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http: //dx.doi.org/10.2147/RRCC.S48424

Heart failure self-care interventions to reduceclinical events and symptom burden

Mary H McGreal 1

Maureen J Hogan 1

Colleen Walsh-Irwin 1

Nancy J Maggio2

Corrine Y Jurgens 11School of N ursing, Stony BrookUniversity, Stony Brook, NY, USA;2School of Nursing, Farmingdale StateCollege, Farmingdale, NY, USA

Correspondence: Corrine Y JurgensStony Brook University, School ofNursing, HSCL 2-246, Stony Brook,NY 11794-8420, USATel + 1 631 444 3236Fax + 1 631 444 [email protected]

Background: Lack of adherence to prescribed therapies and poor symptom recognition arecommon reasons for recurring hospitalizations among heart failure (HF) patients. The purposeof this literature review is to examine the effectiveness of HF self-care interventions in relationto clinical events and symptom burden.

Methods: A systematic review of randomized controlled trials with a HF self-care measure wasconducted. The PubMed, CINAHL, and Medline databases were searched between 2010 and 2014,using the keyword “heart failure” in combination with the terms “self-care”, “self- management”,“self-care maintenance”, “self-care condence”, “symptoms”, and “hospitalizations”. Outcomesof interest were clinical events and/or symptom burden.Results: Nine studies met the inclusion criteria. HF education was the core of all interventionsexamined. Dose and strategies varied across studies. All interventions that effectively decreasedclinical events included education on how to respond to worsening HF symptoms.Conclusion: Knowledge alone does not improve HF self-care behaviors or reduce the riskof clinical events and/or symptom burden. Interventions that augment self-condence or self-efcacy to perform optimal self-care management and self-care maintenance may be useful.Keywords: heart failure, self-care, self-management, self-care maintenance, self-carecondence, symptoms, hospitalizations

IntroductionHeart failure (HF) is a major public health concern worldwide in terms of morbidity,mortality, and cost. Currently, an estimated 5.8 million Americans are diagnosed withHF, with associated costs estimated at over $30 billion dollars annually. 1 The incidenceof HF increases with age, and the prevalence of HF is predicted to increase by 46%

by 2030. Despite advances in pharmacological and medical management, mortalityrates remain high, with 50% of patients dying within 5 years of diagnosis. 1 In termsof morbidity, HF is responsible for more than one million hospitalizations annually.Importantly, many hospitalizations are for symptom management and considered

preventable. 2 Efforts to decrease hospitalization risk include providing guideline-basedtreatment which involves maximizing pharmacotherapy and improving self-care. 3

Patients with HF require education in order to adapt to their chronic conditionand perform self-care behaviors. Despite receiving HF education and perceivingHF information as important, patients often have low levels of knowledge and lacka clear understanding of the causes of HF. 4,5 Similarly, patients with HF often donot understand how and when self-care behaviors should be performed. 6 The mostfavorable strategy for promoting HF self-care should be straightforward, standardized,

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and practical for a variety of health care providers and patient populations. 7

Self-care strategies are a vital link empowering patientsto take responsibility for their health. Consequently, self-carestrategies are patient-centric as opposed to provider-centric. 8 It is important to note that terminology related to self-carevaries across the literature. For the purpose of this review,operational denitions of self-care are based on the work byRiegel and Dickson. 9 Accordingly, self-care encompassesself-care maintenance and self-care management behaviorsthat are moderated by self-care condence. 9–11 Self-caremaintenance is dened as daily activities that maintain clini-cal stability. Typically, these are adherence behaviors, suchas taking medications, limiting dietary sodium, and dailymonitoring of symptoms and weight. Self-care managementinvolves recognizing a change in symptoms and respondingto this change by taking an extra diuretic, limiting uids,or calling one’s health care provider. Self-care condenceis the belief in one’s ability to perform self-care behaviorseffectively. Although self-care condence is an importantdeterminant of self-care, it is not self-care per se. 9,11 Symptommonitoring is a challenge for HF patients. In particular,determining the meaning or importance of symptoms anddifferentiating HF symptoms from other comorbid illnesses isdifcult for patients. 12,13 For example, early symptoms signal-ing impending decompensation (eg, increasing fatigue andweight gain) are not specic to the syndrome, and only 33%of patients weigh themselves frequently or always. 14 Patientsalso commonly attribute these symptoms to less threateningillness, and symptoms may increase insidiously, impedingearly recognition. 4,13 Timely reporting of symptoms and orself-management can lead to early intervention, improvingquality of life and decreasing hospitalization risk. 7

