Self-Management Counseling a Bust in HF

September 28, 2010

September 28, 2010 (Chicago, Illinois) — Providing heart-failure patients with self-management counseling on top of a group-based program of education about their disease had little or no effect on their clinical outcomes over several years, compared with standard management, in a randomized, single-center trial conducted in the Chicago metro area [1]. The findings support past studies that have explored the use of self-management programs in heart failure, write the authors, led by Dr Lynda H Powell (Rush University Medical Center, Chicago, IL), in the September 22/29, 2010 issue of the Journal of the American Medical Association.

In the Heart Failure Adherence and Retention Trial (HART), 902 patients with mild to moderate heart failure regardless of LVEF were randomized to self-management plus education or education-only programs. The former program "featured group-based heart-failure education plus counseling to help patients develop mastery in problem-solving skills and in five self-management skills," according to the authors. The education component consisted of 18 heart-failure tip sheets from the American Heart Association, one tip sheet at each of 18 meetings over the course of a year. In contrast, the education-only intervention consisted of the same 18 tip sheets mailed to each patient on the same schedule they were received by the other group.

The trial was partially blinded, as the staff and patients weren't informed of the study's hypothesis, and randomization assignments were known only to the data-management team, according to Powell et al.

Over a median of two and a half years, the two groups didn't differ significantly with respect to the primary end point of death or heart-failure hospitalization: 40.1% for the self-management group and 41.2% for the education-only patients.

Nor were there significant differences between the groups in individual end points, including the two components of the primary end point, all-cause hospitalization, or quality of life; change in NYHA class or six-minute-walk distance; heart rate, respiratory rate, blood pressure, or body-mass index; or measures of quality of life, emotional support, or "purpose in life."

On the other hand, write Powell et al, the education-only control group showed significant improvements in some parameters that paralleled gains made by the intervention group. Those parameters included self-efficacy scores, measures of depression, and dietary sodium restriction. The group speculates that improvements in the control patients resulted from the enhanced care they received. For example, after they received the education tip sheets in the mail, they also received a follow-up phone call to ensure the materials were read and understood.

Regarding that possibility, agreed Dr John GF Cleland (University of Hull, Kingston-upon-Hull, UK) and Dr Inger Ekman (Göteborg University, Sweden) in an accompanying editorial [2], "it is possible that this intervention precipitated a dialogue that strayed into the realms of self-management. Another possibility is that the highly selected study participants were more motivated and therefore more inclined to better self-management in response to minimal intervention, such as a telephone call."

HART was publically funded. Coauthor Dr James E Calvin Jr (Rush University Medical Center) reports receiving research funding from Novartis. Cleland reports receiving research funding from Philips.