Patients with mild to moderate heart failure who received educational materials and self-management counseling in an attempt to improve adherence to medical advice did not have a reduced rate of death or hospitalization compared to patients who received educational materials alone, according to a study in the September 22/29 issue of JAMA. 1
There have been advances in the development of effective therapies for heart failure, but challenges remain in the delivery of these therapies to patients. “Patient nonadherence to heart failure drugs ranges from 30 percent to 60 percent and nonadherence to lifestyle recommendations from 50 percent to 80 percent, with higher rates occurring in more socioeconomically disadvantaged subgroups. To meet the challenge of delivering evidence-based therapies to patients with heart failure, research has turned to the evaluation of disease management, remote monitoring, and patient self-management programs,” the authors write. “Patient self-management programs aim to motivate patients to collaborate in their care by teaching them self-management skills. If skills such as self-monitoring and environmental rearrangement can be learned, maintained, and used to implement medical advice, this is a potentially cost-effective approach to controlling heart failure costs.”
Lynda H. Powell, Ph.D., of Rush University Medical Center, Chicago, and colleagues conducted the Heart Failure Adherence and Retention Trial (HART) to assess the effect of one year of self-management counseling on the rate of death or heart failure hospitalization among 902 patients with mild to moderate heart failure and reduced or preserved systolic function (contraction of the heart). The patients were randomized between October 2001 and October 2004, with follow-up for 2 to 3 years. All participants were offered 18 contacts (group meetings) and 18 heart failure educational tip sheets during the course of 1 year. Patients randomized to the education group received tip sheets in the mail and telephone calls to check comprehension. Patients randomized to the self-management group received tip sheets in groups and were taught self-management skills to implement the advice.
On average, the patients in the groups were approximately 64 years of age, 47 percent women, 40 percent self-reported racial/ethnic minority, 52 percent with annual family income less than $30,000, and 23 percent with preserved systolic function. Patients were taking an average of 6.8 medications, and 37 percent did not adhere to at least 80 percent of the prescribed dosage of either an ACE inhibitor or beta-blocker. Median (midpoint) sodium intake was more than recommended for patients with heart failure or hypertension.
The researchers found that in estimates of the time to death or heart failure hospitalization there was no benefit of self-management compared with education. During approximately 2.6 years of follow-up, there were 163 events (40.1 percent) in the self-management group and 171 (41.2 percent) in the education group. There was also no significant differences on other outcomes such as all-cause hospitalization and quality of life, or differences between groups on change in heart or respiratory rate, blood pressure or body mass index.
“In summary, the results of HART are consistent with those of past trials. There appears to be no benefit from self-management counseling on important clinical end points in patients with heart failure. However, given the epidemic of heart failure burdening the health care system, identification of innovative and cost-effective approaches to outpatient management is urgently needed. Future trials might evaluate the benefit of self-management counseling in low-income patients,” the authors conclude.
John G. F. Cleland, M.D., of the University of Hull, Kingston-upon-Hull, United Kingdom, and Inger Ekman, Ph.D., R.N., of Göteborg University, Göteborg, Sweden, write in an accompanying editorial that it may be beneficial to incorporate new technologies when developing interventions intended to change patient behavior.2
“Using new technologies to empower patients who have long-term medical conditions such as heart failure may motivate them to take a more active role in their own health care and may promote adherence to treatment. Additional rigorous studies, building on the results reported by Powell et al, may prove useful in unlocking a vast health care resource—patients. The medical and nursing professions should be a catalyst to this revolution.”
1. JAMA. 2010;304:1331-1338.
2. JAMA. 2010;304:1383-1384.