Effective management of HF is a major challenge for both HF patients and their health care providers for severalreasons. Patients with HF are generally older in age andoften have complex comorbid illness proles. As a result,

poly pharmacy related to both HF and comorbid illnessesfurther complicate management by providers and the patient’sability to achieve effective self-care. 15,16 In addition, cognitivedysfunction is common among patients with HF, potentiallyaffecting self-care capacity. 17–19 Published HF guidelinesemphasize the importance of self-care behaviors to decreaseclinical events requiring hospitalization. 3,20 Consequently,the importance of HF patients using self-care strategies tomaintain and manage their illness is critical.

Limitations of prior HF reviews include inconsistentdifferentiation of self-care maintenance versus self-care

management, inclusion of telehealth studies, and omissionof outcomes (eg, symptom burden and clinical events). 8,21,22 Self-care maintenance behaviors are important to maintainclinical stability, but when employed alone are insufcientin preventing clinical events such as hospitalization. 23–26 Inaddition, HF management decisions using telehealth is notthe equivalent of self-care management as providers ratherthan patients are managing the illness. Symptom burdenand clinical events were not included as outcome measuresin the review by Barnason et al. 21 A review by Ditewig et alexamined the effectiveness of self-management interventionswith regard to clinical events and quality of life. Although theauthors reported a positive if not always signicant improve-ment in clinical events and quality of life, some studies inthe review were not true self-management interventions. 8 As symptoms drive health care utilization, interventions thataddress skill in self-management of symptoms are needed toavert hospitalization. Therefore, the purpose of this reviewwas to identify effective HF self-care management interven-tions that decrease clinical event risk and reduce symptom

burden.

MethodsA systematic review of randomized controlled trials wasconducted. 27–29 Electronic databases (PubMed, CINAHL,and Medline) were searched using the key word “heartfailure” in combination with the terms “self-care”,“self-management”, “self-care maintenance”, “self-carecondence”, “symptoms”, and “hospitalizations”. A handsearch was conducted on studies retrieved. The inclusioncriteria were: randomized controlled trials with a HF self-caremeasure, specic self-management component in the inter-vention, reported outcomes of interest which were clinicalevents and/or symptom burden, and studies published inEnglish for the years 2010–2014. Clinical events were denedas unplanned contact with health care providers, emergencydepartment admission, and hospitalization. Years were limitedas prior reviews examined self-care interventions publishedfor years 1996–2010. 8,21,22 Intervention studies targeting self-care knowledge alone were excluded because our outcomeof interest focused on actual self-care behaviors. The authorsreviewed abstracts followed by a full text review to supportthe reliability and validity of studies selected for the review.Consensus was reached among the authors on studies selectedfor inclusion. Two hundred and seventy citations were evalu-ated for inclusion. Duplicate citations (n = 29), nonrandomizedclinical trials, studies that did not address self-care behaviorsor outcomes of interest, and studies not available in English

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Heart failure self-care interventions

were excluded (n = 232; Figure 1). Nine studies (n = 1,415 participants) met the inclusion criteria for this review.

ResultsSelf-care interventions and clinical eventsEight of the nine randomized trials meeting the inclusioncriteria reported on the relationship between self-care

management and clinical events (Table 1). Interventionsvaried across studies in relation to educational content,educational dose, and timeframe to event. Most of thestudies used written materials such as a HF booklet. 7,30–33 One investigator also created an audiotape of the HF educa-tion session for participants 30 and one provided a DVD onHF self-management. 33 All but one study specied use ofone-on-one education. 7,30–36 Instrumental support included

provision of weight scales, 7,30–33 pill boxes and measuringcups, 30 and a telemonitoring system with weight and blood

pressure capability. 36 Monitoring and reinforcement ofeducation was done with follow-up telephone calls, 30,31,33–35 home visits, 7,35 and daily symptom and weight diaries. 7,34,35 Few studies specied teaching patients in use of extradiuretic doses for worsening symptoms. 7,31,34 Most studieslimited the self-management component to recognizing andresponding to worsening symptoms by contacting healthcare providers. Interestingly, six of eight studies reportedimproved self-care or knowledge scores, 7,30–32,35,36 but onlythree studies reported a signicant decrease in clinicalevents. 32–34

