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| QUESTION | |
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| 02. Should education, monitoring, action-based and emotional-based behavioural techniques vs. usual care be used for adult patients living with heart failure? | |
| Population | adult patients living with heart failure |
| Intervention | Monitoring, action-based and emotional-based behavioural techniques See more |
| Comparison | Usual Care |
| Main outcomes | All cause admissions; All cause readmissions; Emergency Room consultations all causes; Heart failure admissions; Heart failure readmissions; Knowledge; Mortality; Quality of life; Self-efficacy |
| 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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| Priority of problem Is the problem a priority? |
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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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View summary of findings of network meta-analysis
View summary of findings of component network meta-analysis |
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The guideline panel judged the desirable effects as large.
The SMI reduces mortality (large effect) and increases self-efficacy (small effect) and knowledge (small effect).
No data available for the rest of critical/important outcomes.
Proportion of direct evidence contributing to the final NMA estimate per outcome: All cause admission: 100% allcausesREADM : 100% Emergency: 100% Exercise capacity: 87% Heart Failure Admission : 100% Heart Failure Re-admission : 100% Knowledge : 100% Mortality (All- cause) : 89% Quality of Life :94% Self-efficacy :100%
Component Network Meta-analysis Mortality: the components with larger effects are education (E), action - based behavioural change techniques (AB), and emotional - based behavioural change techniques (EB). Knowledge: the components with larger effects are education (E), monitoring techniques (MT), emotional - based behavioural change techniques (EB). Self-efficacy: the components with larger effects are education (E), monitoring techniques (MT), emotional - based behavioural change techniques (EB).
Studies that inlcude this SMI: Dewalt Darren-2012 (= Baker 2011) - “Teach to goal” (TTG) educational and behavioral support program - 1 individual, face-to-face session, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Liu-2018a - Multidisciplinary disease management program including comprehensive assessments, individualized education, optimizing medications, pre-scheduled clinic visits, and encouraging regular physical activity at home; either with or without exercise training - 3 individual face-to-face sessions; phone calls, smartphone/tablet contacts and internet-based contacts when needed (all individual) - Duration 2 years - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Ritchie-2016 - In-hospital and postdischarge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up - 1 face-to-face sessions, phone calls and internet-based contacts when needed; all individual - Duration 60 days - Expected patient (or carer) self-management behaviours: o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Doughty-2002 - Clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic - 11 individual/group sessions - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Asking for professional help or emergency care when needed
Yu-2015 - Nurse-implemented transitional care including a pre-discharge visit, two home visits, and then regular telephone calls over 9 months to provide self-care education and support, optimized health surveillance, and facilitation in use of community services - 3 face-to-face sessions, 10 phone calls; all individual - Duration 9 months - Expected patient (or carer) self-management behaviours: o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Bernocchi-2018 - Integrated telerehabilitation home-based program - 1 face-to-face session, 32 phone calls, 16 contacts using a specific device; all individual - Duration 4 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Witham-2012 - Exercise program for functionally impaired older patients - 16 face-to-face group sessions, 6 individual phone calls - Duration 12 weeks - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices o Psychological management § Handling/managing emotions
Otsu-2011 - Educational program consisting of six nurse-directed sessions that were provided to each outpatient once per month in a clinical setting for a total of 6 months - 6 individual face-to-face sessions - Duration 6 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 § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Modeling estimations for long term consequences We used the COMPAR-EU heart failure (HF) model developed for the cost-effectiveness analysis to also inform about long-term health outcomes. Decision analytic models can provide valuable information for outcomes when empirical evidence is not available or is unfeasible (Trikalinos TA, 2009). The following events were estimated over a lifetime and informed by the NMA effect of each SMI on all-cause mortality and all-cause admission outcomes. We suggest cautious interpretation as the certainty of the evidence for those input parameters was low to very low across comparisons. Long-term model outcomes: - Life-Years (LY): 19 days of additional life per patient - Effect on the all-cause admission: increase in hospital costs of 27 euros per patient. |
