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We suggest the intervention (Conditional recommendation)
In patients with heart failure, the COMPAR-EU heart failure panel, suggests in favour of using social support delivered in groups, rather than usual care
Justification
The COMPAR-EU heart failure panel made a conditional recommendation in favour of, Education and social support delivered in groups, rather than usual care, given a balance that probably favours the intervention (very low quality evidence of effects), and an intervention that is probably acceptable for main stakeholders.
Subgroup considerations
Effect of the intervention may differ according to the intensity and duration of the intervention.
Implementation
When implementing SMI in general, the most important contextual factors to keep in mind are:
Healthcare providers’ level: it is important to adapt the advice, communication or intervention to patient’s personal situation and level of knowledge; to have adequate communication skills (for example, show empathy, provide understandable information, ask questions);
Patients’ level: patient’s motivation to engage in self-management; patient’s attitude towards self-management (for example, beliefs about the importance of self-management for health, beliefs about the usefulness of certain self-management tasks).
Interaction level: patients’ preference regarding their own role in treatment (for example, the extent to which a patient wants to be involved in shared decision-making, extent to which a patient expects or wants professional involvement in the daily management of their disease).
When implementing Education the most important contextual factors to keep in mind are:
Healthcare providers’ level: it is important to adapt the advice, communication or intervention to patient’s personal situation and level of knowledge; to have adequate communication skills (for example, show empathy, provide understandable information, ask questions);
Patients’ level: patient’s motivation to engage in self-management; patient’s cognitive and behavioural skills to self-management.
When implementing Social support the most important contextual factors to keep in mind are:
Healthcare providers’ level: it is important to adapt the advice, communication or intervention to patient’s personal situation and level of knowledge; to have expertise in supporting self-management for chronic diseases;
Patients’ level: (perceived) available support from family and friends; peer support and interaction
When implementing SMI delivered in groups the most important contextual factors to keep in mind are:
Healthcare providers’ level: it is important to adapt the advice, communication or intervention to patient’s personal situation and level of knowledge; to have adequate communication skills (for example, show empathy, provide understandable information, ask questions); to have adequate skills in monitoring group interactions.
Patients’ level: to know and adapt to the cultural background and/or language of the patient
SoF
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ComparEuEtdsWeb
QUESTION | |
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08.Should education and social support delivered in groups vs. usual care be used for adult patients living with heart failure? | |
Population | adult patients living with heart failure |
Intervention | Social support delivered in groups See more |
Comparison | Usual Care |
Main outcomes | Self-efficacy; Knowledge |
Setting | European Union, outpatient care |
Perspective | Clinical recommendation- Population perspective |
Background | Heart failure (HF), a complex clinical syndrome, is considered a global pandemic with an increasing overall incidence and prevalence due to ageing of population (Savarese G et al., 2017). HF clinical practice guideline self-management strategies are recommended to increase quality of life and to reduce the risk of HF hospitalization and mortality. However, there are still gaps in the evidence especially regarding the comparative effectiveness and cost-effectiveness of the strategies, due to variations in study locations and time of occurrence and to suboptimal reporting of patient-relevant outcomes (ESC 2021, Jonkman NH et al., 2016, Takeda A et al., 2019) |
Conflict of interest |
This work was supported by the EU Horizon 2020 research and innovation programme (grant agreement no. 754936). The funder had no role in developing the protocol or obtaining the results for this study.
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ASSESSMENT | ||||||||||||||
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Priority of problem Is the problem a priority? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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Heart failure (HF), a complex clinical syndrome, is considered a global pandemic with an increasing overall incidence and prevalence due to ageing of population (Savarese G et al., 2017). HF clinical practice guideline self-management strategies are recommended to increase quality of life and to reduce the risk of HF hospitalization and mortality. However, there are still gaps in the evidence especially regarding the comparative effectiveness and cost-effectiveness of the strategies, due to variations in study locations and time of occurrence and to suboptimal reporting of patient-relevant outcomes (ESC 2021, Jonkman NH et al., 2016, Takeda A et al., 2019). |
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Desirable Effects How substantial are the desirable anticipated effects? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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View summary of findings of network meta-analysis
View summary of findings of component network meta-analysis |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel judged the desirable effects as large.
No data available for the rest of critical/important outcomes.
Proportion of direct evidence contributing to the final NMA estimate per outcome: Knowledge: 100% Self-efficacy: 100%
Component Network Meta-analysis: Knowledge: Component with the largest effect were education (E) and delivered by groups (G) Self-efficacy: Component with the largest effect were education (E), social support (SS) and delivered by groups (G)
Studies that include this SMI: Amaritakomol-2018 - Interactive educational board game - 1 face-to-face group session - Game duration 30 minutes - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Tawalbeh-2018 - Cardiac educational program - 1 face-to-face group session - Duration 3 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction § Alcohol consume, and other harmful consumptions, cessation or reduction o Clinical management § Early recognition of symptoms |
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Undesirable Effects How substantial are the undesirable anticipated effects? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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View summary of findings of network meta-analysis
There are no undesirable observed effects. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel judged the undesirable effects as trivial or marginal.