The dose of the intervention did not consistently relateto frequency of clinical events. Among the interventionseffective in reducing clinical events, the number of contacts

ranged from a one-time one-hour educational session 32 tosix contacts. 33,34 The study by Kommuri et al had the largestsample (n = 265) and the shortest intervention (one hour). 32 The interventions in the studies by Lee et al and Shivelyet al used six sessions either in-person or by telephone. 33,34 Lee et al instructed participants (n = 44) in use of a symp-tom diary, evaluation of symptoms as clusters, and howto weigh themselves daily. 34 Risk for a clinical event washigher in the usual care group at the 90-day follow-up (haz-ards ratio 3.17, 95% condence interval 1.09–9.16). Theintervention (symptom graph, symptom clusters, weigh-ing instructions) was similar to that used by Jurgens et althat did not reduce events at 90 days. 7 The interventionsdiffered in dose. Lee et al conducted ve booster sessionsvia telephone over 90 days, whereas Jurgens et al usedone home visit to reinforce the education. Shively et alemployed a patient activation intervention which addressedinformation, motivation, and behavioral skills necessaryfor self-management. Participants received a tailored edu-cation intervention based on their level of activation andself-selected goals. Participants also received instrumentalsupport, including a blood pressure cuff, a pedometer, anda weight scale along with the DVD and booklet. Shivelyet al reported fewer hospitalizations in the low activationand high activation groups, but not the medium activationgroup. 33 All interventions that effectively decreased clinicalevents included education on how to respond to worseningHF symptoms.

The intervention dose ranged from one contact to ninecontacts in studies reporting little or no effect on clinicalevents. 7,30,31,35,36 The study by De Walt et al (n = 605) reportedthat a multisession intervention did not decrease clinical eventsover 12 months compared with a single session (incidence rateratio 1.01, 95% condence interval 0.83–1.22). 31 However,the multisession intervention was beneficial in reducingHF-related hospitalizations for participants with low literacy.The usual care group received a single education session onsalt avoidance and medication adherence, in addition to aneducational manual and digital weight scale. The interventiongroup received usual care plus specic instructions on dailyweights, diuretic self-adjustment, and ve to eight follow-uptelephone calls over 4 weeks. All participants in the study byJurgens et al similarly received educational booklets and weightscales, which potentially blunted identication of differencesin clinical events between the usual care and interventiongroups. 7 Seto et al reported no difference in number of clinicalevents among intervention group participants who received anindividual educational session and a telemonitoring system to

267 records identified viadatabase search

3 records identified viahand search

270 total recordsidentified

232 records did notmeet inclusion criteriaand were excluded

38 records screened 29 duplicates excluded

9 records analyzed

Figure 1 PRISMA owchart for selection of evidence.Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews andMeta-Analyses.



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T a b

l e 1 ( C o n t i n u e

d )

R e f e r e n c e a n

d a i m

S a m p l e / m e t

h o

d / i n t e r v e n

t i o n s

C l i n i c a l e v e n

t s

S t r e n g t

h s a n

d l i m i t a t

i o n s

K o m m u r i e t a l 3 2

A i m

T o a s s e s s c h a n g e s i n H F k n o w l e d g e

a s s e s s m e n t s b e t w e e n a c o n t r o l g r o u p

a n d a n u r s e e d u c a t o r e d u c a t i o n s e s s i o n

U S A

n = 2 6 5

U C n = 1 3 7

I G n = 1 2 8

M e a n a g e 6 7 y e a r s

6 1 % m a l e

7 8 % w h i t e

M e a s u r e s

1 . H F k n o w l e d g e q u e s t i o n n a i r e a t d i s c h a r g e , 3 0 d a y s , 6

0 , 9 0 ,

a n d 1 8 0 d a y s t o a s s e s s H F d i s e a s e m a n a g e m e n t k n o w l e d g e ,

s e l f - c a r e m a n a g e m e n t b e h a v i o r s a n d m e d i c a t i o n s , d

i e t

r e c o m m e n d a t i o n s , a n d s a l t c o n t e n t *

I n t e r v e n t i o n

U C

1 . S t a n d a r d d i s c h a r g e i n f o r m a t i o n

I G 1 . S t a n d a r d d i s c h a r g e i n f o r m a t i o n

2 . O n e h o u r f a c e - t o - f a c e n u r s e

e d u c a t o r d e l i v e r e d H F p r o g r a m

a . P r i n c i p l e s o f H F

b . D i e t a r y s o d i u m

c .

