That surprising finding, made by a team from the University of Michigan Cardiovascular Center in a randomized controlled clinical trial of 223 patients, will be reported today in an oral presentation at the Scientific Sessions of the American Heart Association.
The dramatic results from such a simple intervention may have major implications for the treatment of heart failure. The life-threatening disease affects more than 5 million Americans whose hearts' pumping ability has been weakened by heart attacks, clogged arteries, high blood pressure, heart muscle infections or other conditions.
The potential benefit of this education program to the health care system and to other hospitals caring for heart failure patients could be sizable. Heart failure is the chief cause of about 1 million hospital admissions each year – many of them repeat visits by patients whose symptoms worsened after they went home from the hospital because they failed to stick to the complex self-care regimen that's proven to help heart failure patients.
The new study shows that systolic heart failure patients who received a one-hour, one-on-one education session with a nurse educator before they went home from the hospital had a 35 percent lower risk of re-hospitalization or death within 180 days of discharge than patients who received the standard pre-discharge brochures and fliers.
The patients who received additional education also scored better on a measure of how well they were following a regimen of salt and fluid intake restrictions, recording daily weights, performing regular exercise and monitoring changes in symptoms.
"We have so many treatments and strategies that have been shown to help people with heart failure live longer and better, but we know many patients don't adhere to them once they go home," says Todd Koelling, M.D., a U-M cardiologist and the lead author of the study. "This shows that arming the patient with information in an individualized way can significantly improve outcomes." He notes this is the first study showing discharge education alone can help heart failure patients just like more-intensive interventions can.
Adds Monica Johnson, RN, BSN, MSA, the nurse who conducted the patient education sessions, "We targeted patients during their most 'teachable moment', when they're inpatients and confronting the significance of their illness. That may be the key."
"We also broke things down into concrete terms so that patients could understand the reasons for the different self-care steps and why it's so important to follow them or consult with their own physician if they're having problems," Johnson continues. "And, we adjusted the education session to meet their needs and their level of understanding and sophistication."
Koelling, an assistant professor of internal medicine at the U-M Medical School, and Johnson, a clinical research coordinator, launched the study along with U-M co-authors Keith Aaronson, M.D. and Robert Cody, M.D. after seeing far too many heart failure patients wind up back in the hospital because of problems sticking to at-home treatment.
"Up to two-thirds of hospital admissions for heart failure patients have been attributed to problems with patient compliance," says Koelling. "We felt that educating patients about their illness and helping them take an active role in their own health care may help to eliminate some of these preventable hospitalizations."
The researchers received funding from the Quality Care Research Fund of the Academic Medicine and Managed Care Forum, which is supported by companies that make heart failure medications.
They randomized the patients to either an education session with Johnson, combined with the standard written discharge information given to all U-M patients, or to the discharge materials alone. Both the sessions and the written materials are based on AHA's heart failure treatment guidelines.
Those patients who were randomized to additional education got an hour of individualized attention. Johnson discussed with them what heart failure is and how it is caused; what the major symptoms and measures of heart-pumping capacity are; what drugs are used to treat heart failure, why there are so many, how they work, what their benefit is and what side effects they can cause; and what lifestyle changes and habits can improve a heart failure patient's prospects.
She also discussed with them more specific information on how and why they should restrict their sodium intake to no more than 2,000 milligrams per day and their fluid intake to no more than two liters per day to keep their bodies from retaining water. She also told them how to weigh themselves daily to spot any fluid retention. And, she counseled them to talk to their regular doctors about an exercise plan, and to make a plan of action for what to do if their symptoms worsened
Then, the researchers called all the patients at 30, 90 and 180 days after they left the hospital. They asked whether the patient had been admitted to any hospital in that time period, and if so, how many days they had stayed in the hospital. They also asked patients a range of questions about their self-care, including adherence to diet restrictions and medications, and about their symptoms and overall well being, using the Minnesota Living with Heart Failure questionnaire. If the patient had died, they recorded that.
Patients who received the extra education had significantly fewer days hospitalized or dead in the follow-up period than those who didn't. They also had a lower risk of re-hospitalization or death – 35 percent lower – although 47 percent of intervention patients had either a re-hospitalization or died by the end of 180 days. Most of the difference between the two groups was in hospitalization rates.
At the 30-day post-hospital mark, a significantly higher percentage of the intervention patients reported weighing themselves daily and following the dietary sodium restriction. Other self-care measures did not reach statistical significance, but intervention patients tended to do better.
Koelling and his colleagues are continuing to analyze the study's results, and hope to publish further data in the near future. But already, he notes, the impact on re-hospitalization rates from the single-session discharge education intervention approaches the effect seen from several medications used to combat heart failure's symptoms.
So, just as those medications are paid for by insurers, he hopes that someday soon it will be possible for hospitals to be reimbursed for discharge education for heart failure patients. Such education is already covered for people with diabetes.
Until that day, he hopes that hospitals will see that it may be cost-effective for them to hire a nurse educator who can visit each heart failure inpatient individually and take time to talk about the how's and why's of their treatment regimen. Because insurers often decline to pay for costs associated with the re-admission of heart failure patients within 30 days of a previous discharge, hospitals can save money and help patients if they reduce re-admissions.
And, says Johnson, she feels that nurses who care for inpatient heart failure patients should take heart from the new results. Many of them, she explains, may feel discouraged that they see the same patients over and over again, when they're re-hospitalized due to non-compliance. But taking part in this study showed her how many patients really were affected by discharge education and made an effort to stick to their regimens.
Even though the study looked at a specific discharge education intervention, she says that anything nurses can do to talk with patients about the specifics of their self-care might have an impact. "This just shows how important discharge education can be for those people who really want to learn about their illness and self-direct their care," she says.
Reference: AHA Scientific Sessions 2003 Abstract Oral Session 2219: "Discharge education improves clinical outcomes and adherence to self-care measures in patients with chronic heart failure". In Session AOP.62.1: Heart Failure: Additional Prognostic Variables. Monday, Nov. 10, 2 p.m., Orange County Convention Center, Rm. 240.
Additional Contact Information:
Kara Gavin, kegavin@umich.edu
At AHA meeting: cell (734) 358-4910, or
Sally Pobojewski, pobo@umich.edu
At U-M: (734) 764-2220