Patterns of self-care and clinical events in a cohort of adults with heart failure: 1 year follow-up

Abstract

Background: Heart failure (HF) self-care is important in reducing clinical events (all-cause mortality, emergency room visits and hospitalizations). HF self-care behaviors are multidimensional and include maintenance (i.e. daily adherence behaviors), management (i.e. symptom response behaviors) and consulting behaviors (i.e. contacting a provider when appropriate). Across these dimensions, patterns of successful patient engagement in self-care have been observed (e.g. successful in one dimension but not in others), but no previous studies have linked patterns of HF self-care to clinical events.

Objectives: To identify patterns of self-care behaviors in HF patients and their association with clinical events.

Methods: This was a prospective, non-experimental, cohort study. Community-dwelling HF patients (n = 459) were enrolled across Italy, and clinical events were collected one year after enrollment. We measured dimensions of self-care behavior with the Self-Care of HF Index (maintenance, management, and confidence) and the European HF Self-care Behavior Scale (consulting behaviors). We used latent class mixture modeling to identify patterns of HF self-care across dimensions, and Cox proportional hazards modeling to quantify event-free survival over 12 months of follow-up.

Results: Patients (mean age 71.8 ± 12.1 years) were mostly males (54.9%). Three patterns of self-care behavior were identified; we labeled each by their most prominent dimensional characteristic: poor symptom response, good symptom response, and maintenance-focused behaviors. Patients with good symptom response behaviors had fewer clinical events compared with those who had poor symptom response behaviors (adjusted hazard ratio = 0.66 [0.46-0.96], p = 0.03). Patients with poor symptom response behaviors had the most frequent clinical events. Patients with poor symptom response and those with maintenance-focused behaviors had a similar frequency of clinical events.

Conclusions: Self-care is significantly associated with clinical events. Routine assessment, mitigation of barriers, and interventions targeting self-care are needed to reduce clinical events in HF patients.

Keywords: Heart failure; Mortality; Prospective study; Self-care; Survival.

Figure 1:. Distribution of clinical events during 12 months of follow-up.

29.6% of patients died, 13.3% required an emergency room visit for heart failure, 16.3% required hospitalization for heart failure and the remaining 40.8% remained alive without events at 12 months. Abbreviations: ER – emergency room; HF – heart failure

Figure 2:. Adjusted clinical event hazard by pattern of heart failure self-care.

Compared with patients who had poor symptom response behaviors, those with good symptom response behaviors were much less likely to die or require emergency care or hospitalization for heart failure over 12 months of follow-up. Those who were maintenance-focused were equally likely die or require emergency care or hospitalization for heart failure compared with those who had poor symptom response behaviors in adjusted survival models. Note: Hazard ratios shown are adjusted for age, education, New York Heart Association functional class, employment, Charlson comorbidity index, hospitalization for heart failure in the prior year, number of medications, left ventricular ejection fraction, serum sodium, serum hemoglobin, home oxygen use, and both physical and emotional health-related quality of life. Abbreviations: HR – adjusted hazards ratio.