Research Article 2016
Vol.10 No.4:5 iMedPub Journals Health Science Journal
ISSN 1791-809X http://www.imedpub.com/ Impact of a Nurses-Led Telephone Intervention Program on the Quality of Life
in Patients with Heart Failure in a District Hospital of Greece Theodosios
Stavrianopoulos*
Infection Control Nurse, MSc, General Hospital of Pyrgos Ilia, Pyrgos, Greece
* Correspondence: Stavrianopoulos Theodosios, Archimidous 4, 27100, PyrgosIlia, Greece, Tel: +30 6945609047; E-mail: sakisstav@hotmail.com
Received: 20.07.2015;
09.04.2016 Accepted: 29.04.2016; Published: Abstract
Background: Patients with chronic heart failure (HF) and
their families experience a wide range of complex
problems, which negatively impact the quality of patients’
lives. Moreover, besides its debilitating symptoms, the
disease necessitates frequent hospital admissions,
imposing a financial burden on the health system.
Aim: To assess whether nurses-led telephone intervention
on a regular basis in HF patients may upgrade the quality
of their lives.
Material and methods: Telephone intervention lasted for
16 weeks in patients with confirmed HF type New York
Heart Association (NYHA) II and III. The study population
comprised 50 patients, male and female, who were
randomly allocated into 2 groups: Group A, the
intervention group and Group B, the control group. Each
study group consisted of 25 patients. Data was collected
via a questionnaire that was completed by the patients
and that included demographic, social data and the
"Minnesota Living with Heart Failure Questionnaire
(MLHFQ)".
Results: Prior to the telephone intervention the MLHFQ
score in group A was 50.88. In group B the score was
52.40. There is no statistical significance between the 2
groups. After the intervention the MLHFQ score in group
A was 31.52 and in group B was 53.80. There is a
statistically significant difference in the total score on the
scale MLHFQ between patients in the 2 groups (p<0.001).
A statistically significant difference was also observed
among scores from the first and the second measurement
of patients between the 2 groups p<0.001.
Conclusions: Our study indicates that the quality of life of
HF patients post-telephone intervention improved
significantly. However, there were no further significant
correlations. © Copyright iMedPub | This article is available from: www.hsj.gr/archive Keywords: Telephone intervention; Program; Heart
failure; Quality life; MLHFQ Background
Despite the progress in research on treatment of heart
failure (HF), morbidity and mortality remain high [1].
Moreover, not only is it a clinical syndrome with poor
outcome, but it also imposes a severe financial strain on the
health system. Nine percent of HF patients after their
discharge from the hospital will be re-admitted within a
week, 23% of patients within a month and 41% within a year
[2,3].
The symptoms and frequent hospitalizations negatively
impact the quality of life of HF patients, [4] with both
physical, social and emotional aspects of their lives and their
life expectancy being significantly reduced [5-7]. However,
avoidance of up to fifty percent of hospital admissions of HF
patients may be achieved when these persons benefit from
better nutrition, better compliance to medication, closer
follow-up by a specialist and more discerning selfobservation regarding worsening of their symptoms [8].
Thus, implementation of a disease management program
(DMP) aiming at controlling risk factors can greatly contribute
to improvement in their quality of life and to reduction of
hospital admissions [9-11].
The assessment of the quality of life of HF patients is an
important aspect in the designing of any intervention
program [12]. These programs promote and improve
patient’s self-care behavior and ability to manage their life in
a better way [13]. In most HF management programs
developed in countries of Europe and America, nursing
personnel were involved and the programs included patient’s
education and early recognition of symptoms of the disease.
Usually these programs are carried out through telephone
intervention, and the patient monitoring is designed for a set
time-period [14]. Reports on these programs show
improvement in the quality of life of HF patients, [15-17] and
reduction of hospital admissions, days of hospitalization and
overall cost [18-24].
Furthermore, data in the literature demonstrated that
telephone intervention positively influenced the emotional 1 Health Science Journal
status of respondents, while its focus on factors that support
routine daily activities, such as managing symptoms,
restriction of fluids, and exercise, was also seen to upgrade
quality of life. Improving the ability of the individual to
function better in daily life is very important for HF patients,
as it enables them to remain active. Moreover, since heart
failure is a condition associated with stress, fear and anxiety,
nursesled telephone intervention provides a sense of
security to a major extent through educating patients how to
act when their symptoms worsen [25]. Knowledge about HF
additionally upgrades their independence, as the patients
discern symptoms and signs of deterioration and are
prepared as to how to react [26].
