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European Journal of Heart Failure 2006 8(2):187-190; doi:10.1016/j.ejheart.2005.06.007
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© 2006 European Society of Cardiology

Patients' knowledge and beta blocker treatment improve prognosis of patients from a heart failure clinic

Mitja Lainscaka,* and Irena Keberb

a General Hospital Murska Sobota, Internal Medicine Department Dr. Vrbnjaka 6, SI-9000 Murska Sobota, Slovenia
b University Medical Centre Ljubljana, Vascular Disease Department Ljubljana, Slovenia

* Corresponding author. Tel.: +38 631379533; fax: +38 625211007. E-mail address: mitja.lainscak{at}guest.arnes.si


   Abstract
Top
 Abstract
1. Background
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: Several studies have shown improvement of prognosis in patients managed in heart failure (HF) clinics. However, the value of the individual management components is not well established.

Aim: To assess the prognostic value of pharmacological treatment and patient's knowledge in patients receiving care in a HF clinic.

Methods and results: In our prospective cohort study we followed 115 patients (50 from an HF clinic and 65 receiving usual care) for at least 12 months. Knowledge was assessed using a Patient Knowledge Questionnaire (PKQ). During a median follow-up of 561 days, fewer patients from the HF clinic died or were rehospitalized due to HF than those receiving usual care (42% vs. 65%, p=0.016). The prescription rates of ACE inhibitors (94% to 98%) and beta blockers (40% to 94%) increased in the patients from the HF clinic. In these patients the PKQ score also increased from 4.8 (1.5) to 7.9 (1.3), p<0.001. In the Cox proportional hazard model, treatment with beta blockers at ≥50% of the target daily dose (Hazard Ratio [HR] 0.3, 95% Confidence Interval [CI] 0.10—0.95) and a PKQ score <7 (HR 3.92, 95% CI 1.39—11.03) predicted prognosis in the patients from the HF clinic.

Conclusions: Patient management in the HF clinic reduced the incidence of death or of HF rehospitalization. Poor prognosis of patients receiving care in the HF clinic was predicted by poor patient knowledge and underdosing with beta blockers.

Key Words: Heart failure • Mortality • Rehospitalization • Knowledge • Beta blockers

Received December 12, 2004; Revised May 24, 2005; Accepted June 17, 2005


   1. Background
Top
 Abstract
 1. Background
2. Methods
 3. Results
 4. Discussion
 References
 
Heart failure (HF) still carries a high morbidity and mortality risk, and poses a major challenge for modern medicine [1]. Further to landmark trials with angiotensin converting enzyme (ACE) inhibitors [2] and beta blockers [3], several studies have shown that a patient's prognosis can be improved by disease management programmes (DMPs) [4-6].

There is sufficient evidence to support the introduction of DMP into everyday clinical practice. Previous studies have demonstrated a reduction in hospitalization, lower costs, and improved quality of life [7], and recent reports have extended the benefit to reduction of mortality [8-12]. However, the actual value of individual components of DMP and their contribution to the overall benefit remain largely unknown.

The aim of this study was to assess the prognostic value of pharmacological treatment and of patient's knowledge in patients receiving care in a HF clinic.


   2. Methods
Top
 Abstract
 1. Background
 2. Methods
3. Results
 4. Discussion
 References
 
In our prospective observational study we followed 115 HF patients for at least 12 months. Over 12 months from March 2002 patients were referred by the discharge physician to the HF clinic (50 patients). A control group of patients receiving usual care (UC) (n=65) was formed retrospectively and was matched for age and sex. The hospital ethics committee approved the study protocol and all patients gave written informed consent to participate.

The DMP in our HF clinic has been described previously [13]. In brief, during the first visit, patients and their relatives or care providers have a consultation with the physician about the basics of HF, the importance of non-pharmacological measures and the basics of self-management strategies. Nurse sessions cover life style changes, warning signs of HF worsening, and self-management strategy.

Survival status and the number of hospitalizations were obtained during visits to the HF clinic, from the medical records, and by contacting the patients or their relatives. In the HF clinic group, knowledge was assessed at baseline and during the third visit, using a validated 10-item self assessment Patient knowledge questionnaire — PKQ [14]. Pharmacological treatment was assessed during every visit.

