Self-care Confidence Research Articles

Randomized controlled trial of family-based education for patients with heart failure and their carers.

The aim of this study was to evaluate a heart failure education programme developed for patients and carers in Thailand. Heart failure is major health problem. This is the first trial of a family-based education programme for heart failure patients and carers residing in rural Thailand. Randomized controlled trial. One hundred patient-carer dyads attending cardiac clinics in southern Thailand from April 2014 - March 2015 were randomized to usual care (n=50) or a family-based education programme (n=50) comprising face-to-face counselling, a heart failure manual and DVD and telephone support. Assessments of heart failure knowledge, health-related quality of life, self-care behaviours and perceived control were conducted at baseline, three and six months. Linear mixed-effects model revealed that patients and carers who received the education programme had higher knowledge scores at three and six months than those who received usual care. Among those who received the education programme, when compared with those who received usual care, patients had better self-care maintenance and confidence, and health-related quality of life scores at three and six months, and better self-care management scores at sixmonths, whereas carers had higher perceived control scores at threemonths. Addressing a significant service gap in rural Thailand, this family-based heart failure programme improved patient knowledge, self-care behaviours and health-related quality of life and carer knowledge and perceived control.

Abstract 13433: Coping Partnership Intervention Improves Heart Failure Self-Care Confidence and Reduces Unplanned Healthcare Utilization

Introduction: Social support and social problem-solving, as coping resources, are related to HF self-care, but interventions which target these resources to enhance HF self-care and reduce unplanned emergency room visits and hospitalizations are lacking. Purpose: To determine the efficacy of a nurse-led telephone coping partnership intervention on HF self-care and unplanned healthcare utilization in patients with HF. Methodology: A 3 group randomized controlled pilot study was conducted with 107 HF patients for 3 months. The 12-week coping intervention ( n = 34) included 1 home visit, weekly telephone calls for month 1, and biweekly calls for months 2 and 3. The attention group ( n = 38) received telephone calls starting at week 2 which followed the same pattern as the intervention group. All groups received usual care, with the control group ( n = 35) receiving usual care only. Characteristics of HF patients were: mean age 61 years; 54.2% male; 54.2% African American; and NYHA I: 8.4%; II: 43.9%; III: 18.7%; IV: 29%. All groups provided data at baseline, 5 weeks, 9 weeks, and 13 weeks. HF self-care was assessed using the Self-Care of Heart Failure Index. Data analysis included descriptive statistics and linear mixed modeling. Results: A total of 64 patients completed the study (18 intervention; 24 attention; 22 control). Three linear mixed models were built, controlling for covariates (e.g., gender, race, marital status, NYHA HF class). No significant effects over time were noted by group for self-care maintenance and self-care management. However, significant effects over time were noted for self-care confidence in the intervention group ( p = .030). Patients in the intervention group also reported fewer emergency room visits at 13 weeks (5.6% versus 8.3 % attention; 27.3% control), as well as fewer hospitalizations (5.6% versus 12.5% attention; 27.3% control). Conclusions: Nurse-led telephone coping partnership interventions that strengthen support and social problem-solving appear to be most effective in improving self-care confidence and in reducing unplanned healthcare utilization in individuals with HF. Future research should explore the influence of other variables (e.g., dyadic relationship) on HF outcomes using telephone coping partnerships.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI).

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.

