Education plus Self-Management in Patients with Heart Failure

Delivering evidence-based therapies to patients with heart failure has proven a challenge to healthcare practitioners. The rates of nonadherence to drug therapies prescribed to treat heart failure range from 30% to 60%, and the rates of nonadherence to recommendations for changes in lifestyle range from 50% to 80%. The higher rates occur in more socioeconomically disadvantaged subgroups, according to researchers. Strategies to address the challenge of delivering effective therapies to patients with heart failure include disease management and patient self-management programs. Researchers have conducted smallscale trials to evaluate the effectiveness of these strategies, but, according to the authors of a recent study, the trials have had methodological limitations. To determine the value of self-management counseling plus heart failure education, compared with heart failure education alone, the researchers conducted the Heart Failure Adherence and Retention Trial (HART). Results were reported in the Journal of the American Medical Association [2010;304(12):1331-1338]. HART was a single-center, multiple-hospital, partially blinded behavioral efficacy randomized controlled trial. Between October 2001 and October 2004, 902 patients from the Chicago area with mild-to-moderate heart failure and reduced or preserved systolic function were randomized in a 1:1 ratio into 2 groups: an education group and an education plus self-management group. The patients underwent follow-up for at least 2 years (1 year of treatment and 1 year of follow-up) and not more than 3 years (1 year of treatment and 2 years of follow-up) depending on the timing of the recruitment. The primary end point was hospitalization for heart failure or death during a median of 2.56 years of follow-up. During the course of 1 year, all patients were offered 18 contacts and 18 heart failure educational tip sheets. Patients in the education group received tip sheets in the mail, followed by telephone calls to ensure understanding. Patients in the education plus self-management group received tip sheets in groups as well as self-management skills designed to aid the patients in following the advice. There were 5 self-management skills taught to patients in the education plus self-management group: (1) self-monitoring, (2) environmental restructuring, (3) elicitation of support from family and friends, (4) cognitive restructuring, and (5) a relaxation response. To encourage proactivity, the patients were provided a problem-solving format to identify barriers to implementation of the tips; they were taught to use the self-management skills to overcome the barriers to implementation. Mean age of the cohort was 63.6 years, 47% were female, 40% were from a racial/ethnic minority, 52% had annual family income of