Effect of Behavioral Management on Quality of Life in Heart Failure
Martha J. Shively PhD RN
VA San Diego Healthcare System
San Diego, CA
Funding Period: April 1998 - March 2002

BACKGROUND/RATIONALE:
Nurses play an important role in helping patients to manage symptoms, adhere to treatment, and change behavior. There has been a lack of research regarding nonpharmacologic interventions with patients with heart failure and other chronic conditions.

OBJECTIVE(S):
The primary objective of this 4-year study was to determine the effect of a nurse-led behavioral management intervention on health-related quality in patients with medically-managed heart failure. The secondary objective was to assess the impact of the behavioral management intervention on health care resource utilization.

METHODS:
DESIGN: randomized controlled trial. SETTING: single site, VA San Diego Healthcare System. SAMPLE: Patients were enrolled in 11 cohorts a total of 116 outpatients were randomly assigned to one of two treatment groups to evaluate the clinical impact of the intervention. Group 1 received usual care for patients with heart failure (n=58). Group 2 was an augmented group receiving usual care plus participation in the 15-week (4-month) behavioral management program (n=58). Inclusion criteria were that the patient had a primary diagnosis of heart failure, a VA primary care provider, stable symptoms for at least one month and was able to walk. INTERVENTION: The behavioral management program augmented usual care and consisted of establishing specific goals with patients related to healthier diet, increased quality and amount of exercise, smoking cessation, and increased social and interpersonal activities. DEPENDENT VARIABLES/OUTCOME MEASURES: The five major dependent variables for this study were psychological symptom distress (Multiple Affect Adjective Check List - MAACL), physical functioning (SF-36 physical component summary score), mental functioning (SF-36 mental component summary score), exercise capability (6-Minute Walk), and general health perceptions (SF-36 general health scale score). Dependent variables were assessed at baseline, at the end of treatment (at 4 months), and then at 10 and 16 months. DATA ANALYSIS: Initial analyses included all subjects who were randomized to treatment and completed all data collection time points in a series of 2 by 4 ANOVAs with time as a repeated measure.

FINDINGS/RESULTS:
Participants were mostly male (95%) and Caucasian (75%), with a mean age of 67 (SD 10) and in functional/SAS classes II and III. There were no group differences on the MAACL or SF-36 scores. Younger patients (< 60 years) in the intervention group had a significantly greater 6-Minute Walk distance over time than those in the control group (p =. 02). Intervention patients showed significantly improved MLHF physical dimension scores over time compared to control patients (p =.03). The MLHF physical functioning scores were initially higher (more impairment) in younger patients but improved in the intervention group. Scores for the older participants (>60 years) were maintained over time for both groups. Walk distance also improved in the younger patients (< 60 years) in the intervention group but showed little change in the older patients (>60 years) in both groups. Intervention patients also showed significantly improved MAACL positive affect scores over time compared to control patients (p =.02).

IMPACT:
This behavioral management intervention shows efficacy in physical functioning and may be more effective with younger patients. This intervention should be tested in a multi-center trial.

PUBLICATIONS:

Journal Articles

1. Shively M, Kodiath M, Smith TL, Kelly A, Bone P, Fetterly L, Gardetto N, Shabetai R, Bozzette S, Dracup K. Effect of behavioral management on quality of life in mild heart failure: a randomized controlled trial. Patient Education and Counseling. 2005; 58(1): 27-34.
2. Kodiath M, Kelly A, Shively M. Improving quality of life in patients with heart failure: an innovative behavioral intervention. Journal of Cardiovascular Nursing. 2005; 20(1): 43-8.
3. Shively M, Fox C, Brass-Mynderse NJ. Health-related quality of life as an outcome for patients with heart failure. Journal of Cardiovascular Nursing. 1996; 10(2): 89-96.

DRA: Chronic Diseases, Health Services and Systems
DRE: Resource Use and Cost, Treatment
Keywords: Behavior (patient), Chronic disease (other & unspecified), Chronic heart failure, Nursing
MeSH Terms: Health Behavior, Heart Failure, Congestive, Quality of Life, Nursing, Behavior