Our results show that compared to a single education session (BEI group), the TTG program that reinforced learning goals and behaviors with 5-8 telephone counseling sessions over the next month (including teaching adjusted-dose diuretics to maintain a target weight) resulted in slightly greater knowledge, substantially better achievement of self-care goals, higher self-efficacy, and greater improvement in heart failure symptoms. Teaching persons with HF proper self-care skills is important for achieving optimal health outcomes and minimizing preventable hospitalizations.2
In the four trials investigating patient self-care education (as distinct from a complete disease management program), HF-specific hospitalizations were reduced by 34%.3
However, the educational methods, intensity, duration, and reinforcement needed to achieve optimal outcomes are unclear,2
and few studies have examined these issues. A one-hour teaching session at the time of hospital discharge increased self-care practices and decreased the combined outcome of death or re-hospitalization compared to the standard discharge process.21
The TTG program was equally efficacious for patients with inadequate/marginal literacy as for those with adequate literacy. Both subgroups showed improvement in knowledge, self-care behaviors, self-efficacy, and HF symptom scores, and the TTG intervention was better than the BEI intervention for both subgroups. An American Heart Association Scientific Statement on Promoting Self-Care in Persons with Heart Failure identified poor health literacy as a factor that impedes self-care management.2
Previous studies of self-care education and skills training have either not measured health literacy or not been adequately powered to determine whether interventions are similarly efficacious for patients with poor health literacy. The TTG intervention was specifically designed to overcome the factors that impede learning and behavior change for persons with poor health literacy. Our results provide encouraging evidence that these impediments can be overcome with interventions that are designed according to theoretical principles of instructional design and behavior change and that provide more intensive education and skills training with repetition and reinforcement over time. However, participants with poor health literacy had worse baseline knowledge, behaviors, and self-efficacy compared to those with adequate literacy, and our intervention did not significantly reduce the difference between them. Thus, further research is needed to find ways to overcome the barriers to learning and behavior change posed by poor health literacy and to eliminate the disparities that result from these.
Despite the limited learning goals, structured curriculum design, and reinforcement with telephone calls, the gains in knowledge for the TTG intervention were modest. Some of this may be explained by the high baseline knowledge of study participants. Most of the patients we enrolled had HF for many years. However, 24% of patients did not know that shortness of breath was a sign of heart failure, and there was no improvement in this among either group.
Similarly, 16% did not know that leg or ankle swelling was a sign of heart failure, and even among the TTG group, only half learned this over the one-month follow-up. Future studies should explore alternative ways of teaching these fundamental self-monitoring concepts to patients, such as video instead of static images. It may be easier to teach this to patients when they are in the midst of an exacerbation rather than the stable outpatients that we enrolled. Knowledge of high-salt foods was also high at baseline, and improvement was likely limited by ceiling effects.
Self-care behaviors and self-efficacy improved much more than knowledge, which suggests that knowledge and behaviors (and changes in the two) are not tightly linked. While theoretical models and practical experience say that knowledge is necessary but not sufficient for behavior change, it remains unclear how much knowledge and what particular learning goals are essential. When designing our intervention, we worked hard to eliminate non-essential information, but our findings suggest that even less educational content and greater emphasis on self-care behaviors may be more effective.
There are several important issues to consider when interpreting our findings. We mostly enrolled established patients who already had high knowledge, and many had advanced skills in HF self- management (e.g., knew about adjusting their diuretic dose to maintain a target weight). It is likely that the benefits of the TTG intervention compared to the BEI would have been even greater among patients hearing this information for the first time. In addition, we believe that the baseline education session received by the BEI group is probably more intensive than what many patients receive. Because we had an active comparison group that is often better than usual care, the benefits achieved by implementation of the TTG intervention could be substantially greater in actual practice than what we report here. It is also possible that our study overestimated the effect size of the TTG intervention. Patients with adequate literacy who were randomized to the TTG group had worse baseline HF symptom scores than those randomized to the BEI group (). If by chance those with adequate literacy randomized to the TTG group had worse baseline HFSS scores on the day of the baseline interview, regression to the mean could lead to an overestimate of their improvement in HF symptoms scores at the follow-up interview and an overestimate of the difference in improvement between the TTG and BEI groups. We found no evidence of unblinding or measurement bias, and the results did not change when we conducted a multivariate analysis that adjusted for differences in baseline HFSS scores. Finally, the intervention was multifaceted, and we cannot determine whether the greater improvement in HFQOL in the TTG group was due to greater improvements in knowledge, self-efficacy, self-care behaviors, or some other direct effect of the intervention.
This study has important implications for health care providers and policy-makers. Disease management programs can improve health outcomes and reduce costs.3
However, it remains unclear what the marginal benefits are for single session education, structured follow-up telephone calls to reinforce teaching goals and self-care behaviors, and more intensive remote monitoring by health professionals. Our findings show that follow-up telephone calls (without remote monitoring of signs and symptoms) incrementally improve knowledge, self-care, and HF symptoms beyond a single, intensive face-to-face teaching session; this incremental benefit can be achieved even for patients with low literacy who may struggle to master critical self-care behaviors. Longer follow-up of this study population is needed to understand what proportion of patients can sustain high-level mastery and regular performance of self-care behaviors and whether this results in sustained improvements in symptoms and reductions in hospitalizations and death. Patients who master and regularly perform self-care behaviors may not need more intensive and expensive remote monitoring, while others who fail to achieve self-care goals may greatly benefit from this extra support. Additional studies will be needed to elucidate the health benefits and incremental cost-effectiveness of these strategies.