care for worsening symptoms in rural patients with HF.

Effects of educational intervention on mortality and patient-reported outcomes in individuals with heart failure: A randomized controlled trial

OBJECTIVE

To examine the effects of an educational intervention on patient-reported outcomes and all-cause mortality in heart failure (HF) patients METHODS: In this randomized controlled trial, we enrolled 122 hospitalized patients with HF. The intervention group (n = 60) received an individual nurse-led education session on HF self-management during hospitalization and three telephone calls after discharge. The control group (n = 62) received care as usual. Patient-reported outcomes were measured at baseline and at 3 and 6 months. Mortality status was determined using the National Death Records. Intervention effects were evaluated using the Cox proportional hazards regression model and linear mixed models.

RESULTS

During the follow-up (median: 568 days), 7 deaths (12%) in the intervention group and 15 deaths (24%) in the control group occurred (adjusted hazard ratio, 0.40; 95% confidence interval, 0.16-0.98; P = .046). From baseline to 3 and 6 months, the intervention group showed greater improvements in HF knowledge (difference=6.14, P = .03; difference=5.76, P = .02, respectively), self-care (difference=-6.08, P < .001; difference=-6.16, P < .001, respectively), and health-related quality of life (difference=-11.90, P = .01; difference=-14.57, P = .004, respectively) than the control group.

CONCLUSION

Educational intervention with telephone follow-up reduced all-cause mortality and improved patient-reported outcomes.

PRACTICE IMPLICATION

Educational intervention should be considered as part of routine care for HF patients.

Sequential Interventions for Major Depression and Heart Failure Self-Care: A Randomized Clinical Trial

BACKGROUND

Major depression and inadequate self-care are common in patients with heart failure (HF). Little is known about how to intervene when both problems are present. This study examined the efficacy of a sequential approach to treating these problems.

METHODS

Stepped Care for Depression in HF was a single-site, single-blind, randomized controlled trial of cognitive behavior therapy (CBT) versus usual care (UC) for major depression in patients with HF. The intensive phase of the CBT intervention lasted between 8 and 16 weeks, depending upon the rate of improvement in depression. All participants received a tailored HF self-care intervention that began 8 weeks after randomization. The intensive phase of the self-care intervention ended at 16 weeks post-randomization. The coprimary outcome measures were the Beck Depression Inventory (version 2) and the Maintenance scale of the Self-Care of HF Index (v6.2) at week 16.

RESULTS

One hundred thirty-nine patients with HF and major depression were enrolled; 70 were randomized to UC and 69 to CBT. At week 16, the patients in the CBT arm scored 4.0 points ([95% CI, -7.3 to -0.8]; P=0.02) lower on the Beck Depression Inventory, version 2 than those in the usual care arm. Mean scores on the Self-Care of HF Index Maintenance scale were not significantly different between the groups ([95% CI, -6.5 to 1.5]; P=0.22).

CONCLUSIONS

CBT is more effective than usual care for major depression in patients with HF. However, initiating CBT before starting a tailored HF self-care intervention does not increase the benefit of the self-care intervention.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02997865.

Association of body mass index and prognosis in patients with HFpEF: A dose-response meta-analysis

BACKGROUND

Although agreements regarding the negative effects of obesity on the development of heart failure with preserved ejection fraction (HFpEF) have been reached, the relationship between body mass index (BMI) and adverse outcomes in HFpEF patients are still debatable. Therefore, we conducted the dose-response meta-analysis to investigate this relationship.

METHODS

We searched the PubMed and Embase databases up to February 2022 for studies that evaluated the association between BMI and prognostic outcomes in patients with HFpEF. A cubic spline random-effects model was used to fit the potential dose-response curve. The effect estimates were expressed as adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

A total of 11 studies involving 69,273 patients with HFpEF were included. The summary HR for all-cause mortality was 0.90 (95% CI, 0.84-0.95) per 5 units increase in BMI, but the association was U-shaped (P_nonlinear < 0.01) with the nadir of risk at a BMI of 32-34 kg/m². The summary HR for HF hospitalization was 1.12 (95% CI, 1.05-1.19) with a significant positive linear association (P_nonlinear = 0.54).

CONCLUSIONS

For patients with HFpEF, there was a positive linear association of BMI with HF hospitalization, while a U-shaped relationship between BMI and all-cause mortality was observed with the lowest event rate at a BMI of 32-34 kg/m².

