Effect and Cost Effectiveness of a Dyadic Empowerment-based Heart Failure Management Program for Self-care

Effect and Cost Effectiveness of a Dyadic Empowerment-based Heart Failure Management Program for Self-care

The Effects and Cost-effectiveness of a Dyadic Empowerment-based Heart Failure Management Program (De-HF) on Self-care, HRQL and Hospital Readmission: A Randomized Controlled Trial

Global population aging has drastically increased healthcare spending worldwide, with the greatest portion going to hospital and community health services. Heart failure (HF), as the final form of many cardiovascular diseases resulting from insufficient myocardial pumping. Ineffective self-care is consistently identified as the major modifiable risk factor for HF decompensation requiring hospitalization. It refers to an active cognitive process that influence patients' engagement in self-care maintenance, symptom perception and self-care management. However, current studies pay much focus on interventions such as motivational interviewing and behavioural activation to enhance the HF-related self-care and health outcomes which only produces short-term benefits. In fact, the lack of a sustainable effect from the self-care supportive interventions might be related the use of patient-centric design in these studies, which totally ignores the fact that HF management takes place in a dyadic context. To advance, active strategies were adopted to mobilize collaborative effort of the dyad in actual disease management. This study aims to evaluate the effects and cost-effectiveness of a Dyadic empowerment-based Heart Failure Management Program (De-HF) for self-care, health outcomes, and health service utilization among HF patients who require family support after hospital discharge. The De-HF program is based on the Theory of Dyadic Illness Management to enhance the congruence in illness perception and active dyadic collaboration in managing HF via both face-to-face and online platforms.

This is a mixed-method RCT to evaluate the effects and cost-effectiveness of the Dyadic Empowerment Heart Failure Program on improving self-care, health-related quality of life, hospital readmission and emergency room utilization among the HF patients discharged from the hospital. The study will be conducted in two regional hospital in Hong Kong, with subjects to be recruited from the in-patient setting. They need to have an index diagnosis of HF in admission, at New York Heart Association Classification Class II-IV, to be discharged home and with Abbreviated Mental Test score >6. The caregiver need to the primary caregivers, co-residing with the patients, and have access to smartphone. Power analysis estimate the sample size as 226 care dyads who will be allocated in a 1:1 ratio to receive the DE-HF Program of the education intervention. The 16-week De-HF program will be commenced within 2 weeks of discharge. It will starts with a dyadic interview in a home visit to identify the usual pattern of collaboration, deficits, strengths and competing concerns in disease management. This is followed by five empowerment modules with the purpose to help the care dyads to get a consensus and optimize their joint efforts in disease management. The five topics include symptom management, dietary and fluid modification, medication management, symptom management, activity and exercise. For each module, there are two sessions for i) perception and cognitive empowerment and ii) develop collaborative goal attainment process. Upon the completion of the ten sessions, two bi-weekly telephone calls will be made to the care dyads to monitor their level of goal attainment, and to give further advice and counselling. The 16-week dyadic education program will cover one home visit to assess their disease management at home, and this will be followed by five standard bi-weekly online education session on the same topics as the modules in the De-HF program. Outcome evaluation will take place at baseline, post-test, 24th week and 32rd week with validated measure.

It is a double-blind study. A research nurse will identify potential subjects from the Clinical Management System, and will screen for the patient's cognitive function and NYHA status. Eligible patients and their primary carers will be invited to participate during their hospital stay. After obtaining their written informed consent, the research nurse will collect their baseline demographic data and administer the following outcome measures in a face-to-face interview. The care dyads will be randomized to receive either the De-HF or educational program in an allocation ratio of 1:1. To ensure double blinding, the dyads will not know whether they are participating in the test or control intervention. The assigned intervention will be commenced within 2 weeks of the baseline measure. Post-test outcome evaluation will take place at the 16th week (post-intervention), 24th week, and 32nd week.