Severe fatigue in type 1 diabetes: Exploring its course, predictors and relationship with HbA1c in a prospective study

AimsTo prospectively identify the course of severe fatigue, its predictors and the relationship with HbA1c in patients with type 1 diabetes. Methods214 adult patients completed questionnaires on fatigue severity and fatigue-related factors at baseline. HbA1c was retrieved from medical records. After 43months, fatigue severity and HbA1c were reassessed in 194 patients. A logistic regression analysis was used to determine predictors of severe fatigue at follow-up with various cognitive-behavioral and clinical factors as potential predictors. The relationship between fatigue and HbA1c was investigated in a sub-analysis by differentiating between patients with suboptimal glucose control [HbA1c>7% (53mmol/mol)] and optimal glucose control [HbA1c⩽7% (53mmol/mol)]. ResultsThe prevalence of severe fatigue was 40% at baseline and 42% at follow-up. In three out of four severely fatigued patients at baseline (76%), severe fatigue persisted over time. More depressive symptoms, more pain, sleep disturbances, lower self-efficacy concerning fatigue, less confidence in diabetes self-care, more fatigue severity at baseline and more diabetes complications predicted severe fatigue at follow-up. Over time, HbA1c at baseline was positively associated with fatigue severity at follow-up in both groups (suboptimal glucose control: r=.18, p<.05; optimal glucose control: r=.09, p<.05). ConclusionsAbout three quarters of patients with type 1 diabetes suffer from persistent fatigue. Aside from the number of diabetes complications, no clinical factors explained the persistence of fatigue. HbA1c and fatigue were weakly associated in a sub-analysis. Since the strongest predictors of severe fatigue were cognitive-behavioral factors, behavioral interventions might be effective in decreasing fatigue.

Diabetes distress in males and females with type 1 diabetes in adolescence and emerging adulthood

BackgroundAge and gender are important factors in the adjustment and psychological well-being of patients with chronic physical illness. AimTo explore the gender and age differences in diabetes distress between adolescents and emerging adults with type 1 diabetes (T1D). Subjects and methodsDiabetes distress was compared in 255 adolescents and 283 emerging adults with T1D using Problem Areas in Diabetes scale. ResultsHigh diabetes distress level was found in 22.8% of participants.Lack of confidence in self-care (6.0 vs 3.0, p=0.002), negative emotional consequences (10.0 vs 6.0, p=0.004), and overall score (18.75 vs 11.25, p=0.002) were higher in adult than in adolescent males, when adjusted for age at T1D onset. Negative emotional consequences (13.0 vs 10.0, p=0.005) and overall score (25.0 vs 20.0, p=0.016) were higher in adult compared to adolescent females, when adjusted for age at T1D onset.Lack of confidence in self-care (6.0 vs 3.0, p=0.002), negative emotional consequences (10.0 vs 6.0, p=0.015), and overall score (20.0 vs 11.2, p=0.005) were higher in adolescent females compared to males, when adjusted for age at T1D onset. Negative emotional consequences score was higher in adult females compared to males (13.0 vs 10.0, p=0.029), when adjusted for age at T1D onset.In conclusion, our findings show that patients with T1D have greater burden of diabetes distress in emerging adulthood than in adolescence and add to evidence suggesting the importance of addressing diabetes distress in clinical care and the necessity of wider picture beyond the physical manifestation of diabetes to be taken into consideration.

Clinical and socio-demographic determinants of self-care behaviours in patients with heart failure and diabetes mellitus: A multicentre cross-sectional study

