Introduction
Heart failure remains one of the most important cardiovascular diseases, posing a major public health challenge worldwide, and may develop in up to one in five individuals during their lifetime (1). Heart failure (HF) may be regarded as a disease with a malignant prognosis comparable to that of the most common cancers, and if left untreated, its prognosis is similarly poor (2).
According to the 2021 European Society of Cardiology (ESC) Heart Failure Guidelines, all patients with HF should be enrolled in a multidisciplinary HF management programme (Class I recommendation, Level of evidence: A) (3). Within this model of care, not only is the management of HF itself of strategic importance, but also the early recognition and effective treatment of comorbidities, in which the involvement of and collaboration with allied specialties also play a key role (4). The Guidelines further emphasize that all patients with HF should be educated in self-care to improve mortality and prevent hospitalization for HF. According to the literature, adequate self-care may reduce the risk of HF-related hospitalization by as much as 20%, while significantly improving quality of life as well (5).
Based on the 2021 ESC Heart Failure Guidelines and the 2021 practical management recommendations of the ESC Heart Failure Association, there is no doubt that patient education must become an integral component of comprehensive care (3,6). However, several practical issues regarding its implementation remain unresolved in contemporary practice, including the educational methodology and structure of the material to be delivered.
Objectives
Our study aimed to analyze the effectiveness of the structured patient education programme implemented by our Working Group on Heart Failure among patients hospitalized for HF at the Heart Failure Unit of the Department of Adult Cardiology of Gottsegen National Cardiovascular Center who had not previously received structured patient education. Specifically, we aimed to assess its impact on HF-related knowledge, recognition of emergency conditions, self-care awareness, and the long-term persistence of this knowledge using the European Heart Failure Self-care Behavior scale (EHFScB-9).
Methods
THE STRUCTURED PATIENT EDUCATION PROGRAMME
In this retrospective observational study, we analyzed data from the first 164 consecutive patients hospitalized for HF and participating in a structured patient education programme at the Heart Failure Unit of the Department of Adult Cardiology of our tertiary cardiology centre, Gottsegen National Cardiovascular Center between 1 June 2023 and 1 July 2024. The study was approved by the National Scientific and Ethical Committee of Hungary (approval number: BM/27849-3/2024) and was conducted in accordance with the ethical principles of the Declaration of Helsinki.
During the structured patient education programme, patients, together with their relatives, participate in an approximately 60-minute interactive lecture jointly led by ESC-certified HF specialists and a specialist nurse dedicated to HF care. This is followed by a discussion that addresses questions and problems that may arise regarding this material. Topics covered include the main HF-related concepts relevant to everyday life; the importance of attending follow-up visits and scheduled investigations; the acquisition of self-care principles; various treatment options of strategic importance and related questions; and preventive issues. During both the lecture and the subsequent discussion, particular emphasis is placed on HF-related clinical situations that may occur in daily life and should be regarded as emergencies requiring prompt medical consultation or even immediate medical attention.
Patients’ knowledge of HF and the effectiveness of the structured patient education programme are routinely assessed using a questionnaire-based approach. For this purpose, we use an 11-item single-choice questionnaire developed by our Working Group on Heart Failure, before and after the educational session. The long-term persistence of this knowledge is routinely assessed at follow-up visits, 3 months after the education by repeated completion of the questionnaire (7), together with the administration of the internationally validated 9-item EHFScB-9 (8).
STATISTICAL ANALYSIS
Clinical data were extracted from our institutional information system and recorded in anonymized form in a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). Statistical analyses were performed using IBM SPSS Statistics version 26.0 (International Business Machines Corporation, Armonk, NY, USA). Continuous variables are presented as median and interquartile range, given their non-normal distribution, whereas categorical variables are reported as percentages. The Wilcoxon signed-rank test was used to compare total scores of the 11-item single-choice questionnaire obtained before and after the education, as well as before the education programme and at 3-month follow-up. Statistical significance was defined as p < 0.05.
The total EHFScB-9 score was transformed to a 0–100 scale using the following formula: ([45 – total EHFScB-9 score] × 2.777), with a score ≥70 indicating adequate self-care according to the literature (9-11). Wagenaar et al. defined this cut-off based on a similar construct, the 100-point standardized Self-Care of Heart Failure Index, in which adequate self-care was defined as a score of 70 or higher (9,12). Predictors of optimal self-care, as defined by the EHFScB-9, were analyzed using logistic regression. In univariable logistic regression analysis, the combination of p < 0.05 and an odds ratio (OR) ≠ 1 was considered statistically significant.
Results
MAIN CLINICAL CHARACTERISTICS OF THE STUDY POPULATION
A marked male predominance was observed in the study population (male sex: 78%), and the median age was 56 [47–64] years (Table 1). The cohort was characterized by multimorbidity, with 61% of patients having ≥2 comorbidities. At hospital discharge, the median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was 1578 [600–2983] pg/mL. Median left ventricular ejection fraction (LVEF) was 27 [20–35] %, and 84% of the cohort belonged to the HFrEF category. A total of 44% of patients had previously been hospitalized for HF, while 37% were diagnosed with de novo HF.
