Examining effect of Nurse-led collaborative management using telemonitoring to improve quality of life and prevent rehospitalization in patients with heart failure

概要

Examining effect of Nurse-led collaborative
management using telemonitoring to improve
quality of life and prevent rehospitalization
in patients with heart failure
QOL

SUMMARY
In a super-aging society in Japan, the number of patients with heart failure
(HF), along with its associated medical expense, has been increasing substantially and
has become a nation-wide problem. To resolve this issue from a nursing perspective, this
project was conducted to establish an effective and practical HF disease management
program, and to verify its effect, so as to prevent its re-hospitalization of HF patients.

Chapter 1 discussed HF issues in the super-aging society in Japan and
worldwide from an epidemiological perspective, examined HF disease management
measures taken in the world and Japan and their effectiveness, and revealed remained
issues that research needed to consider. The

revealed issues indicated that we, as

medical and nursing professionals, needed to develop new measures to support/assist
elderly patients who were not able to follow self-management education and repeated
exacerbation and rehospitalization that results.

Chapter 2 reviewed previous studies conducted on HF patients in order to create
a new strategy for this research. First, I examined self-management education programs
for HF patients and described the rise of telemonitoring. It was clarified that although
disease management based on self-management education and telemonitoring for
patients with HF has been implemented in many countries, its effect was controversial.
The main reasons in this regard are the lack of interactive communication that is
necessary for patients to understand the meaning of data and case management to deal
with difficulties in daily life caused by severe symptoms, since most HF patients are
elderly.

Based on the literature review, I introduced the concept of collaborative
management in which health care professionals, especially nurses, and patients
collaboratively work together to deal with symptoms and issues related to HF. I
operationally defined collaborative management as “the patient working collaboratively
with health care professionals to identify problems and manage their condition and daily
life, using a telemonitoring system with timely care coordination. Collaborative
management is care that strengthens and supports patients’ self-management skills and
early detection of increased symptoms. It is care that promotes taking collaborative
action to deal with problems related to exacerbation of HF.”

Chapter 3 presented the development of the nurse-led collaborative
management program using telemonitoring to prevent rehospitalization in patients with
HF, which was based on the concept discussed in Chapter 2.
The goal of this program was that a patient working collaboratively with health
care professionals could identify problems and manage their diseases and daily life,
using a telemonitoring system with timely care coordination to prevent aggravation of
HF, especially rehospitalization, and consequently improve his/her QOL. The contents
were set based on self-management education as foundation of the program. In this
foundation, patients learn how to manage necessary actions and lifestyle changes from
nurses. The duration and the process of providing the program, and the education
material were created.
On this basis, telemonitoring which measured blood pressure, pulse rate, and
body weight, and timely feedback by telenursing have been incorporated to enhance
timely interactive communication between nurses and patients, and provide case

management.

Chapter 4 verified the effectiveness and feasibility of the nurse-led collaborative
management program on severe HF patients in the community (published in the
60(6), 1293-1302, 2019).
A three-arm randomized controlled trial (RCT) was conducted as a pilot study.
Fifty-nine HF patients were recruited through five collaborating health care facilities in
Hiroshima Prefecture, and were randomly allocated to one of three study groups: the
usual care (UC) group (n = 19), the self-management (SM) group (n = 20), and the CM
group (n = 20). The trial duration was set for 12 months intervention and 12 months
follow-up.
As shown in the results, QOL, as the primary endpoint, improved significantly
(P < 0.05), and the readmission-free survival rate differed significantly between the CM
and UC groups (P = 0.020). Rehospitalization rates were high in the UC (11/19; 57.9%)
compared with the SM (5/20; 27.8%) and CM groups (4/20; 20.0%). Therefore, we
concluded that CM has the potential to improve psychosocial status in patients with HF
and to prevent rehospitalization due to HF.

Chapter 5 examined the results for indicators not included in Chapter 4. In this
chapter, the effects of physiological indicators were examined. There was a statistically
significant increase in Cre in the SM group at 18 months; however, this change was not
critical. The blood pressure of the UC group showed a statistically significant increase
after the intervention; however, it did not yield a clinically abnormal value. Thus, there
were no changes indicating the program’s effectiveness. There was a limitation in

verifying the effect of the program on physiological indicators, due to the small sample
size and a high drop-out rate.

Chapter 6 presented an analysis and discussion on who would benefit most from
the CM program using telemonitoring to prevent rehospitalization based on the pilot
study. A triangulation approach was used in which quantitative data were compared
with qualitative data (This study was a post-hoc analysis of data from the RCT trial
described in Chapter 4 & 5).
Of the 59 patients, 19 and 36 patients were categorized into the CM suitable
and SM suitable groups, respectively. Four patients had to be excluded mainly due to,
worsening cognitive functions. The quantitative findings clarified that CM is effective in
patients with American Heart Association (AHA) stage D HF or an increased
cardiothoracic ratio (CTR), and previous repeated hospitalization history. Qualitative
analysis revealed that CM is appropriate in patients with a narrow threshold of weight
gain; moreover, CM can be an educational tool to enhance self-management skills among
patients in whom educational intervention alone is ineffective. Furthermore, patients
who require social support in ADL/IADL need CM support.
Despite RCTs examining telemonitoring use in patients with HF, only a few
studies have retrospectively performed in-depth analysis of those interventions that can
prevent rehospitalization. In this study, I identified the clinical indicators and clarified
the characteristics of patients who are suitable for CM, including their sociological and
psychological aspects, to prevent rehospitalization.

Conclusions
In this project, an innovative concept of collaborative management was

introduced for disease management of HF, which is expected to solve problems and
concerns, especially for elderly patients with multiple comorbidities who experience
repeat admissions, and have difficulty acquiring self-management. In collaboration, I
developed a program that allows patients to live at home without exacerbation while
suffering from HF, and verified its effectiveness and feasibility in the pilot study.
The collaborative management program not only detects abnormalities early
through telemonitoring, but also provides a mechanism for medical professionals to
collaborate with patients in a timely manner to help solve various problems facing them.
It was shown that re-hospitalization was prevented with a statistically significant
difference compared to usual care of HF management, and that patients' QOL improved.
In addition, the analysis also revealed patient characteristics that are suitable for this
collaborative management.
Although there was study limitation that the results of Study 2 and 3 cannot be
generalized to all HF patients due to the small sample size and the high drop-out rate.
However, I believe that the collaborative management program developed by the
researcher has potential to be effective in improving QOL of elderly patients with HF
with complex conditions and background by preventing readmission, and could be a
model for future severe HF care and management.

Recommendations
In the light of the findings of this study, the following recommendations are
suggested.
1.

To validate the findings from this study, an intervention study with a larger sample
size is needed in which participants are allocated to either a CM or an SM group

based on the characteristics identified in the present study.
2.

Clinical indicators to be considered in the introduction of the CM program are AHA
stage D HF, increased CTR, a narrow threshold for weight gain, and previous
repeated hospitalization.

3.

CM using telemonitoring can be used as a useful educational tool to enhance selfmanagement skills in patients who were not able to acquire self-management skills
with educational intervention alone.

4.

CM using telemonitoring can be used for patients who need social support in
ADL/IADL to assess the patients’ changeable condition and arrange the social
resources.