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| Undesirable Effects How substantial are the undesirable anticipated effects? |
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View summary of findings of network meta-analysis
There are no undesirable observed effects. |
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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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The guideline panel has judged the certainty of the evidence as very low. |
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| Values Is there important uncertainty about or variability in how much people value the main outcomes? |
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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 1. Noonan MC, Wingham J, Taylor RS. “Who Cares?” The experiences of caregivers of adults living with heart failure, chronic obstructive pulmonary disease and coronary artery disease: a mixed methods systematic review. BMJ Open. 2018;8(7):e020927. https:// doi. org/ 10. 1136/ bmjopen- 2017- 020927. 2. Jeon YH, Kraus SG, Jowsey T, Glasgow NJ. The experience of living with chronic heart failure: a narrative review of qualitative studies. BMC Health Serv Res. 2010;10:77. https:// doi. org/ 10.1186/ 1472- 6963- 10- 77. 3. Russell S, Ogunbayo OJ, Newham JJ, Heslop-Marshall K, Netts P, Hanratty B, et al. Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals. NPJ Prim Care Respir Med. 2018;28(1):2. https:// doi. org/ 10. 1038/s41533- 017- 0069-z. 4. Falk H, Ekman I, Anderson R, Fu M, Granger B. Older patients’ experiences of heart failure-an integrative literature review. J Nurs Scholarsh. 2013;45(3):247–55. https:// doi. org/ 10. 1111/jnu. 12025. 5. Olano-Lizarraga M, Oroviogoicoechea C, Errasti-Ibarrondo B, Saracibar-Razquin M. The personal experience of living with chronic heart failure: a qualitative meta-synthesis of the literature.J Clin Nurs. 2016;25(17–18):2413–29. https:// doi. org/ 10.1111/ jocn. 13285. 7. Barclay S, Momen N, Case-Upton S, Kuhn I, Smith E. Endof-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract.2011;61(582):e49-62. https:// doi. org/ 10. 3399/ bjgp1 1X549 018. 8. Wingham J, Harding G, Britten N, Dalal H. Heart failure patients’ attitudes, beliefs, expectations and experiences of selfmanagement strategies: a qualitative synthesis. Chronic Illn.2014;10(2):135–54. https:// doi. org/ 10. 1177/ 17423 95313 502993. 9. Chan A. An integrative review: adherence barriers to a low-salt diet in culturally diverse heart failure adults. Aust J Adv Nurs.2018;36(1):37–47. 10. Clark AM, Spaling M, Harkness K, Spiers J, Strachan PH, Thompson DR, et al. Determinants of effective heart failure selfcare:a systematic review of patients’ and caregivers’ perceptions. Heart (British Cardiac Society). 2014;100(9):716–21. https:// doi.org/ 10. 1136/ heart jnl- 2013- 304852. 11. Currie K, Strachan PH, Spaling M, Harkness K, Barber D, Clark AM. The importance of interactions between patients and healthcare professionals for heart failure self-care: a systematic review of qualitative research into patient perspectives. Eur J Cardiovasc Nurs. 2015;14(6):525–35. https:// doi. org/ 10. 1177/ 14745 15114 12. Giacomini M, DeJean D, Simeonov D, Smith A. Experiences of living and dying with COPD: a systematic review and synthesis of the qualitative empirical literature. Ont Health Technol Assess Ser. 2012;12(13):1–47. 13. Lippiett KA, Richardson A, Myall M, Cummings A, May CR.Patients and informal caregivers’ experiences of burden of treatment in lung cancer and chronic obstructive pulmonary disease (COPD): a systematic review and synthesis of qualitative research. BMJ Open. 2019;9(2):e020515. https:// doi. org/ 10.1136/ bmjop en- 2017- 020515. 14. Baker E, Fatoye F. Patient perceived impact of nurse-led selfmanagement interventions for COPD: a systematic review of qualitative research. Int J Nurs Stud. 2019;91:22–34. https:// doi.org/ 10. 1016/j. ijnur stu. 2018. 12. 004 15 O’Connell S, McCarthy VJ, Savage E. Self-management support preferences of people with asthma or chronic obstructive pulmonary disease: a systematic review and meta-synthesis of qualitative studies. Chronic Illn. 2019. https:// doi. org/ 10. 1177/17423 95319 69443. 16. .Jaime-Lara RB, Koons BC, Matura LA, Hodgson NA, Riegel B. A qualitative metasynthesis of the experience of fatigue across five chronic conditions. J Pain Symptom Manag. 2020;59(6):1320–43. https:// doi. org/ 10. 1016/j. jpain symman.2019. 12. 358. 18. Yu DS, Lee DT, Kwong AN, Thompson DR, Woo J. Living with chronic heart failure: a review of qualitative studies of older people.J Adv Nurs. 2008;61(5):474–83. https:// doi. org/ 10. 