Recent Developments in Self-management Intervention Models in Patients with Chronic Heart Failure

doi:10.12114/j.issn.1007-9572.2019.00.714

Abstract

Abstract: Due to recently increased prevalence of chronic diseases，many self-management interventions become increasingly popular.However，self-management status in chronic heart failure patients is not so optimistic.We reviewed the self-management intervention models recently used in chronic heart failure patients under the guidance of doctors and nurses，and summarized that in foreign countries，the guidance is mainly delivered via the advanced remote supervising system，while in China，the guidance is mainly delivered via health education.To improve the prognosis of these patients through enhancing their self-management abilities，we suggest that both the two aforementioned guidance methods for patients are used together，and self-management status is also encouraged to record daily.

Key words: Heart failure, Disease management, Self-management, Intervention mode, Review

摘要： 近年来，慢性病呈高患病率，因此人们对自我管理的热情日益高涨，但慢性心力衰竭患者的自我管理现状并不乐观。本文回顾了近年来国内外医护人员对慢性心力衰竭患者自我管理的干预模式，分析表明国外主要通过高级远程监督系统进行干预，国内主要通过健康教育。笔者认为可将远程监督及健康教育结合，同时鼓励患者记录慢性心力衰竭日志，进而提高患者自我管理能力，以改善慢性心力衰竭患者的预后。

关键词: 心力衰竭, 疾病管理, 自我管理, 干预模式, 综述

MENG Yanfei,MA Li,MA Desheng. Recent Developments in Self-management Intervention Models in Patients with Chronic Heart Failure　[J]. Chinese General Practice, 2020, 23(9): 1185-1188. DOI: 10.12114/j.issn.1007-9572.2019.00.714.
蒙雁飞,马莉,马德胜. 慢性心力衰竭患者自我管理干预模式的研究进展[J]. 中国全科医学, 2020, 23(9): 1185-1188. DOI: 10.12114/j.issn.1007-9572.2019.00.714.