Telephone support is a cheap, easy and effective
alternative mode of care that is capable of supporting the
individual needs of all patients, especially those in the
transitional period immediately post-discharge from hospital
[27-30]. During this period there is an increased frequency of
relapse in patients’ symptoms, leading to readmissions. Not
only does this place undue stress upon patients but it also
strains countries’ health budgets: e.g. in the USA, frequent
re-admissions of HF patients makes this disease the one with
the highest hospitalization costs [31]. The main components
of a disease management program are nurses, doctors and
specialists highly specialized in HF who undertake the
training of self-care patients and their families. Guidelines
recommend that nurses specialized in HF must be able to
provide the necessary education on medication, diet,
exercise, and weight control, as well as actions to be taken in
the event of worsening symptoms, and must also be able to
follow up patients and their families to seek to ensure
compliance to the course of treatment [32-34].
Many aspects of DMPs still require further research as to
which HF patients will benefit the most from this kind of
intervention and whether the value of the DMP for HF
patients with stable ejection fraction is as clear as that of
people with HF with reduced fraction extrusion [35]. Study Hypothesis
Regular nurses-led telephone intervention in HF patients
may improve the quality of their lives. Material and Methods
Study design
Telephone intervention was conducted in male and female
patients, diagnosed with HF, confirmed by heart ultrasound
and elevated plasma levels of natriuretic peptide BNP.
Patients were randomly allocated into 2 groups. Group A was
the intervention group and group B the control. Prior to and
at the end of the intervention program, all patients in each
group completed the study questionnaire. Patients in both
groups had HF in accordance with the classification NYHA II
and III. Telephone intervention lasted 16 weeks and was 2 ISSN 1791-809X 2016 Vol.10 No.4:5
performed once a week. Each phone intervention lasted
approximately 20 minutes. Study population and sample
The study population was 50 HF patients, male and female.
The sample selection was made irrespective of origin and
marital or socioeconomic status. Two groups of patients were
formed: Group A, the intervention group and group B, the
control. Each study group consisted of 25 patients. Data collection tools
Data was collected via a questionnaire completed by the
patients and included demographic, social data and the scale
"Minnesota Living with Heart Failure Questionnaire"
(MLHFQ), which assessed the quality of the patients’ life
prior to and post the nurses’ telephone intervention.
Completion of the questionnaire lasted about 20 minutes. Place and time of research
The study was conducted in patients in the prefecture of
Ilia in Greece. Ilia is an area inhabited by around 200,000
people in the south-west part of the country. It lasted 16
weeks, from November 2010 to February 2011. Inclusion and exclusion criteria
Patients aged 18 years and over and those who could be
contacted by telephone were eligible for the study, while
those unable to be reached by phone, or under 18 years of
age were excluded from the study. Encoding and statistical analysis
Each question in the questionnaire was transformed into a
variable. The descriptive statistics (percentages) for the
overall sample as well as for each group separately, for both
the first and the second questionnaire were initially
examined. For continuous variables, the observation was
made by the average and standard deviation, while for
continuous variables we used the independent samples ttest. The data were examined for normality with the
Kolmogorov-Smirnov test, while Levene's test was used to
verify the homogeneity of the fluctuations. To examine the
association between demographic variables and the
telephone intervention, the Pearson chi-square test was
used. Data were analysed with the use of the Statistical
Package for Social Sciences (SPSS) Vol. 17. A statistically
significant difference was established when p<0.05. For each
pair of variables, first all the data were initially checked and
then separated according to the first or second interview
and/or group to which each belonged and its re-audited
correlation. The control association was done with the
Pearson chi-square test. This article is available from: www.hsj.gr/archive Health Science Journal Intervention >60
years The telephone intervention was led by 4 nurses. Their
clinical experience ranged from 4-8 years and all worked in
cardiology units. Telephone intervention was performed on a
weekly basis for 16 weeks. Each phone intervention lasted up
to 20 minutes depending on the severity of symptoms and
the type of HF. Participants in group A received
recommendations for the prevention of risk factors.
Specifically, the recommendations focused on understanding
the importance of refraining from smoking, of good control
of blood pressure in hypertensive patients and blood sugar in
diabetics, of maintaining normal body weight, and of
changing dietary habits including avoidance of salt.
Moreover, avoiding increased intake of fluids, limiting alcohol
consumption and preventing malnutrition were also
recommended. The importance of introducing mild daily
exercise was also underlined. Strict consistency in their
medication regime, close observation of their symptoms
(especially breathlessness and fatigue) and the control of
oedema were also stressed. Patients were encouraged to
communicate with the nurses if they had any further
questions. NYHA HF Class Results
Sex, age, marital and educational status, classification of
HF according to NYHA and type of HF, frequency of hospital
follow-up or hospitalization and the unit in which they were
hospitalized for patients in both groups are shown in Table 1.