BackgroundSelf-care is vital for patients with heart failure to maintain health and quality of life, and it is even more vital for those who are also affected by diabetes mellitus, since they are at higher risk of worse outcomes. The literature is unclear on the influence of diabetes on heart failure self-care as well as on the influence of socio-demographic and clinical factors on self-care. Objectives(1) To compare self-care maintenance, self-care management and self-care confidence of patients with heart failure and diabetes versus those heart failure patients without diabetes; (2) to estimate if the presence of diabetes influences self-care maintenance, self-care management and self-care confidence of heart failure patients; (3) to identify socio-demographic and clinical determinants of self-care maintenance, self-care management and self-care confidence in patients with heart failure and diabetes. DesignSecondary analysis of data from a multicentre cross-sectional study. SettingOutpatient clinics from 29 Italian provinces. Participants1192 adults with confirmed diagnosis of heart failure. MethodsSocio-demographic and clinical data were abstracted from patients’ medical records. Self-care maintenance, self-care management and self-care confidence were measured with the Self-Care of Heart Failure Index Version 6.2; each scale has a standardized score from 0 to 100, where a score <70 indicates inadequate self-care. Multiple linear regression analyses were performed. ResultsOf 1192 heart failure patients, 379 (31.8%) had diabetes. In these 379, heart failure self-care behaviours were suboptimal (means range from 53.2 to 55.6). No statistically significant differences were found in any of the three self-care measures in heart failure patients with and without diabetes. The presence of diabetes did not influence self-care maintenance (p=0.12), self-care management (p=0.21) or self-care confidence (p=0.51). Age (p=0.04), number of medications (p=0.01), presence of a caregiver (p=0.04), family income (p=0.009) and self-care confidence (p<0.001) were determinants of self-care maintenance. Gender (p=0.01), number of medications (p=0.004) and self-care confidence (p<0.001) were significant determinants of self-care management. Number of medications (p=0.002) and cognitive function (p<0.001) were determinants of self-care confidence. ConclusionsSelf-care was poor in heart failure patients with diabetes mellitus. This population needs more intensive interventions to improve self-care. Determinants of self-care in heart failure patients with diabetes mellitus should be systematically assessed by clinicians to identify patients at risk of inadequate self-care.

Standardized Discharge Information After Short-Stay Hysterectomy and Relationships With Self-Care Confidence, Perceived Recovery, and Satisfaction

We report on the development and investigation of standardized, nurse-delivered discharge information to women after same-day hysterectomy, including the relationships among discharge information, self-care confidence, perceived recovery, and satisfaction. Fifty-one women reported high levels of self-care confidence and various levels of perceived recovery 48 to 72 hours after surgery. They were satisfied to highly satisfied with their experiences and with the discharge information provided. The important role of standardized patient discharge information is highlighted.

Feasibility study of a nurse-led heart failure education program

Aims/Objectives: To assess the feasibility of a nurse-led heart failure (HF) education program using the Self-Care Heart Failure Index (SCHFI) instrument. Background: HF is a frequent and burdensome condition requiring support with self-care management strategies and education. Translating best practice to health services is important in improving health outcomes. Design: Longitudinal quasi-experimental design. Methods: A convenience sample of (N = 41) patients with HF. We implemented a nurse-led education program with 30-day post-discharge home-based telephone follow-up. The SCHFI was used to measure self-care behaviors. 30-day readmission rates were assessed. Results: A significant difference was found in scores for self-care maintenance (p ≤ .001) and self-care management (p ≤ .001) subscales, not self-care confidence. There was no statistically significant difference between 30-day HF readmission rates. Conclusions: Findings suggest that the nurse-led evidence-based HF education program improved self-care behaviors and decreased 30-day readmissions. There is a need for continued development of interventions focused on improving patient self-care confidence.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model

BackgroundCognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding. ObjectivesThe aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care. DesignSecondary analysis of data from a descriptive study. SettingsThree out-patient sites in Pennsylvania and Delaware, USA. ParticipantsA sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%). MethodsData on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping. ResultsMost participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929–.968; root mean squared error of approximation range: .032–.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care. ConclusionsSelf-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population.

Using a self-care management tool to improve self-care and quality of life in patients with congestive heart failure