At discharge, a substantial proportion of the cohort received neurohormonal antagonist therapy: 97% received a renin–angiotensin system inhibitor (RASi: angiotensin-converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI]), 92% a beta-blocker (βB), and 91% a mineralocorticoid receptor antagonist (MRA); accordingly, 84% were receiving triple therapy (RASi [ACEi/ARB/ARNI] + βB + MRA). Sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy with dapagliflozin or empagliflozin was prescribed in 85% of patients, and quadruple therapy (RASi [ACEi/ARB/ARNI] + βB + MRA + SGLT2i) had been initiated in 76% by the time of discharge. Cardiac resynchronization therapy (with pacemaker/defibrillator [CRT-P/CRT-D]) was present in 9% of the cohort, while 19% had an implantable cardioverter-defibrillator (ICD; without CRT-D) at hospital discharge.
RESULTS
Following the patient education programme, a marked improvement was observed in the scores on the 11-item questionnaire developed by our Working Group on Heart Failure (9 [8–10] vs. 11 [11–11] points, p<0.001; before vs. after education), and this persisted at 3-month follow-up, indicating the durable retention of the educational content (9 [8–10] vs. 11 [11–11] points, p<0.001; before education vs. 3 months after education) (Figure 1).
At 3 months of follow-up, the median total EHFScB-9 score was 13 [11–16], which corresponded to a median score of 89 [81–94] after transformation to the 0–100 scale. A total of 86% of the cohort achieved an EHFScB-9 score ≥70 (Figure 2), thus confirming optimal self-care.
According to univariable logistic regression analysis, optimal self-care as defined by the EHFScB-9 was not influenced by patient characteristics, including age, sex, educational level, family involvement and participation in the patient education programme, comorbidities, de novo diagnosis of HF, and LVEF (Figure 3).
Discussion
The optimization and sustained maintenance of therapy in patients with HF remain major challenges in everyday clinical practice (13,14). There are multiple points at which intervention may optimize care and maintain treatment over time; among these, one of the most important, simplest, and yet strategically most relevant elements is appropriate patient education (15).
A meta-analysis published in 2024 that included data from 5446 patients demonstrated that patient education programmes involving specialist HF nurses also improve prognosis and may reduce HF rehospitalizations by as much as 25% (16). An analysis by the Working Group on Heart Failure of the Central Hospital of Northern Pest-Military Hospital likewise confirmed that multidisciplinary care provided at a Heart Failure Outpatient Clinic with the involvement of a specialist HF nurse had a marked prognostic impact; in a propensity score-matched analysis, the composite endpoint of 1-year all-cause mortality and all-cause hospitalization was reduced by as much as 37.5% (17). These findings further support the strategic importance of comprehensive patient education and multidisciplinary care delivered in dedicated HF outpatient settings with the involvement of specialist HF nurses.
According to everyday clinical experience, patients’ knowledge of HF is frequently inadequate, and a substantial proportion of patients have very limited awareness of optimal self-care behaviors and activities. It is common for patients not to possess the knowledge necessary to recognize worsening HF. Likewise, it is not uncommon for them to be unaware of the basic goals of therapy, the medications prescribed, their dosages, and the strategic importance of these (18-20), which often constitutes a barrier to long-term treatment persistence, in addition to perceived or actual adverse drug effects (21). According to the literature, even after patient education, patients often do not consider their knowledge of HF adequate. This is also supported by a previous analysis by our Working Group on Heart Failure, in which all patients considered the complex patient education programme useful (7), even though 60% of the cohort had previously been diagnosed with HF. This further underscores the indispensable role of the broad, practical implementation of structured, comprehensive patient education programmes in the care of patients with HF. An important component of the structured patient education programme is self-care and the effective acquisition of related tasks. As previously demonstrated by our Working Group on Heart Failure (7), following the educational programme, more than three times as many patients regularly performed daily self-care activities.
The 2021 ESC Heart Failure Guidelines and the 2021 practical management recommendations of the ESC Heart Failure Association do not provide detailed, explicit guidance on the practical implementation of self-care education; for example, on the most appropriate educational models or materials (3,6). Telemedicine, digital health tools, and integrated patient education may substantially improve the effectiveness of self-care (22). In the SMART-HF study published in 2022, the impact of a tool suitable for home symptom monitoring, interactive education, and diuretic dose optimization was evaluated (23). Patients who used the tool demonstrated significantly better self-care behavior, as measured by EHFScB-9 scores, than the control group, and the number of days requiring hospital treatment for HF was also significantly reduced. Abbasi et al. compared a combined-method educational approach (face-to-face education, slide presentation, video demonstration, and problem-solving tasks) with an exclusively multimedia-based digital educational method applicable in the home environment. The authors found that the combined -method approach produced the greatest improvement in patients’ self-care behavior (24). It is also important to emphasize that self-care may be improved not only by the quantitative aspects of education, such as the number or duration of sessions, but also by the quality and content of the educational intervention (25).
