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European Journal of Heart Failure 2005 7(3):393-403; doi:10.1016/j.ejheart.2004.01.016
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© 2005 European Society of Cardiology

Patients with heart failure in primary health care: effects of a nurse-led intervention on health-related quality of life and depression

J. Mårtenssona,b,c,d,*, A. Strömberge,f, U. Dahlströme,f, J.-E. Karlssona and B. Fridlundb,c,g

a Department of Cardiology, County Hospital Ryhov Jönköping S-551 85, Sweden
b Department of Primary Health Care, Göteborg University Göteborg, Sweden
c School of Social and Health Sciences, Halmstad University Halmstad, Sweden
d Unit of Research and Development in Primary Health Care Jönköping, Sweden
e Department of Cardiology, Heart Centre, Linköping University Hospital Linköping, Sweden
f Department of Medicine and Care, Faculty of Health Sciences, Linköping University Linköping, Sweden
g Department of Nursing, Lund University Lund, Sweden

* Corresponding author. Tel.: +46-36-325213; fax: +46-36-325210. E-mail address: jan.martensson{at}ltjkpg.se


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Aims: To determine the effects of a nurse-led intervention designed to improve self-management of patients with heart failure in a primary health care setting regarding health-related quality of life and depression.

Methods: Patients at eight primary health care centres were screened by the Diagnosis Related Groups registry for the diagnosis of heart failure and eligibility for a cluster randomised study. A total of 153 patients were included (n=78 in the intervention group, 54% males, mean age 79 years, 59% in New York Heart Association class III–IV). The intervention involved patient and family education about heart failure and self-management and monthly telephone follow-up during 12 months by a primary health care nurse.

Results: The effects of the nurse-led intervention were limited. Significant differences were found in the physical dimension measured by the SF-36 health survey, and in depression measured by the Zung Self-rating Depression Scale. In comparison within groups at the 3 and 12-month follow-up, the intervention group significantly maintained their health-related quality of life measured by the SF-36 health survey, and their experience of depression measured by the Zung Self-rating Depression Scale to a greater extent than in the control group, especially among women.

Conclusion: A nurse-led intervention directed toward patients with heart failure in a primary health care setting resulted in limited effects between the groups, although the physical and mental status were retained during 12 months of follow-up to a greater extent than in the control group.

Key Words: Heart failure • Nurse-led intervention • Follow-up • Self-management • Primary health care • Health-related quality of life

Received October 8, 2002; Revised January 21, 2004; Accepted January 29, 2004


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
With the increasing number of patients with heart failure being referred from hospital to primary health care, the demands for expanded services in primary health care have increased. Caring for elderly patients with heart failure often involves a number of physical, medical, behavioural, psychological and social factors, and requires appropriate attention to all aspects of care, both pharmacological and non-pharmacological [1]. Educating patients about heart failure treatment and the consequences of heart failure has been shown to improve self-management behaviour [2]. For patients with heart failure, the self-management plan includes monitoring of symptoms such as fatigue and shortness of breath, daily weighing, and knowing what to do if signs of deterioration appear, and when to report the changes to the health care provider [3]. It has been shown that patients in heart failure management programmes that promote self-management by means of intensive education and telephone follow-up have improved their functional status and quality of life [4]. As patients with heart failure grow older, survival as the gold standard of care is slowly being replaced by relevant measures of social, emotional and physical function [5].

A systematic review [6] of randomised studies of disease management programmes in heart failure showed that out of 11 identified studies, only one was conducted in primary health care [7]. Weinberger and colleagues [7] investigated the impact of increased access to a primary health care provider team that consisted of a physician and a nurse. The patients in the intervention group had significantly greater numbers of hospital admissions and days in hospital. The intervention did not improve quality of life, but patients in the intervention group were substantially more satisfied with their care than patients in the control group. Results from the study by Weinberger and colleagues [7] differ from the more positive patient outcomes reported in studies evaluating heart failure care involving community outreach [4,8,9]. Factors that may explain these differences could be that the primary health care physicians and nurses had no specific education in heart failure, that patient counselling was not provided, and that follow-up was insufficient [1].