Self-management is a primary goal for multiple chronic diseases and particularly for Congestive Heart Failure (CHF). Currently, treatment for CHF emphasizes relieving symptoms through teaching patients how to better care for themselves. Patients who take an active role in self-care are more independent; feel more able to manage their disease and experience better psychological outcomes. However, the research focused on self care-management intervention in heart failure patients in Egypt is very inadequate. Thus, this study aims to first explore the self-care management learning needs among patients with CHF, then secondly assess the effects of a self-care-management tool on self-care adequacy and quality of life (QOL) among this group of patients and thirdly identify patient opinions regarding the instructional developed tool. The research design encompasses the two designs of descriptive and quasi-experimental pretest-posttest study. A convenient sample of 256 patients with congestive heart disease was employed for the survey group in the assessment phase of the study. From this sample, 30% were then randomly assigned to use the developed instructional tool as the experimental group. Two tools were used for data collection. The first was the Heart Failure Self-Care Management Questionnaire (HFSCMQ) which included two parts: the Self-Care Heart Failure Index which was developed by Riegel et al., in 2009, and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) that was developed by Rector T, in 1986. The second tool was a patient feedback opinionnaire which was developed by the researchers to determine patient’s feedback after using the developed tool. Results for the survey group revealed observed inadequate self-care management as perceived by patients with CHF involving self-care maintenance, self-care management and self-care confidence elements, as well as poor QOL detection. Results for the experimental group showed that the CHF patient’s perceptions about self-care management with its components were improved before and after use of the developed instructional tool in the second and third assessments. As well, the QOL was slightly improved as perceived by them. This proves that the self-care management tool may be effective as a self-learning reference among Egyptian CHF patients. In conclusion, instructional health education materials, particularly for patients with chronic illnesses such as CHF, are essential nursing interventions to improve patient self-care management literacy and the QOL. Furthermore, the planning, developing, and implementing of different health instructional materials for patient teaching has become a necessary scheme for nurses to improve their practice in exploring innovative roles in the health education field and activate these roles in different health specialties.

(361) - Correlation of GDF-15 with Worsening Functional Capacity and Echocardiographic Parameters in Idiopathic Dilated Cardiomyopathy

s S141 and August 2015. We measured HL using the Newest Vital Sign tool, disease knowledge with the validated English-version Dutch Heart Failure Knowledge Scale, and self-care with the validated Self-Care Heart Failure Index. Results: The sample was predominantly male (72.6%) with an average age of 56.6 years. 43 (32%) had low HL (28/90 in HF; 15/45 in VAD/HTx). Patients with low HL were significantly older (61.3 vs 54.4 years; p 0.1). HF patients with low HL also trended towards poorer self-care maintenance (71.48% vs 78.36%, p= 0.06) and self-care confidence (67.71% vs 75.42%, p= 0.06) but these did not reach statistical significance. Neither self-care maintenance (79.48% vs 81.03%; p> 0.5), nor confidence (75.99% vs 78.21%, p> 0.5) was associated with low HL in the VAD/HTx group. Conclusion: This study found that 32% of patients with HF or VAD/HTx have low HL. This population is characterized by increased age, less formal education, and English as a second language. In HF patients, low HL is associated with poorer HF knowledge and self-care, which may negatively impact outcomes. Despite this effect of low HL in the HF population, in VAD/ HTx patients, low HL does not appear to correlate with HF knowledge or self-care. Low HL represents a marker for patients who may benefit from additional educational supports.

Availability of Care Concordant With Patient-centered Medical Home Principles Among Those With Chronic Conditions: Measuring Care Outcomes.

Care delivery redesign in the form of patient-centered medical home (PCMH) is considered as a potential solution to improve patient outcomes and reduce costs, particularly for patients with chronic conditions. But studies of prevalence or impact at the population level are rare. We aimed to assess whether desired outcomes indicating better care delivery and patient-centeredness were associated with receipt of care according to 3 important PCMH principles. We analyzed data from a representative population survey in California in 2009, focusing on a population with chronic condition who had a usual source of care. We used bivariate, logistic, and negative-binomial regressions. The indicators of PCMH concordant care included continuity of care (personal doctor), care coordination, and care management (individual treatment plan). Outcomes included flu shots, count of outpatient visits, any emergency department visit, timely provider communication, and confidence in self-care. We found that patients whose care was concordant with all 3 PCMH principles were more likely to receive flu shots, more outpatient care, and timely response from providers. Concordance with 2 principles led to some desired outcomes. Concordance with only 1 principle was not associated with desired outcomes. Patients who received care that met 3 key aspects of PCMH: coordination, continuity, and management, had better quality of care and more efficient use of the health care system.

