Follow-up study for a disease management program for chronic heart failure 24 months after program commencement

Abstract

Aim: There are few studies dealing with comprehensive chronic heart failure (CHF) disease management programs, which are based on self-management, in Japan. We developed and conducted a comprehensive educational program for CHF for 6 months that aimed to improve self-management and prevent the deterioration of outpatients with CHF. Our follow-up research focused on whether performance of self-management in the intervention group continued for 24 months after commencement.

Methods: Participants were selected from patients who went for follow-up visits to one Japanese clinic, which specialized in cardiovascular internal medicine, that were diagnosed with CHF. During the first follow-up period, 7 to 12 months after program commencement, 47 participants in the intervention group and 47 participants in the control group were analyzed. During the second follow-up period, 13 to 24 months after program commencement, 41 participants in the intervention group were analyzed.

Results: Participants in the intervention group acquired self-management skills and activities and these continued up to 24 months after the program commencement. As a result, no deterioration in symptoms related to CHF was demonstrated. Meanwhile, quitting smoking and drinking depended on individual preference and it was difficult to improve.

Conclusions: The educational program was effective in the long term and the program is significant for use in busy medical situations that do not offer sufficient follow-up support for patients. Regular intervention and ways that produce longer-lasting effects should be further developed.