Abstract
BackgroundSelf-management programs for patients with heart failure can reduce hospitalizations and mortality. However, no programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care.MethodsWe performed a 12-month randomized controlled trial. From November 2001 to April 2003, we enrolled participants aged 30–80, who had heart failure and took furosemide. Intervention patients received education on self-care emphasizing daily weight measurement, diuretic dose self-adjustment, and symptom recognition and response. Picture-based educational materials, a digital scale, and scheduled telephone follow-up were provided to reinforce adherence. Control patients received a generic heart failure brochure and usual care. Primary outcomes were combined hospitalization or death, and heart failure-related quality of life.Results123 patients (64 control, 59 intervention) participated; 41% had inadequate literacy. Patients in the intervention group had a lower rate of hospitalization or death (crude incidence rate ratio (IRR) = 0.69; CI 0.4, 1.2; adjusted IRR = 0.53; CI 0.32, 0.89). This difference was larger for patients with low literacy (IRR = 0.39; CI 0.16, 0.91) than for higher literacy (IRR = 0.56; CI 0.3, 1.04), but the interaction was not statistically significant. At 12 months, more patients in the intervention group reported monitoring weights daily (79% vs. 29%, p < 0.0001). After adjusting for baseline demographic and treatment differences, we found no difference in heart failure-related quality of life at 12 months (difference = -2; CI -5, +9).ConclusionA primary care-based heart failure self-management program designed for patients with low literacy reduces the risk of hospitalizations or death.
Highlights
Self-management programs for patients with heart failure can reduce hospitalizations and mortality
In pilot testing of the Minnesota Living with Heart Failure Questionnaire (MLHF), we found that low literacy patients had trouble answering questions with the standard 6-point Likert scale [15], so we changed the response scale to 4 points, using a visual display with stars to represent increasing severity
We identified the following variables that could contribute to hospitalization or death based on previous studies: age, race, gender, literacy level, hypertension, diabetes, creatinine, MLHF score, use of β-blockers, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), use of digoxin, and presence of systolic dysfunction [7,25]
Summary
Self-management programs for patients with heart failure can reduce hospitalizations and mortality. No programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care. Low literacy is associated with increased risk of hospitalization and worse control of chronic diseases [1,2,3,4]. The complexity of care for heart failure puts people with low literacy at considerable risk for adverse outcomes including hospitalization, worse quality of life, and mortality. Heart failure disease-management interventions appear effective in reducing rehospitalizations and improving quality of life [6]. The content of self-management education usually includes teaching to understand medications, reduce salt intake, monitor daily weights, and recognize symptoms. A few, uncontrolled studies ask patients to self-adjust their diuretics [11,12]
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