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European Journal of Heart Failure 2003 5(3):371-380; doi:10.1016/S1388-9842(03)00039-4
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© 2003 European Society of Cardiology

Uptake of self-management strategies in a heart failure management programme

S.P. Wrighta,*, H. Walsha, K.M. Ingleya, S.A. Muncastera, G.D. Gamblea, A. Pearlb, G.A. Whalleya, N. Sharpea and R.N. Doughtya

a Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland Private Bag 92019, Auckland 1001, New Zealand
b General Practice and Primary Healthcare, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand

* Corresponding author. Tel.: +64-9-307-4949x7654; fax: +64-9-302-2101. E-mail address: sp.wright{at}auckland.ac.nz


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Questions used...
 References
 
Background: Multidisciplinary heart failure programs including patient education and self-management strategies such as daily recording of body weight and use of a patient diary decrease hospital readmissions and improve quality of life. However, the degree of uptake of individual components of these programs and their contribution to patient benefit are uncertain.

Methods: Patients with heart failure admitted to Auckland Hospital were randomised into the management or usual care groups of the Auckland heart failure management study (AHFMS). Patients in the management group were given a heart failure diary for the recording of daily weights, attended a heart failure clinic and were encouraged to attend three education sessions. Patients in the usual care group received routine clinical care, mainly from general practitioners. Patients were followed to 12 months. This study investigated the uptake of self-management by assessing diary use and self-weighing behaviour in the group receiving the heart failure intervention, and compared the level of knowledge of heart failure self-management of the management group to the control group after 12 months.

Results: Of the 197 patients in the AHFMS, 100 patients were included in the management group and received a diary and education about heart failure self-management including monitoring weight daily. Of these patients, 76 patients used the diary. These patients were on more medication; were more likely to attend the education sessions, heart failure clinic, and primary care, and had a lower mortality rate over the course of the study. Variables independently associated with use of the diary included less severe symptoms (OR 15, 95% confidence intervals 1.7, 144), frequent attendance at the heart failure clinic (OR 15, 95% CI 3, 78) and attendance at an education session (OR 8, 95% CI 1.5, 42). Of the 76 patients who used the diary, 51 weighed themselves regularly. More of these patients owned scales at home; they were also more likely to attend the education sessions, and experienced fewer hospital admissions than those patients who did not weigh themselves regularly. Variables independently associated with regular self-weighing included the presence of scales at home (OR 6.3, 95% CI 1.7, 14.1), left ventricular ejection fraction >30% (OR 4.3, 95% CI 1.1, 17.5), and attendance at the education session(s) (OR 6.3, 95% CI 1.7, 14.1). Patients in the management group exhibited higher levels of knowledge at 12 months of follow-up and were more likely to monitor their condition using daily weighing, compared to the control group.

Conclusions: At 12 months of follow-up, implementation of self-management strategies including daily weight monitoring and level of education on self-management was significantly higher in the management group than the control group. For the patients in the management group, not using the diary or inability to perform daily weighing were associated with less frequent attendance at the heart failure clinic and education sessions and poorer health outcomes. In this study, attendance at the education sessions was associated with the adoption of self-management, underlining the importance of education in multidisciplinary heart failure programmes. Self-weighing could be increased by provision of scales to all patients. The subset of patients who did not adopt self-management strategies in this study were at high risk of death or readmission.

Key Words: Self-management • Heart failure management programmes • Heart failure diary • Patient compliance • Patient education

Received June 11, 2002; Revised October 23, 2002; Accepted February 17, 2003


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Appendix A. Questions used...
 References
 
Heart failure is a chronic disease which causes considerable personal morbidity and impacts significantly on quality of life. Studies have shown that patient knowledge of heart failure is often poor, including awareness of the importance of compliance and of self-management strategies to optimise control of the condition [1–6]. Several randomised studies have demonstrated that multidisciplinary heart failure interventions including patient education, follow-up and self-management strategies delivered by a range of health professionals decrease hospital admissions and improve quality of life in heart failure. Such programs emphasise self-management strategies including daily recording of body weight, maintaining a heart failure diary to monitor weight and to detect early symptoms, ensuring adherence to pharmacological and non-pharmacological treatment, and self-adjustment of diuretics [7–13]. Improvement of compliance [14], patient knowledge [10] and uptake of self-management strategies [9] have been demonstrated with such programmes.