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Certainty of the evidence What is the overall certainty of the evidence of effects? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel has judged the certainty of the evidence as very low.
Certainty of the evidence was downgraded due to heterogeneity (of interventions and severity of disease), risk of bias, and imprecision. |
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Values Is there important uncertainty about or variability in how much people value the main outcomes? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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An overview of systematic reviews provided information about how patients value several of the outcomes of interest (critical/important) included in this clinical question:
References
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel judged that there is probably no important uncertainty or variabilty y on how patients value the main outcomes.
The panel agreed that there is some variability on how patients value the outcomes, since preferences will vary based on patients' particular starting point, and their disease progression. The panel also noted, that the variability on how patients value the main outcomes, could also depend on the intensity of monitoring. |
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Balance of effects Does the balance between desirable and undesirable effects favor the intervention or the comparison? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel judged that the balance of effects probably favours the intervention. This is due to the large desirable effects, the trivial undesirable effects, the probably no important uncertainty and variability on how patients value outcomes, as well as the very low certainty of evidence of effects. |
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Resources required How large are the resource requirements (costs)? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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No included studies |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The estimates from the cost-effectiveness (CE) analysis are limited mainly from not including the impact of SM intervention on short-term mortality. Most SM interventions on HF patients had a moderate effect on decreasing the risk of mortality which might be translated to additional QALYs Therefore, the CE estimates might be undervaluing the benefits of the SM interventions |
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Certainty of evidence of required resources What is the certainty of the evidence of resource requirements (costs)? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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No included studies |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The estimates from the cost-effectiveness (CE) analysis are limited mainly from not including the impact of SM intervention on short-term mortality. Most SM interventions on HF patients had a moderate effect on decreasing the risk of mortality which might be translated to additional QALYs Therefore, the CE estimates might be undervaluing the benefits of the SM interventions |
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Cost-effectiveness Does the cost-effectiveness of the intervention favor the intervention or the comparison? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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No included studies |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The estimates from the cost-effectiveness (CE) analysis are limited mainly from not including the impact of SM intervention on short-term mortality. Most SM interventions on HF patients had a moderate effect on decreasing the risk of mortality which might be translated to additional QALYs Therefore, the CE estimates might be undervaluing the benefits of the SM interventions |
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Equity What would be the impact on health equity? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The panel agreed that the impact on health equity varies, due to the variability across European countries on the levels of health literacy and socioeconomic status. Equity may be affected by geography and accessibility.
If implemented, tailored to culture and health literacy, it may increase equity. |
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Acceptability Is the intervention acceptable to key stakeholders? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups, peers) of self-management interventions according to stakeholders.
References
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel has judged that this type of SMI is probably acceptable to key stakeholders.
Patients/caregivers: overall acceptable but may vary since it could be influenced by setting, accessibility, tailoring, and other factors.
Healthcare perspective: It could be time and resource consuming.
Healthcare payers’ perspective: Overall acceptable.
Studies' Interventions Amaritakomol-2018 - Interactive educational board game - 1 face-to-face group session - Game duration 30 minutes - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Tawalbeh-2018 - Cardiac educational program - 1 face-to-face group session - Duration 3 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction § Alcohol consume, and other harmful consumptions, cessation or reduction o Clinical management § Early recognition of symptoms |
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Feasibility Is the intervention feasible to implement? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups,peers) of self-management interventions according to stakeholders.
References
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ADDITIONAL CONSIDERATIONS | ||||||||||||||
The guideline panel judged that the feasibility of implementing this type of SMI varies.
Implementation may be difficult, depending on the context and the use of specific devices for monitoring, for example, online feedback could be more complicated to obtain in certain contexts. and may depend on resources availablity.
Limited human resources, healthcare system coordination and transport services may complicate the implementation of this SMI
Usually, duration of follow-up was not provided in the studies.
