The effect of early initiation of self-management program based on multidisciplinary education in heart failure patients
Heart failure (HF) is a clinical syndrome due to any structural or functional abnormalities that affect ventricular filling and ejection . Consequently, HF has a high incidence, mortality, and readmission rate, which seriously endangers human health . According to the registry data of the American Heart Association (AHA), the prevalence of HF will increase by 46% between 2012 and 2030, where patients with HF who are younger than 65 years old will have a 6 to 9 times greater risk of experiencing sudden cardiac death when compared with that of the general population . Moreover, a 2003 Chinese survey showed that the HF incidence in adults aged 35–74 was 0.9%. Notably, the annual incidence is on the rise . Another Chinese survey indicated the in-hospital mortality of HF in 1980, 1990, and 2000 was 15.4%, 12.3%, and 6.2%, respectively . Guidelines emphasize that cardiac rehabilitation (CR) should be initiated soon after stabilization of acute HF to optimize target medication, improve volume management, and increase self-care ability . Effective self-management is essential for ensuring stable medical conditions, maintaining functional status, and returning to work . However, HF patients often lack health awareness, good compliance, and self-management skills. Additionally, self-management requires a certain amount of time . Thus, self-management program is nesseray to help HF patients master their self-care skills. Notably, some previous studies have focused on promoting self-management skills in HF patients following discharge . However, self-managemen program is supposed to inicaite as early as possible and detailed contents is needed to explore. Therefore, this study aims to explore new self-management approaches in HF patients and evaluate the effects on quality of life, sleep quality, psychological status, and major cardiovascular events (MACEs). As such, we expect to provide new ideas and methods for self-care of HF patients. 