Self-management is defined as an active cognitive process [15] undertaken by the patient to manage their heart failure [15,16], typically the adoption of practices such as self weighing and monitoring of symptoms, and the interpretation of changes in weight and symptoms. Strategies designed to enhance patient awareness and self-management behaviours are often part of a comprehensive multi-disciplinary intervention addressing several aspects of heart failure management. Isolating the influence of different elements of the program, such as the impact of self-weighing or the importance of education sessions is difficult [17]. Little is known about the uptake of self-management strategies promoted to patients as part of these programs. Knowledge in this area may allow the targeting of key strategies to patients most likely to benefit.

Education about self-management strategies is an important part of the care of a patient with a chronic disease such as heart failure [9,18,20]. Patients with access to education programs show improved understanding of their disease and the importance of treatment for some time after attending education sessions [10]. They also are more likely to adopt self-management strategies [9] and may gain psychological and social benefits [19]. Conversely, lack of patient knowledge is often associated with poor compliance, feelings of lack of control and disempowerment with regards to health, and may contribute to hospital readmission [21] and other morbidity. For example, the inability to recognise worsening symptoms or increasing weight at home (an early marker of peripheral congestion) may delay a patient seeking help when such action could avert a hospital admission.

This study evaluates the use of a heart failure diary and a schedule of daily self-weighing for patients enrolled in an integrated, comprehensive, out-patient heart failure management program, the Auckland heart failure management study (AHFMS) [11].


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Appendix A. Questions used...
 References
 
This substudy had two aims. First, to investigate the uptake of self-management by patients receiving the heart failure management intervention (the management group of the AHFMS) by assessing diary use and self-weighing behaviour. Second, to compare the level of knowledge of heart failure self-management of the management group to the control group receiving usual care after 12 months, using a pragmatic questionnaire containing open-ended questions.

2.1. Patient population
Patients admitted to Auckland Hospital with either a first diagnosis or an exacerbation of pre-existing heart failure between 1996 and 1997 were prospectively identified each day using hospital admission registers. Patients were identified for inclusion in a randomised, controlled single-centre study of an integrated heart failure out-patient management program, the AHFMS [11]. Patients were excluded if they had a surgically remediable cause for heart failure (such as severe aortic stenosis), if they were being considered for cardiac transplantation, if unable to give informed consent, had terminal cancer, were already participating in other trials, or did not survive to discharge.

Heart failure was diagnosed on the basis of typical symptoms and signs, with review of the chest X-ray, ECG and echocardiogram. Patients were randomised either to an integrated out-patient heart failure management program involving patient and family, primary and secondary care, or to receive usual care, mainly based in primary care [11]. The management programme consisted of 6-weekly heart failure clinic visits with counselling by a heart failure nurse specialist and optimisation of medication, 6-weekly planned primary care visits, patient education sessions, provision of a diary and instructions on daily weighing. The intervention continued for 12 months and all surviving patients were followed up.

Ninety-seven patients were randomised to the usual care group; these patients received usual post-discharge care (mainly provided by as-needed primary care consultations) without any structured patient education, provision of a diary nor advice on self-management. Surviving patients in the usual care group were followed up at 12 months [11].

2.2. Patient education and self-management strategies
Patients randomised to the heart failure program (the management group) were scheduled for an out patient clinical review within 2 weeks of discharge followed by planned 6-weekly visits for the 12-month duration of the study. Extra clinic reviews and telephone follow-up by heart failure clinic staff were performed as required. Clinical appointments included one-on-one patient counselling and heart failure education by a specialist heart failure nurse, optimisation of medical therapy by a heart failure physician, and liaison with the patient's family and primary healthcare providers. Each patient in the management group was given a heart failure diary after the index hospital admission. This diary included a list of medications, contact details for the clinic, schedule of appointments and education sessions, and a calendar-based record of daily weighs for the patient to complete. The aim was for the patient to monitor weight changes and to take action if their weight increased or decreased by more than 2 kg from their target weight. Each patient's action plan was individualised and included early review with the patient's primary care practitioner or self-adjustment of diuretics. Each diary lasted 3 months; new diaries were given to each patient through the study. Patients were encouraged to purchase scales for home use if they did not have them, although the clinic did not purchase scales for use by patients.