In a recent study, Doughty et al. [10] determined the effect of an integrated heart failure management programme performed in hospital and primary health care. The intervention group received support and education from their general practitioner, a specialist at the heart failure clinic and a nurse practitioner. The study showed a significant improvement in the intervention group regarding the physical dimension of quality of life and in the reduction of multiple hospital admissions over 12 months, but not in the emotional dimension of quality of life. Dedicated and well-educated nurses in primary health care have the potential to improve the care of patients with heart failure, as is the case with other chronic conditions such as diabetes [11]. The main aim of this study was to determine if a nurse-led intervention, designed to improve self-management in patients with heart failure in a primary health care setting would enhance the health-related quality of life and reduce signs of depression if any compared to the control. The aim was also to see effects of the health-related quality of life and depression as well as gender differences.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
2.1. Study sites
The study was approved by the Ethical Committee of Human Research at Linköping University, Linköping, Sweden and conducted at primary health care centres situated in two cities in Southeastern Sweden during the period from April 1999 to April 2000. To find comparable primary health care centres, a profile including age and population was obtained for all primary health care centres in the two cities. A total of eight primary health care centres were matched by age and population. After combining two comparable centres in each city, the centres were randomly assigned by drawing lots to receive either the usual care or the nurse-led intervention programme, i.e. using a cluster randomised design.

2.2. Study patients
The primary health care centres in the study were screened for patients with heart failure through the Diagnosis Related Groups (DRGs) registry in order to find those who were eligible for inclusion. As shown in Fig. 1, the screened population from the eight primary health care centres consisted of 159 876 persons over the age of 18 years. A total of 836 patients (0.52%) in the DRG registry were listed as having heart failure. The medical records of all patients found in the screening were reviewed by an experienced heart failure nurse, a primary health care nurse and a primary health care physician at each primary health care centre. The inclusion criteria for the study were diagnosed heart failure, based on echocardiography, radiographic evidence of pulmonary congestion or typical symptoms and signs of heart failure, age >18 years, New York Heart Association (NYHA) class II–IV, and residence within the catchment area. Exclusion criteria were serious psychiatric disease, suffering from a life-threatening disease, follow-up at a hospital heart failure clinic, and inability to speak Swedish. Of the 836 patients who were listed as having heart failure, only 225 were assessed as being eligible for the study (Fig. 1). The most common reasons for ineligibility were that the patient fulfilled one of the exclusion criteria, or that assessment of the diagnosis was very uncertain and without any evidence of abnormal cardiac function. The patients considered as eligible were initially invited by letter to participate in the study, and 1 week later they were contacted by telephone for consent. Of the 225 eligible patients, 153 patients were included in the study and 72 patients (32%) refused to participate. The most common reasons for refusal were fatigue and unwillingness to participate.


Figure 1
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  		Fig. 1 Flow chart describing how patients with heart failure were screened, included and followed-up in the study.

 
2.3. Usual care
Primary health care in Sweden is characterised by health care centres owned by the County Council that offer team-based care. The team usually consists of primary health care physicians, primary health care nurses, assistant nurses and a physiotherapist. Home visits are usually made by the primary health care nurse and the assistant nurse, and less frequently by the primary health care physician. Patient care can be provided by primary health care physicians and/or primary health care nurses, as well as by other health care providers at hospitals or other institutions.

