Do Self-Management Interventions Work in Patients With Heart Failure? An Individual Patient Data Meta-Analysis.

BACKGROUND: Self-management interventions are widely implemented in the care for patients with heart failure (HF). However, trials show inconsistent results, and whether specific patient groups respond differently is unknown. This individual patient data meta-analysis assessed the effectiveness of self-management interventions in patients with HF and whether subgroups of patients respond differently. METHODS AND RESULTS: A systematic literature search identified randomized trials of self-management interventions. Data from 20 studies, representing 5624 patients, were included and analyzed with the use of mixed-effects models and Cox proportional-hazard models, including interaction terms. Self-management interventions reduced the risk of time to the combined end point of HF-related hospitalization or all-cause death (hazard ratio, 0.80; 95% confidence interval [CI], 0.71-0.89), time to HF-related hospitalization (hazard ratio, 0.80; 95% CI, 0.69-0.92), and improved 12-month HF-related quality of life (standardized mean difference, 0.15; 95% CI, 0.00-0.30). Subgroup analysis revealed a protective effect of self-management on the number of HF-related hospital days in patients <65 years of age (mean, 0.70 versus 5.35 days; interaction P=0.03). Patients without depression did not show an effect of self-management on survival (hazard ratio for all-cause mortality, 0.86; 95% CI, 0.69-1.06), whereas in patients with moderate/severe depression, self-management reduced survival (hazard ratio, 1.39; 95% CI, 1.06-1.83, interaction P=0.01). CONCLUSIONS: This study shows that self-management interventions had a beneficial effect on time to HF-related hospitalization or all-cause death and HF-related hospitalization alone and elicited a small increase in HF-related quality of life. The findings do not endorse limiting self-management interventions to subgroups of patients with HF, but increased mortality in depressed patients warrants caution in applying self-management strategies in these patients.

What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? An Individual Patient Data Meta-analysis.

BACKGROUND: 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. METHODS AND RESULTS: 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. CONCLUSION: 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.

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology.

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure-orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.

How much responsibility should heart failure nurses take?

This article examines the emerging role of the heart failure nurse and the responsibilities and educational and training requirements surrounding such a role. There may be variations in the role and its responsibilities in different health care settings. However the principles are similar and include: history taking, carrying out clinical assessment and making appropriate decisions about patient management within the context of practice. An example of this is nurse supervision of adjusting and titration of medication in a clinic setting or in the patient's own home. A major challenge to this role is defining the limitations and scope of practice. Patients with chronic heart failure (CHF) are generally a frail, elderly population, and often have significant other co-morbidities. They can be on multiple medications and are frequently prescribed sub-optimal doses of evidence-based medication. Many patients are not managed by specialists, thus creating a huge potential for improved management.

European Society of Cardiology Heart Failure Association Standards for delivering heart failure care.

The management of heart failure (HF) is complex. As a consequence, most cardiology society guidelines now state that HF care should be delivered in a multiprofessional manner. The evidence base for this approach now means that the establishment of HF management programmes is a priority. This document aims to summarize the key elements which should be involved in, as well as some more desirable features which can improve the delivery of care in a HF management programme, while bearing in mind that the specifics of the service may vary from site to site. We envisage a situation whereby all patients have access to the best possible care, including improved access to palliative care services, informed by and responsive to advances in diagnosis management and treatment. The goal should be to provide a 'seamless' system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.

Self-care management of heart failure: practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology.

Guidelines on heart failure (HF) stress the importance of lifestyle advice, although there is little evidence that such recommendations improve symptoms or prognosis. Patients experience symptoms of different intensities which impair their daily activities and reduce the quality-of-life. To cope with their clinical condition, many patients seek advice about lifestyle and self-management strategies when in contact with medical care providers, particularly specialized HF services. Self-care management is an important part of HF treatment, thus health professionals working with patients with HF have recognized the need for more specific recommendations on lifestyle advice. The present paper summarizes the available evidence, promotes self-care management, and aims to provide practical advice for health professionals delivering care to HF patients. It also defines avenues of research to optimize self-care strategies in a number of key areas to derive further benefits.

Patient differences related to management in general practice and the hospital: a cross-sectional study of heart failure in the community.

AIM: To compare patients treated for heart failure in relation to the management in general practices versus hospital admission. METHODS AND RESULTS: Twelve randomly selected general practices (GP) were screened for patients receiving ACE-inhibitor, digoxin, or loop diuretic treatment. The first 500 volunteers of 959 potential subjects were invited to a cardiac examination after exclusion of 235 frail, physically or mentally disabled patients. A diagnosis of heart failure during hospital admission (Hospital-HF, n = 102) was more related (p < 0.05) to male sex (45% vs. 21%), advanced age (73 vs. 70 years), breathlessness (75% vs. 62%), LV systolic dysfunction (47% vs. 20%), objective cardiac abnormality (92% vs. 65%) and higher 4-year mortality (33% vs. 15%) than patients taking loop diuretics due to signs and symptoms of heart failure in GP (GP-HF). Patients without clinical heart failure (n = 301) had the same survival but less symptoms and cardiac abnormalities than GP-HF patients. CONCLUSION: A surplus morbidity and mortality was related to a hospital-based rather than a GP based diagnosis of HF. Patients managed in GP were different from patients entering previous clinical trials of heart failure. We estimate that the pool of patients hospitalised with systolic heart failure would be increased from 1.3 to 1.4 more if all patients from primary care were included.