1111/j.1365- 2648. 2007. 04553.x. 19. Bhattarai B, Walpola R, Mey A, Anoopkumar-Dukie S, Khan S. Barriers and strategies for improving medication adherence among people living with COPD: a systematic review. RespirCare. 2020;65(11):1738–50. https:// doi. org/ 10. 4187/ respc are.07355. 20. Clari M, Ivziku D, Casciaro R, Matarese M. The unmet needs of people with chronic obstructive pulmonary disease: a systematic review of qualitative findings. COPD. 2018;15(1):79–88. https://doi. org/ 10. 1080/ 15412 555. 2017. 14173 20. Clari M, Ivziku D, Casciaro R, Matarese M. The unmet needs of people with chronic obstructive pulmonary disease: a systematic review of qualitative findings. COPD. 2018;15(1):79–88. https://doi. org/ 10. 1080/ 15412 555. 2017. 14173 73. 21. Russell S, Ogunbayo OJ, Newham JJ, Heslop-Marshall K, Netts P, Hanratty B, et al. Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals. NPJ Prim Care Respir Med. 2018;28(1):2. https:// doi. org/ 10. 1038/s41533- 017- 0069-z. 22. Hopp FP, Thornton N, Martin L. The lived experience of heart failure at the end of life: a systematic literature review. Health Soc Work. 2010;35(2):109–17 23. Clari M, Matarese M, Ivziku D, Marinis M. Self-care of people with chronic obstructive pulmonary disease: a meta-synthesis. Patient. 2017;10(4):407–27. https:// doi. org/ 10. 1007/s40271- 017- 0218-z. 24. Schulman-Green D, Jaser SS, Park C, Whittemore R. A metasynthesis of factors affecting self-management of chronic illness. J Adv Nurs. 2016;72(7):1469–89. https:// doi. org/ 10. 1111/ jan.12902. 25. Ivynian SE, DiGiacomo M, Newton PJ. Care-seeking decisions for worsening symptoms in heart failure: a qualitative metasynthesis. 26 Low J, Pattenden J, Candy B, Beattie JM, Jones L. Palliative care in advanced heart failure: an international review of the perspectives of recipients and health professionals on care provision. JCard Fail. 2011;17(3):231–52. https:// doi. org/ 10. 1016/j. cardf ail.2010. 10. 003. 27. Dyer MT, Goldsmith KA, Sharples LS, Buxton MJ. A review of health utilities using the EQ-5D in studies of cardiovascular disease. Health Qual Life Outcomes. 2010;8:13. https:// doi. org/10. 1186/ 1477- 7525-8- 13. 28. Cooper AF, Jackson G, Weinman J, Horne R. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clin Rehabil. 2002;16(5):541–52. https:// doi. org/ 10.1191/ 02692 15502 cr524 oa. 29. Ru TZ, Associate A, Hegney DG. A qualitative systematic review on the experiences of self-management in community-dwelling older women living with chronic illnesses. JBI Libr Syst Rev. 2011;9(62):2778–828. https:// doi. org/ 10. 11124/ 01938 924- 201109620- 00001. 30. Daley C, Al-Abdulmunem M, Holden RJ. Knowledge among patients with heart failure: a narrative synthesis of qualitative research. Heart Lung. 2019;48(6):477–85. https:// doi. org/ 10.1016/j. hrtlng. 2019. 05. 012. 31. Walthall H, Floegel T. The lived experience of breathlessness for people diagnosed with heart failure: a qualitative synthesis of the literature. Curr Opin Support Palliat Care. 2019;13(1):18–23.https:// doi. org/ 10. 1097/ spc. 00000 00000 000405. 32. Grant JS, Graven LJ. Problems experienced by informal caregivers of individuals with heart failure: an integrative review. Int J Nurs Stud. 2018;80:41–66. https:// doi. org/ 10. 1016/j. ijnur stu.2017. 12. 016. 33. Harrison SL, Apps L, Singh SJ, Steiner MC, Morgan MD, Robertson N. ’Consumed by breathing’—a critical interpretive meta-synthesis of the qualitative literature. Chronic Illn.2014;10(1):31–49. https:// doi. org/ 10. 1177/ 17423 95313 493122. 34. Kim EY, Oh S, Son Y-J. Caring experiences of family caregivers of patients with heart failure: a meta-ethnographic review of the past 10 years. Eur J Cardiovasc Nurs. 2020;19(6):473–85. https://doi. org/ 10. 1177/ 14235 15120 915040. 35. Kirkpatrick P, Wilson E, Wimpenny P. Support for older people with COPD in community settings: a systematic review of qualitative research. JBI Libr Syst Rev. 2012;10(57):3649–763. https:// doi. org/ 10. 11124/ 01938 924- 20121 0570- 00001. 36. Brundisini F, Giacomini M, DeJean D, Vanstone M, Winsor S,Smith A. Chronic disease patients’ experiences with accessing health care in rural and remote areas: a systematic review and qualitative meta-synthesis. Ont Health Technol Assess Ser.2013;13(15):1–33. |
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| ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||
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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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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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Estimated costs for the intervention across all types of self-management interventions (SMIs), as described in the included studies of the network meta-analysis, were on average 794 euros per patient, with a range from 85 to 2,045 euros. Please note that this average/range estimate has been based on ten cost estimates of SMIs for HF reported in publications.
