The American Heart Association (AHA) recently issued a scientific statement for the promotion of self-care in people with heart failure (HF). The statement, published in the September 22, 2009 issue of Circulation, highlights concepts and evidence that are important to the understanding and promotion of self-care in this patient group as well as others. “In recent years, physicians and professional associations have better recognized the critical need for and benefit from self-care among patients,” explains Barbara Riegel, DNSc, RN, FAHA, who chaired the committee that generated the scientific statement. “Tremendous advances have been made in medical therapies for HF, but clinicians often have difficulty with assisting HF patients in the integration of the daily self-care behaviors they need. These behaviors, however, are important to offsetting the burden of HF.”
The AHA scientific statement aims to bring attention to the importance of self-care for HF and offers recommendations for physicians on how to promote self-care. While targeted to HF patients and the providers who manage them, the statement can also be applicable to primary care physicians. “HF is typically the final common pathway for other chronic conditions, such as hypertension and coronary artery disease,” says Dr. Riegel. “Anyone caring for a patient with diabetes, high blood pressure, elevated cholesterol, etc, can use the principles in this statement to promote self-care.”
“Keeping lines of communication open between HF patients and providers is essential.”
Self-care is defined in the AHA statement as a decision-making process that patients use to maintain their health through ongoing practices and healthy behaviors (Table 1). “Physicians should advise HF patients on the importance of these behaviors,” Dr. Riegel explains. “Patients and their caregivers are responsible for self-care. Physicians should engage patients and their caregivers to provide additional support and promote self-care. Encouragement by family members may lead to further improvements in self-care and enhance outcomes.”
elf-care also includes active monitoring of symptoms and responding to them as needed. “Keeping lines of communication open between HF patients and providers is essential,” says Dr. Riegel. “Providers can educate patients on how to monitor their symptoms and when to inform them of any changes.”
Spot Potential Barriers
There are several factors that interfere with self-care management for HF, including patient barriers, healthcare system barriers, and provider barriers. When considering patient barriers, it should be noted that nearly all individuals with HF have other illnesses to consider (eg, hypertension, coronary artery disease, diabetes, renal insufficiency, and arthritis). The presence of comorbidities contributes to difficulties in self-care. There may be challenges with taking medications, adhering to a healthy diet, and monitoring symptoms. Depression and anxiety are also common among HF patients and adversely affect self-care practices. Dr. Riegel says age can also be associated with poor self-care. “Younger patients tend to be less aware of the effects of their behavior on their HF. It’s hard to get younger patients’ attention about the need to practice self-care; they feel invincible,” she says. Additionally, about 25% to 50% of HF patients have cognitive impairment, and many also have sleep disturbances. Both conditions can interfere with patients’ ability to focus on health and practice self-care. Lastly, the health literacy level of HF patients is often low.
A key problem in HF is that most healthcare systems fail to promote self-care for these patients. In particular, self-care education in the inpatient and outpatient settings is lacking. The absence of a common medical record and the existence of multiple providers complicate processes even further. Dr. Riegel says “many healthcare systems operate in silos when it comes to treating HF. It’s critical that they collaborate as providers to treat HF patients more successfully and promote greater adherence to self-care.” She adds that clinical guidelines should be updated to reflect the importance of and evidence for promoting self-care skills among patients with HF. “Policy makers should reconsider reimbursement for patient education, counseling, and coordination of care as these are essential to effective self-care.” Furthermore, the AHA scientific statement recommends that medical school curricula include physician education on how to instruct patients in self-care. Consistent and accurate information should be communicated from providers.”
Recommendations for Clinicians
The AHA scientific statement offers specific recommendations for healthcare providers, based upon expert opinion (Table 2). Among these, routine, repeated, and ongoing assessment of health literacy level, comorbidities, depression/anxiety, and sleep disorders is critical. “Healthcare providers should approach each patient with the suspicion that they’re not performing good self-care,” says Dr. Riegel. “Clinicians should expect that they may have circumstances that impair their ability to succeed at self-care, such as daytime sleepiness, cognitive impairment, or depression. Fortunately, clinicians can make a difference by taking time to educate and encourage HF patients. There are also a few simple screening tools to help identify HF patients that are at high-risk for poor self-care. The key is to utilize these tools at every opportunity in an effort to reduce the burden of HF.”
Riegel B, Moser DK, Anker SD, et al; on behalf of the American Heart Association Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Nutrition, Physical Activity, and Metabolism, and Interdisciplinary Council on Quality of Care and Outcomes Research. State of the Science. Promoting self-care in persons with heart failure. A scientific statement from the American Heart Association. Circulation. 2009;120:1141-1163. Available at: http://circ.ahajournals.org/cgi/content/full/120/12/1141.
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