Shared Care Contributions to Self-Care and Quality of Life in Chronic Cardiac Patients.

Shared care is an interpersonal interaction system composed of communication, decision making, and reciprocity; it is used by patients and family caregivers (care dyads) to exchange social support. This study's purpose was to describe the contributions of shared care to outcomes for individuals with cardiac disease. A secondary data analysis was used to answer the following questions. What is the association between elements of shared care and patient outcomes? Do dyad perceptions of shared care differentially contribute to patient outcomes? Participants in this study were 93 individuals with a cardiac disease and 93 family caregivers. Composite index structured equation modeling was the analytic tool. Caregiver communication and reciprocity were related to patient mental quality of life. Patient communication and reciprocity were related to their own mental and physical quality of life and self-care confidence. Findings from this study contribute a better understanding of how care dyads are integral to patient outcomes.

Self-care and Its Predictors in Patients With Chronic Heart Failure in Western Iran.

Chronic heart failure (CHF) is an increasing and costly health problem worldwide. Effective self-care behaviors reduce the cost and improve CHF outcomes. Interventions targeting improvement of self-care need to identify the baseline status of patients and factors associated with self-care to tailor the programs to patients' needs. The aim of this study was to describe self-care and its predictors in patients with CHF in western Iran. In a cross-sectional study, 255 patients with CHF in Kermanshah were recruited and 231 (mean [SD] age, 66 [13] years; 51.5% women) completed the interviews. Self-care maintenance, self-care management, and self-care confidence were evaluated using a Persian heart failure self-care index. Each of these 3 measures had a total possible score of 100, with 22 indicators. The mean (SD) self-care scores were low: maintenance, 33.8 (10.7); management, 32.2 (12.0); and confidence, 43.6 (15.6). Self-care maintenance was significantly and positively associated with education, disease duration, and living conditions. Self-care management was significantly and positively associated with education and number of hospital admissions. However, the parameter estimates in all those relationships were small. Self-care in patients with CHF in Iran needs major improvement, and many determinants of self-care identified by other studies were not consistently associated with poor self-care scores in Iran. Further research considering a wide range of factors associated with self-care (eg, socioeconomic and health system-related factors) and application of culturally relevant interventional strategies is recommended.

Low Self-Confidence and Diabetes Mismanagement in Youth with Type 1 Diabetes Mediate the Relationship between Behavioral Problems and Elevated HbA1c.

Introduction. Previous studies indicated an association between behavior problems (internalizing, externalizing) and glycemic control (HbA1c) in youth with type 1 diabetes (T1D). The aim of this study is to examine if this association is mediated by self-confidence and mismanagement of diabetes. Methods. Problem behavior was assessed with the Strengths and Difficulties Questionnaire. Mediating variables were assessed using the Confidence in Diabetes Self-Care-Youth and Diabetes Mismanagement Questionnaire. HbA1c was derived from hospital charts. Bootstrap mediation analysis for multiple mediation was utilized. Results. 88 youths with T1D, age 11–15 y, participated. The relation between both overall problem behavior and externalizing behavior problems and HbA1c was mediated through confidence in diabetes self-care and mismanagement (a 1 b 1 + a 2 b 2 path; point estimate = 0.50 BCa CI 95% 0.25–0.85; a 1 b 1 + a 2 b 2 path; point estimate = 0.73 BCa CI 95% 0.36–1.25). Conclusions. Increased problem behavior in youth with T1D is associated with elevated HbA1c and mediated by low self-confidence and diabetes mismanagement. Screening for problem behavior and mismanagement and assisting young patients in building confidence seem indicated to optimize glycemic control.

