The role of self-control and self-help in the treatment of patients with severe chronic heart failure

The dissertation is devoted to the study of the role of self-monitoring and self-care in the treatment of patients with severe chronic heart failure (CHF). It examines the epidemiological and economic aspects of CHF, in particular the high frequency of hospitalizations of elderly persons and the significant costs of treatment, associated mainly with inpatient care. The causes of repeated hospitalizations are analyzed, with an important place given to non-compliance with drug therapy and dietary recommendations. The aim of the research is to evaluate the effectiveness of approaches to the organization of self-management and self-monitoring in patients with NYHA functional class III-IV CHF, as well as to develop practical recommendations for optimizing such approaches in the setting of practical health care.

Relevance of the Problem

Chronic non-communicable diseases in many developed countries have assumed a pandemic character. According to forecasts, in the United States by 2030, 148 million people will suffer from these diseases.1 Chronic heart failure (CHF) occupies a significant place among them. In developed countries, CHF has become one of the common pathological conditions.2,3,4 Compared with 1968, the total number of deaths caused by CHF has increased fourfold.5 This is due, firstly, to an increase in the general population of the proportion of elderly and senile persons, and, secondly, to improvements in therapeutic and cardiac surgical treatment methods,6,7,8 which allow a greater number of patients to live until those stages of heart disease at which CHF develops.

Despite evidence of the possibility of improving the prognosis of patients with CHF through drug therapy, obtained in randomized clinical trials,9,10,11,12,13,14,15,16,17 there is no clear evidence of an improvement in CHF prognosis in the general population. Four epidemiological studies evaluating mortality in CHF patients both before the widespread introduction of angiotensin-converting enzyme inhibitors (ACEIs) into clinical practice19,20 and against the background of the use of these drugs18 did not reveal a reliable change in mortality rates.

In industrially developed countries, CHF is the most common cause of hospitalization among elderly persons.23,24 An epidemiological study of 7,286 persons aged 70 years and older, conducted in the United States, showed that over an 8-year period from 1984 to 1991, 15.1% of persons in the surveyed population were hospitalized at least once with a primary or concomitant diagnosis of CHF.25 In the age group of 80-84 years, the risk of hospitalization for CHF during the specified period was almost twice as high as in the group of 70-74 years (21.1% and 11.5%, respectively). In some cities of Japan, by 1996 the proportion of persons aged 65 and older already amounted to 34% of the population,26 which was accompanied by a significant increase in health care costs.

The highest frequency of repeated hospitalizations among patients with CHF was also observed in the age group over 65 years: it ranges from 40% to 57%.27,28 The frequency of early repeated hospitalizations (within 3-6 months after discharge from hospital) in this population of CHF patients reaches 27-47%.29,30

In the United States alone, the number of hospitalizations caused by CHF amounts to about 1 million per year.31 The treatment of CHF requires large financial expenditures. Expenditures on the treatment of CHF constitute 1-2% of all health care expenditures,32,33 reaching in the United States about US$40 billion per year.34 From 67% to 75% of all financial resources allocated to pay for the treatment of patients with severe CHF are accounted for by expenditures related to hospitalization.33,35

Analysis of the causes of hospitalizations of patients with CHF, carried out in several studies, showed that in the majority of cases hospitalizations could have been prevented with the help of certain interventions. Thus, in a study by Ghali J.K. et al.,36,37 64% of hospitalizations for worsening CHF symptoms were due to non-compliance by patients with prescribed drug therapy and/or diet. In a later study, Bennett S.J. et al.38 showed that in 55% of cases hospitalization for decompensated CHF could be caused by retention of excess sodium intake with food.

The problem of low compliance with prescribed drug therapy and non-pharmacological recommendations is particularly relevant in older age groups of patients.39 In observational studies, it was found that adherence to drug therapy among elderly patients is about 50%, while overall adherence among patients of all age groups approaches 80%.40,41 The same trend has been noted with regard to non-pharmacological measures.42

Thus, by the mid-1990s, the need to apply new approaches to organizing medical care for patients with CHF, which would allow a fuller use of the achievements of medical science in practical health care, became evident.43,44,45,46 Among them, an important place is occupied by approaches related to the organization of self-management and self-monitoring of patients with CHF. The study of the effectiveness of these approaches represents a relevant problem of modern therapy.

In the foreign literature, there are only data from a few studies that evaluated the influence of the self-management and self-monitoring abilities of CHF patients. In Russia, such studies have not yet been carried out.

Aim of the Study: to examine the role of self-monitoring and self-care in the treatment of patients with severe chronic heart failure.

Objectives of the Study

1. To study, on the basis of literature data, modern approaches to the organization of self-monitoring and self-management in patients with chronic heart failure.

2. To apply these approaches in patients with severe chronic heart failure of NYHA functional class III-IV.

3. To evaluate the influence of the studied approaches to the organization of self-management and self-monitoring on the patients' self-management and self-monitoring abilities.

4. To compare the results of treatment of patients according to clinical criteria, indicators of functional status, and quality of life criteria in the intervention group and the control group.

5. On the basis of the obtained data, to develop practical recommendations for the organization of self-management and self-monitoring in the treatment of patients with severe chronic heart failure.

The following main propositions are put forward for defense:

Structured therapeutic education of patients with severe chronic heart failure during their hospital stay and careful monitoring after discharge make it possible to improve the patients' self-management and self-monitoring abilities.

- Existing approaches to organizing the self-management and self-monitoring abilities of patients are insufficient.

- Careful monitoring of patients with severe chronic heart failure contributes more to ensuring acceptable treatment outcomes compared with self-management and self-monitoring.

Scientific Novelty of the Study

The scientific novelty of the study is determined by the fact that it is the first study in Russia to examine the effectiveness of approaches to the organization of self-monitoring and self-management in patients with severe chronic heart failure.

Practical Significance of the Study

The practical significance of the study is determined by the obtained data on the limited effectiveness of the studied approaches to the organization of self-management and self-monitoring of patients with severe chronic heart failure, which can be used in practical health care when implementing measures to optimize approaches to self-management and self-monitoring in this category of patients.

Approbation of the Work

The results of the work were reported:

- at the 2nd Annual Conference of the Society of Specialists in Heart Failure. Moscow. December 14, 2001.

- at a Joint Meeting of the Department of Clinical Pharmacology and Therapy of RMAPE with the participation of physicians of the base hospital of CKB MPS and trainees of the cycle "Clinical Pharmacology," April 19, 2002.