Effect of behavioral management on quality of life in mild heart failure: a randomized controlled trial

doi:10.1016/j.pec.2004.06.007

Patient Education and Counseling

Volume 58, Issue 1, July 2005, Pages 27-34

https://doi.org/10.1016/j.pec.2004.06.007 Get rights and content

Abstract

There has been a lack of research regarding nonpharmacologic interventions in heart failure. The objective was to determine the effect of behavioral management on health related quality of life (HRQL) in patients with heart failure. Participants (N = 116) were randomly assigned to one of two groups: usual care for heart failure (n = 58) and the 15-week behavioral management program (n = 58). Outcomes included exercise performance (6-min walk), physical and mental functioning (SF-36), general health perceptions (SF-36), and disease specific HRQL (Minnesota Living with Heart Failure Questionnaire—MLHF). Outcomes were assessed at baseline, 4, 10 and 16 months. Participants were mostly male (95%) and Caucasian (75%), with a mean age of 67 years (S.D. = 10). Intervention patients showed significantly improved self-reported disease specific HRQL (MLHF physical dimension scores) over time compared to control patients. There were no group differences in exercise performance, physical functioning, mental functioning or general health perceptions.

Introduction

It is well known that heart failure is a significant and growing health care problem with high mortality, reduced quality of life and significant economic burden on society [1]. Patient management and guideline recommendations include encouraging patients to be more active in their own care, patient and family education, symptom management, exercise training, dietary modification, and adherence to the prescribed medications [1], [2], [3]. Behavioral self-management in patients with heart failure may help to control symptoms, maintain function, avoid preventable re-hospitalization, and ultimately decrease morbidity and mortality. One desired outcome from behavioral self-management is enhanced health related quality of life (HRQL); however, only a few groups have reported behavioral interventions specific to heart failure [4], [5]. Evaluation of behavioral interventions is still lacking and interventions to improve HRQL in patients with heart failure still need to be tested. The primary objective of this study was to determine the effect of a nurse-led behavioral management intervention on HRQL in patients with mild heart failure. It was hypothesized that patients who participated in a nurse-led behavioral management intervention as compared to usual care over a 16-month follow-up period (baseline, 4, 10, and 16 months) would have improved exercise performance, physical functioning, mental functioning, and general health perceptions.

Section snippets

General design

This was a randomized clinical trial design (Fig. 1). Following eligibility screening and consent, 116 patients were randomly assigned to one of two treatment groups to evaluate the clinical impact of the intervention. A stratified blocked randomization approach based on the Specific Activity Scale (SAS) was used to assure that patients were equally distributed based on functional performance. The control group received usual care for patients with heart failure (n = 58). The intervention group

Patient characteristics

A total of 116 patients enrolled in the study. Participants were primarily male (n = 110, 95%), reflecting the VA population, and Caucasian (n = 87, 75%). The mean age of the entire sample was 67 years (S.D. = 10); ages ranged from 41 to 90 years. The median ejection fraction for both groups was 40%; these data were available in 69 (60%) of the participants from the total sample. Heart failure etiology was available for 88 (76%) of the 116 participants. The most frequently reported etiologies

Discussion

The important results from this study are in the domain of physical functioning. The physical functioning measures included an objective measurement of exercise performance (the 6-min walk) and a self-report measure of impairment due to heart failure (MLHF physical functioning score). The MLHF self-report measure demonstrated a better outcome in the participants randomized to the behavioral management intervention compared to the control group. The 6-min walk was significantly better only with

Conclusions and practice implications

This study demonstrates efficacy of the behavioral management intervention on a self-reported disease specific physical functioning. This study is unique in that it focused on HRQL as a primary patient outcome, used both generic and disease-specific questionnaires for measuring HRQL, tracked HRQL longitudinally, and examined optimal timing of the behavioral management intervention, as well as measurements to evaluate the intervention. The major practice implication suggested by this study is

Acknowledgements

We gratefully acknowledge the work of research associates Debbie Dugan, MS, RN, Malinda Fox, MS, RN, Joan Hall, MS, RN, Mary Jane Hoban, MS, RN, Lien Khuat, MS, RN, Vicki McCalmont, MS, RN, Kimberly Newell, MS, RN, Beth Schanke, MS, RN; database management specialist Jo-Anne Toomey, MBA; quality control consultant Ann Bryant, MS, RN; data review board members Kirk Peterson, MD, Barbara Riegel, DNSc, RN; intervention advisors Sheri Pruitt, PhD and Allen Gifford, MD; and general support of the VA

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Kodiath M, Kelly A, Shively M. Improving quality of life in heart failure patients: an innovative behavioral...

T.M. Gill et al.