The 16-week De-HF Program is delivered on a dyadic basis. The program consists of three core elements: i) joint dyadic interview in a home visit (1st-2nd week), ii) five ICT-enhanced empowerment-based modules (3rd-12th week; 2 sessions/ each module), and iii) post-module telephone follow-up (13th-16th week). The overall aim of the dyadic interview is to understand their usual pattern of collaboration, deficits, strengths and competing concerns in disease management. This is followed by the empowerment modules with the purpose to help the care dyads to get a consensus in disease interpretation (1st session: Perceptual and Cognitive Empowerment Session) and develop collaborative goal attainment process (2nd Session: Collaborative Gaol-Setting Process). This will be followed by two bi-weekly telephone calls to the care dyads using a speaker phone to monitor their level of goal attainment for the five modules, and to give further advice and counselling.

The 16-week HF education program comprises a home visit, five bi-weekly online training sessions, and the subsequent telephone follow-up for the care dyads. The nurse will first assess how they manage HF in terms of medication compliance, fluid and dietary control, symptom monitoring and responses in a home visit and clarify their major misconceptions in self-care. This will be followed by five bi-weekly online education sessions on the same topics as the empowerment modules in the De-HF program.

The 16-week De-HF Program is delivered on a dyadic basis, The program consists of three core elements: i) joint dyadic interview in a home visit (1st-2nd week), ii) five ICT-enhanced empowerment-based modules (3rd-12th week; 2 sessions/ each module), and iii) post-module telephone follow-up (13th-16th week). The overall aim of the dyadic interview is to understand their usual pattern of collaboration, deficits, strengths and competing concerns in disease management. This is followed by the empowerment modules with the purpose to help the care dyads to get a consensus in disease interpretation (1st session: Perceptual and Cognitive Empowerment Session) and develop collaborative goal attainment process (2nd Session: Collaborative Gaol-Setting Process). This will be followed by two bi-weekly telephone calls to the care dyads using a speaker phone to monitor their level of goal attainment for the five modules, and to give further advice and counselling.

The 16-week HF education program comprises a home visit, five bi-weekly online training sessions, and the subsequent telephone follow-up for the care dyads. The nurse will first assess how they manage HF in terms of medication compliance, fluid and dietary control, symptom monitoring and responses in a home visit and clarify their major misconceptions in self-care. This will be followed by five bi-weekly online education sessions on the same topics as the empowerment modules in the De-HF program.

Measure the self-care maintenance, self-care management, and symptom perception of the HF patients. There are 28 questions are rated from 1 to 5, and one question are rated from 0 to 5. The three subscale scores are transformed to 0-100, with higher scores indicating better self-care attributes.

Measure the self-care maintenance, self-care management, and symptom perception of the HF patients. There are 28 questions are rated from 1 to 5, and one question are rated from 0 to 5. The three subscale scores are transformed to 0-100, with higher scores indicating better self-care attributes.

Measure the self-care maintenance, self-care management, and symptom perception of the HF patients. There are 28 questions are rated from 1 to 5, and one question are rated from 0 to 5. The three subscale scores are transformed to 0-100, with higher scores indicating better self-care attributes.

Measure the self-care maintenance, self-care management, and symptom perception of the HF patients. There are 28 questions are rated from 1 to 5, and one question are rated from 0 to 5. The three subscale scores are transformed to 0-100, with higher scores indicating better self-care attributes.

Measure the disease-specific HRQL (primary outcome of the HF patient), covering the physical and emotional health of HF patients. There are 21 items and each item is rated from 0 to 5, with higher scores indicating poor health.

Measure the disease-specific HRQL (primary outcome of the HF patient), covering the physical and emotional health of HF patients. There are 21 items and each item is rated from 0 to 5, with higher scores indicating poor health.

Measure the disease-specific HRQL (primary outcome of the HF patient), covering the physical and emotional health of HF patients. There are 21 items and each item is rated from 0 to 5, with higher scores indicating poor health.

Measure the disease-specific HRQL (primary outcome of the HF patient), covering the physical and emotional health of HF patients. There are 21 items and each item is rated from 0 to 5, with higher scores indicating poor health.