A multimodal technology intervention for heart failure patients to reduce readmissions

Background: Heart failure (HF) is a prevalent and costly condition. Technology is increasingly being used to deliver patient self-care programs to provide knowledge and skills for early symptom recognition, prompt treatment, and successful management. Objective: The purpose of this study was to provide a home telemonitoring (HT) and telephonic nurse coach (NC) motivational interviewing (MI) educational intervention. Methods: Thirty participants (M age = 75) were enrolled in a three-arm randomized controlled trial. Group A participants ( n = 9) received HT devices, NC, and MI HF self-care education while Group B ( n = 11) had NC, MI HF self-care, and Group C ( n = 9) received NC health promotion only. Results: Eighty-four percent of participants completed the study. Only 1, of the total 9 readmissions that occurred among the 3 groups, was in Group A but there was no statistical significance regarding readmissions. Both depression ( p = .008) and telemedicine satisfaction ( p = .046) were statistically significant between the groups. Over time, Group A participant depression declined ( p = .047) while Group C demonstrated improved self-care confidence ( p = .047). Implications: There are numerous challenges related to the care and management of chronically ill HF patients. Potential benefits that may result from the use of HT in promoting self-care of HF patients should be further explored.

Abstract 18621: Self-care Confidence is Important in Self-care in Emerging Adults With Congenital Heart Disease

Background: Emerging adults (ages 18-25 years) with congenital heart disease (CHD) are expected to perform self-care, behaviors that maintain physiologic stability and the response to symptoms as they occur. In spite of the seriousness of CHD, some emerging adults forego self-care. Identifying those unlikely to perform self-care is essential.Objective: The purpose of this study was to describe self-care and to identify the correlates of self-care in emerging adults with CHD. We hypothesized that knowledge and beliefs would be the primary determinants of self-care. Methods: In this descriptive, cross-sectional study, we enrolled a convenience sample (n=57) of emerging adults from two outpatient CHD centers (adult, n=37; pediatric, n=20) in the Northeastern US. All participants completed neuropsychological testing (PMR, DSST, Trail-Making Tests and the Letter Number Sequencing Tests) and scales measuring developmental stage (Course of Life), mood, knowledge of CHD (Leuven Knowledge Questionnaire), self-efficacy (the NGSES), family functioning (FAD), and a demographic survey. Disease severity was determined by the diagnosis and the number of repairs. Variables were tested as correlates of self-care measured using the Self-Care in CHD Scale (SC-CHD). Scores are standardized 0-100; higher scores indicate higher self-care. Multivariate regression was conducted in two blocks. First age, disease severity, developmental stage, mood, family functioning, cognition, and self-care confidence were entered. Second, knowledge and beliefs were entered for hypothesis testing. Results: Participants (42% female, mean age 21 years, SD 2.32) had predominantly moderate (42%) to severely (45.6%) complex CHD. Self-care was low (SC-CHD=mean 57, SD 11.23). More CHD repairs, higher levels of self-care confidence, and older age explained 41% of the variance in self-care (Block 2: F=3.785, df=3, 46, p=0.17). The higher the level of self-care confidence, the more likely the performance of self-care. Conclusions: These results can be used to identify a subset of CHD patients at risk for poor self-care. Self-care confidence is the only modifiable determinant, suggesting that interventions designed to increase self-care confidence may be useful in this population.

Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients: A Randomized Clinical Trial.