References

［1］MOSTERD A，HOES A W.Clinical epidemiology of heart failure［J］．Heart，2007，93（9）：1137-1146．DOI：10.1136/hrt.2003.025270.
［2］顾东风，黄广勇，何江，等．中国心力衰竭流行病学调查及其患病率［J］．中华心血管病杂志，2003，31（1）：3-6．DOI：10.3760/j：issn：0253-3758.2003.01.002.
［3］ROGER V L，GO A S，LLOYD-JONES D M，et al．Executive summary：heart disease and stroke statistics——2012 update：a report from the American Heart Association［J］．Circulation，2012，125（1）：188-197．DOI：10.1161/CIR.0b013e3182456d46.
［4］ANGERMANN C E，ST?RK S，GELBRICH G，et al．Mode of action and effects of standardized collaborative disease management on mortality and morbidity in patients with systolic heart failure：the Interdisciplinary Network for Heart Failure（INH）study［J］．Circ Heart Fail，2012，5（1）：25-35．DOI：10.1161/CIRCHEARTFAILURE.111.962969.
［5］BARLOW J，WRIGHT C，SHEASBY J，et al．Self-management approaches for people with chronic conditions：a review［J］．Patient Educ Couns，2002，48（2）：177-187.
［6］RIEGEL B，DRISCOLL A，SUWANNO J，et al．Heart failure self-care in developed and developing countries［J］．J Card Fail，2009，15（6）：508-516．DOI：10.1016/j.cardfail.2009.01.009.
［7］SON Y J，LEE Y，SONG E K.Adherence to a sodium-restricted diet is associated with lower symptom burden and longer cardiac event-free survival in patients with heart failure［J］．J Clin Nurs，2011，20（21/22）：3029-3038．DOI：10.1111/j.1365-2702.2011.03755.x.
［8］SCHNELL-HOEHN K N，NAIMARK B J，TATE R B.Determinants of self-care behaviors in community-dwelling patients with heart failure［J］．J Cardiovasc Nurs，2009，24（1）：40-47．DOI：10.1097/01.JCN.0000317470.58048.7b.
［9］OOSTEROM-CALO R，VAN BALLEGOOIJEN A J，TERWEE C B，et al．Determinants of adherence to heart failure medication：a systematic literature review［J］．Heart Fail Rev，2013，18（4）：409-427．DOI：10.1007/s10741-012-9321-3.
［10］TUNG H H，CHEN S C，YIN W H，et al．Self care behavior in patients with heart failure in Taiwan［J］．Eur J Cardiovasc Nurs，2012，11（2）：175-182．DOI：10.1016/j.ejcnurse.2011.02.002.
［11］JONKMAN N H，SCHUURMANS M J，GROENWOLD R H H，et al．Identifying components of self-management interventions that improve health-related quality of life in chronically ill patients：Systematic review and meta-regression analysis［J］．Patient Educ Couns，2016，99（7）：1087-1098．DOI：10.1016/j.pec.2016.01.022.
［12］CURRIE K，STRACHAN P H，SPALING M，et al．The importance of interactions between patients and healthcare professionals for heart failure self-care：a systematic review of qualitative research into patient perspectives［J］．Eur J Cardiovasc Nurs，2015，14（6）：525-535．DOI：10.1177/1474515114547648.
［13］SETO E，LEONARD K J，CAFAZZO J A，et al．Mobile phone-based telemonitoring for heart failure management：a randomized controlled trial［J］．J Med Internet Res，2012，14（1）：e31．DOI：10.2196/jmir.1909.
［14］PIOTROWICZ E.The management of patients with chronic heart failure：the growing role of e-Health［J］．Expert Rev Med Devices，2017，14（4）：271-277．DOI：10.1080/17434440.2017.1314181.
［15］DOMINGO M，LUPóN J，GONZáLEZ B，et al．Evaluation of a telemedicine system for heart failure patients：feasibility，acceptance rate，satisfaction and changes in patient behavior：results from the CARME（CAtalan Remote Management Evaluation）study［J］．Eur J Cardiovasc Nurs，2012，11（4）：410-418．DOI：10.1016/j.ejcnurse.2011.02.003.
［16］DING H，JAYASENA R，MAIORANA A，et al．Innovative Telemonitoring Enhanced Care Programme for Chronic Heart Failure（ITEC-CHF）to improve guideline compliance and collaborative care：protocol of a multicentre randomised controlled trial［J］．BMJ Open，2017，7（10）：e017550．DOI：10.1136/bmjopen-2017-017550.
［17］INGLIS S C，CLARK R A，DIERCKX R，et al．Structured telephone support or non-invasive telemonitoring for patients with heart failure［J］．Cochrane Database Syst Rev，2015（10）：CD007228．DOI：10.1002/14651858.CD007228.pub3.