The assessment of effective self-care may be challenging in routine practice (26). Questionnaires assessing disease-related knowledge are often highly complex, and their accurate completion may only be feasible in patient populations with higher baseline knowledge, which greatly limits their universal applicability (19). Based on the results of our Working Group on Heart Failure’s 11-item single-choice questionnaire, the educational method used in our study population was effective in improving both self-care and HF knowledge.
The internationally validated 9-item EHFScB-9 may serve as a useful tool for assessing conscious self-care behavior and the effectiveness of self-care education (8). According to the literature, after transformation to a 0–100 scale, a score ≥70 may indicate adequate self-care (9-11). Using the earlier 12-item version of this scale, Pulignano et al. demonstrated that patients with HF who received HF education exhibited more favorable self-care behavior than those who did not (27). In the present analysis, based on the EHFScB-9 results, 86% of our patients showed adequate self-care 3 months after education. In a secondary analysis of the COACH-2 study, sustained optimal self-care was observed in 52% of patients over 12 months, defined similarly to the present study, based on an EHFScB-9 score of below 70 (10).
The effectiveness of self-care and education aimed at improving it may be influenced by several factors, including the individual clinical characteristics of the patient — such as age, cognitive function, or the presence of comorbidities — as well as the complex interactions between disease-related and environmental factors (28-30). Social isolation and longer disease duration in older patients may also adversely affect conscious decision-making related to self-care (30). According to the analysis by Kamrani et al., in their elderly HF patient population assessed with the 12-item EHFScB, 80.5% of patients did not weigh themselves daily or did so inadequately, 89.7% did not receive an annual influenza vaccination or did so inadequately, and 55.4% reported that they did not notify their physician appropriately in the event of sudden weight gain (31). Similar findings were reported by Niriayo et al.; in their analysis, 71.5% of patients did not weigh themselves daily, while 75.6% did not contact their physician in the event of sudden weight gain (11). In that study, rural residence, illiteracy, polypharmacy, and previous hospitalization were all predictors of inadequate self-care, the latter further emphasizing the importance of using HF hospitalization as an opportunity to improve patient knowledge. Frailty, defined in the 2021 ESC Heart Failure Guidelines as a multidimensional and dynamic condition conferring increased vulnerability to stressors irrespective of age, may also adversely affect self-care behavior (3,29,32). Multimorbidity is another factor that may unfavorably influence self-care behavior and disease outcomes (4,28,31). In our analysis, 61% of patients had at least two comorbidities, illustrating the complexity of the studied cohort. Although differences between study populations hamper direct comparison with international data, it is noteworthy that in the Swedish Heart Failure Registry (SwedeHF), where the median age was considerably higher at 76 years, 61.2% of patients had at least four comorbidities (33).
Patients’ motivations, habits, cultural beliefs and values, previous experiences and capabilities, as well as their access to healthcare, may all substantially impact the effectiveness of self-care (34). Bahrodi et al. identified inadequate family support as a cause of suboptimal self-care (35), which further highlights the importance of involving family members in the structured patient education programme, in line with the methodology applied in our model. In addition to greater social support, higher educational attainment and greater confidence related to health awareness may also favorably influence self-care and quality of life (36). Based on the results of our logistic regression analysis, under the educational model applied by our group, patient characteristics, including age, educational level, and comorbidities, did not influence self-care behavior or the effectiveness of self-care education at 3-month follow-up. These findings suggest that effective self-care can be achieved in a broad spectrum of patients.
LIMITATIONS
Our study is limited by the relatively small sample size and short follow-up duration. The 11-item single-choice questionnaire developed and used by our Working Group on Heart Failure has not undergone external validation, which may limit its universal applicability. Our single-centre analysis included individuals of Caucasian ethnicity exclusively; therefore, our results and conclusions cannot be reliably extrapolated to other ethnic groups. Furthermore, only patients hospitalized at the Heart Failure Unit of the Department of Adult Cardiology of our tertiary cardiology centre were analyzed, which may have resulted in a specific patient population. Owing to the study design, the present analysis was not intended to assess the prognostic impact of the structured patient education programme or its effect on medication adherence.
Conclusions
Structured patient education programmes and self-care optimization can play an unquestionable role in the long-term management of patients with HF.
Our results indicate that structured patient education leads to a significant improvement in patients’ knowledge, and that this knowledge is durably retained (Figure 4). Based on the 3-month follow-up results assessed using the EHFScB-9, 86% of patients demonstrated adequate self-care following the structured patient education. Self-care was not influenced by patient characteristics, including age, educational level, and comorbidities, which supports the broad applicability of such programmes.
