Follow‐up study for a disease management program for chronic heart failure 24 months after program commencement

Abstract

There are few studies dealing with comprehensive chronic heart failure (CHF) disease management programs, which are based on self-management, in Japan. We developed and conducted a comprehensive educational program for CHF for 6 months that aimed to improve self-management and prevent the deterioration of outpatients with CHF. Our follow-up research focused on whether performance of self-management in the intervention group continued for 24 months after commencement. Participants were selected from patients who went for follow-up visits to one Japanese clinic, which specialized in cardiovascular internal medicine, that were diagnosed with CHF. During the first follow-up period, 7 to 12 months after program commencement, 47 participants in the intervention group and 47 participants in the control group were analyzed. During the second follow-up period, 13 to 24 months after program commencement, 41 participants in the intervention group were analyzed. Participants in the intervention group acquired self-management skills and activities and these continued up to 24 months after the program commencement. As a result, no deterioration in symptoms related to CHF was demonstrated. Meanwhile, quitting smoking and drinking depended on individual preference and it was difficult to improve. The educational program was effective in the long term and the program is significant for use in busy medical situations that do not offer sufficient follow-up support for patients. Regular intervention and ways that produce longer-lasting effects should be further developed.