［18］HALE T M，JETHWANI K，KANDOLA M S，et al．A remote medication monitoring system for chronic heart failure patients to reduce readmissions：a two-arm randomized pilot study［J］．J Med Internet Res，2016，18（5）：e91．DOI：10.2196/jmir.5256.
［19］EVANGELISTA L S，LEE J A，MOORE A A，et al．Examining the effects of remote monitoring systems on activation，self-care，and quality of life in older patients with chronic heart failure［J］．J Cardiovasc Nurs，2015，30（1）：51-57．DOI：10.1097/JCN.0000000000000110.
［20］DANG S，KARANAM C，GóMEZ-MARíN O.Outcomes of a mobile phone intervention for heart failure in a minority county hospital population［J］．Telemed J E Health，2017，23（6）：473-484．DOI：10.1089/tmj.2016.0211.
［21］OTSU H，MORIYAMA M.Effectiveness of an educational self-management program for outpatients with chronic heart failure［J］．Jpn J Nurs Sci，2011，8（2）：140-152．DOI：10.1111/j.1742-7924.2010.00166.x.
［22］BAKER D W，DEWALT D A，SCHILLINGER D，et al．“Teach to goal”：theory and design principles of an intervention to improve heart failure self-management skills of patients with low health literacy［J］．J Health Commun，2011，16（Suppl 3）：73-88．DOI：10.1080/10810730.2011.604379.
［23］HA DINH T T，BONNER A，CLARK R，et al．The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease：a systematic review［J］．JBI Database System Rev Implement Rep，2016，14（1）：210-247．DOI：10.11124/jbisrir-2016-2296.
［24］CHANG Y L，CHIOU A F，CHENG S M，et al．Tailored educational supportive care programme on sleep quality and psychological distress in patients with heart failure：a randomised controlled trial［J］．Int J Nurs Stud，2016，61：219-229．DOI：10.1016/j.ijnurstu.2016.07.002.
［25］BOYNE J J，VRIJHOEF H J，SPREEUWENBERG M，et al．Effects of tailored telemonitoring on heart failure patients' knowledge，self-care，self-efficacy and adherence：a randomized controlled trial［J］．Eur J Cardiovasc Nurs，2014，13（3）：243-252．DOI：10.1177/1474515113487464.
［26］CURRIE K，STRACHAN P H，SPALING M，et al．The importance of interactions between patients and healthcare professionals for heart failure self-care：a systematic review of qualitative research into patient perspectives［J］．Eur J Cardiovasc Nurs，2015，14（6）：525-535．DOI：10.1177/1474515114547648.
［27］PIETTE J D，STRIPLIN D，MARINEC N，et al．A mobile health intervention supporting heart failure patients and their informal caregivers：a randomized comparative effectiveness trial［J］．J Med Internet Res，2015，17（6）：e142．DOI：10.2196/jmir.4550.
［28］GRANGER B B，EKMAN I，HERNANDEZ A F，et al．Results of the Chronic Heart Failure Intervention to Improve MEdication Adherence study：a randomized intervention in high-risk patients［J］．Am Heart J，2015，169（4）：539-548．DOI：10.1016/j.ahj.2015.01.006.
［29］DUNBAR S B，CLARK P C，REILLY C M，et al．A trial of family partnership and education interventions in heart failure［J］．J Card Fail，2013，19（12）：829-841．DOI：10.1016/j.cardfail.2013.10.007.
［30］PRESCHER S，DECKWART O，KOEHLER K，et al．Will telemonitoring be adopted by patients with chronic heart failure?［J］．Dtsch Med Wochenschr，2014，139（16）：829-834．DOI：10.1055/s-0034-1369849.
［31］POWELL L H，CALVIN J E Jr，RICHARDSON D，et al．Self-management counseling in patients with heart failure：the heart failure adherence and retention randomized behavioral trial［J］．JAMA，2010，304（12）：1331-1338．DOI：10.1001/jama.2010.1362.
［32］REDEKER N S，JEON S，ANDREWS L，et al．Feasibility and efficacy of a self-management intervention for insomnia in stable heart failure［J］．J Clin Sleep Med，2015，11（10）：1109-1119．DOI：10.5664/jcsm.5082.
［33］王爽，徐奕旻，高军毅，等．基于移动健康的慢性心力衰竭患者自我管理模式构建及效果评价［J］．中国实用内科杂志，2017，37（12）：1102-1105．DOI：10.19538/j.nk2017120116.
［34］叶芳，林秀铭.自我管理干预对慢性心力衰竭患者预后的影响［J］．吉林医学，2013，34（30）：6412.
［35］霍昱，马春蓉，魏葳.强化自我管理教育对慢性心力衰竭患者药物依从性及生活质量的影响［J］．中国医药导刊，2016，18（6）：646-648.
［36］周艳，陈梅青，王顺娣.心衰日记模本在慢性心力衰竭患者院外管理中的效果评价［J］．实用临床医药杂志，2014，18（18）：4-7.
［37］金园园，彭幼清.基于系统论的老年慢性心力衰竭患者自我管理干预模式的构建［J］．中华现代护理杂志，2018，24（10）：1137-1142．DOI：10.3760/cma.j.issn.1674-2907.2018.10.004.