Depression and inadequate self-care are common and interrelated problems that increase the risks of hospitalization and mortality in patients with heart failure (HF). To determine the efficacy of an integrative cognitive behavior therapy (CBT) intervention for depression and HF self-care. Randomized clinical trial with single-blind outcome assessments. Eligible patients were enrolled at Washington University Medical Center in St Louis between January 4, 2010, and June 28, 2013. The primary data analyses were conducted in February 2015. The participants were 158 outpatients in New York Heart Association Class I, II, and III heart failure with comorbid major depression. Cognitive behavior therapy delivered by experienced therapists plus usual care (UC), or UC alone. Usual care was enhanced in both groups with a structured HF education program delivered by a cardiac nurse. The primary outcome was severity of depression at 6 months as measured by the Beck Depression Inventory. The Self-Care of Heart Failure Index Confidence and Maintenance subscales were coprimary outcomes. Secondary outcomes included measures of anxiety, depression, physical functioning, fatigue, social roles and activities, and quality of life. Hospitalizations and deaths were exploratory outcomes. One hundred fifty-eight patients were randomized to UC (n = 79) or CBT (n = 79). Within each arm, 26 (33%) of the patients were taking an antidepressant at baseline. One hundred thirty-two (84%) of the participants completed the 6-month posttreatment assessments; 60 (76%) of the UC and 58 (73%) of the CBT participants completed every follow-up assessment (P = .88). Six-month depression scores were lower in the CBT than the UC arm on the Beck Depression Inventory (BDI-II) (12.8 [10.6] vs 17.3 [10.7]; P = .008). Remission rates differed on the BDI-II (46% vs 19%; number needed to treat [NNT] = 3.76; 95% CI, 3.62-3.90; P < .001) and the Hamilton Depression Scale (51% vs 20%; NNT = 3.29; 95% CI, 3.15-3.43; P < .001). The groups did not differ on the Self-Care Maintenance or Confidence subscales. The mean (SD) Beck Depression Inventory scores 6 months after randomization were lower in the CBT (12.8 [10.6]) than the UC arm (17.3 [10.7]), P = .008. There were no statistically significant differences between the groups on the Self-Care Maintenance or Confidence subscale scores or on physical functioning measures. Anxiety and fatigue scores were lower and mental- and HF-related quality of life and social functioning scores were higher at 6 months in the CBT than the UC arm, and there were fewer hospitalizations in the intervention than the UC arm. A CBT intervention that targets both depression and heart failure self-care is effective for depression but not for HF self-care or physical functioning relative to enhanced UC. Additional benefits include reduced anxiety and fatigue, improved social functioning, and better health-related quality of life. clinicaltrials.gov Identifier: NCT01028625.

Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized controlled trial

ObjectiveThe purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life. MethodsThis is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3–4 follow-up phone calls by a nurse over 90 days. ResultsA total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days. ConclusionPatients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care. Practice ImplicationsThese data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes.

Cost-effectiveness of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort — The WHICH? study (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care)

ObjectiveTo assess the long-term cost-effectiveness of two multidisciplinary management programs for elderly patients hospitalized with chronic heart failure (CHF) and how it is influenced by patient characteristics. MethodsA trial-based analysis was conducted alongside a randomized controlled trial of 280 elderly patients with CHF discharged to home from three Australian tertiary hospitals. Two interventions were compared: home-based intervention (HBI) that involved home visiting with community-based care versus specialized clinic-based intervention (CBI). Bootstrapped incremental cost–utility ratios were computed based on quality-adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed based on incremental net monetary benefit (NMB). We performed multiple linear regression to explore which patient characteristics may impact patient-level NMB. ResultsDuring median follow-up of 3.2years, HBI was associated with slightly higher QALYs (+0.26years per person; p=0.078) and lower total healthcare costs (AU$ −13,100 per person; p=0.025) mainly driven by significantly reduced duration of all-cause hospital stay (−10days; p=0.006). At a willingness-to-pay threshold of AU$ 50,000 per additional QALY, the probability of HBI being better-valued was 96% and the incremental NMB of HBI was AU$ 24,342 (discounted, 5%). The variables associated with increased NMB were HBI (vs. CBI), lower Charlson Comorbidity Index, no hyponatremia, fewer months of HF, fewer prior HF admissions <1year and a higher patient's self-care confidence. HBI's net benefit further increased in those with fewer comorbidities, a lower self-care confidence or no hyponatremia. ConclusionsCompared with CBI, HBI is likely to be cost-effective in elderly CHF patients with significant comorbidity.