Assess the health-related quality of life of the care dyads and to generate the utility score for cost-effective analysis. It consists of two parts, with the first part to assess the health status on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 5-level (no problems, slight problems, moderate problems, severe problems and unable to) response set, with "unable to" levels mean a worse situation. The second part as a 0-100 scores VAS to measure perceived health, higher scores mean a better outcome.

Assess the health-related quality of life of the care dyads and to generate the utility score for cost-effective analysis. It consists of two parts, with the first part to assess the health status on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 5-level (no problems, slight problems, moderate problems, severe problems and unable to) response set, with "unable to" levels mean a worse situation. The second part as a 0-100 scores VAS to measure perceived health, higher scores mean a better outcome.

Assess the health-related quality of life of the care dyads and to generate the utility score for cost-effective analysis. It consists of two parts, with the first part to assess the health status on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 5-level (no problems, slight problems, moderate problems, severe problems and unable to) response set, with "unable to" levels mean a worse situation. The second part as a 0-100 scores VAS to measure perceived health, higher scores mean a better outcome.

Assess the health-related quality of life of the care dyads and to generate the utility score for cost-effective analysis. It consists of two parts, with the first part to assess the health status on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 5-level (no problems, slight problems, moderate problems, severe problems and unable to) response set, with "unable to" levels mean a worse situation. The second part as a 0-100 scores VAS to measure perceived health, higher scores mean a better outcome.

Measure the level of shared care in terms of communication, decision-making, and reciprocity of care dyads. Each item is rated from zero to five (completely agree, mostly agree, slightly agree, slightly disagree, mostly disagree, and completely disagree), with higher scores representing better shared care.

Measure the level of shared care in terms of communication, decision-making, and reciprocity of care dyads. Each item is rated from zero to five (completely agree, mostly agree, slightly agree, slightly disagree, mostly disagree, and completely disagree), with higher scores representing better shared care.

Measure the level of shared care in terms of communication, decision-making, and reciprocity of care dyads. Each item is rated from zero to five (completely agree, mostly agree, slightly agree, slightly disagree, mostly disagree, and completely disagree), with higher scores representing better shared care.

Measure the level of shared care in terms of communication, decision-making, and reciprocity of care dyads. Each item is rated from zero to five (completely agree, mostly agree, slightly agree, slightly disagree, mostly disagree, and completely disagree), with higher scores representing better shared care.

Measure the perceived control in disease management. Each item was rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and summed to create a total score after two negative items were reverse coded. The possible total score ranges from 8 to 40 with a higher score indicating higher perceived controllability.

Measure the perceived control in disease management. Each item was rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and summed to create a total score after two negative items were reverse coded. The possible total score ranges from 8 to 40 with a higher score indicating higher perceived controllability.

Measure the perceived control in disease management. Each item was rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and summed to create a total score after two negative items were reverse coded. The possible total score ranges from 8 to 40 with a higher score indicating higher perceived controllability.

Measure the perceived control in disease management. Each item was rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and summed to create a total score after two negative items were reverse coded. The possible total score ranges from 8 to 40 with a higher score indicating higher perceived controllability.

Inclusion Criteria: Aged 55 or over Confirmed medical diagnosis of Heart Failure by a cardiologist of at least 6 months New York Heart Association (NYHA) Class II-IV symptoms Discharged home after an admission to the recruitment setting Carer co-residing with the patients in the same household Carer self-identified as the primary carer for the patients Both the patient and the carer having adequate cognitive ability (as indicated by an Abbreviated Test Score of >6) Have at least one Smartphone or device to access the online meetings and videos Exclusion Criteria: Not living with primary caregiver With end-stage renal disease relying on hemodialysis rather than HF medications to regulate fluid volume.

Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail. 2020 Aug;22(8):1342-1356. doi: 10.1002/ejhf.1858. Epub 2020 Jun 1.

