Counseling May Not Help Heart Failure Patients Comply with Rx
Posted Sep 21 2010 1:00pm
Many too overwhelmed to follow doctor's orders, experts say
Tuesday, September 21, 2010
TUESDAY, Sept. 21 (HealthDay News) -- Living with heart failure can put a patient on overload. The rigors of having to lose weight, strictly limit salt intake, exercise and take a half-dozen or more medications lead many people to disregard their doctor's orders.
Chicago researchers thought that a combination of group counseling and reading materials on how to manage heart failure would improve adherence to medical recommendations, but their new study finds otherwise. The two-pronged approach was no more effective than simply giving patients reading materials, they found.
Though disappointing, their data did suggest that counseling might be beneficial for lower-income patients, though not more affluent ones, said lead study author Lynda H. Powell, a professor of preventive medicine at Rush University Medical Center.
"This is a health disparities issue," Powell said. "In Chicago, we have three blacks for every white hospitalized for heart failure. Being more attentive to some of the special needs of some of these underserved populations is certainly in order."
For the study, published in the Sept. 22/29 issue of the Journal of the American Medical Association, 902 patients with mild to moderate heart failure were divided into two groups. One group took part in 18 self-management meetings over the course of a year and also received educational materials; the other group were sent tip sheets on managing the condition and received follow-up calls after each mailing to make sure they understood what they'd read.
The patients' average age was 64. About 40 percent were racial or ethnic minorities, while about 52 percent had an annual family income of less than $30,000. Many patients also had other conditions, including depression, diabetes and lung disease. On average, patients took seven different medications.
During the group sessions, patients received disease-management advice, such as how to read ingredient labels; tips for coping with stress, such as deep breathing; tricks for remembering to take pills; and the importance of talking about heart failure with family and friends, the idea being that social supports help in making and maintaining lifestyle changes, Powell said.
Over two to three years of follow-up, 163 people (40.1 percent) were hospitalized for heart failure or died in the self-management counseling group vs. 171 (41.2 percent) of those who received reading materials alone.
In addition, no significant differences were noted in hospitalizations for any cause, quality of life, blood pressure or body mass index .
In patients with congestive heart failure, the heart no longer pumps enough blood to meet the body's needs for blood and oxygen. Common causes include coronary artery disease, past heart attacks, atrial fibrillation and hypertension, according to the American Heart Association.
Medication can help control symptoms, which include fatigue, shortness of breath and swollen feet and ankles. And lifestyle changes can help keep the condition from worsening, experts say.
Yet many patients don't heed their doctor's instructions. Previous research has shown 30 to 60 percent of patients don't take medications as prescribed, while 50 to 80 percent don't make the lifestyle changes needed, according to background information in the study.
"Adherence to medications and lifestyle changes for heart failure are atrocious," Powell said. "When you get to people of lower socioeconomic status, the rates of non-adherence are the highest."
Dr. Gregg Fonarow, American Heart Association spokesman and professor of cardiology at the University of California, Los Angeles, said the study is well done, but the findings should not be interpreted to mean nothing can be done to help people manage heart failure.
Other research has shown that more intensive interventions, including help from physicians who specialize in heart failure and specially-trained nurses, can help patients stick to healthier lifestyles and medications.
Telemedicine, including sensors that can monitor vital signs and heart pressure and transmit data to physicians, is also promising, Fonarow said.
Especially for those with mild symptoms, making the lifestyle changes and sticking to prescribed medications can go a long way, but all of the steps required can be overwhelming, said Dr. John Cleland, a cardiologist at Hull York Medical School at the University of Hull in England, who wrote an accompanying editorial.
"The potential for information overload is exceedingly high," Cleland said. "Education and motivation are required to improve outcomes because it is the patients with rather mild symptoms who may not feel the need to bother that benefit most from intervention. Patients who have severe symptoms have often reached the end of the road and then there is little we can do for most."
SOURCES: Lynda H. Powell, Ph.D., chair, department of preventive medicine, Rush University Medical Center, Chicago; Gregg Fonarow, M.D., American Heart Association spokesman and professor, cardiology, University of California, Los Angeles; John G. F. Cleland, cardiologist, Hull York Medical School, University of Hull, Kingston-upon-Hull, England; Sept. 22/29, 2010, Journal of the American Medical Association