Background
Chronic heart failure (HF) is a common, disabling and fatal medical condition [
1]. In view of the aging population it will affect even more people in the future [
2]. It requires multidisciplinary management programs including patient education concerning self-care/self-management [
3‐
5]. Self-management includes management of symptoms, treatment, consequences and lifestyle changes implicated by HF and aims to maintain quality of life [
6]. For patients with HF, self-monitoring and responding to changes in symptoms are central components of self-management. The situation-specific theory of heart failure self-care [
7,
8] states that self-care is a decision-making process, which involves maintenance (treatment adherence and healthy behavior), symptom perception and management (response to symptoms). Self-management interventions proved to be effective with regard to knowledge, self-efficacy, self-management behavior, quality of life, hospitalization, and mortality [
9‐
11]. Thus, self-management is considered the central outcome of such programs and a means to achieve other important outcomes [
5,
12]. Self-management can be conceived of as an important proximal outcome of patient education that is a necessary (but not sufficient) prerequisite for the achievement of more distal goals as course of disease, quality of life or social participation [
13]. Furthermore, in addition to improving self-management skills during treatment, it is important for patients to sustain and apply the acquired skills after treatment.
Studies have shown that quality of life in HF patients is reduced compared to the general population or patients with other chronic conditions [
14‐
16]. Furthermore, depression is common among patients with HF and worsens the prognosis [
17‐
19]. Therefore, both quality of life and depressive symptoms are considered important distal outcomes in patients with HF.
However, the relations between proximal and distal outcomes of self-management programs have rarely been studied so far. For example, there is no evidence yet that in patients with HF improvement in self-management is actually associated with subsequent improvement in quality of life. Most studies only report separate effects on different proximal and distal outcomes without relating them to each other [
10,
11,
20], e. g., without examining whether improvements in knowledge or self-care lead to improvements in quality of life. Two cross-sectional studies showed that self-care behavior (in contrast to self-care confidence) was not associated with higher quality of life in patients with HF [
21,
22]. However, these studies did not take into account changes in self-care or quality of life. According to the situation-specific theory of heart failure self-care [
7,
8], one study tested whether there were different patterns of change in HF self-care management and whether these were associated with different patterns of change in quality of life over six months [
23]. Results show that those who improved in self-care management over time also improved in quality of life. However, the study did not include an intervention and investigated concurrent rather than subsequent changes in outcome variables. In a previous study in patients with different chronic disorders, we showed that short-term changes (before/after inpatient rehabilitation including patient education) in self-reported self-management skills predicted 3-months changes in quality of life and depressive symptoms [
24]. The purpose of the present study was to examine whether similar relationships are found in patients with HF and to extend the follow-up period. Particularly, this study investigated whether patients with HF who report an increase in self-reported self-management skills both directly after inpatient rehabilitation including self-management education and after six months show a subsequent increase in quality of life and a decrease in depressive symptoms after both six and twelve months. We hypothesized (1) that the difference of self-reported self-management skills between start and
end of rehabilitation (duration 3 weeks) predicts the difference of both quality of life and depressive symptoms between start of rehabilitation and follow-up measurements six and twelve months later. We further hypothesized (2) that the difference of self-reported self-management skills between start of rehabilitation and
follow-up after six months predicts the difference of both quality of life and depressive symptoms between start of rehabilitation and follow-up after twelve months.
Discussion
To our knowledge, this is the first study that examined the associations between change in self-reported self-management skills and subsequent change in quality of life and depressive symptoms in patients with HF undergoing inpatient rehabilitation including self-management patient education. Results show that changes in self-management skills predict changes in these distal outcomes. Concerning hypothesis 1, results differ between outcomes. Short-term change in self-reported self-management skills (between start and end of rehabilitation) predicted long-term change in physical quality of life (between start of rehabilitation and follow-up twelve months later), but not intermediate-term change (after six months). By contrast, it predicted intermediate-term, but not long-term, change in mental quality of life. Finally, it did neither predict intermediate nor long-term change in depressive symptoms. Thus, hypothesis 1 was only partly confirmed. Regarding hypothesis 2, the picture is consistent: Intermediate-term change in self-reported self-management skills (between start of rehabilitation and follow-up after six months) predicted long-term changes in all three outcomes (between start of rehabilitation and follow-up after twelve months). Thus, hypothesis 2 was confirmed.