A critical appraisal of the quality of quality-of-life measurements

JAMA

(1994)

Cited by (53)

A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies
2019, Patient Education and Counseling
Citation Excerpt :
Studies assessed a wide range of participant outcomes (Table 3) that were categorized into the seven outcome categories (i.e. Process, Resource, Health Behaviour and Disease Controlling, Emotional, Activities and Social Interaction, Global Self-Efficacy, Global Quality of Life and Global Disease). Outcomes related to Health Behaviour and Disease Controlling (n = 21/31) [45,47,49,51,52,54,55,58,59,61–64,67,69,70,72–76] and Global Quality of Life (n = 19/31) [45,47–51,53,54,56,57,59,60,62,65,66,72–75] outcomes were the most commonly assessed outcomes. Seventy-one percent of the studies assessing Health Behaviour and Disease Controlling outcomes showed significant differences between the intervention and control groups, compared to 37% of the studies assessing Global Quality of Life.
To identify whether community-based Self-Management Programs (SMPs) actively engaged, or taught, individuals patient-oriented strategies; and whether having these attributes led to significant differences in outcomes.
This systematic review included randomized controlled trials (RCTs)and cluster RCTs reporting on community-based SMPs with a group component for older adults with chronic conditions. The ways SMPS actively engaged participants and whether they taught patient-oriented strategies were analyzed. All study outcomes were reported.
The 31 included studies demonstrated community-based SMP programs actively engaged participants and provided strategies to improve health behaviour or care of their condition. Few included strategies to help manage the impact of conditions on their everyday lives. Seventy-nine percent of studies reported significant differences; variations in sample sizes and outcomes made it difficult to conclude whether having these attributes led to significant differences.
SMPs are not supporting older adults to use strategies to address the impact of conditions on their everyday lives, addressing the needs of older adults with multiple conditions, nor assessing outcomes that align with the strategies taught.
Health-care providers delivering SMPs to older adults need to tailor programs to the needs of older adults and assess whether participants are using strategies being proposed.
Heart Failure
2018, Integrative Medicine: Fourth Edition
What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? An Individual Patient Data Meta-analysis
2016, Journal of Cardiac Failure
To identify those characteristics of self-management interventions in patients with heart failure (HF) that are effective in influencing health-related quality of life, mortality, and hospitalizations.
Randomized trials on self-management interventions conducted between January 1985 and June 2013 were identified and individual patient data were requested for meta-analysis. Generalized mixed effects models and Cox proportional hazard models including frailty terms were used to assess the relation between characteristics of interventions and health-related outcomes. Twenty randomized trials (5624 patients) were included. Longer intervention duration reduced mortality risk (hazard ratio 0.99, 95% confidence interval [CI] 0.97–0.999 per month increase in duration), risk of HF-related hospitalization (hazard ratio 0.98, 95% CI 0.96–0.99), and HF-related hospitalization at 6 months (risk ratio 0.96, 95% CI 0.92–0.995). Although results were not consistent across outcomes, interventions comprising standardized training of interventionists, peer contact, log keeping, or goal-setting skills appeared less effective than interventions without these characteristics.
No specific program characteristics were consistently associated with better effects of self-management interventions, but longer duration seemed to improve the effect of self-management interventions on several outcomes. Future research using factorial trial designs and process evaluations is needed to understand the working mechanism of specific program characteristics of self-management interventions in HF patients.
The Effectiveness of a Nurse-Led Cognitive–Behavioral Therapy on the Quality of Life, Self-Esteem and Mood Among Filipino Patients Living With Heart Failure: a Randomized Controlled Trial
2016, Applied Nursing Research
The diagnosis and complications associated with heart failure (HF) have been very well established to adversely impact an individual's physical and psychosocial well-being, and interventions such as cognitive–behavioral techniques have demonstrated potential positive benefits among patients with HF. However, the effects of such interventions among Filipino HF patients have not been studied. This study aimed to determine the effectiveness of a nurse-led cognitive–behavioral intervention program on the quality of life, self-esteem and mood among Filipino patients with HF.
A randomized control two-group design with repeated measures and collected data before and after the intervention was used in this study. Participants were assigned to either the control (n = 48) or the intervention group (n = 52). Control group participants received traditional care. Intervention participants underwent a 12-week nurse-led cognitive–behavioral intervention program focusing on patient education, self-monitoring, skills training, cognitive restructuring and spiritual development. Measures of quality of life, self-esteem and mood were obtained at baseline and after the intervention.
At baseline, participants in both groups have poor quality of life, low self-esteem, and moderate depressive symptom scores. After the 12-week intervention period, participants in the intervention group had significant improvement in their quality of life, self-esteem and mood scores compared with those who received only standard care.
Nurse-led cognitive–behavioral intervention is an effective strategy in improving the quality of life, self-esteem and mood among Filipino patients living with HF. It is recommended that this intervention be incorporated in the optimal care of patients with this cardiac condition.
Identifying components of self-management interventions that improve health-related quality of life in chronically ill patients: Systematic review and meta-regression analysis
