Issues in cardiovascular nursingThe effect of a tailored message intervention on heart failure readmission rates, quality of life, and benefit and barrier beliefs in persons with heart failure
Introduction
Cardiovascular disease, the leading cause of death in the United States today, is one of the most prevalent chronic illnesses of adulthood.1 A common clinical endpoint of many cardiovascular disorders is heart failure (HF), defined as the inability of the heart to provide the tissues with oxygen at a rate necessary to meet oxidative requirements.2 The American College of Cardiology/American Heart Association Task Force reports that 4.8 million Americans experience HF, with 550,000 new cases and 50,000 deaths reported annually.1, 3 In 1999, 962,000 Americans were discharged from acute care facilities with a primary diagnosis of HF, the most prevalent diagnosis in those aged more than 65 years.
HF is characterized by an unstable course of illness with unpredictable exacerbations and progression of symptoms, often without further damage to the myocardium.4 Symptoms such as weight gain, edema, dyspnea, and fatigue characterize these exacerbations and further limit functional status and quality of life.5, 6 Because HF is a chronic condition, most lifestyle change is made on an outpatient basis, necessitating follow-up in the home setting to evaluate medication effectiveness, monitor symptoms, and promote self-care behaviors. However, current capitation rates fiscally limit the quantity of nursing care provided in the home. The end result of these combined factors is a high cost, reported to be close to 10 billion dollars.7
It is imperative that nurses develop innovative methods to improve the self-care behaviors of this population while attempting to decrease costly rehospitalizations. A tailored message intervention is one proposed alternative. In this case, education is based on an evaluation of the beliefs of the person with HF concerning perceived benefits and perceived barriers of performing certain HF self-care behaviors. In self-care areas with more identified barriers or less perceived benefits, a tailored message is given. The purpose of this investigation was to determine whether the tailored message intervention decreased readmission rates, improved reported quality of life, and changed beliefs about perceived benefits and perceived barriers of self-care in persons with HF.
Section snippets
Literature review
Research demonstrates that older adults with HF have the highest hospital readmission rates, ranging from 29% to 47% of all hospitalized adult patient groups, primarily in the first few weeks after discharge.8, 9, 10, 11 As a result, most intervention studies have focused on trying to decrease readmission rates in this vulnerable population. Interdisciplinary teams composed of dietitians, social workers, pharmacists, physicians, and nurses have all played a role in significantly reducing
Conceptual framework
The Health Belief Model (HBM) provides the organizing framework for the study. In this model, an individual performs a health behavior based on perceived susceptibility, perceived severity, perceived benefits, and perceived barriers to an illness.40, 41, 42 Perceived susceptibility and perceived severity relate to the psychologic components of the model whereby individuals evaluate subjective risk of HF to them. Inherent in the process of psychologic evaluation of risk is both internal
Study purposes and research questions
This study determines the efficacy of a tailored message intervention administered during hospital admission and at 1 week and 1 month after discharge on HF readmission rates, reported quality of life, and perceived benefit and barrier beliefs in elderly patients with HF. The times selected for study correspond with times identified in the literature as the period of greatest risk for rehospitalization in elderly patients.8, 27, 28 The following research questions are the basis for the study:
- 1.
Hypotheses
There were 3 hypotheses for the study. The first 2 hypotheses were that persons who received the intervention would have lower HF readmission rates and report better quality of life. The third hypothesis was that intervention subjects would report fewer barriers and more benefits to performing self-care of HF after receiving the tailored message intervention.