2.4. Intervention care
In the first part of the intervention, an education programme was offered for all primary health care nurses and primary health care physicians at the intervention centres. Out of possible 30 primary health care nurses and 23 physicians, 29 and 10, respectively, participated. This was carried out prior to inclusion of the patients. A heart failure nurse and a cardiologist were responsible for the education, and it was given as a course comprising three sessions of 3 h each. The education consisted of three parts: (1) Anatomy and physiology of the heart, and pathophysiological changes in heart failure; (2) Routine evaluation and conventional treatment of chronic heart failure; and (3) Non-pharmacological treatment, including self-management regarding changes in lifestyle and regulation of symptoms. The programme aimed at increasing the competence for providing heart failure care at the primary health care centres. During the programme the study intervention was presented and emphasised, and optimal care and follow-up were discussed. The nurse-led intervention programme consisted of one extensive session lasting for approximately 2 h at the beginning of the study including education and counselling, and after that telephone follow-up for a 12 month period after the inclusion (Fig. 1). The educational session was provided in the home of the patient and the family, usually the spouse was also invited to participate. It was based on recommended guidelines [12,13] and pertinent literature and aimed at enhancing the patient's understanding of heart failure and improving self-management, thereby improving health-related quality of life (HRQOL) and reduce signs of depression if any. The education included written, verbal and interactive information focusing on the patient's needs and skills. The education was particularly aimed at assisting patients to improve the self-management of their heart failure, e.g. by restricting the intake of fluids and sodium, monitoring their weight, and detecting early signs of sodium and fluid retention such as shortness of breath and oedema, and to have a flexible diuretic regimen based on symptoms. The interactive information about heart failure included a multimedia program on CD-ROM [14] provided on a laptop computer. The program encouraged the patients to choose their own areas of interest and to repeat the information as often as needed. The CD-ROM program [14] was designed for elderly persons with large, clear illustrations and buttons, and has been found to provide increased and longer lasting knowledge about heart failure [15]. In order to coach and support the patient in self-management, provide additional education, and evaluate the patient's status, the primary health care nurse also carried out standardised telephone interviews. A standardised format was followed for each telephone contact to probe for signs of deterioration or side effects of medication. Patients whose heart failure remained stable received monthly nurse-initiated telephone contacts for a period of 1 year after inclusion, except at 3 and 12 months when home visits were carried out in order to administer the questionnaires. The appearance of new or worsening symptoms increased the frequency of telephone contacts or visits as required.

2.5. Measurements
Baseline demographic and clinical characteristics were extracted from the patients’ medical records. These included the patient's medical history, the establishment of the diagnosis, NYHA class, and prescribed medication.

Because of the multidimensional nature of the HRQOL, it has been suggested that both generic and disease specific HRQOL instruments must be used when studying patients with a chronic disease such as heart failure [16]. The SF-36 health survey [17] has been shown to be one of the best generic instruments, whereas the Minnesota Living with Heart Failure questionnaire (MLWHF) [18] has been shown to be one of the best disease specific instruments available [19].

The SF-36 health survey [17] consists of 36 items that rate HRQOL along eight scales: physical functioning, role functioning (due to physical limitations), social functioning, bodily pain, general health, vitality, mental health, and role functioning (due to emotional limitations). Scores for these eight scales can be grouped into a physical health component score and a mental health component score. The theoretical range is from 0 to 100. The SF-36 has been translated into Swedish, adjusted to and tested in a Swedish population [20].

The MLWHF [18] is a 21-item questionnaire assessing how heart failure has affected the life of the patient during the last month, and the questions cover symptoms and signs relevant to heart failure, physical activity, social interaction, sexual activity, work and emotions. The theoretical range for MLWHF is from 0 to 105 and it can be divided into a physical and an emotional subscale. A translated and back translated Swedish version was used in the study.

Depression was assessed using the Zung Self-rating Depression Scale (SDS) [21]. The SDS was designed to provide a quantitative assessment of the subjective experience of depression, and it emphasises somatic and behavioural components (50% of the total score) to a greater extent than most other self-rating depression scales. The SDS contains 20 items covering affective, psychological and somatic features of depression. The total raw SDS scores range from 20 to 80, and converted SDS scores range from 0.25 to 1.0. Non-depressed individuals typically score less than 0.50, mildly depressed 0.50–0.60, moderate depressed 0.61–0.70, and those with severe depression generally score higher than 0.70 [21,22]. The evidence on validity supports the use of the SDS as a screening tool or as an aid in clinical evaluation [23], but not as a diagnostic measure of depression [24]. The scale correlates well with Beck depression Inventory scores, with the ratings of clinicians, and with the Diagnostic and Statistical Manual of Mental Disorders (3rd edn revised) (DSM-III-R) diagnosis of depression [25]. A translated and back translated Swedish version was used in the study.