L i m

i t i n g

u i d s

d . D i u r e t i c m e c h a n i s m s

e . R a t i o n a l e f o r m e d i c a t i o n

f . D a i l y w e i g h t m o n i t o r i n g

g . S e l f - c a r e b e h a v i o r s

h . M e d i c a t i o n c o m p l i a n c e

i . S m o k i n g c e s s a t i o n

j . A v o i d n o n s t e r o i d a l m e d i c a t i o n s

k . R e s p o n s e t o w o r s e n i n g s y m p t o m s

l . A v o i d a l c o h o l

m .

H F g u i d e l i n e s i n l a y t e r m s

P r i m a r y e n d p o i n t : c l i n i c a l e v e n t s o f h o s p i t a l i z a t i o n o r d e a t h

w i t h i n 1 8 0 d a y s

C h a n g e i n H F k n o w l e d g e s c o r e s f r o m b a s e l i n e t o 3 0 d a y s

a n d 1 8 0 - d a y f o l l o w u p

I G h a d s i g n

i c a n t

l y h i g h e r

k n o w

l e d g e s c o r e s

a t 3 m o n t h s c o m p a r e d w i t h U C . C l i n i c a l

e v e n t s a s s o c i a t e d w i t h l o w e r H F k n o w l e d g e

( 1 0 v e r s u s 1 1 , P

= 0 . 0 0 2 ) a n d H F m a n a g e m e n t

s c o r e s ( 4 v e r s u s 5 , P

= 0 . 0 0 1 ) w h e n c o m p a r e d

w i t h p a t i e n t s w i t h o u t c l i n i c a l e v e n t s

H F n u r s e e d u c a t i o n a t t h e t i m e o f h o s p i t a l

d i s c h a r g e r e s u l t s i n i m p r o v e d p a t i e n t

k n o w l e d g e a n d r e d u c e d r i s k o f r e a d m i s s i o n

S e l f - c a r e

S t r o n g a s s o c i a t i o n b e t w e e n H F k n o w l e d g e

a n d a d h e r e n c e t o H F s e l f - c a r e m e a s u r e s

( m e d i a n , I

Q R 1 . 0 t o 4 v e r s u s 0 ,

- 2 t o 2 ,

P =

0 . 0 0 7 )

S i g n

i c a n t

i m p r o v e m e n t

i n I G d i s e a s e

m a n a g e m e n t k n o w l e d g e s c o r e s ( P , 0 . 0 0 1 )

N o i m p r o v e m e n t o r d i f f e r e n c e b e t w e e n

g r o u p s f o r d i e t a r y a n d s o d i u m k n o w l e d g e

S t r e n g t h s

L a r g e

s a m p l e

L i m i t a t i o n s

H F k n o w l e d g e q u e s t i o n n a i r e l a c k s

r e l i a b i l i t y a n d v a l i d i t y d a t a

U n a b l e t o s h o w i m p r o v e m e n t s

i n d i e t a r y k n o w l e d g e d u e t o

w e a k n e s s i n e d u c a t i o n a l p r o g r a m



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U S A

M e a s u r e s

1 . P a t i e n t a c t i v a t i o n m e a s u r e

2 . S C H F I , α

= 0 . 4 2 – 0 . 8

8

3 . M e d

i c a l o u t c o m e s s t u d y s p e c i

c a d

h e r e n c e s c a l e

4 . H o s p i t a l i z a t i o n a n d E D v i s i t s


U C

1 . R o u t i n e m e d i c a l c a r e i n p r i m a r y c a r e o r n o n - H F s p e c i a l t y c l i n i c

I G 1 . R o u t i n e m e d i c a l c a r e i n p r i m a r y c a r e o r n o n - H F s p e c i a l t y c l i n i c

2 . A c t i v a t i o n a s s e s s e d a n d i n d i v i d u a l i z e d h e a l t h b e h a v i o r g o a l s s e t

3 . S i x s e s s i o n s o n e - t o - o n e e d u c a t i o n b y t e l e p h o n e o r i n p e r s o n

b y a d v a n c e d p r a c t i c e n u r s e

4 . E d u c a t i o n a l b o o k l e t

5 . B P c u f f

6 . H F s e l f - m a n a g e m e n t D V D

7 . W e i g h t s c a l e

8 . P e d o m e t e r

M e a s u r e s t a k e n a t b a s e l i n e , a n d

a t 3 a n d 6 m o n t h s

S e l f - c a r e

N o s i g n

i c a n t

d i f f e r e n c e s

i n g r o u p - b

y -

t i m e i n t e r a c t i o n s f o r S C H F I m a i n t e n a n c e ,

m a n a g e m e n t o r c o n

d e n c e s c o r e s

I G h a d s i g n

i c a n t

i n c r e a s e

i n p a t i e n t

a c t i v a t i o n s c o r e s

N o t e : * C r o n b a c h ’ s a l p h a n o t r e p o r t e d .