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Self-care, symptom experience, needs, and past health-care utilization in individuals with heart failure: results of a cross-sectional study

AIMS

Self-care in heart failure (HF) is generally sub-optimal and impacts morbidity and mortality. To describe self-care prevalence and explore its relationships with symptom experience, patient needs, and health-care utilization in a Swiss hospital providing regional secondary care.

METHODS AND RESULTS

Cross-sectional study, convenience sample of individuals with HF from four campuses of one regional Swiss hospital. Self-care was assessed via the Self-Care of Heart Failure Index (SCHFI) and the European Heart Failure Self-care Behaviour Scale (EHFScBS), symptom experience via the M.D. Anderson Symptom Inventory-HF (MDASI-HF) and needs via the Heart Failure Needs Assessment Questionnaire (HFNAQ). Healthcare utilization reflected the preceding year's hospitalization incidence. A cut-off level of ≥70% indicated adequate self-care. We analysed SCHFI, EHFScBS, MDASI-HF and HFNAQ scores' relationships with hospitalizations using Spearman's rho correlation; no prior hypotheses were stated. Sample of 310 individuals with HF (37.4% female; mean age 76.8; 55% NYHA III). Adequate self-care maintenance, management, and confidence were reported by 24%, 10%, and 61%. respectively. The sample's mean number of experienced symptoms was 12.8 (SD 4.0) and 14.0 (SD 5.8) for needs. Over the previous year, 269 hospitalizations had occurred (median: 0, IQR 1). Hospitalizations positively correlated with self-care; symptom experience with needs. Neither symptom experience nor needs correlated with hospitalizations.

CONCLUSION

The findings indicated low self-care levels and suggest a need for increased support to maintain physiological stability, manage symptoms and prevent hospitalizations. This study is the first of its kind in Switzerland and among few studies worldwide to report on self-care, symptom experience, needs, and health-care utilization. Interventional studies are warranted considering baseline self-care capabilities, symptoms, and needs of individuals with HF.

Applying the COM-B behaviour model to overcome barriers to heart failure self-care: A practical application of a conceptual framework for the development of complex interventions (ACHIEVE study)

BACKGROUND

Effective interventions to enhance adherence to self-care recommendations in patients with heart failure have immense potential to improve health and wellbeing. However, there is substantial inconsistency in the effectiveness of existing self-management interventions, partly because they lack theoretical models underpinning intervention development.

AIM

To outline how the capability, opportunity and motivation behaviour model has been applied to guide the development of a theory-based intervention aiming to improve adherence to heart failure self-care recommendations.

METHODS

The application of the capability, opportunity and motivation behaviour model involved three steps: (a) identification of barriers and facilitators to heart failure self-care from two comprehensive meta-studies; (b) identification of appropriate behaviour change techniques to improve heart failure self-care; and (c) involvement of experts to reduce and refine potential behaviour change techniques further.

RESULTS

A total of 119 barriers and facilitators were identified. Fifty-six behaviour change techniques remained after applying three steps of the behaviour model for designing interventions. Expert involvement (n=39, of which 31 were patients (67% men; 45% New York Heart Association II)) further reduced and refined potential behaviour change techniques. Experts disliked some behaviour change techniques such as 'anticipated regret' and 'salience of consequences'. This process resulted in a final comprehensive list consisting of 28 barriers and 49 appropriate behaviour change techniques potentially enhancing self-care that was put forward for further use.

CONCLUSION

The application of the capability, opportunity and motivation behaviour model facilitated identifying important factors influencing adherence to heart failure self-care recommendations. The model served as a comprehensive guide for the selection and design of interventions for improving heart failure self-care adherence. The capability, opportunity and motivation behaviour model enabled the connection of heart failure self-care barriers to particular behaviour change techniques to be used in practice.

Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

Effects of an educational intervention on heart failure knowledge, self-care behaviors, and health-related quality of life of patients with heart failure: Exploring the role of depression

OBJECTIVES

To test effects of an educational intervention on patient-reported outcomes among rural heart failure (HF) patients and to examine whether effects differed between patients with and without depression.

