Synthesis of best evidence
Five research studies demonstrated a decrease in all-cause hospitalization rates (ACHR) and HF hospitalization rates (HFHR) related to self-care of HF (see Effect of HF self-care interventions). Three of the studies showed a statistically significant decrease in hospitalizations.16-18 Ditewig and colleagues and Windham and colleagues showed a reduction in hospitalization rates, but statistical significance was not reported.6,19
A decrease in hospitalization rates was reported with self-care of HF interventions. A synthesis of the self-care of HF interventions was reported in the five studies, and two guidelines included some aspect of symptom management, treatment management, and physical consequences (see Defined criteria of self-care interventions). Cognitive behavioral response, multidisciplinary interventions, home visits, and structured guidelines were implemented in over 70% of the studies as a part of the self-care of HF intervention.
Evaluation and synthesis of the best evidence must account for gaps in the literature. There were four issues identified as gaps in this synthesis:
- Difficult-to-assess independent effects of self-care of HF components (weight monitoring, activity, medication management, and diet) on hospitalizations
- No standardization of self-care of HF interventions
- Minimal home-based self-care of HF education programs
- Frameworks not used in higher-level evidence studies.
Minimal application of theoretical frameworks to guide research or conceptualize terms makes study comparison difficult. In addition, multiple self-care of HF intervention components lacked clear definitions or standardization, making comparison of results between studies difficult. Synthesis of the self-care of HF components following the appraisal guided the HF S2S program content and intervention design.
Development of the HF S2S program
The Self-Care of Heart Failure Model guided the content development and implementation of the HF S2S toolkit over 12 months. In this EBP project, HF S2S was developed and implemented using the best available evidence as a support and guide. The HFSA nonpharmacologic HF guidelines and AHA expert opinion were incorporated into HF S2S program content.4,11 Four NPs with expertise in HF education/management provided feedback throughout the development and evaluation of this program.
The Self-Care of Heart Failure Model components of HF maintenance, HF management, and HF confidence are evident in the HF S2S program.10 This program includes an individual calendar and a toolkit guide for implementation by NPs (see HF S2S program toolkit). The HF S2S program calendar contains a self-record symptom area. A 12-month calendar encourages patients to record their weight, monitor symptoms, and reminds them to take daily medications (see HF S2S calendar page). The opposite side of the self-record system includes education on HF knowledge, maintenance (symptom monitoring), and management (treatment) information.11
Contact information is completed containing the phone number of the NP, emergency contact, and cardiologist. The last page of the calendar is a record of the patient's current medications. The patient is encouraged to share the calendar with caregivers and other healthcare providers. HF S2S is self-paced by patients along with one-on-one discussions with the NP during regularly scheduled office visits. One-on-one counseling is reported to be beneficial to patients.13
Evaluation of the HF S2S program
The HF S2S was piloted by NPs in a house call and cardiology practice to measure effectiveness on patient outcomes and processes. Both of the research pilots used a single-group, pre- and postintervention design, and were externally funded. The purpose of the pilots was to compare HF hospital admission rates and self-care of HF behaviors before and after HF S2S. The hypothesis was that the use of HF S2S by direct care NPs would decrease HF hospital admission rates and improve self-care behaviors.
The house call practice pilot was funded by a foundation grant from the Gerontological Advanced Practice Nurses Association. The project was approved by the university's Institutional Review Board. The pilot recruitment began in January 2012 and lasted 6 months. Bryant, the principal investigator, reported that 6 months following HF S2S implementation, they had 18 participants in the urban Midwest, 0 HF hospital admissions, and a statistically significant increase in their self-care of HF behaviors (maintenance 5.7, p < 0.001; management 4.9, p = 0.008; confidence 6.9, p < 0.001) using the Self Care of Heart Failure Index (SCHFI, version 6.2).21,22 A post hoc power analysis was performed using Statistical Package for Social Sciences (SPSS) version 15 on the SCHFI scores. The power was 0.98 for maintenance, 0.95 for management, and 0.99 for the confidence sections for this population sample.21
In January 2014, with grant support from the American Association of Nurse Practitioners, HF S2S was replicated in a cardiology practice with eight geriatric participants from an Appalachian population over a 6-month period.23 The project was approved by the university's Institutional Review Board. This number was limited due to severe weather during recruitment. A significant mean difference in pre- and post-HF S2S was reported for HF hospital admissions (3.06 , p < 0.02) and a significant improvement in HF management of participants (p = 0.02) using the SCHFI.22,23
There was no statistically significant change noted in maintenance or confidence. Furthermore, a post hoc power analysis was performed on the SCHFI scores using SPSS version 15. The power for the management score was the same as the house call practice (0.95), and lower for the maintenance (0.16) and confidence (0.37) scores for the cardiology practice population.
Currently, a study is underway at three HF clinics in the Midwest using the HF S2S program toolkit by an NP. This study began recruitment of 100 participants in November 2015 to help identify predictive variables, including demographic, HF hospital admission rates, and HF S2S intervention response (demonstrated ability to increase self-care behaviors) using the HF S2S toolkit. All of the NPs in the current and previous studies provided direct care for patients with HF.
The feedback from NPs and patients who participated in the HF S2S pilots was used in the development of the toolkit. This toolkit was designed to be used as a one-on-one counseling strategy between NPs and patients in an outpatient practice setting. The toolkit includes a detailed implementation process to be used with patients with HF. Healthcare providers may use the HF S2S toolkit or adapt it for their own purposes citing the author.