Patient enrollment Patients were consecutively enrolled in the Cardiology Department of Beijing Hospital from June 2022 to May 2023. Inclusion criteria included: (i) Diagnosis of HF according to Chinese guidelines for diagnosis and treatment of heart failure 2018 ; (ii) Stage II to IV of heart function according to New York Heart Association (NYHA); (iii) Ability to independently complete questionnaire; (iv) Signed written informed consent. Exclusion criteria included: (i) Unconsciousness or cognitive impairment; (ii) Severe infection; (iii) Severe liver and kidney dysfunction; (iv) End-stage tumor. HF patients admitted from June 2022 to August 2022 were divided into the control group; those admitted from September 2022 to February 2023 were divided into the CR group. The self-management program lasted 3 months. Furthermore, our study agreed with the Declaration of Helsinki and the laws and regulations related to ethical review. The Ethical Committee of Beijing Hospital approved this study (2022BJYYEC-011-02). All the participants signed the informed consent. Self-management program on CR The early self-management program on CR was initiated 1–2 days following admission. As such, cardiologists evaluated the patient’s disease condition, quality of life, sleep quality, and psychological status to develop an individualized CR plan. Then, educational handbooks were delivered to the patients. Moreover, nurses guided patients in joining the WeChat group. Multiple educational programs were conducted from the 3rd day to the 1st day before discharge. The pharmacists explained the type, single dose, and frequency of drugs to the patients and informed them of the precautions for taking medication. Nutritionists evaluated the patients’ nutritional status and dietary habits and guided them in ordering meals. Additionally, nurses used food models to educate on volume management content. They provided water content tables for common foods, assisted patients in body weighing in the morning, and recorded daily intake and output volume. Cardiologists used the self-rating anxiety and depression scale to evaluate the psychological status of patients. They encouraged patients to maintain an optimistic mood, promoting their confidence in disease coping. For patients with clear anxiety and depression, psychological consultation was preceded. Nurses provided face-to-face self-management education twice during hospitalization, every 30 min, mainly focusing on HF knowledge, self-weight measurement, symptom control, water and salt intake restriction, dietary advice, and exercise suggestions. A CR package was given to the patients before discharge, including a calibrated weight scale, graduated counting cup, and salt spoon, explaining the usage of the package. Self-management skills were enhanced from the day of discharge to 3 months of discharge. Short scientific articles were pushed weekly through the Wechat group, mainly around HF knowledge, medications, exercise, diet, and symptom recognition. Symptoms, intake and output volume, body weight, and daily activities were followed up every two weeks through phone visits. Physicians adjusted diuretic dosage as needed. Patients in the control group only received two instances of education during hospitalization. The content of education was the same as that of the CR group. Patients also joined the same WeChat group and received weekly short scientific articles. Follow-ups were also provided every 2 weeks through phone calls. Data collection Quality of life Quality of life was investigated using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) . The questionnaire contained 21 items, covering the physical dimension (8 items), emotional dimension (5 items), and other dimension (8 items). Each item ranged from 0 to 5 points, and the total score ranged from 0 to 105 points by adding up the scores of each item. The higher scores indicated a poorer quality of life. Quality of sleep Buysse et al. developed the Pittsburgh Sleep Quality Index (PSQI) in 1989 to assess participants’ sleep quality in the past month . There were 19 self-evaluation items and 5 other evaluation items on the scale. Each factor was scored on a 0–3 scale. The cumulative score of each factor was the total score of PSQI, with a range of 0–21. The higher the score, the worse the sleep quality. Anxiety and depression assessment The self-rating Anxiety Scale (SAS) contained 20 items that reflect anxiety feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Fifteen questions were rated positively, and 5 questions were rated negatively. A higher score indicated severe anxiety. The self-rating Depression Scale (SDS) consisted of 20 items that reflect depression feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Ten questions were rated positively, and 10 questions were rated negatively. A higher score indicated severe depression. Major cardiovascular events (MACEs) MACEs in this study were defined composite outcomes including as acute HF exacerbation, severe electrolyte imbalance (serum sodium concentration less than 120 mmol/L or more than 160 mmol/L, and serum potassium less than 3.0 mmol/L or more than 5.5mmol/L), hypotension, cardiac readmission, and all-cause mortality. MACEs were acquired via medical record system inquiry and phone calls 30 days and 3 months of discharge. Meassurer of data MLHFQ and PSQI, were investigated by the two nurses during hospitalization. SAS, SDS were assessed by cardilogyists during hospitalization. Face-to-face survey was used. At 30 days and 3 months of discharge follow-up, nurses gave the phone call to the patients to investigate the four scales and MACEs. These scales were printed out in advance, recorded on paper by the nurses, and then input into a database. Statistical analysis Randomization and blinding were not used in this study. The sample size was calculated depending on Meng’s study . Based on multiple outcomes, the total sample size was estimated to be 80 cases, with 40 cases in each group. Baseline data was described according to variable types. The Kolmogorov-Smirnow test was used to detect a normal distribution of measurement data. Normally distributed variables were presented as mean ± standard deviation. A median (Q1, Q3) was used for non-normally distributed variables. Independent sample Student’s t-test was used for continuous, normally distributed variables, and the Mann–Whitney U test was used for other metric variables in comparing two groups. The chi-square or Fisher’s exact test was used for categorical variables. In a single group comparison, paired t-tests were chosen to analyze before and after intervention. Two-way repeat measurement ANOVA was used to consider two times of measurement and different intervention for each group. Within-subjects effects and interactions were also tested. SPSS software (version 20.0; SPSS, Inc., Chicago, IL, USA) was used for statistical analyses. Two sides of P < 0.05 indicated a significant difference. 

Patients were consecutively enrolled in the Cardiology Department of Beijing Hospital from June 2022 to May 2023. Inclusion criteria included: (i) Diagnosis of HF according to Chinese guidelines for diagnosis and treatment of heart failure 2018 ; (ii) Stage II to IV of heart function according to New York Heart Association (NYHA); (iii) Ability to independently complete questionnaire; (iv) Signed written informed consent. Exclusion criteria included: (i) Unconsciousness or cognitive impairment; (ii) Severe infection; (iii) Severe liver and kidney dysfunction; (iv) End-stage tumor. HF patients admitted from June 2022 to August 2022 were divided into the control group; those admitted from September 2022 to February 2023 were divided into the CR group. The self-management program lasted 3 months. Furthermore, our study agreed with the Declaration of Helsinki and the laws and regulations related to ethical review. The Ethical Committee of Beijing Hospital approved this study (2022BJYYEC-011-02). All the participants signed the informed consent. 