Three group education sessions were offered, two within 6 weeks of hospital discharge and a further one after 6 months. The group education sessions included explanation of the symptoms and signs of heart failure, the importance of monitoring of daily body weight, plan of action should weight change, effects of medications, the importance of compliance, and recommendations regarding exercise and diet. Diary use and self-weighing were particularly emphasised. The advice given was individualised and reinforced at each subsequent clinic visit during one-on-one counselling sessions by the specialist heart failure nurse.

The heart failure diaries were collected from the patients at each follow-up visit and their use reviewed. Every attempt was made to retrieve diaries, including phone calls, self-addressed envelopes and enlisting the help of family members for patients who had died during the study. For the purposes of this study, diary use was defined as any significant patient annotation in the heart failure diary, including use of the medication compliance record, recording of symptoms, and recordings of daily body weights. Only use of the initial heart failure diary is included in this report, as all patients received a diary at the commencement of the heart failure program.

Patient knowledge regarding self-management strategies in heart failure was assessed in both the management group and usual care group at 12 months of follow-up using a pragmatic questionnaire of four questions (Appendix A), as validated questionnaires assessing patient self-management knowledge were not available at the time this study was conducted. The questionnaire was administered verbally by a nurse at the follow-up visit. Questions were asked in a standardised, non-leading, open-ended manner.

2.3. Statistical analyses
For categorical variables, results are expressed as median (interquartile range, IQR); non-parametric analyses were utilised to examine differences. For continuous variables, results are expressed as mean (S.D.); 2-tailed t-tests and Fisher's exact tests were used to examine differences. Multivariate regression utilised logistic regression with stepwise selection; the significance level for entry into the model was 0.05.

All tests were 2-tailed and significant at the >0.05 level. Doses of angiotensin-converting enzyme (ACE) inhibitor drugs are expressed as enalapril equivalents. Echocardiography methodology has been described previously [11].


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Appendix A. Questions used...
 References
 
3.1. Results of the AHFMS
One hundred and ninety-seven patients were recruited into this study. 100 patients were randomised to the integrated heart failure programme for 12 months (management group), and 97 patients were randomised to the usual care group (control group), Fig. 1. Patients randomised to the management and control groups were comparable at baseline. Patients randomised to the management group attended the heart failure clinic 4 times during the 12 months on average, and telephoned the clinic staff for advice a median of 6 times. Sixty percent attended the first group education session, and 40% attended the 6-month session. Patients attended their own primary care practitioner an average of 14 times during the 12-month study period.


Figure 1
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  		Fig. 1 Flowchart of patients in the study.

 
The intervention had no effect on the primary endpoint of death or hospital readmission (time to first event analysis), but decreased total bed days, decreased multiple readmissions and improved patient quality of life [11].

3.2. The AHFMS management group: patient characteristics and uptake of self-management
3.2.1. Patient characteristics
The mean age of patients in the management group was 73 years (range 34–92); 36% were female; 77% were Caucasian, 22% were of Maori or Pacific Island ethnicity. Approximately a third of patients lived alone. In approximately half the patients, ischaemic heart disease was considered to be the underlying heart failure aetiology. Forty-six percent of patients had a documented history of prior myocardial infarction, 52% had prior hypertension, and 29% diabetes. Fifty-two percent had a prior admission for heart failure before the index admission; 17% had 3 or more previous heart failure admissions. Patients were receiving a median of 6 medications at discharge from hospital. The average left ventricular ejection fraction at admission was 32% (S.D. 13).

3.2.2. Use of the heart failure diary by patients in the AHFMS management group
All 100 patients randomised to the management group received a diary at the commencement of the program, either at their first clinic visit (within 2 weeks of discharge from hospital) or via mail if unable to attend the clinic. Seventy-six patients used the diary and 24 patients did not (Fig. 1). The patients who used the diary were receiving more medications than those who did not use the diary. Other demographic characteristics including age, gender, whether living alone, and number of previous heart failure admissions did not differ between those who did and did not use the diary (Table 1). The patients who used the diary were more likely to attend the education sessions (Table 2). On multivariate analysis (Table 4a), independent predictors of diary use included better New York Heart Association functional class, attendance at education sessions and heart failure clinic visits.