2.6. Data collection
An experienced primary health care nurse at each primary health care centre acted as the study co-ordinator. These nurses contacted eligible patients, entered patients into the study, administered the questionnaires, and directed the intervention programme. At the time of enrolment, the patient was interviewed in his/her own home in order to collect sociodemographic data. Questionnaires regarding HRQOL and signs of depression were filled in by the patient at the time of enrolment, before the beginning of the nurse-led intervention programme, and at the 3 and 12-month follow-up in the home of the patient.

2.7. Statistical power and missing data
The main aim was to determine the effects of a nurse-led intervention designed to improve self-management of patients with heart failure in a primary health care setting regarding HRQOL and signs of depression if any. With 75 patients in each group (intervention and control) it would be possible to detect a 20% difference between the two groups of the measurements for HRQOL and depression used (two-sided alpha=0.05, beta 0.80). Frequencies were examined in order to determine the amount of missing data. Depending on the type and quantity of data missing, data were either eliminated from the analysis or estimated. If less than 20% of the data were missing from a scale, the data were estimated. In the SF-36, the average score on the sub-scale for valid items was used in place of the missing item. In the MLWHF and the SDS, the sum of the values obtained was divided by the number of answered items, and this was used in place of the missing item. Since data missing were very limited, no data were eliminated from the analysis.

2.8. Statistical analysis
The intervention group and the control group were compared using Student's t test for normally distributed continuous variables and the chi-square test for nominal variables. For statistical evaluation, non-parametric tests (the Mann–Whitney U test for comparisons between groups, and the Wilcoxon matched pairs test for within group comparisons) were used to avoid potential errors from exceptional distributions of data. A P value <0.05 was considered statistically significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
3.1. Study patients
As a check for the randomisation procedure, the baseline characteristics for the control and intervention groups were compared (Table 1). The baseline comparison was made regarding demographic and clinical characteristics, outcome variables, and characteristics of the patients who died or did not respond due to severe disease or study withdrawal. The groups were similar in all demographic characteristics, 54% were men, and the mean age of the entire sample was 80 years for women and 78 years for men. There were no statistically significant differences in the clinical variables, although there was a trend towards increased severity of symptoms (NYHA IV) in the intervention group (10% vs. 1%, P=0.051). At baseline, 92% of the patients were prescribed diuretics, 72% were prescribed ACE inhibitors, 54% β-blockers and 37% digitalis. The most common cause of heart failure was ischaemic heart disease (59%), and 40% of the study patients had a myocardial infarction. Echocardiography was used to diagnose heart failure in 74% of the patients. In the comparison of outcome variables at baseline, the groups were similar in all outcomes variables except for role functioning (due to physical and emotional limitations) and social functioning in the SF-36 health survey where the control group was better at baseline.


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  		Table 1 Baseline demographic and clinical characteristics of the included patients with heart failure

 
3.2. The follow-up period
The mean number of standardised telephone follow-up in the intervention group was 9.6 out of a projected number of 10. The most common reason for a missed telephone follow-up was that the patient was hospitalised. During the 12-month follow-up, 10 patients (13%) in the intervention group died compared to 3 (4%) in the control group. Four patients (5%) in the intervention group and two (3%) in the control group were lost to the study due to other severe diseases. Two patients (3%) in each group withdrew at their own request. A comparison was made between the baseline characteristics of the patients who died or did not respond due to severe disease or study withdrawal (n=23), and the patients completing both follow-up (n=130). The patients who did not completing both follow-ups were significantly older (P=0.011), had worse heart failure according to their NYHA classification (P=0.024), were more frequently on digitalis (P=0.005), had a higher daily dosage of diuretics (P=0.024), and did more often belong to the intervention group (P=0.013). At baseline and after 3 and 12 months there was no difference in the prescription of ACE-inhibitors and beta-blockers between the groups. After 12 months the patients in the control group had 58% of target dose for ACE-inhibitors and 23% of target dose for beta-blockers compared to 49 and 23% in the intervention group. None of these differences were statistically significant.