The results are in line with Musekamp et al. [
24], but not only confirm the prior findings in a HF sample but also expand them with regard to the follow-up period. Although there may be differences in concrete self-management activities between different conditions, increase in self-reported self-management skills is associated with subsequent increase in quality of life and decrease in depressive symptoms regardless of condition. These results are consistent with definitions of self-management and models of patient education in patients with chronic conditions in general suggesting such relationships between self-management skills and quality of life [
6,
13]. They are also consistent with the propositions of the situation specific theory of heart failure self-care [
8]. Together, they support the importance of self-management in HF patient education [
4,
5].
Our results suggest that, in patients with HF, the acquirement of self-management skills during self-management education may have a long-term influence on physical quality of life and an intermediate-term influence on mental quality of life. Thus, improved self-management skills may influence mental quality of life more directly, because they immediately convey a sense of exerting control. Physical quality of life may be influenced in a delayed (but more sustainable) fashion, however, because it takes more time to influence physical conditions. For example, it takes some time until the appropriate reaction to HF symptoms affects the physical condition and the individual takes notice of this improvement. For the long-term changes in mental quality of life and depressive symptoms the baseline level of self-management skills seems a better predictor than the short-term change in self-management skills.
Changes in self-reported self-management skills were not only observed immediately after rehabilitation, but also after six months, with medium effect sizes. Thus, the aim of rehabilitation and self-management patient education to sustain self-management skills in everyday life was reached. Interestingly, change of self-management skills up to six months after rehabilitation seems to influence further change in distal outcomes. Thus, it is not only important to increase self-management skills during self-management education, but also to sustain them afterwards. This emphasizes the importance of fostering self-management skills that can be applied and sustained after treatment. Self-management programs should therefore have a strong focus on everyday life and implement aftercare plans.
However, it remains unclear, whether changes in distal outcomes are initiated by self-management education alone or also by other processes or events coming into effect during the follow-up period. This might for example include events like job changes or retirement.
Further studies should investigate treatment mechanisms of self-management patient education, as they are still unclear [
44]. The causal pathway between self-management skills and quality of life needs further examination. It should be examined whether the influence of self-management skills is mediated by actual self-management/self-care behaviors, such as symptom monitoring and responding to symptoms or health behaviors, such as adherence to medication or moderate physical activity [
4,
8]. These variables should be included in future models to clarify the effects of self-management skills and other potential predictor variables. Others [
45] have investigated the effect of improvement in knowledge after a nurse-led education session on clinical outcomes and found associations with reduced hospital readmissions. On the other hand, knowledge alone may not be sufficient to establish adequate self-care [
46]. Therefore, it should be investigated how knowledge and skills work together in establishing adequate self-management behavior and quality of life.
Limitations
There are some limitations that should be considered. First, while longitudinal associations were examined, causality cannot be proved due to the non-experimental design of our study.
Second, the scale used to assess self-management skills is generic in nature and possibly does not cover all self-management skills important for patients with HF as symptom-monitoring [
3]. Thus, our scale might not be specific enough to cover more than general expectations about self-management. Further studies should explore whether specific measures of self-management skills in HF add to prediction of distal outcomes. Third, it was based on self-report and thus susceptible to bias. However, it is difficult to implement objective measures of self-management. Fourth, possibly confounding factors influencing the course of both quality of life and depressive symptoms after self-management education were not taken into account in this study. For example, trait factors like dispositional optimism might influence assessment of both self-management skills and quality of life [
47].
Acknowledgements
The authors wish to thank the participating rehabilitation clinics: Rehabilitation Hospital Kirchberg-Klinik (Dr. Ernst Knoglinger), Rehabilitation Hospital Möhnesee (Dr. Rainer Schubmann), Rehabilitation Hospital Wetterau (Dr. Ulrich Kiwus), Segeberger Kliniken GmbH, Rehabilitation Hospital (Dr. Ronja Westphal), which supported the evaluation of the program.