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  		Table 1 Patient demographic data and clinical characteristics in relation to diary use

 


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  		Table 2 Mortality and healthcare resource use between diary and non-diary users in the AHFMS management group

 
Mortality and number of readmissions differed when patients were stratified as to whether the diary was used or not (Table 2). Eleven (46%) of the 24 patients who did not use the diary died within 12 months compared with only 8 (11%) of the 76 who did use the diary (P<0.001). Of the 24 patients who did not use the diary, 9 (38%) did not attend any follow-up visits. Patients who used the diary had more heart failure clinic visits, telephone calls and visits to their own primary care practitioner, as well as a longer mean length of follow up, and more days alive and out of hospital compared to those patients who did not use the diary (Table 2).

3.2.3. Adherence to self-weighing in the AHFMS management group
The recording of daily weight was examined in those patients in the management group who used the heart failure diary (n=76). Patients were considered to weigh themselves regularly if they did so once a week or more, and irregularly if they did so less frequently than once a week. Fifty-one patients (67%) weighed themselves regularly (at least once a week, Fig. 1). Over two-thirds of these patients had scales at home (Table 3). Patients who weighed themselves regularly but did not own scales attended their general practice (6 patients), pharmacist (1 patient) or used district nursing services (2 patients) in order to monitor their weights. Twelve patients who weighed themselves needed assistance from a care-giver. Patients who weighed themselves regularly were also more likely to attend the education sessions (Table 3). Only 4 (16%) of the 25 patients who did not weigh themselves regularly had scales at home. Independent predictors of adherence to self-weighing included having scales at home, an ejection fraction over 30%, and attendance at one or more education sessions (Table 4b).


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  		Table 3 Clinical characteristics and healthcare resource use of patients according to weighing status in those patients who utilised the diary in the AHFMS management group (n=76)

 


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  		Table 4 Multivariate analysis of diary use and adherence to daily self-weighing

 
Despite similar clinical parameters, patients who did not weigh themselves regularly had fewer heart failure clinic visits, poorer attendance at the education sessions, a greater number of hospital admissions, more days in hospital, a shorter time to first readmission, and fewer total days alive and out of hospital over the course of the study.

3.2.4. Continuity of self-management behaviour
Each diary was designed to last for 3 months, so it was anticipated that a patient with optimal uptake of the program would use 4 diaries within the study period. Approximately half the cohort used 3 diaries (range 0–6). During the 12 months of follow-up, the number of patients continuing to use the diary progressively decreased; this decrease was not accounted for by mortality. Over the first 6 months, diary use decreased by 18%. Adherence to weight recording and diary documentation peaked at 3–6 months of follow-up.

3.3. Self-management and level of education in the AHFMS control group
Patients randomised to the AHFMS control group did not receive structured education, a patient diary nor advice on self-management. Surviving patients in both the management and control groups were reviewed at 1 year. In addition to review of clinical status, patients were asked if they knew about and implemented heart failure self-management strategies using pragmatic, open-ended questions (Appendix A). Patients randomised to the management group were significantly more likely to monitor their symptoms, to perform daily weighing, and knew what to do if their weight increased (Table 5). Of the surviving patients in the management group, 92% had a method of self-monitoring their heart failure, mostly by daily weight monitoring. Over two thirds of patients surveyed in the management group understood the rationale of weight monitoring in heart failure and 69% knew what to do if their weight altered. This contrasted with only 29% of patients using daily weight monitoring in the control group. Only 20% of patients in the control group were aware that they should seek help if their weight increased. No patients in the control group recorded their weights in a diary.


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  		Table 5 Difference between AHFMS control and management groups

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Appendix A. Questions used...
 References
 
Self-management strategies such as monitoring weight and self-adjustment of diuretics are recommended in heart failure guidelines [17,19,22–24] and are acceptable to and beneficial for patients [19,25]. Self-management strategies are also a fundamental component of comprehensive, integrated heart failure programs which, despite different approaches, have consistently shown improvements in hospital use and quality of life [7–9,11–13]. The heart failure interventions in these studies included several different approaches to care delivery, including clinic follow-up, [7,11,12,26] home visits [7,8,12,26,27], and integration between primary and secondary care [11]. However, little is known about the uptake of such strategies by the patients in these programs, and the degree of adherence by patients with strategies such as weight monitoring. Investigating which components have the greatest uptake by patients would help in the formulation of guidelines for the streamlined design of patient self-management programs for heart failure.