METHODS

Patients (N = 614) were randomized to usual care (UC) or 1 of 2 intervention groups. Both intervention groups received face-to-face education, followed by either 2 phone calls (LITE) or biweekly calls until they demonstrated content competency (PLUS). Follow-up lasted 24 months. Statistical analyses included linear mixed models and subgroup analyses by depression status.

RESULTS

Both intervention groups showed improvement in HF knowledge at 3 months (LITE-UC, p = 0.003; PLUS-UC, p < 0.001). Improvement lasted 24 months only in the PLUS group. Compared to UC, both intervention groups exhibited better self-care at 3 months (LITE-UC, p < 0.001; PLUS-UC, p < 0.001) and 12 months (LITE-UC, p = 0.001; PLUS-UC, p = 0.002). There were no differences in health-related quality of life (HRQOL) among groups. In subgroup analyses, similar effects were found among non-depressed, but not among depressed patients.

CONCLUSION

The educational intervention improved HF knowledge and self-care, but not HRQOL. No intervention effects were observed in patients with depressive symptoms.

PRACTICE IMPLICATIONS

The simple educational intervention is promising to improve HF knowledge and self-care. Additional strategies are needed for depressed patients.

Effectiveness of Mobile Phone-Based Interventions for Improving Health Outcomes in Patients with Chronic Heart Failure: A Systematic Review and Meta-Analysis

Mobile phone-based interventions are increasingly used to prevent adverse health outcomes in heart failure patients. However, the effects of mobile phone-based interventions on the health outcomes of heart failure patients remain unclear. Our review aims to synthesize the randomized controlled trials (RCT) of mobile phone-based interventions for heart failure patients and identify the intervention features that are most effective. Electronic searches of RCTs published from January 2000 to July 2019 were conducted. Primary outcomes included all-cause mortality, readmission, emergency department visits, length of hospital stays, and quality of life. Secondary outcomes were self-care behaviors, including medication adherence and other clinical outcomes. A total of eight studies with varying methodological quality met the inclusion criteria and were analyzed. Voice call intervention was more frequently used compared with telemonitoring and short message services. Our meta-analysis showed that voice call interventions had significant effects on the length of hospital stays. However, no significant effects on all-cause mortality, readmission, emergency department visits, or quality of life were found. Compared to other mobile phone-based interventions, voice calls were more effective in reducing the length of hospital stay. Future studies are needed to identify which features of mobile phone-based intervention most effectively improve health outcomes.

Heart failure disease management: a systematic review of effectiveness in heart failure with preserved ejection fraction

AIMS

Heart failure with preserved ejection fraction (HFpEF) poses a substantial challenge for clinicians, but there is little guidance for effective management. The aim of this systematic review was to determine if there was evidence that disease management programmes (DMPs) improved outcomes for patients with HFpEF.

METHODS AND RESULTS

A systematic review of controlled studies in English or Greek of DMPs including patients with HFpEF from 2008 to 2018 was conducted using CINAHL, Cochrane, MEDLINE, and Embase. Interventions were assessed using a DMP taxonomy and scored for complexity and intensity. Bias was assessed using the Cochrane Collaboration tool. Initial and updated searches found 6089 titles once duplicates were removed. The final analysis included 18 studies with 5435 HF patients: 1866 patients (34%, study ranges 18-100%) had potential HFpEF (limited by variable definitions). Significant heterogeneity in terms of the population, intervention, comparisons, and outcomes prohibited meta-analysis. Statistically significant or positive trends were found in mortality, hospitalization rates, self-care ability, quality of life, anxiety, depression, and sleep, but findings were not robust or consistent. Four studies reported results separately for study-defined HFpEF, with two finding less positive effect on outcomes.

CONCLUSIONS

Varying definitions of HFpEF used in studies are a substantial limitation in interpretation of findings. The reduced efficacy noted in contemporary HF DMP studies may not only be due to improvements in usual care but may also reflect inclusion of heterogeneous patients with HFpEF or HF with mid-range EF who may not respond in the same way as HFrEF to individual components. Given that patients with HFpEF are older and multi-morbid, DMPs targeting HFpEF should not rely on a single-disease focus but provide care that addresses predisposing and presentation phenotypes and draws on the principles of comprehensive geriatric assessment. Other components could also be more targeted to HFpEF such as modification of lifestyle factors for which there is emerging evidence, rather than simply continuing the model of care used in HFrEF. Based on current evidence, HF DMPs may improve mortality, hospitalization rates, self-care, and quality of life in patients with HFpEF; however, further research specifically tailored to appropriately defined HFpEF is required.