Studies' Interventions Amaritakomol-2018 - Interactive educational board game - 1 face-to-face group session - Game duration 30 minutes - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Tawalbeh-2018 - Cardiac educational program - 1 face-to-face group session - Duration 3 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction § Alcohol consume, and other harmful consumptions, cessation or reduction o Clinical management § Early recognition of symptoms |
TYPE OF RECOMMENDATION | ||||
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Strong recommendation against the intervention | Conditional recommendation against the intervention | Conditional recommendation for either the intervention or the comparison | Conditional recommendation for the intervention | Strong recommendation for the intervention |
CONCLUSIONS |
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Recommendation |
For patients with heart failure, the COMPAR-EU heart failure panel, suggests in favour of using Education and social support delivered in groups, rather than usual care (conditional, very low certainty of the evidence about the effects). |
Justification |
The COMPAR-EU heart failure panel made a conditional recommendation in favour of, Education and social support delivered in groups, rather than usual care, given a balance that probably favours the intervention (very low quality evidence of effects), and an intervention that is probably acceptable for main stakeholders. |
Subgroup considerations |
Effect of the intervention may differ according to the intensity and duration of the intervention. |
Implementation considerations |
When implementing SMI in general, the most important contextual factors to keep in mind are:
When implementing Education the most important contextual factors to keep in mind are:
When implementing Social support the most important contextual factors to keep in mind are:
When implementing SMI delivered in groups the most important contextual factors to keep in mind are:
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Monitoring and evaluation |
Research priorities |
- Future studies should measure patient important outcomes, both critical and important (list below), have adequate sample size and follow-up, including after the intervention is finished. - Future studies should address also preferences and values of patients in relation to their self management, cost effectiveness and sub-categories of self-monitoring interventions. - Future studies should describe in detail the aspects of the intervention and evalute the long term effectiveness.
Critical outcomes
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REFERENCES SUMMARY |
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Summary of findings of network meta-analysis
COMPAR-EU iSoF Web
Summary of findings of component network meta-analysis
COMPONENT NETWORK META-ANALYSIS (sensitivity analysis)
Outcome | Components’ effect (95% Confidence Interval) | CNMA effect (95% Confidence Interval) | ||
E | SS | G | ||
Knowledge | 0.58 (0.25 to 0.91) | -0,2611 (-0,81 to 0,29) | 0,32 (-0,37 to 1,02) | 0,89 (0,38 to 1,40) |
Self-efficacy | 0,95 (0,41 to 1,49) | 0,3901 (-0,21 to 0,99) | 0,17 (-0,51 to 0,85) | 1,51 (0,87 to 2,15) |
Components definitions:
E: Education; SS Social support techniques; G delivered by groups
Components
Education (E)
Education (E)
Sharing information. This form of support consists in sharing of information about self-management topics like coping with symptoms, diet, exercise, medication, information about what other people are doing, and information about the disease itself, or about any other relevant aspects that could lead to improved self-management, and ultimately better health. This information can be told or distributed in printed materials like a folder or workbook, or via website or DVD.
Examples: Educational session on healthy eating for people with obesity, provision of a printed leaflet on the importance of foot care in diabetes, or a link to a website with information on chronic obstructive pulmonary disease care.
Social support (SS)
Social support (SS)
Helping you to think through how you could obtain social support from others to help them achieve behavioural or outcome goals. It could also include the actual provision of social support or discussions about social support networks suited to your preferences, needs, disease burden, or additional life burdens. Part of this support would include linking you to relevant community services to enhance socialization and make the most of support mechanisms in the local community.
Examples: Encouraging family members to become involved in helping you to manage your disease or encouraging you to participate in a local exercise group.
In group
Two or more patients or caregivers receive a self-management intervention. Group interventions are normally organized for efficiency purposes or to facilitate learning and knowledge exchange among peers (people living with the same health condition). For example, peer-led education group to enhance physical activity in obese individuals.
Face-to-face
Self-management support delivered in a face-to-face encounter between the providers and patients and/or caregivers.
Wissen [Herzinsuffizienz] | Selbstwirksamkeit [Herzinsuffizienz] | |
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Soziale Unterstützung, die in Gruppen vermittelt wird | ||
Siehe praktische Überlegungen. |
Evidence table description for recommendations section
To enter the decision aids section please press "start".
Praktische Überlegungen
Research priorities
- Future studies should measure patient important outcomes, both critical and important (list below), have adequate sample size and follow-up, including after the intervention is finished.
- Future studies should address also preferences and values of patients in relation to their self management, cost effectiveness and sub-categories of self-monitoring interventions.
- Future studies should describe in detail the aspects of the intervention and evalute the long term effectiveness.
Critical outcomes
Knowledge
Self-efficacy
Patient activation
Quality of life
Mortality
Emergency visits
Admission all cause
Admission HF
Readmissions all cause
Readmissions HF
Adherence
Exercise capacity
Background
Heart failure (HF), a complex clinical syndrome, is considered a global pandemic with an increasing overall incidence and prevalence due to ageing of population (Savarese G et al., 2017). HF clinical practice guideline self-management strategies are recommended to increase quality of life and to reduce the risk of HF hospitalization and mortality. However, there are still gaps in the evidence especially regarding the comparative effectiveness and cost-effectiveness of the strategies, due to variations in study locations and time of occurrence and to suboptimal reporting of patient-relevant outcomes (ESC 2021, Jonkman NH et al., 2016, Takeda A et al., 2019)