A b b r e v

i a t i o n s :

B P , b l o o

d p r e s s u r e ; C

I , c o n

d e n c e

i n t e r v a l ; H

F , h e a r t

f a i l u r e ; E

C G

, e l e c t r o c a r

d i o g r a m ; E

D , e

m e r g e n c y

d e p a r t m e n t ;

U C

, u s u a l c a r e

g r o u p ; I

G , i

n t e r v e n t

i o n g r o u p ; I

Q R

, i n t e r q u a r t i

l e r a n g e ;

I R R

, i n c

i d e n c e r a t e r a t i o ; S

C H F I

,

S e l f - C a r e o f H F I n d e x ; M L H F , M i n n e s o t a L i v i n g w i t h H F Q u e s t i o n n a i r e ; H R , h a z a r d r a t i o ; N Y H A , N e w Y o r k H e a r t A s s o c i a t i o n ( f u n c t i o n a l c l a s s ) ; α , C r o n b a c h ’ s a l p h a ; S D , s t a n d a r d d e v i a t i o n .

monitor weight, blood pressure, and electrocardiograms for6 months. 36 Finally, among investigators using symptom diariesor some form of symptom tracking, 7,30,34,35 only the study byLee et al had a signicant effect on clinical events. 34

Self-care interventionsand symptom burdenSymptom burden, as a predictor of quality of life andhospitalization, is an important outcome of interest inrelation to the effectiveness of self-care interventions. 37,38 Symptom burden was reported as an outcome in fourstudies (Table 2). 34–36,39 In some cases, measurement wasextrapolated from quality of life measures with physicalsymptom subscales. 34,36 Two studies reported signicantimprovement in symptom burden in relation to instituting aself-management intervention. 35,39

Baker et al compared a brief educational intervention(usual care group) compared with a teach-to-goal interventionon self-care behaviors and HF quality of life. 39 Both groupsreceived a 40-minute educational session on self-care main-tenance and self-care management. All participants (n = 605)also received an educational manual and a digital scale. Theintervention group was provided with specic instructions ondaily weights and diuretic self-adjustment followed by ve toeight phone calls over 4 weeks to reinforce the education. Theintervention group had signicant improvement in symptomsand self-efcacy whereas symptom burden was unchangedin the usual care group. Both groups had significantlyimproved self-care scores; however, the improvement in theintervention group was signicantly greater. Strengths of thisstudy were its large sample size and heterogeneity in termsof gender and ethnicity. Limitations include high baselineHF knowledge and younger mean age than typically foundamong samples of patients with HF.

The intervention group in the study by Shao et al receivedthe same intervention as the usual care group, supplemented

by a home visit, one extra phone call, and a diary for dailysodium, uid intake, and weight. 35 Self-care managementand symptom scores improved in the intervention group. The

intervention by Lee et al was similar; however, the symptom burden did not differ between groups at 3 months. 34

DiscussionThis review was limited to studies with a self-managementcomponent in the intervention. We found the majority ofself-care interventions increased knowledge and improvedself-care scores, but were inconsistent in relation to decreas-ing clinical events or reducing symptom burden. The core



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T a b

l e 2 S e l f - c a r e a n

d s y m p t o m

b u r d e n


d a i m

S a m p

l e / m e t

h o d / i n t e r v e n

t i o n s

S y m p t o m

b u r

d e n

S t r e n g t

h s a n

d l i m i t a t

i o n s

B a k e r e t a l 3 9

A i m

T o e x a m i n e t h e e f f e c t o f t w o

d i f f e r e n t l e v e l s o f s e l f - c a r e l e a r n i n g

o n t h e a d o p t i o n o f k e y s e l f - c a r e

b e h a v i o r s a n d o n H F - r e l a t e d q u a l i t y

o f l i f e

U S A

n = 6 0 5

U C n = 3 0 2

I G n = 3 0 3

M e a n a g e 6 0 . 7

( S D 1 3 . 1

) y e a r s

5 2 % m a l e

3 9 % w h i t e

M e a s u r e s

1 . S - T O F H L A

2 . I C I C E *

3 . H e a r t F a i l u r e S y m p t o m s S c a l e ( u s e d a s m e a s u r e o f q u a l i t y o f l i f e ) *