Symptom perception in heart failure - Interventions and outcomes: A scoping review

BACKGROUND

Symptom perception in heart failure has recently been described as essential in the self-care process bridging self-care maintenance and self-care management. Accordingly, symptom perception appears to be critical for improving patient outcomes such as decreased hospital readmission and increased survival.

OBJECTIVES

To explore what interventions have been reported on heart failure symptom perception and to describe outcomes responsive to symptom perception.

DESIGN

We conducted a scoping review using PRISMA Extension for Scoping Reviews.

DATA SOURCES

Structured searches of Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, Joanna Briggs Institute and Grey literature databases.

REVIEW METHODS

Two authors independently screened references for eligibility. Eligible articles were written in English, French, German, Swedish, Italian or Spanish and concerned symptom perception in adults with heart failure. Data were extracted and charted in tables by three reviewers. Results were narratively summarized.

RESULTS

We identified 99 eligible studies from 3055 references. Seven interventional studies targeted symptom perception as the single intervention component. Mixed results have been found: while some reported decreased symptom frequency, intensity and distress, enhanced health-related quality of life, improved heart failure self-care maintenance and management as well as a greater ability to mention heart failure symptoms, others found more contacts with healthcare providers or no impact on anxiety, heart failure self-care nor a number of diary reported symptoms. Additional interventional studies included symptom perception as one component of a multi-faceted intervention. Outcomes responsive to symptom perception were improved general and physical health, decreased mortality, heart failure decompensation, as hospital/emergency visits, shorter delays in seeking care, more consistent weight monitoring, improved symptom recognition as well as self-care management, decreased hospital length of stay and decreased costs.

CONCLUSIONS

While many studies allowed to map a comprehensive overview of interventions supporting symptom perception in heart failure as well as responsiveness to outcomes, only a few single component intervention studies targeting symptom perception have been reported and study designs preclude assessing intervention effectiveness. With regard to multiple component interventions, the specific impact of symptom perception interventions on outcomes remains uncertain to date. Well-designed studies are needed to test the effectiveness of symptom perception interventions and to elucidate relationships with outcomes.

Rehabilitation Intervention for Individuals With Heart Failure and Fatigue to Reduce Fatigue Impact: A Feasibility Study

OBJECTIVE

To investigate feasibility of recruitment, tablet use in intervention delivery, and use of self-report outcome measures and to analyze the effect of Energy Conservation plus Problem-Solving Therapy versus Health Education interventions for individuals with heart failure-associated fatigue.

METHODS

This feasibility study was a block-randomized controlled trial involving 23 adults, blinded to their group assignment, in a rural southern area in the United States. Individuals with heart failure and fatigue received the interventions for 6 weeks through videoconferencing or telephone. Participants were taught to solve their fatiguerelated problems using energy conservation strategies and the process of Problem-Solving Therapy or educated about health-related topics.

RESULTS

The recruitment rate was 23%. All participants completed the study participation according to their group assignment, except for one participant in the Energy Conservation plus Problem-Solving Therapy group. Participants primarily used the tablet (n=21) rather than the phone (n=2). Self-report errors were noted on Activity Card Sort (n=23). Reported fatigue was significantly lower for both the Energy Conservation plus Problem-Solving Therapy (p=0.03, r=0.49) and Health Education (p=0.004, r=0.64) groups. The Health Education group reported significantly lower fatigue impact (p=0.019, r=0.48). Participation was significantly different in low-physical demand leisure activities (p=0.008; r=0.55) favoring the Energy Conservation plus Problem-Solving Therapy group.

CONCLUSION

The recruitment and delivery of the interventions were feasible. Activity Card Sort may not be appropriate for this study population due to recall bias. The interventions warrant future research to reduce fatigue and decrease participation in sedentary activities (Clinical Trial Registration number: NCT03820674).

Predictors of Adherence to Self-Care in Rural Patients With Heart Failure

BACKGROUND

The common reality of not following a recommended course of treatment is a major cause of poor health outcomes in patients with heart failure (HF). The purpose of this study was to identify predictors of adherence to HF self-care recommendations in rural HF patients who received an intervention to promote symptom management and self-care.