No difference was observed between the average body
weight of the 2 groups comprising the study population. n 84 18 72 II 10 40 8 32 III 15 60 17 68 Ischemic HF 17 68 15 60 Cardiomyopathy 8 32 10 40 1/month 8 32 6 24 2/ month 8 32 19 76 2+/ month 9 36 Short 10 40 11 44 Cardiology Clinic 14 56 14 56 Heart Unit 1 4 Diagnosis Hospital follow-up frequency Hospitalization Intervention on hospitalizations, weight and quality of life:
in group A, a reduction in the frequency of hospital visits and
the duration of hospitalization were observed (Table 2). In
group B, a relative reduction in the frequency of hospital
visits and the duration of hospitalization were observed. In
group A the mean score on the MLHF scale decreased from
50.88 preintervention to 31.52 post-intervention, whereas in
group B the relevant mean pre-intervention score was 52.40
and the post-intervention 53.80.
Table 2 Effects after intervention.
Intervention group Routine group n % n % 1/month 20 80 8 33.3 2/ month 5 20 16 66.7 2+/ month 0 Group B
% n % Gender
Male 18 72 16 64 Female 7 28 9 36 Hospital Frequency 0 Hospitalization Education
High school or Lower 4 16 2 8 High school graduate 11 44 13 52 University or College 10 40 10 40 Single/Never married 4 16 3 12,5 Married 13 52 14 58,3 Divorced/Separated 8 32 7 29,2 4 16 7 28 Marital Status Age
50-60 years 2016
Vol.10 No.4:5 21 Table 1 Demographic data of the study population.
Group A ISSN 1791-809X Short 22 88 13 52 Cardiology Clinic 3 12 12 48 Heart Unit 0 0 There is a statistically significant difference in total score
on the MLHF scale of patients between the 2 groups
(p<0.001) as shown in Table 3. Α statistically significant
difference was also observed between differences in score
from first and second measurement of patients between the
2 groups, as shown in Table 4 (p<0.001). No correlation
between the NYHA degree with MLHF scale score or marital
status was observed. Table 3 Presentation of a statistically significant difference in scores between the two groups by using the MLHFQ after a
telephone intervention at 16 weeks. © Copyright iMedPub 3 Health Science Journal SCORE 2016 ISSN 1791-809X Group N Mean Std. Deviation Std. Error Mean Interv 25 315,200 301,552 0,60310 Routin 25 538,000 264,575 0,52915 Vol.10 No.4:5 T-test for Equality of Means
95% Confidence
Interval
of
Difference SCORE Equal variances
assumed T df p Mean Difference Std.
Difference -27,769 48 <0,001 -2,228,000 0,80233 the Error
Lower Upper -2,389,319 -2,066,681 Table 4 Comparison of pre-test and post-test scores. diff Group N Mean Std. Deviation Std. Error Mean Interv 25 -19,36 7,251 1,450 Rout 25 1,40 2,582 0,516 T-test for Equality of Means
95% Confidence Interval of the
Difference diff Equal variances
assumed not T df p Mean Difference Std.
Error
Difference Lower Upper -13,486 29,99 <0,001 -20,760 1,539 -23,904 -17,616 Discussion
Our study shows that the nurses’ telephone intervention
program has a positive effect on quality life of HF patients
NYHA II and III as evident by the total score in the MLHF scale
between the two groups. In line with our findings are data in
the literature also demonstrating similar results [36-39].
Improvement in the quality of life in the intervention group
which delayed re-hospitalization only for the first six months
and did not last more than twelve months was reported by
other studies [40,41]. Taken together, telephone intervention
programs appear to reduce the risk factors [42] and have a
positive effect on self-care [43]. The quality of life is
significantly improved when programs add education on
selfcare [11,44].
Regarding the impact of the intervention programs on
patients’ depression, conflicting results have been reported so
far. Some report decreased depression, [45] while other
studies noted no differences [30,46]. On the other hand,
there were no statistically significant differences in studies
that showed that the telephone support of patients is
feasible, [27] the score on the MLHF scale decreased and the
program seemed to be effective in patient outcomes [47]. In
other studies where the quality of life was assessed with the
MLHF scale, no significant differences were observed in the
total scores between groups, [48,49] while in the present
study we found significant differences in quality of life
between the two groups (p<0.001).
This can possibly be explained by the fact that the majority
of study patients [48] were quite stable, as opposed to other
studies where the patients were unstable, as for example 4 immediately on discharge from the hospital after treatment
and up to two weeks subsequently [18,50,51]. This may affect
the results and possibly explains why the telephone
intervention by nurses did not improve their quality of life.
The telephone intervention program implemented in stable
patients with HF seemed to improve their quality of life on
the MLHF scale [52,53]. Modern interventional heart
rehabilitation programs, incorporating systematic training and
information imparted to patients and which provides support
and counselling have a significant impact on improving the
quality of life and psychosocial factors.