3.3. The SF-36 health survey
3.3.1. Differences within groups
As shown in Figs. 2 and 3, neither the intervention group nor the control group had a significant improvement in any of the dimensions. The intervention group preserved their HRQOL in all dimensions (Fig. 2), while the control group had significantly deteriorated in several domains (Fig. 3). Role functioning due to physical limitations (P=0.035), and vitality (P=0.029) was significantly impaired in the control group at 3-month follow-up. At both the 3 and 12-month follow-up, physical functioning (P=0.035 and 0.001), role functioning due to emotional limitations (P=0.001 and 0.022), and the mental component summary (MCS) (P=0.017 and 0.047) had deteriorated in the control group. Women in the control group had worse physical functioning at the 3 and the 12-month follow-up (P=0.003 and 0.005) compared to men. The physical component summary (PCS) was also poorer for women at both the 3 and the 12-month follow-up (P=0.018 and 0.043), as was bodily pain at both baseline and the 12-month follow-up (P=0.023 and 0.022).


Figure 2
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  		Fig. 2 SF-36 health survey difference of mean after 3 and 12 months within the intervention group. Higher scores indicate greater HRQOL.

 


Figure 3
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  		Fig. 3 SF-36 health survey difference of mean after 3 and 12 months within the control group. Higher scores indicate greater HRQOL.

 
3.3.2. Differences between groups
There was a significant improvement in the intervention group at 3-month follow-up regarding role function due to physical limitations (P=0.008), and a tendency toward improved vitality and social functioning (P=0.051 and 0.056). The differences had disappeared at the 12-month follow-up (Fig. 4).


Figure 4
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  		Fig. 4 SF-36 health survey difference of mean between the intervention and control group 3 and 12 months after the intervention.

 
3.4. The Minnesota living with heart failure questionnaire
There were no significant mean differences between or within the groups at baseline or at the 3 and 12-month follow-up in total scores, or in emotional or physical scores. There were no significant gender differences within the groups (Fig. 5).


Figure 5
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  		Fig. 5 MLWHF score differences after 3 and 12 months within the intervention and the control group. Higher scores indicate poorer HRQOL.

 
3.5. The Zung Self-rating depression scale
3.5.1. Differences within groups
There were no significant mean differences within the two groups at baseline or at the 3 and 12-month follow-up (Fig. 6). There were no significant gender differences within the groups.


Figure 6
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  		Fig. 6 Zung Self-rating Depression Scale (SDS) cut-off scores for patients with heart failure at baseline and 3 and 12 months after the intervention.

 
3.5.2. Differences between groups
There was no significant median difference between the two groups. In Fig. 6 the SDS cut off scores show that there was a significant difference in moderate and severe depression (P=0.023) from baseline until the 3-month follow-up, with patients in the intervention group having significantly less depression. At 12-month follow-up there was no difference between the groups.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
4.1. Methodological issues
Screening for patients with heart failure who were eligible for the study was done at eight primary health care centres. Of the people living in the catchment area, 836 (0.52%) were diagnosed as having heart failure, which is in the lower range of the estimation for the general European population [26]. One reason for the low prevalence rate in our study could be that some patients with heart failure within the catchment area were diagnosed, treated and received follow-up at a hospital, and were therefore not in the primary care registry. The screening method, however, assured that patients included in the study were representative of the known heart failure population in primary health care. In a European survey of primary health care physician perceptions concerning the diagnosis and management of heart failure, Hobbs and colleagues [27] found that a majority of physicians underestimate the true prevalence of heart failure, with 32% believing it to be at least 10 times less frequent than its actual prevalence. This misunderstanding may influence how the physician judges signs and symptoms of heart failure and whether he/she considers heart failure as a possible diagnosis. Misdiagnosis of heart failure in primary health care of up to 70% have been found when patients were assessed against objective criteria such as echocardiography [28]. In our study 95% of the patients were diagnosed on the basis of chest radiography and/or echocardiography and that reduced the risk of misdiagnosis.