The early self-management program on CR was initiated 1–2 days following admission. As such, cardiologists evaluated the patient’s disease condition, quality of life, sleep quality, and psychological status to develop an individualized CR plan. Then, educational handbooks were delivered to the patients. Moreover, nurses guided patients in joining the WeChat group. Multiple educational programs were conducted from the 3rd day to the 1st day before discharge. The pharmacists explained the type, single dose, and frequency of drugs to the patients and informed them of the precautions for taking medication. Nutritionists evaluated the patients’ nutritional status and dietary habits and guided them in ordering meals. Additionally, nurses used food models to educate on volume management content. They provided water content tables for common foods, assisted patients in body weighing in the morning, and recorded daily intake and output volume. Cardiologists used the self-rating anxiety and depression scale to evaluate the psychological status of patients. They encouraged patients to maintain an optimistic mood, promoting their confidence in disease coping. For patients with clear anxiety and depression, psychological consultation was preceded. Nurses provided face-to-face self-management education twice during hospitalization, every 30 min, mainly focusing on HF knowledge, self-weight measurement, symptom control, water and salt intake restriction, dietary advice, and exercise suggestions. A CR package was given to the patients before discharge, including a calibrated weight scale, graduated counting cup, and salt spoon, explaining the usage of the package. Self-management skills were enhanced from the day of discharge to 3 months of discharge. Short scientific articles were pushed weekly through the Wechat group, mainly around HF knowledge, medications, exercise, diet, and symptom recognition. Symptoms, intake and output volume, body weight, and daily activities were followed up every two weeks through phone visits. Physicians adjusted diuretic dosage as needed. Patients in the control group only received two instances of education during hospitalization. The content of education was the same as that of the CR group. Patients also joined the same WeChat group and received weekly short scientific articles. Follow-ups were also provided every 2 weeks through phone calls. 

Quality of life Quality of life was investigated using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) . The questionnaire contained 21 items, covering the physical dimension (8 items), emotional dimension (5 items), and other dimension (8 items). Each item ranged from 0 to 5 points, and the total score ranged from 0 to 105 points by adding up the scores of each item. The higher scores indicated a poorer quality of life. Quality of sleep Buysse et al. developed the Pittsburgh Sleep Quality Index (PSQI) in 1989 to assess participants’ sleep quality in the past month . There were 19 self-evaluation items and 5 other evaluation items on the scale. Each factor was scored on a 0–3 scale. The cumulative score of each factor was the total score of PSQI, with a range of 0–21. The higher the score, the worse the sleep quality. Anxiety and depression assessment The self-rating Anxiety Scale (SAS) contained 20 items that reflect anxiety feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Fifteen questions were rated positively, and 5 questions were rated negatively. A higher score indicated severe anxiety. The self-rating Depression Scale (SDS) consisted of 20 items that reflect depression feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Ten questions were rated positively, and 10 questions were rated negatively. A higher score indicated severe depression. Major cardiovascular events (MACEs) MACEs in this study were defined composite outcomes including as acute HF exacerbation, severe electrolyte imbalance (serum sodium concentration less than 120 mmol/L or more than 160 mmol/L, and serum potassium less than 3.0 mmol/L or more than 5.5mmol/L), hypotension, cardiac readmission, and all-cause mortality. MACEs were acquired via medical record system inquiry and phone calls 30 days and 3 months of discharge. Meassurer of data MLHFQ and PSQI, were investigated by the two nurses during hospitalization. SAS, SDS were assessed by cardilogyists during hospitalization. Face-to-face survey was used. At 30 days and 3 months of discharge follow-up, nurses gave the phone call to the patients to investigate the four scales and MACEs. These scales were printed out in advance, recorded on paper by the nurses, and then input into a database. 