Model analyses showed that over lifetime the total costs (without cost of the intervention) for the SMI were 8,905 euros higher compared to usual care. This cost increase was mainly the result of an increased life-expectancy with additional costs in the life-years gained.
References Trikalinos TA, Siebert U, Lau J. Decision-analytic modeling to evaluate benefits and harms of medical tests: uses and limitations. Med Decis Making. 2009 Sep-Oct;29(5):E22-9. Girling A, Lilford R, Cole A, Young T. Headroom approach to device development: current and future directions. Int J Technol Assess Health Care. 2015 Jan;31(5):331-8. |
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Despite the scarcity of data in available publications, and the important variability in the characteristics of self-monitoring interventions the panel considered that the resources required varies for this SMI.
Resource use and costing data for SMIs should be interpreted with caution. We could not provide cost for any specific type of SMI intervention, because in many publications detailed information needed to estimate the intervention cost was missing (for example number of sessions, average group size or duration of sessions). As an alternative, we searched for intervention cost estimates as presented by the authors of publications and used the average value as an estimate of the average costs of SMI programs for HF in general. |
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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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The guideline panel agreed on a very low certainty of the evidence on this domain .
Resource use and costing data for SMIs should be interpreted with caution. We could not provide cost for any specific type of SMI intervention, because in many publications detailed information needed to estimate the intervention cost was missing (for example number of sessions, average group size or duration of sessions). As an alternative, we searched for intervention cost estimates as presented by the authors of publications and used the average value as an estimate of the average costs of SMI programs for HF in general. Further, the costs of the SMI, implementation of SMIs and HF management programs vary between countries and target group. |
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| Cost-effectiveness Does the cost-effectiveness of the intervention favor the intervention or the comparison? |
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The table below shows the cost-effectiveness results for the SMI intervention. Costs and QALYs in this analysis were discounted at 3.5% annual rate.
NA: not applicable; QALY: quality adjusted life years; ICER: incremental cost-effectiveness ratio Explanations The cost-effectiveness results are for the UK setting. For more information on the cost-effectiveness analysis and the results for other countries, please see the cost-effectiveness section. The headroom analysis presented here estimated how much an intervention may maximally cost, based on a willingness-to-pay threshold of €20,000 per QALY. For more information on the headroom analyses and other threshold levels, please see the cost-effectiveness section. |
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The guideline panel judged that the cost-effectiveness does not favor either the intervention or the comparison
There is a possibility that this specific SMI can be cost-effective, but this depends on the intervention costs of the particular intervention and the threshold used. The intervention is never cost-effective with a threshold value of 20,000 euro/QALY and 5,164 euro maximum when a threshold value of 50,000 euro/QALY is used. There is a possibility that this specific SMI can be cost-effective at a threshold of 50,000 euro/QALY because the average cost of SMI for HF in the literature (793 euro, range: 65 to 2,045) is lower than the headroom estimate for 50,000 euro/QALY. This does not hold at a threshold of 20,000 euro/QALY.