This heart failure program relied on regular out-patient review in primary and secondary care with telephone follow-up, but without the facility for visits to patients’ homes. The provision of a heart failure diary for the documentation of symptoms, daily weight and self-adjustment of diuretic dose was an important component of this heart failure management program. Diaries were provided to each patient by the study team, diary use was explained at education sessions and emphasised in the heart failure clinic. For the purposes of this study, completion of the diary provided a surrogate measure of adherence to the principles of heart failure self-management. Three quarters of the patients used the diary, which is comparable to uptake in other studies [25]. No patient in the control group used a diary. Factors independently associated with use of the diary on multivariate analysis included less severe symptoms (as classified by NYHA functional class), more frequent attendance at heart failure clinic and attendance at one or more of the education sessions. This supports the role of ongoing patient education, provided in this study by formal education sessions and during heart failure clinic visits, in the adoption of self-management strategies such as use of a diary by patients with heart failure.

At 12 month follow-up, implementation of self-management strategies such as monitoring of daily weights was significantly higher in the management group than in the control group of patients who did not receive structured education, advice on daily weighing and who were not provided with a diary. Although two-thirds of patients in the control group stated they had methods by which they monitored their condition, only a third used weight monitoring and only 20% were aware of appropriate action to take if their weight changed. Although the uptake of diary use and weight monitoring was not complete in the intensive intervention group, it was significantly better compared to those patients receiving standard care after discharge from hospital. Major deficiencies in the recognition of heart failure symptoms and poor knowledge regarding appropriate action in the case of new symptoms have been described in surveys of patients with heart failure [15,28]. The positive effect on heart failure knowledge shown in this study at 12 months of follow-up reinforces the usefulness of heart failure management programmes. The difference in the level of knowledge between patients in the management and control groups may in part explain the patterns of subsequent readmissions seen in the AHFMS [11]. Improving uptake of self-management strategies in the context of heart failure management programmes may improve the outcomes of such programmes.

Of the patients in the management group who were all provided with a heart failure diary, the group of patients who did not use the diary had a high non-attendance rate at the first and subsequent clinic appointments, a higher mortality rate, and a 50% shorter time to readmission. Patients who did not weigh themselves regularly had more hospital admissions, more days in hospital and a shorter time to first readmission. These patients also attended the heart failure clinic and education sessions less frequently. Independent predictors of regular self-weighing included attendance at the education sessions, the presence of scales at home, and ejection fraction >30%.

Patients in the management group who did not use the diary at all and those who used the diary, but did not record their weights are clearly groups at high risk of hospital readmission. The association between poorer outcomes and non-adherence with self-management strategies observed in these high-risk patients may be explained by differences in characteristics not assessed by this study. Possible differences include social support, socio-economic status, or psychological and cognitive characteristics known to influence self-management abilities such as self-efficacy [16]. Additionally, these patients may be at a more advanced stage of their disease process and hence may be less susceptible to self-management programs. This is supported by the independent associations of less impaired ejection fraction and NYHA functional class with adherence to self-weighing and diary use, respectively, on multivariate analysis. Previous studies examining determinants of adherence to medication regimes [4,5,29], level of heart failure knowledge [29] and self-management strategies [29] have not addressed the effect of disease severity.

In patients with more advanced disease, a diary-based self-management approach may be less appropriate. Patients who find it difficult to comply with self-management strategies, such as patients with higher morbidity, high levels of dependency or more severe disease may need other interventions, such as home visits [4,12] or the involvement of home carers. Heart failure management programs must be flexible and individualised, able to be tailored both to the needs of individual patients and to their risk of hospital readmission.

One of the purposes of the diary was to provide a medication guide and compliance record. Although no different in terms of socio-demographic criteria, patients who used the diary were, on average, prescribed a third more medications. This may suggest that the diary was found helpful as an aid for adherence to medication.

The provision of education sessions was a key component of this heart failure program and provided a forum to emphasise self-management strategies to patients. Education session attendance was associated with the implementation of regular self weighing and with the overall use of the heart failure diary in both univariate and multivariate analyses, reinforcing the importance of education and support in the successful implementation of self-management strategies. The education level of patients in the management group regarding self-management and action plans was significantly higher than in the control group receiving standard post-discharge care when assessed by interview at 12 months of follow-up.