U C B r i e f E d u c a t i o n a l I n t e r v e n t i o n

1 . 4 0 - m

i n u t e e d u c a t i o n a l s e s s i o n o n d a i l y s e l f - a s s e s s m e n t , a c t i o n p l a n n i n g

i n c a s e o f e x a c e r b a t i o n s , s a l t a v o i d a n c e , a n d m e d i c a t i o n a d h e r e n c e

2 . E d u c a t i o n a l m a n u a l

3 . D i g i t a l w e i g h t s c a l e

I G T e a c h t o g o a l

1 . 4 0 - m

i n u t e e d u c a t i o n a l s e s s i o n o n d a i l y s e l f - a s s e s s m e n t , a c t i o n p l a n n i n g

i n c a s e o f e x a c e r b a t i o n s , s a l t a v o i d a n c e , a n d m e d i c a t i o n a d h e r e n c e

2 . E d u c a t i o n a l m a n u a l

3 . D i g i t a l w e i g h t s c a l e

4 . S p e c

i c

i n s t r u c t

i o n s o n

d a i l y w e i g h t s t o g u

i d e

d i u r e t

i c s e

l f a d

j u s t m e n t

5 . 5 – 8 p h o n e c a l l s o v e r 4 w e e k p e r i o d t o r e i n f o r c e e d u c a t i o n a n d g u i d e

p a t i e n t t o w a r d s b e t t e r s e l f - c a r e s k i l l s

T i m e f r a m e o f 4 w e e k s

I G h a d s i g n

i c a n t

i m p r o v e m e n t

i n H F

s y m p t o m s c o m p a r e d w i t h U C ( P , 0 . 0 0 1 )

S y m p t o m s w e r e u n c h a n g e d i n U C g r o u p

S e l f - c a r e

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i n c r e a s e c o m p a r e

d w

i t h

U C 0 . 7 0

v e r s u s 0 . 3 0 ; P =

0 . 0 0 8

C h a n g e s

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l f - e f

c a c y

T e a c h - t

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g r o u p ( 1 . 0 v e r s u s 0 . 4 ; P

= 0 . 0 0 6 )

S t r e n g t h s

L a r g e s a m p l e

H e t e r o g e n e o u s s a m p l e i n t e r m s

o f g e n d e r a n d e t h n i c i t y


H i g h b a s e l i n e k n o w l e d g e o f s t u d y

p a r t i c i p a n t s

Y o u n g m e a n a g e o f s a m p l e

L e e e t a l 3

4

A i m

T o t e s t t h e e f f e c t o f a c o m p r e h e n s i v e

d a i l y s y m p t o m d i a r y i n t e r v e n t i o n

( e d u c a t i o n a n d c o u n s e l i n g a b o u t

H F s y m p t o m s , h o w t o r e c o g n i z e

s y m p t o m s , a n d w h a t t o d o w i t h

e s c a l a t i n g s y m p t o m s ) o n e v e n t - f r e e

s u r v i v a l a n d h e a l t h - r e l a t e d q u a l i t y

o f l i f e

U S A

n = 4 4

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M e a n a g e 6 0 ( S D 1 2 ) y e a r s

5 2 . 3

% m a l e

6 1 . 4

% w h i t e

M e a s u r e s

1 . E v e n t - f r e e s u r v i v a l a s s e s s e d a t 1 a n d 3 m o n t h s

2 . M L H F ( p h y s i c a l s y m p t o m s u b s c a l e ) *

3 . S y m p t o m d i a r y


U C 1 . D i s c h a r g e e d u c a t i o n b o o k l e t d e s c r i b i n g H F , a l o w s o d i u m d i e t ,

a n d m e d i c a t i o n i n s t r u c t i o n s

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s y m p t o m

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) w e r e n o t s i g n

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S e l f - c a r e

N o d i f f e r e n c e b e t w e e n g r o u p s a t b a s e l i n e

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S t r e n g t h s

H e t e r o g e n e o u s s a m p l e i n t e r m s

o f g e n d e r


S m a l l s a m p l e s i z e

Y o u n g m e a n a g e o f s a m p l e



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T a b

l e 2 ( C o n t i n u e

d )


d a i m

S a m p

l e / m e t

h o d / i n t e r v e n

t i o n s

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b u r

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i o n s

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= 0 . 6 7

4 . H e a l t h s e r v i c e u s e ( i n c l u d e p a t i e n t c l i n i c a l , E D v i s i t s , a n d h o s p i t a l i z a t i o n )