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| Equity What would be the impact on health equity? |
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In a US study on a “teach to goal” educational and behavioral support program, heart failure-related quality of life improved somewhat more for patients with inadequate/marginal literacy than for patients with adequate literacy (9.4 vs. 5.3 point increase, respectively); other outcomes did not differ between literacy levels (Baker, 2011)
In a Taiwanese study on a multidisciplinary disease management program, at 6 months, patients with exercise training had a significantly lower heart failure-related rehospitalization rate than patients without exercise training (log rank=4.96, p=0.026); at 12 months, no significant differences were observed (Liu, 2018). In a subgroup of patients without contraindications to exercise, patients with exercise training showed a significantly lower rate of heart failure-related rehospitalization than the control group (hazard ratio: 0.17, 95% CI: 0.03–0.87, p=0.033), but patients without exercise training did not hazard ratio: 0.31, 95% CI: 0.06–1.56, p=0.155). |
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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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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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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 Dewalt Darren-2012 (= Baker 2011) - “Teach to goal” (TTG) educational and behavioral support program - 1 individual, face-to-face session, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Liu-2018a - Multidisciplinary disease management program including comprehensive assessments, individualized education, optimizing medications, pre-scheduled clinic visits, and encouraging regular physical activity at home; either with or without exercise training - 3 individual face-to-face sessions; phone calls, smartphone/tablet contacts and internet-based contacts when needed (all individual) - Duration 2 years - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Ritchie-2016 - In-hospital and postdischarge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up - 1 face-to-face sessions, phone calls and internet-based contacts when needed; all individual - Duration 60 days - Expected patient (or carer) self-management behaviours: o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptomsu
Doughty-2002 - Clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic - 11 individual/group sessions - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Asking for professional help or emergency care when needed
Yu-2015 - Nurse-implemented transitional care including a pre-discharge visit, two home visits, and then regular telephone calls over 9 months to provide self-care education and support, optimized health surveillance, and facilitation in use of community services - 3 face-to-face sessions, 10 phone calls; all individual - Duration 9 months - Expected patient (or carer) self-management behaviours: o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Bernocchi-2018 - Integrated telerehabilitation home-based program - 1 face-to-face session, 32 phone calls, 16 contacts using a specific device; all individual - Duration 4 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Witham-2012 - Exercise program for functionally impaired older patients - 16 face-to-face group sessions, 6 individual phone calls - Duration 12 weeks - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices o Psychological management § Handling/managing emotions
Otsu-2011 - Educational program consisting of six nurse-directed sessions that were provided to each outpatient once per month in a clinical setting for a total of 6 months - 6 individual face-to-face sessions - Duration 6 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 § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions |
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| Feasibility Is the intervention feasible to implement? |
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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 | ||||||||||||||||||||||||||
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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 Bernocchi-2018 - Integrated telerehabilitation home-based program - 1 face-to-face session, 32 phone calls, 16 contacts using a specific device; all individual - Duration 4 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Baker 2011 - “Teach to goal” (TTG) educational and behavioral support program - 1 individual, face-to-face session, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Ritchie-2016 - In-hospital and postdischarge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up - 1 face-to-face sessions, phone calls and internet-based contacts when needed; all individual - Duration 60 days - Expected patient (or carer) self-management behaviours: o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Liu-2018a - Multidisciplinary disease management program including comprehensive assessments, individualized education, optimizing medications, pre-scheduled clinic visits, and encouraging regular physical activity at home; either with or without exercise training - 3 individual face-to-face sessions; phone calls, smartphone/tablet contacts and internet-based contacts when needed (all individual) - Duration 2 years - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence
Doughty-2002 - Clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic - 11 individual/group sessions - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Asking for professional help or emergency care when needed
Yu-2015 - Nurse-implemented transitional care including a pre-discharge visit, two home visits, and then regular telephone calls over 9 months to provide self-care education and support, optimized health surveillance, and facilitation in use of community services - 3 face-to-face sessions, 10 phone calls; all individual - Duration 9 months - Expected patient (or carer) self-management behaviours: o Clinical management § Condition-specific behaviours § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Otsu-2011 - Educational program consisting of six nurse-directed sessions that were provided to each outpatient once per month in a clinical setting for a total of 6 months - 6 individual face-to-face sessions - Duration 6 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 § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Witham-2012 - Exercise program for functionally impaired older patients - 16 face-to-face group sessions, 6 individual phone calls - Duration 12 weeks - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices o Psychological management § Handling/managing emotions