At baseline, the patients filled in the questionnaires themselves before receiving information from the primary health care nurse. That made it possible for the nurse to clarify misunderstandings about any issues, and more complete data was thus obtained. However, there might have been some reluctance on the part of the participants to respond to certain questions (for example, questions on depression and sexuality), whereas they might have been more willing to respond to the same questions if the questionnaire had been anonymous [29].

As the aim was to determine the effects of a nurse-led intervention performed in primary health care and directed toward patients with heart failure, there were some differences between our patients and those in a hospital-based study population. Patients followed-up by nurses and physicians in a hospital-based heart failure clinic are often younger and have a more severe heart failure. Since follow-up in a heart failure clinic was an exclusion criterion in our study, most of our patients were older, with ages comparable to those of individuals in the community with heart failure, i.e. approximately 80 years. Cluster randomisation was performed using the primary health care centres as the unit for randomisation. The reason the primary health care centres were randomised instead of the patients was that the education and the intervention programme had to be applied to the whole centre to reduce the risk of bias. We estimated that a randomisation of the primary health care centres would guarantee equality between the groups at baseline, but that was not completely achieved since the intervention group had a tendency toward worse scores in all measurements at baseline and this might have affected the results. Dropout is a well-known problem in longitudinal studies [30]. Selective drop out in the intervention group of eligible patients before the inclusion may have biased the results. The patients who were in good health might not see the point to participate in the intervention programme or the patients who were in poor health might not have the energy to join the intervention. The higher mortality in the intervention group (10 vs. three patients) might be explained by the fact that the patients in this group seemed to have more severe heart failure according to the NYHA classification and the pharmacological treatment (Table 1). This was confirmed by the trend towards increased severity of symptoms (NYHA IV) in the intervention group (eight vs. one, P=0.051) and the fact that six of the patients who died in the intervention group were NYHA IV. Another explanation could be that the intervention programme had no positive influence on the optimization of the pharmacotherapy with, e.g. titration to maximally tolerated doses of ACE-inhibitors and betablockers. The reason for this might be that the nurses were focused on non-pharmacological treatment and on the patients’ symptoms and psychosocial needs. The physicians were not actively involved in the intervention and the nurses were not trained and delegated to make protocol-led changes in medications such as nurses working in heart failure clinics [31].

4.2. Interventional issues
Heart failure management programmes promoting self-care have been found to improve self-care behaviour [2], functional status and quality of life [4] in patients hospitalised due to heart failure. The patients in our study were followed up solely in primary health care, and the majority therefore had fairly stable heart failure. This is a different situation than in studies in which the condition of the patients is more unstable, such as at hospital discharge or within 2 weeks of discharge [4,8,31]. These circumstances probably affected the results of our study and might explain why the nurse-led intervention did not significantly improve quality of life and reduce depression more clearly.

Some of the effects achieved between the groups after 3 months were not retained after 12 months. These results raise the question whether follow-up by monthly telephone contacts is the best intervention in this patient or if another type of intervention should be used, such as nurse-led heart failure programmes that involves fewer scheduled contacts and involves additional contacts based on patient's needs with no limits on number [8,31].

4.2.1. Differences between groups
The effects of the nurse-led interventions between the groups were limited, with significant differences shown in the physical dimension measured by the SF-36, and in depression measured by the SDS. There were significantly fewer physical problems in daily life in the intervention group after 3 months. The reason why the intervention affected physical health may be that the education on self-management especially focused on factors influencing daily life activities such as symptom management, fluid restriction and exercise. Winters and colleagues [32] have reported that preserved or improved physical function is very important for patients with heart failure, since remaining active, and independent play an important role in their life situation.