METHODS

Data from 349 rural HF patients (42% female, 90% Caucasian) randomized to the intervention arms of the study were used. Adherence was measured using the European Heart Failure Self-Care Scale questionnaire, a brief measure that asks patients to report their adherence to a variety of recommended HF symptom management behaviors (ie, daily weight monitoring, when to call the physician, medications, diet, and exercise). The following predictors were tested: age, gender, marital status, education level, depression score (measured using PHQ-9), anxiety score (measured with the Brief Symptom Inventory), and level of perceived control (measured using Control Attitudes Scale-R). Multivariate linear regression was used to test the model.

RESULTS

The model to predict adherence was significant (P < .0001). Of the covariates tested in the regression model, being a male (P = .009), having less anxiety (P = .018), not being depressed (P = .017), and having higher perceived control (P = .003) were predictors of improved self-care score at 3 months.

CONCLUSION

Adherence is a multifaceted and a challenging behavior based on the assumption that the patient agrees with self-care recommendations. These data suggest interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.

Cluster randomized controlled trial testing the effectiveness of a self-management intervention using the teach-back method for people with heart failure

In this study, we examined the effectiveness of a self-management intervention delivered to people with heart failure in Vietnam. It used teach-back, a cyclical method of teaching content, checking comprehension, and re-teaching to improve understanding. A single-site cluster randomized controlled trial was conducted, and six hospital wards were randomized into two study groups. On the basis of ward allocation, 140 participants received either usual care or the teach-back heart failure self-management intervention plus usual care. The intervention involved, prior to discharge, an individual educational session on heart failure self-care, with understanding reinforced using teach-back, a heart failure booklet, weighing scales, diary, and a follow-up phone call 2 weeks post-discharge. The control group received usual care and the booklet. Outcomes were heart failure knowledge, self-care (maintenance, management and confidence), and all-cause hospitalizations assessed at 1 and 3 months (end-point). Upon completion of the study, the intervention group had significantly greater knowledge and self-care maintenance than the control group. Other outcomes did not differ between the two groups. The teach-back self-management intervention demonstrated promising benefits in promoting self-care for heart failure patients.

Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.

Sedentary lifestyle associated with mortality in rural patients with heart failure

BACKGROUND

The incidence of mortality five years after the onset of symptomatic heart failure is about 50%. Lifestyle behaviors differ substantially and likely lead to prognostic differences.

AIMS

We sought to determine the factors associated with all-cause mortality in patients with heart failure, particularly the impact of a sedentary lifestyle on mortality.

METHODS

This is a secondary analysis of a randomized controlled trial (REMOTE-HF) to improve self-care through education and counseling ( N=602). We conducted an unadjusted Cox proportional hazards regression analysis with sedentary lifestyle as a predictor of mortality, then added depressive symptoms as a confounder. A Kaplan-Meier survival analysis assessed time to event comparing sedentary lifestyle. Cox models included variables of clinical relevance as well as all significant variables from baseline characteristics associated with all-cause mortality.

RESULTS

The mean ± SD age was 66 ± 12.4 years, 41% were women, and 90% were of white race. There were 125 all-cause deaths over 24 months. Sedentary lifestyle was associated with a 75% increase in the expected hazard of all-cause mortality (hazards ratio 1.75; p = 0.003; 95% CI 1.21-2.54) after adjusting for moderate to severe depressive symptoms. Two Cox models showed an 89 and 95% increase, respectively, in all-cause mortality in sedentary participants holding all other variables constant.

CONCLUSIONS

Sedentary lifestyle is strongly associated with all-cause mortality, independent of having moderate to severe depressive symptoms. Clinicians and researchers have an important role in promoting sustained and safe physical activity to improve survival. Other important modifiable targets to improve survival include depressive symptoms, low literacy, and low body mass index. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique Identifier: NCT00415545.

Disease management interventions for heart failure

BACKGROUND

Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012.

OBJECTIVES

To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness.

MAIN RESULTS

We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective.

AUTHORS' CONCLUSIONS

We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.