Ryan CJ, Bierle RS, Vuckovic KM. The Three Rs for Preventing Heart Failure Readmission: Review, Reassess, and Reeducate. Crit Care Nurse. 2019 Apr;39(2):85-93. doi: 10.4037/ccn2019345. Erratum In: Crit Care Nurse. 2019 Oct;39(5):12.

Riegel B, Barbaranelli C, Carlson B, Sethares KA, Daus M, Moser DK, Miller J, Osokpo OH, Lee S, Brown S, Vellone E. Psychometric Testing of the Revised Self-Care of Heart Failure Index. J Cardiovasc Nurs. 2019 Mar/Apr;34(2):183-192. doi: 10.1097/JCN.0000000000000543.

Jonkman NH, Westland H, Groenwold RH, Agren S, Atienza F, Blue L, Bruggink-Andre de la Porte PW, DeWalt DA, Hebert PL, Heisler M, Jaarsma T, Kempen GI, Leventhal ME, Lok DJ, Martensson J, Muniz J, Otsu H, Peters-Klimm F, Rich MW, Riegel B, Stromberg A, Tsuyuki RT, van Veldhuisen DJ, Trappenburg JC, Schuurmans MJ, Hoes AW. Do Self-Management Interventions Work in Patients With Heart Failure? An Individual Patient Data Meta-Analysis. Circulation. 2016 Mar 22;133(12):1189-98. doi: 10.1161/CIRCULATIONAHA.115.018006. Epub 2016 Feb 12.

Buck HG, Harkness K, Wion R, Carroll SL, Cosman T, Kaasalainen S, Kryworuchko J, McGillion M, O'Keefe-McCarthy S, Sherifali D, Strachan PH, Arthur HM. Caregivers' contributions to heart failure self-care: a systematic review. Eur J Cardiovasc Nurs. 2015 Feb;14(1):79-89. doi: 10.1177/1474515113518434. Epub 2014 Jan 6.

Strachan PH, Currie K, Harkness K, Spaling M, Clark AM. Context matters in heart failure self-care: a qualitative systematic review. J Card Fail. 2014 Jun;20(6):448-55. doi: 10.1016/j.cardfail.2014.03.010. Epub 2014 Apr 13.

Clark AM, Spaling M, Harkness K, Spiers J, Strachan PH, Thompson DR, Currie K. Determinants of effective heart failure self-care: a systematic review of patients' and caregivers' perceptions. Heart. 2014 May;100(9):716-21. doi: 10.1136/heartjnl-2013-304852. Epub 2014 Feb 18.

Buck HG, Stromberg A, Chung ML, Donovan KA, Harkness K, Howard AM, Kato N, Polo R, Evangelista LS. A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes. Int J Nurs Stud. 2018 Jan;77:232-242. doi: 10.1016/j.ijnurstu.2017.10.007. Epub 2017 Oct 19.

Vellone E, Rebora P, Ausili D, Zeffiro V, Pucciarelli G, Caggianelli G, Masci S, Alvaro R, Riegel B. Motivational interviewing to improve self-care in heart failure patients (MOTIVATE-HF): a randomized controlled trial. ESC Heart Fail. 2020 Jun;7(3):1309-1318. doi: 10.1002/ehf2.12733. Epub 2020 Apr 28.

Lyons KS, Lee CS. The Theory of Dyadic Illness Management. J Fam Nurs. 2018 Feb;24(1):8-28. doi: 10.1177/1074840717745669. Epub 2018 Jan 20.

Sebern M, Riegel B. Contributions of supportive relationships to heart failure self-care. Eur J Cardiovasc Nurs. 2009 Jun;8(2):97-104. doi: 10.1016/j.ejcnurse.2008.07.004. Epub 2008 Aug 15.

Srisuk N, Cameron J, Ski CF, Thompson DR. Randomized controlled trial of family-based education for patients with heart failure and their carers. J Adv Nurs. 2017 Apr;73(4):857-870. doi: 10.1111/jan.13192. Epub 2016 Nov 30.