U C 1 . E d u c a t e d o n i m p r o v i n g g e n e r a l k n o w l e d g e o f H F , c a u s e s , s

i g n s

a n d s y m p t o m s , c o m p l i c a t i o n s , m e d i c a t i o n s , a c t i v i t y , a n d d i e t a r y

r e c o m m e n d a t i o n s

2 . P h o n e c a l l s a t w e e k s 3 , 7 , a n d 1 1

I G 1 . E d u c a t e d o n i m p r o v i n g g e n e r a l k n o w l e d g e o f H F , c a u s e , s i g n s a n d

s y m p t o m s , c o m p l i c a t i o n s , m e d i c a t i o n s , a n d a c t i v i t y a n d d i e t a r y

r e c o m m e n d a t i o n s .

2 . H o m e v i s i t w i t h i n 3 d a y s a f t e r e n r o l l m e n t

3 . F o u r p h o n e c a l l s a t w e e k s 1 , 3 , 7 , a n d 1 1

4 . D i a r y o

f d a i l y s o

d i u m a n

d u i d i n t a k e a n

d d a i l y w e i g h t

P r i m a r y e n d p o i n t : H F - r e l a t e d s y m p t o m s , h o s p i t a l i z a t i o n a t 1 2 w e e k s

U n a b l e t o c o n c l u d e w h i c h

i n t e r v e n t i o n w a s e f f e c t i v e

b e c a u s e t h e e f f e c t i v e n e s s o f f o u r

i n f o r m a t i o n s o u r c e s c o u l d n o t b e

d e t e r m i n e d

N o t e : * C r o n b a c h ’ s a l p h a n o t r e p o r t e d .

A b b r e v

i a t i o n s : B P , b

l o o d p r e s s u r e ; H F , h e a r t f a i l u r e ; E C G , e

l e c t r o c a r d i o g r a m ; E D , e m e r g e n c y d e p a r t m e n t ; U C , u s u a l c a r e g r o u p ; I C I C E , I m p r o v i n g C h r o n i c I l l n e s s C a r e E v a l u a t i o n ; I G , i n t e r v e n t i o n g r o u p ; S C H F I , S e l f - C a r e o f H F I n d e x ;

M L H F , M i n n e s o t a L i v i n g w i t h H F Q u e s t i o n n a i r e ; α , C r o n b a c h ’ s a l p h a ; S D , s t a n d a r d d e v i a t i o n ; S - T

O F H L A , S

h o r t - T e s t o f F u n c t i o n a l H e a l t h L i t e r a c y i n A d u l t s .

of each intervention was patient education, and educationalcontent was similar across studies. Other components ofinterventions such as use of symptom diaries or instrumentalsupport (eg, provision of weight scales) also were inconsis-tent in relation to the outcomes of interest. Only one inves-tigator evaluated the self-care intervention components toidentify those that were most effective. Provision of a weightscale and conducting a home visit were the two componentsassociated with statistically signicant improved self-care. 40 Without additional responder analysis data, we are unableto conclusively identify which self-care interventions aremost effective in reducing clinical event risk and symptom

burden. However, interventions focused on improving skillin symptom monitoring and timely response to escalatingsymptoms are important. 5,11

Self-care, an integral component of HF disease manage-ment, is benecial in terms of reducing morbidity, mortal-ity, and symptom burden, and improving quality of life. 41–43 Considering HF is a chronic and progressive illness, need foroversight by health care providers will presumably increaseover time. However, it is preferable to maximize self-carecapacity to assist patients in maintaining clinical stabilityand independence for as long as possible.