Health Literacy and Mortality in Patients With Heart Failure: A Systematic Review and Meta-Analysis

Heart failure (HF) remains the most common diagnosis of hospital admission among U.S. adults. Although diagnosis and treatment have improved, mortality rates have not changed, and mortality risk remains high after hospitalization. The current researchers examined how limited health literacy is associated with mortality risk in adults with recent hospitalization due to decompensated HF. Researchers conducted a systematic literature search, selecting three cohort and three intervention studies. The fixed-effect model was used. From the three cohort studies, 2,858 study participants were analyzed. Among participants, limited health literacy was associated with higher all-cause mortality (pooled odds ratio = 2.95; 95% confidence interval [2.34, 3.72]; p < 0.01; I² = 47.38%). However, none of the intervention studies showed an association between limited health literacy and cardiac (or all-cause) mortality. Future research should focus on the efficiency and safety of telehealth-based medicine in patients with HF, particularly those with limited health literacy. [Res Gerontol Nurs. 2019; 12(2):91-108.].

Rapid 5 lb weight gain is not associated with readmission in patients with heart failure

Aims

Heart failure (HF) patients are taught to identify a rapid 5 lb body‐weight gain for early detection of cardiac decompensation. Few data support this common advice. The study aim was to determine whether a 5 lb weight gain in 1 week and signs and symptoms of HF increased risk for unplanned physician or emergency department (ED) visits or hospital admission in rural HF patients.

Methods and results

This was a secondary analysis of a randomized trial. Patients tracked body weight and HF symptoms using diaries. We included patients adherent to daily diaries >50% over 24 months (N = 119). Mean age was 69 ± 11 years; 77% (65) were male, and 67% completed diaries. A weight gain of 5 lb over 7 days was associated with a greater risk for ED visits but not hospital admission [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.04, 1.08; P < 0.0001 vs. HR 1.01, 95% CI 0.88, 1.16; P = 0.79]. Increased dyspnoea over 7 days was associated with a greater risk of ED visits and hospital admissions (HR 9.64, 95% CI 3.68, 25.22; P < 0.0001 vs. HR 5.89, 95% CI 1.73, 20.04; P = 0.01). Higher diary adherence was associated with older age, non‐sedentary behaviour, lower depression, and HF knowledge.

Conclusions

Heart failure patients are counselled to observe for body‐weight gain. Our data do not support that a 5 lb weight gain was associated with hospital admission. Dyspnoea was a better predictor of ED visits and hospital admissions. Daily tracking of dyspnoea symptoms may be an important adjunct to daily weight to prevent hospitalization.

Self-management intervention using teach-back for people with heart failure in Vietnam: A cluster randomized controlled trial protocol

Globally, the increasing prevalence of heart failure is a burden on health-care systems, especially in under-resourced countries, such as Vietnam. We describe a prospective single-site, cluster randomized controlled trial of an intervention designed to teach adult patients about heart failure and how to undertake self-care activities. The intervention, delivered by a nurse, comprises of an individual teaching session using teach-back, a heart failure booklet, weighing scales, a diary to document daily weight, and a follow-up phone call 2 weeks after hospital discharge. Teach-back is a process of asking patients to repeat information and for the nurse to fill any gaps or misunderstanding until adequate understanding is demonstrated. The control group will receive usual education plus the heart failure (HF) booklet. A total of 140 participants will be allocated into two study groups. The level of randomization is at the ward level. The primary outcome (HF knowledge) and secondary outcomes (self-care behaviors and all-cause hospitalizations) will be measured at 1 and 3 months. This study will make an important contribution regarding a protocol of teach-back and chronic disease self-management.

Enhancing self-care adherence in patients with heart failure: a study protocol for developing a theory-based behaviour change intervention using the COM-B behaviour model (ACHIEVE study)

INTRODUCTION

Although international guidelines recommend self-care as an integral part of routine heart failure management, and despite evidence supporting the positive outcomes related to self-care, patients are frequently unable to adhere. Self-care can be modified through behaviour change interventions (BCIs). However, previous self-care interventions have shown limited success in improving adherence to self-care, because they were neither theory-based nor well defined, which precludes the identification of underlying causal mechanisms as well as reproducibility of the intervention. Thus, our aim is to develop an intervention manual that contains theory-based BCIs that are well-defined using eight descriptors proposed to describe BCIs in a standardised way.