[1]	HAN Leyang, ZHENG Huixian, TIAN Yiran, TANG Haoqing, LONG Ren, LI Daihan, LIU Xiaoyun. Measuring Integrated Services for Rural Chronic Disease Patients Based on Formative Measurement Theory [J]. Chinese General Practice, 2026, 29(31): 4543-4550.
[2]	TIAN Xiangyang, ZHOU Yingsheng, GAO Ying. Prospects of Behavioral and Lifestyle Interventions for Diabetes Mellitus [J]. Chinese General Practice, 2026, 29(31): 4513-4520.
[3]	KUANG Li, DING Xinxin, MA Yuanzhu. Application of Motivational Interviewing in Healthcare Provider-Patient Communication for Chronic Disease Management in Primary Care: from Principles to Practice [J]. Chinese General Practice, 2026, 29(31): 4536-4542.
[4]	LI Xiling, ZHANG Fan, YANG Xinyue, YANG Heng. Application of Exercise Snacks in Chronic Disease Management: a Scoping Review [J]. Chinese General Practice, 2026, 29(30): 4472-4479.
[5]	GUO Junchi, ZHANG Mingyan, QIN Guangning, XU Qiang, LU Meijuan. Preliminary Application of the Novel Biomarker TANS01 in Cardiovascular Risk Assessment among Individuals with Phlegm-dampness Constitution [J]. Chinese General Practice, 2026, 29(27): 3924-3930.
[6]	FU Mengru, XUE Meiqiyang, JIANG Yutong, CHEN Mingsheng, QIAN Dongfu, LI Zhong. Study on the Influencing Factors of Self-management Ability of Atrial Fibrillation Patients in Rural Areas [J]. Chinese General Practice, 2026, 29(27): 3947-3955.
[7]	WANG Wei, YU Fei, YAN Xiaohong. Application and Mechanisms of Sodium-glucose Cotransporter 2 Inhibitors in Heart Failure with Different Etiologies: Evidence from Ischemic and Non-ischemic Heart Failure [J]. Chinese General Practice, 2026, 29(27): 3976-3984.
[8]	ZHAO Yiru, HAO Xinyu, ZHAO Lei, ZHANG Caihui, WANG Zhaoxia, ZHANG Yueying. Summary of the Best Evidence for the Management of Diuretic Resistance in Patients with Heart Failure [J]. Chinese General Practice, 2026, 29(25): 3694-3703.
[9]	XUE Cuirong, WEI Wei, WU Renyuan, XUE Yaqin, XU Huijiang, LYU Weijiang, JIANG Dandan. Prevalence and Management Status of Chronic Kidney Disease in Hypertensive and Type 2 Diabetic Populations: a Community-based Cross-sectional Study [J]. Chinese General Practice, 2026, 29(25): 3650-3654.
[10]	LI Xueni, LIU Gejing, LIU Yongming. Efficacy and Safety of Semaglutide in Patients with Heart Failure: a Meta-Analysis [J]. Chinese General Practice, 2026, 29(24): 3509-3519.
[11]	CHENG Yu, HAN Shiyao, SUN Ping, XIANG Juan, YANG Hui, LI Dongze, ZHENG Li, LIAO Xiaoyang. Analysis of Socioeconomic and Demographic Challenges in Chronic Disease Management [J]. Chinese General Practice, 2026, 29(20): 2800-2807.
[12]	CHEN Qiulong, CHEN Jia, FANG Jing, DAI Wei, YANG Qing. Application Status and Research Progress of Observer-reported Outcome [J]. Chinese General Practice, 2026, 29(18): 2561-2570.
[13]	LI Shilong, WANG He, ZHOU Xiaoyu, FU Lei, ZHAO Zhuo, HUA Chengjun, SI Chunying. Advances in the Study of Cardiac Macrophages in Heart Failure with Preserved Ejection Fraction [J]. Chinese General Practice, 2026, 29(15): 2084-2091.
[14]	YANG Rong, JIN Hua, SHI Ling, YI Chuntao, HOU Jin, CHEN Chen, HUAN Hongmei, NI Hengru, YU Dehua. A Survey on the Quality of Diabetes Normative Management at Grassroots Level [J]. Chinese General Practice, 2026, 29(12): 1541-1547.
[15]	JIAO Xitong, LIU Lu, GUO Jiayue, YOU Lili. Prospects for the Application of Digital Therapy Products for Hypertension at Home and Abroad and the Implications for China [J]. Chinese General Practice, 2026, 29(10): 1354-1360.