Self-care capacity is known to vary among patients. 44 Several factors affect self-care capacity, including butnot limited to cognitive status, 17,18,45 health literacy, 46,47 depression, 48–50 and self-efcacy or self-condence. 39,51 Consequently, determining which self-management inter-ventions are effective for improving outcomes in different

populations is challenging. Attention to modiable fac-tors affecting self-care capacity is therefore warranted. In

particular, self-efcacy and self-condence are importanttargets for self-management interventions because of amoderating and mediating effect on self-care. Lee et alreported that higher levels of self-care were associated with

better health status, but only if self-condence was high. 51 A case in point is a lack of difference in clinical events inthe study by Jurgens et al. The intervention group had astatistically signicant improvement in self-care condencefrom baseline to 90 days (from 54.3 to 65.2, P 0.01);however, Self-Care of HF Index scores were below 70,which is the cutoff score considered adequate. 7 Exploringuse of interventions that improve self-efcacy and self-carecondence may support increased effectiveness of many ofthe interventions currently in use. Motivational interview-ing and similar cognitive behavioral interventions may bea useful strategy for increasing condence and subsequentself-management skills. 52,53



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Limitations of studies in this review include both method-ological concerns and sampling. Treatment delity to ensureconsistency in delivery of interventions is an important aspectof research. Only one study specically reported treatmentdelity procedures. 7 In other studies, delity was implied

by delivery of the intervention by the same person 31–33,39 or not reported. 30,34–36 Limitations to generalizability of thestudies also include small sample sizes, 7,30,33,36 homogenoussamples with respect to ethnicity, 7,30,32,33,35,36 and limited timeto follow-up. 30 Lastly, reporting instrument reliability coef-cients affects the interpretation of study results. Only fourof the nine studies 7,30,33,35 reported reliability coefcients.

Research implicationsThis review highlights several implications for future conductof research on HF self-care interventions. First, differentiat-ing the components of self-care, particularly in relation tomaintenance and management, is important. Studies in thisreview support the usefulness of HF education to improve

patient knowledge. However, knowledge alone is insufcientto improve outcomes. Knowledge of self-care maintenanceor adherence behaviors plus skill in HF self-management isneeded to reduce clinical event risk and symptom burden. Theevidence also suggests the importance of self-efcacy andself-condence for effective self-care management. Second,all interventions evaluated in this review incorporated severalcomponents, but little is known about which componentsare most important. As health care resources are limited,conducting responder analyses would assist in lling gapsin knowledge regarding which component(s) to emphasizein terms of outcomes and cost. Third, self-care capacity andeffectiveness of interventions varies across individuals and

populations. Therefore, analyses of interventions in relationto their effectiveness in subpopulations are needed to guidechoice and dose of interventions. 5,44,54 Finally, research isneeded to examine the effect of self-care on health outcomesimportant to patients, insurance providers, and health caresystems. Outcomes of interest include but are not limited tosymptom burden, quality of life, morbidity, mortality, andhospitalization.

Implications for practiceSelf-care is an essential component of HF management, but

patient education frequently occurs in the time-limited pro-cess of hospital discharge. As a result, self-care interventionsneed to be standardized and feasible for clinicians acrosshealth care settings. 55,56 Consideration of patient factors suchas adequacy of social support, health literacy, cognition,

depression, socioeconomic status, and advanced age is alsoimportant when choosing an intervention. 11,21 Importantly,

patients with HF seek information on how to negotiate all thecomponents of self-management in addition to understandingmedications, dietary restrictions, and symptom monitoring. 6 Consequently, a focus on skill-building educational tacticsis needed in addition to basic self-care information. Timelyself-management is challenging for patients due to difcultyin detecting an increase over baseline symptoms. 4 As a result,delay in seeking care for symptoms is common, becausesymptoms such as weight gain and increasing fatigue arenot perceived as important or related to HF. 12,57 To supporteffective self-management, patients need specic instructionon the importance of symptoms and what to do when symp-toms occur (eg, weight gain). Inclusion of family membersor other support persons in education and skill building isrecommended as they can assist with many components ofself-care, including detecting a change in status. 11

ConclusionSelf-management of HF is a complex proposition for patientsand their families based on the skills required to maintainclinical stability as well as skills for symptom management.The most effective dose for self-care interventions isunknown. Strategies that increase self-care condence may

be a key factor in determining the frequency and amountof oversight needed over time. 50,51 Finally, patients needto understand the importance of acting when a change in

status occurs. Patients with HF are known to wait to see ifsymptoms improve. 12 Understanding the importance of self-management of the early symptoms of HF, such as weightgain, increasing fatigue, decreasing activity tolerance, anddyspnea on exertion, is particularly important. If the earlysymptoms of impending decompensation are recognizedand treated, hospitalization for symptom management may

be averted.

DisclosureThe authors report no conicts of interest in this work.

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