Quality of life was investigated using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) . The questionnaire contained 21 items, covering the physical dimension (8 items), emotional dimension (5 items), and other dimension (8 items). Each item ranged from 0 to 5 points, and the total score ranged from 0 to 105 points by adding up the scores of each item. The higher scores indicated a poorer quality of life. 

Buysse et al. developed the Pittsburgh Sleep Quality Index (PSQI) in 1989 to assess participants’ sleep quality in the past month . There were 19 self-evaluation items and 5 other evaluation items on the scale. Each factor was scored on a 0–3 scale. The cumulative score of each factor was the total score of PSQI, with a range of 0–21. The higher the score, the worse the sleep quality. 

The self-rating Anxiety Scale (SAS) contained 20 items that reflect anxiety feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Fifteen questions were rated positively, and 5 questions were rated negatively. A higher score indicated severe anxiety. The self-rating Depression Scale (SDS) consisted of 20 items that reflect depression feelings . Each item was rated at four levels based on the frequency of symptom occurrence. Ten questions were rated positively, and 10 questions were rated negatively. A higher score indicated severe depression. 

MACEs in this study were defined composite outcomes including as acute HF exacerbation, severe electrolyte imbalance (serum sodium concentration less than 120 mmol/L or more than 160 mmol/L, and serum potassium less than 3.0 mmol/L or more than 5.5mmol/L), hypotension, cardiac readmission, and all-cause mortality. MACEs were acquired via medical record system inquiry and phone calls 30 days and 3 months of discharge. 

MLHFQ and PSQI, were investigated by the two nurses during hospitalization. SAS, SDS were assessed by cardilogyists during hospitalization. Face-to-face survey was used. At 30 days and 3 months of discharge follow-up, nurses gave the phone call to the patients to investigate the four scales and MACEs. These scales were printed out in advance, recorded on paper by the nurses, and then input into a database. 

Randomization and blinding were not used in this study. The sample size was calculated depending on Meng’s study . Based on multiple outcomes, the total sample size was estimated to be 80 cases, with 40 cases in each group. Baseline data was described according to variable types. The Kolmogorov-Smirnow test was used to detect a normal distribution of measurement data. Normally distributed variables were presented as mean ± standard deviation. A median (Q1, Q3) was used for non-normally distributed variables. Independent sample Student’s t-test was used for continuous, normally distributed variables, and the Mann–Whitney U test was used for other metric variables in comparing two groups. The chi-square or Fisher’s exact test was used for categorical variables. In a single group comparison, paired t-tests were chosen to analyze before and after intervention. Two-way repeat measurement ANOVA was used to consider two times of measurement and different intervention for each group. Within-subjects effects and interactions were also tested. SPSS software (version 20.0; SPSS, Inc., Chicago, IL, USA) was used for statistical analyses. Two sides of P < 0.05 indicated a significant difference. 