2016, Patient Education and Counseling
To quantify diversity in components of self-management interventions and explore which components are associated with improvement in health-related quality of life (HRQoL) in patients with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), or type 2 diabetes mellitus (T2DM).
Systematic literature search was conducted from January 1985 through June 2013. Included studies were randomised trials in patients with CHF, COPD, or T2DM, comparing self-management interventions with usual care, and reporting data on disease-specific HRQoL. Data were analysed with weighted random effects linear regression models.
47 trials were included, representing 10,596 patients. Self-management interventions showed great diversity in mode, content, intensity, and duration. Although self-management interventions overall improved HRQoL at 6 and 12 months, meta-regression showed counterintuitive negative effects of standardised training of interventionists (SMD = −0.16, 95% CI: −0.31 to −0.01) and peer interaction (SMD = −0.23, 95% CI: −0.39 to 0.06) on HRQoL at 6 months.
Self-management interventions improve HRQoL at 6 and 12 months, but interventions evaluated are highly heterogeneous. No components were identified that favourably affected HRQoL. Standardised training and peer interaction negatively influenced HRQoL, but the underlying mechanism remains unclear.
Future research should address process evaluations and study response to self-management on the level of individual patients.
Therapeutic patient education in heart failure: Do studies provide sufficient information about the educational programme?
2014, Archives of Cardiovascular Diseases
Citation Excerpt :
No study asked about the patient's perception of TPE usefulness and the existence of a personal project. Record keeping (one study: [24]), smoking and alcohol cessation (five studies [25,32,33,37,40]), family support (three studies [23,35,36]), social functioning (three studies [35,37,40]), preventive behaviours (one study: [37]) and management of co-morbidities were seldom mentioned. Better communication with the health care provider was never cited.
Therapeutic patient education programmes on heart failure have been widely proposed for many years for heart failure patients, but their efficiency remains questionable, partly because most articles lack a precise programme description, which makes comparative analysis of the studies difficult. To analyse the degree of precision in describing therapeutic patient education programmes in recent randomized controlled trials. Three major recent recommendations on therapeutic patient education in heart failure inspired us to compile a list of 23 relevant items that an ‘ideal’ description of a therapeutic patient education programme should contain. To discover the extent to which recent studies into therapeutic patient education in heart failure included these items, we analysed 19 randomized controlled trials among 448 articles published in this field from 2005 to 2012. The major elements required to describe a therapeutic patient education programme were present, but some other very important pieces of information were missing in most of the studies we analysed: the patient's educational needs, health literacy, projects, expectations regarding therapeutic patient education and psychosocial status; the educational methodology used; outcomes evaluation; and follow-up strategies. Research into how therapeutic patient education can help heart failure patients will be improved if more precise descriptions of patients, educational methodology and evaluation protocols are given by authors, ideally in a standardized format.
L’efficience des programmes d’éducation thérapeutique (ETP) dans l’insuffisance cardiaque (IC) est encore discutée ; la description insuffisamment précise des programmes dans la plupart des articles rend plus difficile l’analyse comparative des études. Analyser le degré de précision dans la description des programmes d’ETP issus d’études randomisées récentes. En s’inspirant de trois recommandations internationales récentes sur l’ETP dans l’IC, nous avons constitué une liste de 23 critères de précision qu’une description idéale d’un programme d’ETP devrait comporter. Pour vérifier si ces critères étaient présents dans la littérature récente (2005–2012), nous avons analysé 19 études randomisées contrôlées portant sur l’ETP dans l’IC. Bien que la plupart des éléments descriptifs des programmes d’ETP soient présents, nous avons repéré des lacunes d’information dans les études concernant les besoins d’éducation des patients, leur litéracie en santé, leurs attentes vis-à-vis de l’ETP, leurs projets et leur statut psycho social. La description de la méthodologie éducative, comme celle de l’évaluation des résultats font souvent défaut, ainsi que les stratégies de suivi. La recherche sur l’efficience de l’ETP dans l’IC pourrait être améliorée si la description des patients, des méthodologies pédagogiques, d’évaluation et de suivi utilisées étaient décrites de façon plus complète et plus précise. Une standardisation des critères de précision des études pourrait s’avérer utile.

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View full text

Effect of behavioral management on quality of life in mild heart failure: a randomized controlled trial

Abstract

Introduction

Section snippets

General design

Patient characteristics

Discussion

Conclusions and practice implications

Acknowledgements

J Am College Cardiol

Chest

Am J Cardiol

Heart Lung

J Heart Lung Transplant

Heart failure, evaluation and care of patients with left-ventricular systolic dysfunctionClinical Practice Guideline No. 11.

Team management of patients with heart failure: a statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association

Circulation

Impact of biofeedback-relaxation training on hemodynamics, neuroendocrine function and rehospitalizations in advanced heart failure (abstract)

Am J Crit Care

Changing AIDS-risk behavior

Psychol Bull

Changing AIDS risk behavior: effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population

Health Psychol

A critical appraisal of the quality of quality-of-life measurements

JAMA