Even with one year of counseling in how to manage their disease, the patients fared no better than if they learned the basics of heart health from simple tip sheets.
“Like any chronic illness, heart failure logically needs the collaboration of a health care provider to prescribe therapy and a patient to implement that therapy,” said Lynda Powell, PhD, professor and chair of preventive medicine at Rush University Medical Center. Powell was principal investigator of the study, and Dr. James Calvin, chief of cardiology at Rush, a co-principal investigator. “To encourage patients’ involvement in their care, we thought that education supplemented by training in self-management skills would help patients actually do what the medical literature prescribes. But our study showed that adding this training made no difference.”
Overall, the counseling had no added value. But the data showed that for half of the patients—those falling in the lower income bracket—counseling may have had some benefit.
A total of 902 patients diagnosed with mild to moderate heart failure with reduced or preserved systolic function (contraction of the heart) were enrolled in the study between 2001 and 2004 and followed for up to two to three years.
The patients were divided into two groups. One group received by mail tip sheets on heart failure management designed for patients by the American Heart Association. The other group received, in addition, training on how to achieve the guidance laid out in the tip sheets about restricting salt, adhering to medication regimens, controlling weight, engaging in moderate physical activity and managing stress. The group training sessions covered such things as self-monitoring and relaxation strategies, as well as eliciting support from family and friends and restructuring their home and work environments—e.g., removing high-sodium canned goods from the home. The sessions involved a problem-solving format that engaged participants in finding their own solutions.
At the start of the study, the average age of participants was 64, about 47 percent female, 40 percent minority and 23 percent with preserved systolic function—representing the kinds of patients typically seen in the clinical setting.
Participants were taking an average of 6.8 medications, and 37 percent did not adhere to at least 80 percent of their prescribed heart failure medications. Median sodium intake was 3,338 mg/day, well over the 2,000 mg/day recommended for heart failure patients. Major depressive symptoms were evident in 29 percent of the participants.
The researchers found that in terms of time to death or hospitalization due to heart failure problems, the group that received counseling in self-management did no better than the group that received only the educational tip sheets. 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.
However, the researchers found indication of benefit from counseling in self-management for those with an income of less than $30,000.
“Our results suggest that self-management counseling may be useful for this important group of the population. They may need special help whether because of poor health habits, poor health literacy, or limited health insurance,” Calvin said. “But we need to study this issue further to determine whether our results hold up.”
“If the results do hold up,” Powell added, “they would suggest that outpatient management of heart failure should be tailored to the economic resources of the patient. The current standard of care does not feature such tailoring and may account for the large disparities in heart failure hospitalization we currently see among disadvantages subgroups.”