In this study the incidence of hospital visits is frequent
before the intervention, an issue also noted by other studies
[54-56]. After completion of the intervention program, most
patients visited the hospital only once a month, while before
the intervention more than one third of the sample group
visited hospital more than twice. These findings are
consistent with a study which showed reduced readmissions
after the intervention program, though not considerably, [47]
while another study did not reveal any statistically significant
differences [57].
It is noteworthy that in the intervention group of this study,
readmissions were greatly reduced, but there is no statistical
correlation between the frequency of visits to the hospital
with the intervention. In other studies, there is a significant
reduction in hospitalization rates and readmission time but
without significant improvement in quality of life or mortality
rates [9,11,58,59].
The average weight of patients in the intervention group
decreased during the study period, in contrast to patients’
This article is available from: www.hsj.gr/archive Health Science Journal
weight in the routine group which increased, but neither
reached statistical significance. Similar results have been
reported in another study [38]. Other authors found that
there was no relationship between quality of life and sex, [60]
while in another study differences were observed in how
patients experience heart failure, with men showing social
isolation as opposed to women who experience feelings of
fear [61]. A study in which women evaluated the quality of
their life more negatively and showed signs of depression
displayed similar findings. Additionally, in other studies
women evaluated their quality of life more negatively in
comparison to men regarding their everyday lives and social
activities [62-64].
Regarding age, the findings from different studies are
conflicting as far as the relationship between age and quality
of life is concerned and indicate that older patients do not
necessarily experience a poorer quality of life. An older
patient with heart failure is commonly found to enjoy a
greater general satisfaction towards life and the fulfillment of
objectives and dreams [65]. From our data analysis, this study
found that 85% of the patients were over 60, a finding
consistent with contemporary literature which argues that the
prevalence of disease increases with age. The progressive
aging of the population today, a global phenomenon of
unprecedented proportions, will affect the incidence of heart
failure over the coming years [66]. In other studies, there was
no relationship between quality of life with sex, age, marital
status and education [18,38], as the findings in this study have
shown.
Primary school graduates and pensioners experienced
more negative emotions than those of higher education and
employees. Perhaps this finding may be related to age, since
pensioners, as is known, are aged >65 years and the extent of
their independence is limited. They may need help from
another person to access hospital, they face difficulties in
performing daily activities and they are likely to have low
economic resources, all of which results in the negative
evaluation of their quality of life [65-67].
A low level of education also seems to be responsible for
the high rate of hospital readmissions [68]. The NYHA
classification has a significant impact on the quality of life of
patients with HF. In the present study this is not seen, as
there is no significant statistical relationship with the score
from the MLHF scale after the intervention. However, in other
studies the higher the level of NYHA the poorer the quality of
life of the patient [38]. These results are in accordance with
other studies, [69-72] which observed that as the degree of
their independence lessened, so much more negative was
their view of the quality of life. Another study intervention
program showed that patients with NYHA I and II exhibited an
improvement in the quality of life after the intervention in
contrast to patients with NYHA III [37].
From the aforementioned it is concluded that the more
advanced the stage of heart failure and impaired functional
capacity, the greater the restrictions upon the degree of
independence become, even in routine daily activities
© Copyright iMedPub ISSN 1791-809X 2016 Vol.10 No.4:5
performed by the individual, thus leading the individual to
negatively evaluating their quality of life. Conclusions
Heart failure continues to be an epidemiological,
diagnostic, prognostic, therapeutic, and socioeconomic
challenge. Despite the significant progress in heart failure
therapy, prognosis and quality life of patients is still poor. Our
results showed that the quality of life of patients with type
NYHA II and III improved significantly after the nurses’
telephone intervention program. However, apart from
improving the quality of life as reflected through MLHFQ scale
there were no further significant statistical correlations. Limitations of the Study
The main limitation of this study is the relatively small
sample, thus, due to its size it is difficult to generalize the
findings. Another limitation to the internal validity is that the
method of pre-test/post-test which the study provided may
have given some participants the opportunity to deliberately
change their answers. This would especially apply to those
who knew they belonged to the intervention group and that,
by influencing the study results, they could justify the effort
and the time which nurses dedicated to them. Nevertheless,
despite the limitations the results show improved quality of
life through the program, and this should be the starting point
for further research on this topic. Recommendations
Effective programs such as these can be adopted by all
national health systems. It is proposed that the program staff
should be experienced nurses specialized in the subject of
heart failure. Their provision of recommendations will result
in the avoidance of hospital readmissions and the
improvement of both the quality of life of the patients living
with HF as well as a cost reduction in hospitalization. More
research is needed over time to further evaluate this issue. References
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