Jill Pattenden

Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model

The Transtheoretical Model (TTM) has gained widespread popularity and acceptance, yet little is known about its effectiveness as a basis for health behavior intervention. A systematic review was conducted in order to evaluate the effectiveness of TTM interventions in facilitating health-related behavior change. Thirty-five electronic databases, catalogues, and internet resources were searched for relevant studies. In addition, the bibliographies of retrieved references were scanned for further relevant publications and authors were contacted for further information where necessary. Thirty-seven randomized controlled trials, targeting seven health-related behaviors, satisfied the inclusion criteria. Overall, the methodological quality of trials was variable, and there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change or for facilitating stage progression, irrespective of whether those interventions were compared with other types of intervention or with no intervention or usual care controls. The theoretical and practical implications of these findings are discussed.

Living with Heart Failure; Patient and Carer Perspectives

Patients with heart failure have multiple readmissions to hospital, a poor prognosis and varying quality of life. This paper explores how patients with heart failure and their family carers cope with daily life. 36 patients and 20 family caregivers were interviewed in five centres in the UK. Analysis showed that living with heart failure can be frightening, restrictive and distressing for both patients and their family carers. Patients found most difficulty coping with functional limitation and adapting to living with heart failure, but also reported particular problems due to side effects of medications, co-morbidities and a lack of psychosocial support and rehabilitation services. Those with less socio-economic resources found it harder to cope. Patients from minority ethnic groups held different beliefs about the illness and its treatment, and some had profound problems communicating with health and social care professionals that made managing the disease even more difficult. Caring for a person with heart failure often has a considerable impact on the psychological and physical health of family caregivers. Psychosocial support and rehabilitation services provided at diagnosis and after an acute episode would enable families to better manage living with this syndrome.

Systematic review of interventions to reduce delay in patients with suspected heart attack

Objectives: To evaluate the effectiveness of interventions aiming to reduce time from onset of signs and symptoms of an acute myocardial infarction (AMI) to seeking medical help/arrival at hospital. Methods: A systematic review was conducted. Fifteen electronic databases, the internet, and bibliographies of included studies were searched, and experts in the field of cardiac care were contacted. Randomised controlled trials (RCTs), controlled trials, and before and after studies conducted in any setting that assessed an intervention aimed at reducing time from onset of signs and symptoms of an AMI to seeking medical help and/or arrival in hospital were eligible for inclusion. Results: Eleven media/public education intervention studies met the inclusion criteria. Five (one controlled and four before and after studies) reported the intervention to have a statistically positive effect on delay time and six (two RCTs and four before and after studies) reported no statistically significant effect. Three (one RCT and two before and after studies) of five studies evaluating the effect of the intervention on emergency department visits reported an increase in this outcome as a result of the intervention, and both studies (one RCT and one before and after study) examining calls made to emergency switchboards reported an increase in this outcome after the intervention. Conclusions: There was little evidence that media/public education interventions reduced delay. There is some evidence that they may result in an increase in emergency switchboard calls and emergency department visits. Despite substantial expenditure of time and effort, methodological deficiencies of the studies mean that it is not possible to make definitive recommendations.

Nurse facilitated Self-management support for people with heart failure and their family carers (SEMAPHFOR): a randomised controlled trial

OBJECTIVE To compare the clinical effectiveness of a newly developed cognitive behavioural self-management manual delivered by specialist heart failure nurses or the same programme followed by the patient on their own, in terms of readmissions/admissions to hospital for any reason within a 12 month period, patient health related quality of life, self-management and carer quality of life. DESIGN Pragmatic, open parallel group, randomised controlled trial. SETTING Open access heart failure diagnostic clinics and primary care. PARTICIPANTS 260 patients with a definitive diagnosis of symptomatic heart failure (LVSD) as defined by ECHO, clinical diagnosis or coronary angiography were eligible for the study. INTERVENTION A newly developed nurse facilitated, cognitive behavioural self-management programme was developed and was delivered either by a heart failure nurse or by the patient on their own. MAIN OUTCOME MEASURES Patient admission/readmission to hospital for any reason within a 12 month period following randomisation. Secondary outcomes were: participant health related quality of life as measured by the Minnesota Living with Heart Failure questionnaire, the Hospital, Anxiety and Depression Scale, the European self-care form. RESULTS There was no evidence of a difference between the groups in whether or not a patient was re-admitted to hospital during the 12 month follow-up period (p=0.66). There was no evidence of a difference between the treatment groups in the mean MLHF scores over time (p=0.768), the European self-care questionnaire (p=0.340) or the mean HAD anxiety score (p=0.786). However, when adjusted for baseline scores the self-management group had a statistically significant higher HADS depression score at 12 months (p=0.003). CONCLUSION There was no evidence of a difference in admissions/readmission to hospital between patients who undertook a brief heart failure self-management programme facilitated by a specialist heart failure nurse and those also receiving care from a specialist nurse who followed the programme on their own. TRIAL REGISTRATION This trial is registered as ISRCTN84692046.

Collaborative palliative care for advanced heart failure: outcomes and costs from the ‘Better Together’ pilot study

Background Patients with heart failure often receive little supportive or palliative care. ‘Better Together’ was a 2-year pilot study of a palliative care service for patients with advanced congestive heart failure (CHF). Objective To determine if the intervention made it more likely that patients would be cared for and die in their place of choice, and to investigate its cost-effectiveness. Methods This pragmatic non-randomised pilot evaluation was set in two English primary care trusts (Bradford and Poole). Prospective patient-level data on outcomes and costs were compared with data from a historical control group of clinically comparable patients. Outcomes included death in preferred place of care (available only for the intervention group) and ‘hospital admissions averted’. Costs included medical procedures, inpatient care and the direct cost of providing the intervention. Results 99 patients were referred. Median survival from referral was 48 days in Bradford and 31 days in Poole. Most patients who died did so in their preferred place of death (Bradford 70%, Poole 77%). An estimated 14 and 18 hospital admissions for heart failure were averted in Bradford and Poole, respectively. The average cost-per-heart failure admission averted was £1529 in Bradford, but the intervention was cost saving in Poole. However, there was considerable uncertainty around these cost-effectiveness estimates. Conclusions This pilot study provides tentative evidence that a collaborative home-based palliative care service for patients with advanced CHF may increase the likelihood of death in place of choice and reduce inpatient admissions. These findings require confirmation using a more robust methodological framework.

New Models of Care and Support

In many industrialized countries, the percentage of the population that is elderly is rising;more people are surviving with conditions that in the past were fatal, and obesity and a sedentary lifestyle are still increasing.As a result, the number of people living with a chronic illness is also rising rapidly. For example, in the UK the proportion of people living with a chronic condition has risen from 21% in 1972 to 35% in 2002; 17% of those with a chronic condition have a cardiovascular illness or hypertension. Approximately 25% have three or more chronic health problems. The healthcare systems designed over the 20th century faced different challenges, initially to eradicate and then to control infectious disease and also to manage acute events. There was less attention given to prevention and rehabilitation, and services are not well suited to caring for a large number of people living, often for decades, with a high level of disability or complex disease management regimes.