Baseline characteristics A total of 91 HF patients were finally selected from June 2022 to February 2023. Among them, 44 patients were enrolled in the CR group, while 47 patients were divided into the control group. There were 57 male patients and 34 female patients. The average age was 73.00 ± 8.51 years, ranging from 37 to 90 years. Other characteristics are shown in Table . Quality of life and sleep quality comparison between the CR and control groups T test showed that MLHFQ scores significantly decreased at 3 months of discharge in both groups compared with baseline. Repeat measurement ANOVA analysis indicated that MLHFQ score had significant decrease before and after program ( F = 51.557, P < 0.001), while different self-management program also showed significant difference ( F = 47.503, P < 0.001). No significant difference of change of NLHFQ was detected between two management program ( F = 0.015, P = 0.902) The results were shown in Tables and ; Fig. . T test indicated that PSQI score decreased to some extent at 3 months of discharge, but without significant change in both groups. Repeat measurement ANOVA analysis showed that PSQI score had significant decrease before and after program ( F = 12.580, P = 0.001), but different self-management program did not show significant difference ( F = 0.855, P = 0.360). No significant difference of change of PSQI was detected between two management program ( F = 0.028, P = 0.868). The results were shown in Tables and ; Fig. . Comparison of anxiety and depression between CR group and control group T test indicated that SAS score significantly decreased at 3 months of discharge in both groups. (Tables and ; Fig. ). Repeat measurement ANOVA analysis showed that SAS had significant decrease before and after program ( F = 31.257, P <0.001), but different program group did not show significant difference ( F = 0.151, P = 0.699). Moreover, the change of SAS was detected significant difference between two management program ( F = 5.385, P = 0.025). The decrease of SAS was more significant in control group. T test indicated that SDS scores in the CR group were significantly increased after 3 months of program in CR groups with significantly higher than control group (Tables and ; Fig. ). Repeat measurement ANOVA analysis showed that SDS had no significant change before and after program ( F = 0.391, P = 0.535), but different program group showed significant difference ( F = 47.098, P < 0.001). Furthermore, change of SDS was not detected significant difference between two management program ( F = 0.391, P = 0.535). MACEs occurrence MACEs during follow-up at 30 days and 3 months of discharge are shown in Table . Notably, the rate of MACEs was not significantly different between the two groups. At 30 days of discharge, there were 2 cases of HF exacerbation. One patient was readmitted to hospital because of HF exacerbation in the CR group, while one case died becuse of severe pneumonia subsequent to septic shock in the control group. The cumulative MACEs in the CR and control groups were 4.55% and 2.12% respectively (χ 2 = 0.417, P = 0.608). At 3 months of discharge, there were 4 cases of HF exacerbation, and one patient was readmitted to hospital because of HF exacerbation and 2 cases died in the CR group. Two death cases were chronnic HF pateints complicated with severe pneumonia subsequent to septic shock and renal failure. The cumulative MACEs in the CR and control groups were 9.09% and 4.26% (χ 2 = 0.580, P = 0.678). 

A total of 91 HF patients were finally selected from June 2022 to February 2023. Among them, 44 patients were enrolled in the CR group, while 47 patients were divided into the control group. There were 57 male patients and 34 female patients. The average age was 73.00 ± 8.51 years, ranging from 37 to 90 years. Other characteristics are shown in Table . 

T test showed that MLHFQ scores significantly decreased at 3 months of discharge in both groups compared with baseline. Repeat measurement ANOVA analysis indicated that MLHFQ score had significant decrease before and after program ( F = 51.557, P < 0.001), while different self-management program also showed significant difference ( F = 47.503, P < 0.001). No significant difference of change of NLHFQ was detected between two management program ( F = 0.015, P = 0.902) The results were shown in Tables and ; Fig. . T test indicated that PSQI score decreased to some extent at 3 months of discharge, but without significant change in both groups. Repeat measurement ANOVA analysis showed that PSQI score had significant decrease before and after program ( F = 12.580, P = 0.001), but different self-management program did not show significant difference ( F = 0.855, P = 0.360). No significant difference of change of PSQI was detected between two management program ( F = 0.028, P = 0.868). The results were shown in Tables and ; Fig. . 

T test indicated that SAS score significantly decreased at 3 months of discharge in both groups. (Tables and ; Fig. ). Repeat measurement ANOVA analysis showed that SAS had significant decrease before and after program ( F = 31.257, P <0.001), but different program group did not show significant difference ( F = 0.151, P = 0.699). Moreover, the change of SAS was detected significant difference between two management program ( F = 5.385, P = 0.025). The decrease of SAS was more significant in control group. T test indicated that SDS scores in the CR group were significantly increased after 3 months of program in CR groups with significantly higher than control group (Tables and ; Fig. ). Repeat measurement ANOVA analysis showed that SDS had no significant change before and after program ( F = 0.391, P = 0.535), but different program group showed significant difference ( F = 47.098, P < 0.001). Furthermore, change of SDS was not detected significant difference between two management program ( F = 0.391, P = 0.535). 