Methods
A randomized control trial was used to evaluate the effect of a tailored message intervention on HF readmission rates, quality of life, and perceived benefit and barrier beliefs in an elderly sample of subjects with HF. Benefit and barrier scores were measured during initial hospitalization and 1 week and 1 month after discharge in the treatment group. Quality of life scores were obtained in both groups during initial hospitalization and 1 month after hospital discharge. HF readmission rates
Sample
The sample was drawn from a population of adults with a primary diagnosis of chronic HF who were admitted to 1 community hospital in the Northeast between October 1999 and December 2000. Persons with HF who consented to participate were randomly assigned to the treatment or control group. Criteria for study enrollment included the following: (1) primary diagnosis of either systolic or diastolic HF listed in the medical record, confirmed by the presence of symptoms of HF for 3 months or longer;
Heart failure readmission rates
The outcome variable of HF readmission rates was measured by counting the total number of admissions for HF in each group during the 3-month study interval. Each admission counted as 1 number, regardless of the number of days admitted.
Quality of life
The variable of quality of life was measured with the Minnesota Living with Heart Failure (MLHF) questionnaire.47 The MLHF is a disease-specific 21-item measure of health-related quality of life. Patients with HF rate their perceptions about how much HF impacts
Procedure
Approvals were received from the institutional review board at the community hospital where the study was conducted. Two baccalaureate-prepared research nurses enrolled participants and completed the study intervention as outlined in a detailed protocol. Weekly meetings were held between the coinvestigators and the research nurses to review the protocol, answer any questions, and update the status of data collection. Periodic practice with delivering the intervention according to the protocol
Treatment subjects
Subjects in the treatment group received a tailored message intervention by the same research nurse during hospitalization and 1 week and 1 month after hospital discharge. All subjects assigned to the treatment group received the intervention. The intervention was based on the perceived benefits and barriers to self-care of HF that were identified by persons with HF. An evaluation of health beliefs was performed using the Health Belief Scales. Questions on the Health Belief Scales are divided
Analysis
Data were entered into the Statistical Package for Social Sciences 10.0 (SPSS Inc, Chicago, IL), and descriptive statistics were computed on all study variables and examined for the presence of random or systematic missing data, significant skewness, and outliers. Appropriate reliability and validity measures were performed on measurement instruments. Because the outcome variable of HF readmission rates was skewed, the nonparametric Kruskall-Wallis statistic was computed to determine
Readmission rates
A Kruskall-Wallis test was run to answer research question 1. HF readmission rate was not significantly related to group assignment in this study (P = .22). As seen in Table IV, 12 subjects in the control group were rehospitalized 1 or more times, whereas 6 subjects in the treatment group were rehospitalized 1 or more times.
Quality of life
A repeated-measures ANOVA comparing quality of life by group assignment over time was performed to answer research question 2. The assumption of equality of covariance
Discussion
Although overall HF readmission rates between the treatment and control groups did not differ significantly, fewer individuals in the treatment group were readmitted during the 3-month follow-up period (6 vs 12). The 35% of subjects rehospitalized in this study is comparable to rates reported in the literature of 29% to 66% for other samples with HF.11, 54, 55 Previous research has demonstrated that persons with HF are frequently readmitted for the same reason as their primary admission because
Implications
The results of this study demonstrate that a tailored message intervention changed the perceived benefit and perceived barrier of self-care of HF beliefs in this population. The psychoeducational focus of the intervention included facets of self-care that are traditionally part of home-based HF education but were tailored to the specific beliefs of the person with HF. This reduced redundancy of the education. The messages in this study were easy to deliver, took approximately 15 minutes, and
Limitations
There were 3 limitations to this study. The first limitation is the lack of measurement of the actual self-care behaviors of this sample. Although beliefs were measured and did change, actual self-care behaviors, including following a low-sodium diet, daily weighing, and taking medication, were not measured. Future study should include these variables to determine whether a change in beliefs translates to actual behavior change. Second, a number of participants were lost to follow-up because of
Acknowledgements
The authors thank Drs. Diane Carroll, Susan Chase, and Ellen Mahoney for thoughtful review of an earlier version of this article. The authors also thank Stacey Just, BSN, RN, and Denise Tailby, BSN, RN, for assistance with data collection. Finally, the authors thank the staff of the PCU and TCU at St Luke's Hospital for assistance with identifying appropriate subjects for the study.
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