The HF S2S toolkit was developed through formative research and feedback from NPs and patients. The feedback from NPs frequently included that a formalized educational tool would be beneficial for assisting with one-on-one counseling during office visits. The results from the two pilot studies (in decreasing HF hospital admissions and improving self-care behaviors across two practice settings and diverse populations) indicate an effective operational toolkit.21,23 These findings are reinforced by the positive feedback from the NPs implementing this program. Furthermore, given these findings, the toolkit appears to be effective at enhancing one-on-one counseling and improving the HF management of patients with worsening HF symptoms.
Since the HF S2S toolkit was developed in 2011, an updated search was conducted using CINAHL with full text and MEDLINE with full text (July 2011 to August 2016) and the Cochrane Library (2012 to 2016). Due to the current use of HF S2S in research studies, the combination of keywords and subject headings in all databases included “heart failure,” “self-care,” and “hospital admissions.” The studies were limited for English language, humans, and peer-reviewed.
Inclusion criteria included patients with HF of all ages, self-care interventions, and both outcome measurements of self-care behaviors and hospital admissions. CINAHL/MEDLINE and the Cochrane Library search resulted in 18 and 8 hits, respectively. The titles and abstracts of these articles were reviewed with only one relevant article identified from the Cochrane Library.24
Inglis and colleagues provide a systematic review protocol to review and quantify the potential benefits of online mobile education in patients with HF.24 Outcome measures stated in this review relevant to the HF S2S program include HF knowledge, self-efficacy, medication adherence, and HF hospitalizations. There has been no update to the HFSA nonpharmacologic guidelines or AHA expert statement since the search in 2011.4,11
Studies support the inclusion of self-care programs in outpatient practice settings with direct care providers.21,23,25 In addition, the ACA has emphasized that policy changes in the future are driving the importance of value-based care. NPs as direct care providers will facilitate improvement of self-care behaviors and reduce hospitalizations.4
Additional dissemination of the toolkit, continuing to review the literature, and future research using the HF S2S toolkit can have substantial impacts on HF hospital admissions and self-care behaviors. To this end, some realistic strategies can be employed in the near future to improve patients' HF self-care. Some possibilities include:
- Identifying opportunities to incorporate self-care as a routine part of practice in academic training programs for NPs
- Engaging leaders and community partners to influence healthcare systems to use this program as a transition mechanism for improved patient outcomes
- Promoting partnerships with corporate systems and venture capitalists to move HF S2S into the online era
- Working with interprofessional teams toward the future application of this toolkit
- Incorporating this into an opportunity to collect data on behavioral health through electronic medical record technology with insurance companies paying for the cost.
In future research trajectories, the use of technology needs to be explored as an innovative means to empower patients in self-care activities and improve provider communication. This aligns with recent developments in healthcare technology and practice with other chronic diseases.26,27 In the future, integration of HF S2S into a mobile app with the functionality to inform, instruct, record, prompt, remind, and improve direct care provider communication of patients with HF via numerous technology features would be innovative.
Patient engagement with self-care can promote improved provider and patient communication that has not been demonstrated with current time-consuming telehealth and monitoring systems. With the rise of technology, it will be critical to the future sustainability and continued use of the HF S2S toolkit to explore mobile app development.
Despite the rigorous background work invested in the development of the toolkit, the evaluation evidence to date has a number of limitations. Most critically, no comparative outcome study with a control group has been conducted. Additionally, the lack of a longitudinal observation on the outcomes (change in practice behavior of NPs, reduction in risk ratio, predictors of self-care behavior improvement) and the small sample size are limitations of this program.
Without a controlled trial of the toolkit and more diverse sample, a definitive statement that the improvements in HF knowledge and patient outcomes are attributable to the toolkit and not to other potential confounding variables cannot be stated. The lack of longitudinal observation limits the ability to determine lasting positive effects of the toolkit over time. Furthermore, due to the small sample and specific populations studied, these findings are not generalizable to the HF population. The implementation of the toolkit in longitudinal, randomly controlled studies with larger sample and varied practice settings is recommended to address these limitations.
Empower and engage
The HF S2S toolkit is a promising program for improving self-care behavior with HF and decreasing HF hospital admissions. The toolkit was developed based on a process of translating research, clinical practice guidelines, and EBP into the practice arena to add to the self-care of HF knowledge base and improve patient outcomes. This toolkit empowers patients and engages the NP toward improved patient outcomes by focusing on the key areas of HF self-care behaviors and decreased healthcare utilization. The HF S2S toolkit is poised to have a significant and enduring impact on HF outcomes.
HF S2S program toolkit
Program goal: To empower HF patients to achieve optimal heart health and independence through self-care maintenance, management, and confidence
Provider objective: To assist providers in the education of patients in HF self-care
Materials needed: HF S2S calendar/journal and weight scale
Instruction methods: Patient self-paced and one-on-one NP counseling
Step one: Complete and update information on calendar:
- Provider information on first page with phone numbers
- Medication list and describe purpose for all medications on back page
- Begin “month” and fill in dates
Step two: Calendar recordings (maintenance):
- Daily weights
- Level of swelling
- Medication administration
- Other (tests, provider appointments, home health visits)
- Share calendar with all caregivers and other providers
- Review HF S2S calendar at each visit
Step three: HF education
- NP: Quick review of HF education on calendar pages
- – Basic knowledge (maintenance/management)
- – Daily weights/record (maintenance)
- – Worsening signs/symptoms (management)
- – Action plan (management)
- – Sodium intake (maintenance)
- – Fluid intake (maintenance)
- – Medication administration (maintenance)
- – Activity (maintenance)
- – Prevention/lifestyle (maintenance)
- – Pulling it all together (confidence)
- – Ongoing one-on-one counseling
- Patient: Self-paced learning
- – Call with questions about the program
- – Develop and adjust HF management action plan with provider
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
heart failure; HF; hospital admissions; self-care; toolkit