MACEs during follow-up at 30 days and 3 months of discharge are shown in Table . Notably, the rate of MACEs was not significantly different between the two groups. At 30 days of discharge, there were 2 cases of HF exacerbation. One patient was readmitted to hospital because of HF exacerbation in the CR group, while one case died becuse of severe pneumonia subsequent to septic shock in the control group. The cumulative MACEs in the CR and control groups were 4.55% and 2.12% respectively (χ 2 = 0.417, P = 0.608). At 3 months of discharge, there were 4 cases of HF exacerbation, and one patient was readmitted to hospital because of HF exacerbation and 2 cases died in the CR group. Two death cases were chronnic HF pateints complicated with severe pneumonia subsequent to septic shock and renal failure. The cumulative MACEs in the CR and control groups were 9.09% and 4.26% (χ 2 = 0.580, P = 0.678). 

The present study highlighted that early initiation of a self-management program based on multidisciplinary education was helpful to improve quality of life, sleep quatily and reduce anxiety. In our self-management program, we focused on training patient self-management of medication compliance, volume control, food choice, and weight monitoring. Previous studies showed self-care education programs including self-care assessment, goal-orientated symptom recognition and response actions, fluid and dietary modification was proved to improve HF symptom, knowledge and confidence, lower risk of emergency department attendance and hospital admission, and reduced cardiovascular events . Education on symptom recognition, symptom control, diuretics adjustment, water, and dietary restrictions were the key points to improve patients’ self-care abilities . Regular home visits, telephone follow-up, email, remote monitoring, and other forms could promote adherence . Thus, the exploration of new approaches for patients’ self-management is important. Fluid restriction is important for decompensated HF. Volume management education was practical to increase adherence and reduce adverse events . In many studies, volume management included the guidance of diuretic correct usage, identification of worsening symptoms, monitoring the side effects of drugs, limitation of sodium intake in the diet, restriction of fluid intake, daily record of body weight, and coping methods when volume overload occurs . In our study, we prepared calibrated weight scale, counting cup, salt spoon for paitnts and educated them how to use. Although more HF exacerbation events in self-management CR group, the difference of MACEs ratio was not significant. HF patients had higher raio of sleep disorder, including short sleep time, low sleep quality, and sleep-disordered breathing . ACC/AHA guidelines identified poor sleep quality as barriers to self-care and treatment adherence in HF patients . Multiple studies indicated that cognitive behavioral therapy (CBT) may help to improve sleep quality in HF patients . Other evidence showed that in medically stable HF patients, treatment of coexisting obstructive sleep apnea by continuous positive airway pressure improved left ventricular systolic function . The above studies suggested that if CBT specialists and sleep experts in the team, it would be better to assist managing the patient’s sleep disorder. A high proportion of HF patients suffer from anxiety and depression because of long-term discomfort symptoms, long-term use of multiple medications and heavy economic burden . Anxiety and depression would irrigate the sympathetic nervous system, increase platelet activity, and lead to endothelial damage in arteries and exacerbating clinical symptoms . Our results showed that after a 3-month program, the SAS score significantly decreased in both groups, while SDS score showed a significant increase in CR group. But the SAS score and SDS score were all in normal range. Possible explanations for this results were the scale inquiry in this study was completed by different person. Doctors finished the scale during hospitalization, and nurses collected the scale data during follow-up peroid. Furthermore, more diuretic usage and higher BNP levels were seen in the CR group at baseline. Those may have led to some bias in the scale score. For those HF patients with anxiety-depressive disorders, psychiatrist’s opinions are required in the self-management program. There were some noted limitations in this study. Firstly, this was a single-center study with a small sample size, which restricted the representativeness of the samples. Secondly, in our discharge self-care package, the content of exercise training was not detailed enough. We only provided physical activity suggestions and did not conduct supervised exercise training. Lastly, we did not distinguish between ejection fractions that reduced heart failure and ejection fractions that preserved heart failure because of the limited sample size. We hope to provide new ideas for the content design of self-management programs for HF patients. 

Early initiation of self-management program based on multidisciplinary education may help improve quality of life, sleep quality, and reduce anxiety for in-hospital HF patients. 