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| TYPE OF RECOMMENDATION | ||||
|---|---|---|---|---|
| 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 |
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For patients with heart failure, the COMPAR-EU heart failure panel, suggests in favour of the use of Education, monitoring, action-based (problem-solving and/or goal settings) and emotional-based (coaching, motivation, and stress management) behavioural techniques rather than usual care (conditional, very low certainty of the evidence about the effects). |
| Justification |
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The COMPAR-EU heart failure panel made a conditional recommendation in favour of, Education, monitoring, action-based (problem-solving and/or goal settings) and emotional-based (coaching, motivation, and stress management) behavioural techniques, rather than usual care, given a balance that probably favours the intervention (very low quality evidence of effects), the cost-effectiveness evaluation that favours either the intervention or usual care, and an intervention that is probably acceptable for main stakeholders. |
| Subgroup considerations |
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Effect of the intervention may differ according to the intensity and duration of the intervention. |
| Implementation considerations |
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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 monitoring techniques, the most important contextual factors to keep in mind are:
When implementing action-based behavioural techniques (problem solving and/or goal setting), the most important contextual factors to keep in mind are:
When implementing Emotional-based behavioural techniques, the most important contextual factors to keep in mind are:
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| Monitoring and evaluation |
| Research priorities |
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- 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 Web Isof
Summary of findings of component network meta-analysis
Component network meta-analysis model (sensitivity analysis)
Outcome |
| Components’ effect (95% Confidence Interval) | CNMA effect (95% Confidence Interval) | |||
E | MT | AB | EB | |||
Mortality | 0,95 (0,79 to 1,14) | 1,02 (0,84 to 1,22) | 0,85 (0,72 to 1,01) | 0,85 (0,70 to 1,02) | 0,69 (0,57 to 0,83) | |
Knowledge | 0,83 (0,28 to 1,38) | 0,19 (-0,32 to 0,71) | -0,57 (-1,16 to 0,03) | 0,32 (-0,34 to 0,98) | 0,78 (0,16 to 1,40) | |
Self-efficacy | 0,95 (0,41 to 1,49) | 0,47 (-0,07 to 1,01) | -0,74 (-1,16 to -0,31) | -0,05 (-0,58 to 0,48) | 0,63 (0,16 to 1,10) | |
Components' definition:
E: Education; MT: Monitoring techniques; AB: action-based behavioural techniques; EB: emotional-based behavioural techniques
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.
Monitoring techniques (MT)
Monitoring techniques (MT)
Self-monitoring training and feedback. Training and encouraging people to recognize, monitor, and record behaviours, symptoms, or clinical data. This process may include regular feedback from a clinician, or a synopsis of information registered in a digital tool to encourage you to continue monitoring your illness and behaviours.
Example: Showing a patient how to record blood sugar levels, physical activity, or pain.
Action-based behavioural change techniques (AB)
Action-based behavioural change techniques (AB)
There are different action-based behavioural change techniques:
Enhancing problem-solving skills. This technique consists in teaching on how to analyse factors that influence your behaviour and provide you or help you to develop strategies to reduce or overcome barriers and/or support facilitators (e.g., not eating unhealthy foods when you feel depressed). Strategies include anticipation, self-treatment, resource utilization, and problem management. Ideally, there should be an initial plan, but this is not a requisite.
Example: Identification and attenuation of environmental barriers (e.g., no gym in the neighbourhood when one want to exercise) and facilitators (e.g., someone who keeps you company during exercise) to everyday physical activities.
Goal setting and action planning. This technique consists in encouraging you to set one or more achievable goals based on your needs and preferences. These goals may be behaviours (e.g., a consuming a healthy meal three times a day) or outcomes (e.g., less pain) and can be used as a starting point. The process usually involves the formulation of a detailed action plan, specifying what you would do and at least when and/or where you will do it. It could also include an assessment of your behaviours with your health care provider and a discussion of goals and the writing up of agreed-on action plans, including plans for emergency situations.
Examples of goals: achieving a daily walking distance of 2 km or a weight loss of some kilograms in x months with diet and exercise.
Emotional-based change techniques (EB)
Emotional-based change techniques (EB)
There are different emotional-based behavioural change techniques:
Stress and/or emotional management. This technique consists in helping you to understand the role of stress and emotions and teaching them to use different coping strategies to manage, for example, stress and painful emotions caused by your disease.
Examples: Mindfulness, exercise, stretching, listening to music, deep breathing, or meditation.
Coaching and motivational interviewing. This kind of support helps you to change behaviours by looking what’s important to you, and then offering support, taking into account your needs and preferences. One provider (healthcare professional, peer or lay person) is usually your coach. Motivational interviewing and counselling are included, as well as collaborative conversations with a practitioner, helping with motivation and commitment, minimizing resistance, and resolve ambivalence to change.
Examples: coaching sessions led by a nurse to ease the transition from hospital to home, or rehabilitation programs using coaching methods.
Individual sessions
A single person receives the self-management support. Examples: self-guided actions (without the participation of any other person) during a clinical visit or within the context of a support or educational session
Face-to-face
Self-management support delivered in a face-to-face encounter between the providers and patients and/or caregivers.