METHODS AND ANALYSIS

BCIs will be based on statements of findings derived through qualitative meta-summary techniques and a quantitative meta-analysis. These reviews will be used to extract factors (target behaviours) associated with self-care adherence/non-adherence. Extracted target behaviours will be mapped onto the 'Capability, Opportunity, Motivation and Behaviour' (COM-B) model to capture the underlying mechanisms involved. To develop approaches for change, the 'Taxonomy of Behaviour Change Techniques' will be used to allow effective mapping of the target behaviours onto established behaviour change techniques. Suggested BCIs will then be translated into locally relevant interventions using the Normalisation Process Theory to overcome the difficulties of implementing theoretically derived interventions into practice. Finally, a consensus development method will be employed to fine-tune the content and acceptability of the intervention manual to increase the likelihood of successfully piloting and implementing future BCIs into the German healthcare system.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Ethics Committee of the Medical Faculty of the Heinrich Heine University Düsseldorf, Germany (Ref #: 2018-30). The results will be disseminated via peer-reviewed journal publications, conference presentations and stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

DRKS00014855; Pre-results.

Micronutrient Deficiency Independently Predicts Time to Event in Patients With Heart Failure

Background Dietary micronutrient deficiencies have been shown to predict event-free survival in other countries but have not been examined in patients with heart failure living in the United States. The purpose of this study was to determine whether number of dietary micronutrient deficiencies in patients with heart failure was associated with shorter event-free survival, defined as a combined end point of all-cause hospitalization and death. Methods and Results Four-day food diaries were collected from 246 patients with heart failure (age: 61.5±12 years; 67% male; 73% white; 45% New York Heart Association [NYHA] class III / IV ) and analyzed using Nutrition Data Systems for Research. Micronutrient deficiencies were determined according to methods recommended by the Institute of Medicine. Patients were followed for 1 year to collect data on all-cause hospitalization or death. Patients were divided according to number of dietary micronutrient deficiencies at a cut point of ≥7 for the high deficiency category versus <7 for the no to moderate deficiency category. In the full sample, 29.8% of patients experienced hospitalization or death during the year, including 44.3% in the high-deficiency group and 25.1% in the no/moderate group. The difference in survival distribution was significant (log rank, P=0.0065). In a Cox regression, micronutrient deficiency category predicted time to event with depression, NYHA classification, comorbidity burden, body mass index, calorie and sodium intake, and prescribed angiotensin-converting enzyme inhibitors, diuretics, or β-blockers included as covariates. Conclusions This study provides additional convincing evidence that diet quality of patients with heart failure plays an important role in heart failure outcomes.

Emergency department arrival times in Florida heart failure patients utilizing Fisher-Rao curve registration: A descriptive population-based study

BACKGROUND

Emergency room utilization and hospital readmission rates are disproportionately high for heart failure patients (HF). Emergency department (ED) utilization is intimately intertwined with hospital readmissions.

OBJECTIVE

Describe the arrival time distribution of HF patients presenting to the ED.

METHOD

The study analyzed heart failure discharge data from the Florida State Emergency Department Database and the Florida State Inpatient Database from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Data were treated as a Poisson process and analyzed using functional data analysis tools.

RESULTS

HF arrivals are multi-modal with the largest peak arrival time in the middle of the day as well as a smaller peak in the early morning hours, especially in rural areas.

CONCLUSIONS

The arrival pattern has minor differences in rural and urban areas. HF clinic appointments should be established in the early morning hours when these patients utilize the ED.

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.

Living Arrangements Modify the Relationship Between Depressive Symptoms and Self-care in Patients With Heart Failure

BACKGROUND

Depressive symptoms hinder heart failure patients' engagement in self-care. As social support helps improve self-care and decrease depressive symptoms, it is possible that social support buffers the negative impact of depressive symptoms on self-care.

OBJECTIVE

The purpose of this study is to examine the effect of living arrangements as an indicator of social support on the relationship between depressive symptoms and self-care in heart failure patients.

METHODS

Stable heart failure patients (N = 206) completed the Patient Health Questionnaire-9 to measure depressive symptoms. Self-care (maintenance, management, and confidence) was measured with the Self-Care of Heart Failure Index. Path analyses were used to examine associations among depressive symptoms and the self-care constructs by living arrangements.

RESULTS

Depressive symptoms had a direct effect on self-care maintenance and management (standardized β = -0.362 and -0.351, respectively), but not on self-care confidence in patients living alone. Depressive symptoms had no direct or indirect effect on any of the 3 self-care constructs in patients living with someone.