Patients who weighed themselves regularly were much more likely to have scales at home. Patients with scales at home were over 6 times more likely to weigh themselves on multivariate analysis. Owning scales was an obvious but important determinant of adherence to daily weighing and is easily modifiable. The purchase of scales for patient use at home should be considered as part of any comprehensive out-patient heart failure program and is likely to have a direct effect on rates of implementation of daily weight monitoring.

Comprehensive heart failure programs including patient education, self-management strategies and integrated follow-up by a multidisciplinary team show benefits in terms of improved patient quality of life and fewer hospitalisations [11]. Patient adherence with recommended treatments and self-management strategies includes complex interactions between patient and family, health carers and health care provision in the widest sense. Complete uptake by all patients is rare in clinical practice. Psychological and social factors, such as acceptance of disease, social supports, sense of empowerment and control are also important factors influencing patient adherence [30,31]. These factors were not addressed in the current study, which examined clinical factors associated with patient participation in self-management strategies in the context of an integrated, comprehensive heart failure management program.

Self-management strategies proven to reduce admissions may not be implemented to expected levels, even in the context of intensive follow-up, but implementation was superior to standard post-discharge care in this study. Strategies not utilised in the AHFMS, such as home visiting by heart failure nurses, may increase implementation of diary use and daily weighing and may be a particularly useful adjunct for patients at high risk of readmission.

Individualisation of heart failure programs, the provision of scales to patients and the availability of education sessions to enhance knowledge about self-management are three approaches that may improve the uptake of self-management strategies in patients with heart failure. Additionally, the identification of patients who are at high risk of death or hospital readmission for whom an out-patient based intervention is less appropriate, and the provision of alternative healthcare delivery to this population is also likely to be important. Improved uptake of self-management by heart failure patients may increase the benefits of heart failure management programs to patients, their families and the community.


   Appendix A. Questions used to assess patient knowledge at 12 months
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Questions used...
References
 

  1. Do you have a way of monitoring your heart failure? If so, what?
  2. Do you weight yourself each day in order to monitor your condition?
  3. Do you understand the significance of your weight increasing?
  4. If your weight increased, what action would you take?

Questions were administered verbally to all patients at 12 months of follow-up by a nurse.


   Acknowledgements
 
The Auckland Heart Failure Management Study was funded by a Project Grant from the National Heart Foundation of New Zealand and an unrestricted educational grant from Merck Sharp and Dohme (NZ) Ltd. KI was the recipient of a NZ National Heart Foundation summer studentship. RND was the recipient of the NZ Heart Foundation BNZ Senior Fellowship. We acknowledge the involvement of participating Auckland general practitioners [11].


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Questions used...
 References
 