Data are presented as mean value (±standard deviation). Baseline characteristics were compared using Student's t-test for independent samples and the {chi}2 test. Event-free survival (absence of death or HF rehospitalization) was estimated by the Kaplan-Meier curves and compared by the log-rank test. To examine the effects of the baseline variables on prognosis, the Cox proportional hazard model was used. The predefined variables to examine the specific effect of the management in the HF clinic group on event-free survival were: treatment with ACE inhibitors or beta blockers, prescription of more or less than 50% of the target daily dose for ACE inhibitors or beta blockers, and PKQ score more or less than the median score. A probability value of p<0.05 was taken as statistically significant. All calculations were made using SPSS 11.0 (SPSS Inc, 2001, USA).


   3. Results
Top
 Abstract
 1. Background
 2. Methods
 3. Results
4. Discussion
 References
 
The groups were well matched for baseline demographic and clinical characteristics (Table 1). During the median follow-up time of 561 days, 29 patients (58%) from the HF clinic and 23 patients (35%) receiving UC remained event-free (Fig. 1). Median event-free survival was longer in the HF clinic group than in the UC group (280 days vs. 72 days, p<0.001). Independent predictors of prognosis were assignment to the HF clinic (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.07-0.53, p=0.001) and NYHA class III or IV (HR 2.2, 95% CI 1.07-4.54, p=0.032).


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  		Table 1 Baseline demographic and clinical characteristics

 


Figure 1
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  		Fig. 1 Cumulative probability of event-free survival (absence of death or heart failure rehospitalization) during the follow-up.+Censored cases.

 
At the end of follow-up or prior to the event of interest (death or HF rehospitalization) 98% and 94% of patients from the HF clinic group received ACE inhibitors and beta blockers. At that point, the mean equivalent enalapril and carvedilol daily doses [15] were 14.9 (8.7) mg and 23.5 (18.3) mg. At least 50% of the target daily dose was prescribed to 48% of these patients. The PKQ score improved significantly in the HF group during the follow-up (4.8 (1.5), 95% CI 4.2-5.2, to 7.9 (1.3), 95% CI 6.9-7.8, p<0.001). Prior to the event of interest the median score was 7 points. After applying the predefined Cox proportional hazard model, prognosis was independently associated to a PKQ score <7 points (HR 3.92, 95% CI 1.39-11.03, p=0.01) and to treatment with ≥50% of the beta blocker target daily dose (HR 0.30, 95% CI 0.10-0.95, p=0.04).


   4. Discussion
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
References
 
In unselected HF patients assigned to the DMP in the HF clinic we observed a reduced incidence of death or HF rehospitalization when compared to the patients receiving UC. In the HF clinic group, significant improvement in pharmacological management and patient knowledge during the follow-up were observed. Our analysis identified poor patient's knowledge and under dosing of beta blockers as predictors of adverse prognosis in these patients.

Previous reports have established the important role of the HF DMP in reducing clinical events [4-6]. Assignment to an intervention group has been shown to be an independent predictor of better prognosis [10-12]. However, the optimal structure of the DMP is still unknown. Optimization of guideline based medical therapy is one of the major DMP goals [16], and is largely accomplished [13,17]. Indeed, retrospective analysis of the MERIT-HF [18] and CIBIS-II [19] data showed the beneficial effect of beta blockers even at moderate doses, if the heart rate was reduced. Moreover, there are data supporting the dose related survival benefit in HF patients treated with carvedilol [20]. Thus, the combination of the clinically significant risk reduction in beta blockers trials [3] and the reported predictive value of the DMP [10], coupled with the findings of this study, leads to the suggestion that the benefit may be largely driven by treatment with beta blockers.

Nevertheless, patient education and self-management are another standard DMP component. In a recent report, self-care behaviour improved significantly in the intervention group [8]. Patient knowledge is the basis for effective self-care and could be accepted as a surrogate marker of intervention efficacy [21]. There are only a few validated instruments to assess knowledge in HF patients [14,22,23]. Our study supports the theory that it is important to evaluate patient's knowledge and to investigate its possible association with clinical outcome.

In conclusion, DMP in the HF clinic improves pharmacological treatment and patient's knowledge, both of which can contribute to a more favourable outcome. Future studies with larger sample size and randomized design are needed to investigate the separate prognostic importance of patient's knowledge and non-pharmacological measures in HF patients. The ongoing COACH [23] study will add relevant information to this topic.


   References
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 References
 

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