CONCLUSIONS

Depressive symptoms had negative effects on self-care in patients living alone, but were not related to self-care in patients living with someone. Our results suggest that negative effects of depressive symptoms on self-care are buffered by social support.

Implementing a Protocol to Improve Self-Care Behaviors in Adult Patients With Heart Failure

Background:

Heart failure (HF) is a condition that affects millions of Americans and costs $30 billion to treat annually. HF is the cause for frequent hospitalizations. Self-care practices have been found to improve quality of life, decrease hospitalizations, and reduce treatment costs.

Participants:

Fifteen adult patients with a HF diagnosis ages 18 to 70 voluntarily participated in the implementation of a protocol aimed at improving self-care behaviors in patients with HF in a private cardiology practice located in a southeastern city.

Methods:

The project was a quality improvement design. A protocol was implemented using resources from the American Heart Association. Monitoring logs were provided to patients to record daily weights, sodium intake, blood pressure, and symptoms. Educational resources included information about medications and a list of valid HF websites. Participants were provided medication organizers and a two-liter container with which to monitor daily fluid intake. The written information and logs were compiled in red folders.

Results:

Of the 15 participants, there were no hospital admissions or readmissions for HF during the implementation period. Leg and ankle swelling worsened; dyspnea improved; fewer participants felt like a burden to their family; HF knowledge improved.

Discussion:

The findings indicate the feasibility of implementing the protocol throughout a private practice organization.

Relationship between self-care and comprehensive understanding of heart failure and its signs and symptoms

Background:

Although incomplete understanding of heart failure and its signs and symptoms appears to be a barrier to successful self-care, there are few studies examining the relationship between self-care and levels of comprehensive understanding of heart failure and its signs and symptoms.

Aim:

To determine whether incomplete understanding of heart failure and its signs and symptoms is associated with self-care in heart failure patients who were recently discharged from the hospital due to heart failure exacerbation.

Methods:

Patients completed the nine-item European Heart Failure Self-care Behavior scale and questionnaire to assess knowledge of heart failure and its signs and symptoms. Three groups were formed by their different levels of understanding of heart failure and its signs and symptoms. Multivariable linear regression was used to determine whether these three levels of understanding groups predicted self-care after controlling for demographic and clinical variables.

Results:

Of 571 patients 22.1%, 40.1% and 37.8% had poor, moderate, and complete understanding, respectively. Compared with patients in the poor understanding group, patients in complete and moderate understanding groups were more likely to have better adherence to self-care activities (standardized β = −0.14, 95% confidence interval −3.41, −0.47; standardized β = −0.19, 95% confidence interval −4.26, −1.23, respectively).

Conclusions:

Fewer than half of the patients had a comprehensive understanding of heart failure and its signs and symptoms, which was associated with poor self-care. Our study suggests that patient education should include contents to promote comprehensive understanding of heart failure and its symptoms, as well as the importance of self-care behaviors.

Symptom Diary Use and Improved Survival for Patients With Heart Failure

BACKGROUND

Attention to symptoms of weight gain and dyspnea are central tenets of patient education in heart failure (HF). However, it is not known whether diary use improves patient outcomes. The aims of this study were to compare mortality among rural patients with HF who completed versus did not complete a daily diary of weight and symptom self-assessment and to identify predictors of diary use.

METHODS AND RESULTS

This is a secondary analysis of a 3-arm randomized controlled trial on HF education of self-care with 2 intervention groups versus control who were given diaries for 24 months to track daily weight, HF symptoms, and response to symptom changes. Mean age was 66±13, 58% were men, and 67% completed diaries (n=393). We formed 5 groups (no use, low, medium, high, and very high) based on the first 3 months of diary use and then analyzed time to event (cardiac mortality, all-cause mortality, and HF-related readmission) starting at 3 months. Compared with patients with no diary use, high and very high diary users were less likely to experience all-cause mortality (P=0.02 and P=0.01, respectively). Self-reported sedentary lifestyle was associated with less diary use in an adjusted model (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P=0.03). Depression and sex were not significant predictors of diary use in the adjusted model.

CONCLUSIONS

In this study of 393 rural patients with HF, we found that greater diary use was associated with longer survival. These findings suggest that greater engagement in self-care behaviors is associated with better HF outcomes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00415545.