Although depression is clearly a common problem in elderly patients with heart failure [33], it is not yet clear whether functional impairment plays a causal role in depression in this population; it is also possible that depression may deteriorate functional impairment. Either way, it is evident that patients in NYHA class III–IV are at very high risk for depression [34]. The Mental Health Scale in SF-36 has been shown to be useful in screening for psychiatric disorders [35]. The reason why the Mental Health Scale did not show differences when the SDS did in this study could be explained by the fact that SDS has several questions involving somatic components, which seemed to be more deteriorated in the control group. A nurse-led intervention provides an element of security by giving patients knowledge about where to turn when their symptoms become worse. Knowledge about heart failure improves their sense of security and independence since they know which symptoms and signs of deterioration should be observed and which counteractive measures should be taken [3]. These issues, together with the fact that the patients in the intervention group maintained there physical condition, might explain why depression was less prevalent in the intervention group after 3 months.

4.2.2. Differences within groups
The intervention seemed to have the greatest effect within the physical dimension measured by the SF-36. Patients in the control group reported significant deterioration in physical function after both 3 and 12 months. This is supported in a review by Leidy and colleagues [36] which conclude that the primary impact of treatment for heart failure is on functional status rather than across all domains of HRQOL.

The intervention in this study also seemed to have a positive effect on mental life, since the intervention group maintained their mental health and role functioning due to emotional limitations, while the control group deteriorated after the 3 and the 12-month follow-up. Heart failure is a condition associated with varying degrees of anxiety, fear and anguish. A nurse-led intervention provides an element of security by giving patients knowledge about where to turn when their symptoms are worsening. Knowledge about heart failure improves their sense of security and independence since they know which symptoms and signs of deterioration should be observed and which counteractive measures should be taken.

4.3. Gender differences
The only area in the intervention group which contained gender differences was in the area of general health, where men scored worse than the women. This area included expectations of future health. This finding is in accordance with other studies showing that women with heart failure are less concerned about the future and has accepted their mortality, and that they ascribe more positive meaning to their illness than men [37–39]. Women in the control group had significantly more problems within the physical dimension with respect to functional status and pain but, surprisingly, not in role limitations due to physical health problems. This gender difference was not found in the intervention group, which could indicate that the education was more successful among the women in the intervention group. Several investigators have demonstrated that female patients with heart failure have lower physical function and more problems with symptoms and pain than male patients [40–42].


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
A nurse-led intervention designed to improve self-management in patients with heart failure in a primary health care setting showed limited improvements in comparison with a control group. Significant differences were found in the physical dimension, as well as in depression. In comparison within groups at the 3 and 12-month follow-up, the intervention group significantly maintained their health-related quality of life and their experience of depression to a greater extent than in the control group, especially among women. Since many of the effects became less pronounced after 12 months and that the programme had no positive influence on the optimization of the patients’ pharmacotherapy, the method of follow-up by means of telephone interviews on a regular basis may be questioned. The clinical importance of this study is that it presents a favourable follow-up programme for elderly patients with heart failure in primary health care. Further research is needed to find the most appropriate way of following up these patients on a long-term basis.


   Acknowledgements
 
The Research Council of Southeastern Sweden (FORSS), the Swedish Heart and Lung Foundation, the County Research Council of Jönköping, the Health Care Section of Jönköping County Council, Sweden, for financial support. Primary health care nurses Ingrid Carlegrim, Helena Ekblad, Gunilla Hultman, Helen Jansson, Sofia Lundén-Blom, Christina Ståhlbom, Berit Sydbom, Ing-Marie Sörstedt for their involvement in the study.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

  1. Grady K.L., Dracup K., Kennedy G., et al. Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation (2000) 102:2443–2456.[Free Full Text]
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