Sebern MD, Woda A. Shared care dyadic intervention: outcome patterns for heart failure care partners. West J Nurs Res. 2012 Apr;34(3):289-316. doi: 10.1177/0193945911399088. Epub 2011 Mar 7.

Boczor S, Daubmann A, Eisele M, Blozik E, Scherer M. Quality of life assessment in patients with heart failure: validity of the German version of the generic EQ-5D-5L. BMC Public Health. 2019 Nov 6;19(1):1464. doi: 10.1186/s12889-019-7623-2.

Tidermark J, Bergstrom G, Svensson O, Tornkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res. 2003 Dec;12(8):1069-79. doi: 10.1023/a:1026193812514.

Yu DS, Lee DT, Stewart S, Thompson DR, Choi KC, Yu CM. Effect of Nurse-Implemented Transitional Care for Chinese Individuals with Chronic Heart Failure in Hong Kong: A Randomized Controlled Trial. J Am Geriatr Soc. 2015 Aug;63(8):1583-93. doi: 10.1111/jgs.13533.

Yu DS, Li PW, Zhang F, Cheng ST, Ng TK, Judge KS. The effects of a dyadic strength-based empowerment program on the health outcomes of people with mild cognitive impairment and their family caregivers: a randomized controlled trial. Clin Interv Aging. 2019 Oct 4;14:1705-1717. doi: 10.2147/CIA.S213006. eCollection 2019.

Jaarsma T, Hill L, Bayes-Genis A, La Rocca HB, Castiello T, Celutkiene J, Marques-Sule E, Plymen CM, Piper SE, Riegel B, Rutten FH, Ben Gal T, Bauersachs J, Coats AJS, Chioncel O, Lopatin Y, Lund LH, Lainscak M, Moura B, Mullens W, Piepoli MF, Rosano G, Seferovic P, Stromberg A. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2021 Jan;23(1):157-174. doi: 10.1002/ejhf.2008. Epub 2020 Oct 20.

Rahmani A, Vahedian-Azimi A, Sirati-Nir M, Norouzadeh R, Rozdar H, Sahebkar A. The Effect of the Teach-Back Method on Knowledge, Performance, Readmission, and Quality of Life in Heart Failure Patients. Cardiol Res Pract. 2020 Nov 23;2020:8897881. doi: 10.1155/2020/8897881. eCollection 2020.

Ho CC, Clochesy JM, Madigan E, Liu CC. Psychometric evaluation of the Chinese version of the Minnesota Living with Heart Failure Questionnaire. Nurs Res. 2007 Nov-Dec;56(6):441-8. doi: 10.1097/01.NNR.0000299849.21935.c4.

Wong EL, Cheung AW, Wong AY, Xu RH, Ramos-Goni JM, Rivero-Arias O. Normative Profile of Health-Related Quality of Life for Hong Kong General Population Using Preference-Based Instrument EQ-5D-5L. Value Health. 2019 Aug;22(8):916-924. doi: 10.1016/j.jval.2019.02.014. Epub 2019 Jul 27.

Sebern MD. Refinement of the Shared Care Instrument-Revised: a measure of a family care interaction. J Nurs Meas. 2008;16(1):43-60. doi: 10.1891/1061-3749.16.1.43.

Chen S, Zheng S, Wang X, Zhang X, Fa T, Fu L, Zang X, Zhao Y. Linguistic and Psychometric Validation of the Chinese Version of the Control Attitudes Scale-Revised in Patients With Chronic Heart Failure. J Cardiovasc Nurs. 2021 Jul-Aug 01;36(4):349-356. doi: 10.1097/JCN.0000000000000705.

Vickerstaff V, Ambler G, King M, Nazareth I, Omar RZ. Are multiple primary outcomes analysed appropriately in randomised controlled trials? A review. Contemp Clin Trials. 2015 Nov;45(Pt A):8-12. doi: 10.1016/j.cct.2015.07.016. Epub 2015 Jul 26.