  1. Horan M., Barrett F., Mulqueen M., Maurer B., Quigley P., McDonald K.M. The basics of heart failure management: are they being ignored? Eur J Heart Failure (2000) 2:101–105.[Abstract/Free Full Text]
  2. Bushnell F.K. Self-care teaching: for congestive heart failure patients. J Gerontol Nurs (1992) 18:27–32.[Medline]
  3. Sulzbach-Hoke L.M., Kagan S.H., Craig K. Weighing behaviour and symptom distress of clinic patients with CHF. Med Surg Nursing (1997) 6:288–293, 314.
  4. Stewart S., Pearson S. Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill. Aust NZ J Med (1999) 29:220–227.[Web of Science][Medline]
  5. Cline C.M., Bjorck-Linne A.K., Israelsson B.Y., Willenheimer R.B., Erhardt L.R. Non-compliance and knowledge of prescribed medication in elderly patients with heart failure. Eur J Heart Failure (1999) 1:145–149.[Abstract/Free Full Text]
  6. Ni H., Nauman D., Burgess D., Wise K., Crispell K., Hershberger R.E. Factors influencing knowledge of and adherence to self-care among patients with heart failure. Arch Intern Med (1999) 159:1613–1619.[Abstract/Free Full Text]
  7. Krumholz H., Amatruda J., Smith G., et al. Randomised trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol (2002) 39:83–89.[Abstract/Free Full Text]
  8. Blue L., Lang E., McMurray J., et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ (2002) 323:715–718.[CrossRef][Web of Science]
  9. Jaarsma R., Halfens R., Huijer Abu-Saad H., et al. Effects of education and support on self-care and resource utilization in patients with heart failure. Eur Heart J (1999) 20:673–682.[Abstract/Free Full Text]
  10. Bjorck-Linne A., Liedholm H., Israelsson B. Effects of systematic education on heart failure patients’ knowledge after 6 months. A randomised, controlled trial. Eur J Heart Failure (1999) 1:219–227.[Abstract/Free Full Text]
  11. Doughty R.N., Wright S.P., Pearl A., et al. Randomised, controlled trial of integrated heart failure management: the Auckland heart failure management study. Eur Heart J (2002) 23:139–146.[Abstract/Free Full Text]
  12. Rich M.W.R., Beckham V., Wittenberg C., Leven C., Freedland K.E., Carney R.M. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med (1995) 333:1190–1195.[Abstract/Free Full Text]
  13. Stewart S., Vanderbroek A.J., Pearson S., Horowitz J.D. Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Ann Int Med (1999) 159:257–261.[CrossRef]
  14. Fulmer T.T., Feldman P.H., S K.T., et al. An intervention study to enhance medication compliance in community-dwelling elderly individuals. J Gerontol Nurs (1999) 25:6–14.[Medline]
  15. Carlson B., Riegel B., Moser D.K. Self-care abilities of patients with heart failure. Heart Lung (2001) 30:351–359.[CrossRef][Web of Science][Medline]
  16. Riegel B., Carlson B., Glaser D. Development and testing of a clinical tool measuring self-management of heart failure. Heart Lung (2000) 29:4–15.[CrossRef][Web of Science][Medline]
  17. Konstam M, Dracup K, Baker D, et al. Clinical practice guideline number 11: heart failure: evaluation and care of patients with left ventricular dysfunction. In: agency for health care policy and research PHS, US Department of Health and Human Services (edition). AHCPR Publication No 94-0612. Rockville, MD, USA, 1994.
  18. McMurray J., Stewart S. Nurse led, multidisciplinary intervention in chronic heart failure. Heart (1998) 80:430–431.[Free Full Text]
  19. Dunbar S.B., Jacobson L.H., Deaton C. Heart failure: strategies to enhance patient self-management. AACN Clin Issues (1998) 9:244–256.[Medline]
  20. Hagenhoff B.D., Feutz C., Conn V.S., Sagehorn K.K., Moranville-Hunziker M. Patient education needs as reported by congestive heart failure patients and their nurses. J Adv Nurs (1994) 19:685–690.[CrossRef][Web of Science][Medline]
  21. Happ M.B., Naylor M.D., Roe-Prior P. Factors contributing to rehospitalisation of elderly patients with heart failure. J Cardiovasc Nurs (1997) 11:75–84.[Medline]
  22. Remme W.J., Swedberg K. Comprehensive guidelines for the diagnosis and treatment of chronic heart failure. Task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology. Eur J Heart Failure (2002) 4:11–22.[Free Full Text]
  23. Uretsky B.F., Pina I., Quigg R.J., et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J (1998) 135:S265–S282.
  24. O'Driscoll G. Chronic heart failure: a guide for practical management. Aust Fam Physician (2000) 29:423–427.[Medline]
  25. Burman M.E. Health diaries in nursing research and practice. Image J Nurs Sch (1995) 27:147–152.[Medline]
  26. Stewart S., Pearson S., Horowitz J.D. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Int Med (1998) 158:1067–1072.[Abstract/Free Full Text]
  27. Cline C.M.J., Israelsson B.Y.A., Willenheimer R.B., Broms K., Erhardt L.R. Cost effective management programme for heart failure reduces hospitalisations. Heart (1998) 80:442–446.[Abstract/Free Full Text]
  28. Jaarsma R., Abu-Saad H.H., Dracup K., Halfens R. Self-care behaviour of patients with heart failure. Scand J Caring Sci (2000) 14:112–119.[CrossRef][Web of Science][Medline]
  29. Stromberg A. Heart failure clinics. Heart (1998) 80:426–427. editorial.[Free Full Text]
  30. Nagy V.T., Wolfe G.R. Cognitive predictors of compliance in chronic disease patients. Med Care (1984) 22:912–921.[CrossRef][Web of Science][Medline]
  31. Stromberg A., Brostrom A., Dahlstrom U., Fridlund B. Factors influencing patient compliance with therapeutic regimens in chronic heart failure: A critical incident technique analysis. Heart Lung (1999) 28:334–341.[CrossRef][Web of Science][Medline]

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