Nursing Research and Practice / 2013 / Article / Tab 1

Review Article

Cardiovascular Disease Self-Care Interventions

Table 1

Description of nurse-led CVD self-care interventions.

Study and locationSample (as reported)Intervention/controlPrimary outcomes and measurementKey findings

Albert et al. (2007); USA [18]N = 112
Gender: males n = 86
Ethnicity: Caucasian n = 93
CVD diagnosis: HF
Attrition not reported
IG: multimedia (video education)
CG: standard education by physician and/or nurse
Healthcare resource utilization: hospitalization, emergency care, office visits, and laboratory tests medical records
Self-care/adherence: adapted from SCHFI
Functional class: NYHA status change
Timeframe: baseline, 3 m
(1) 3-month healthcare utilization (P = NS)
(2) IG had greater sign/symptom recognition (P < .04) and higher mean self-care behavior/adherence (P < .01)

Artinian et al. (2003); USA [19]N = 18
Gender: males n = 17
Ethnicity: Black n = 11
Caucasian n = 6
CVD diagnosis: HF
Attrition not reported
IG: web-based monitoring
CG: usual care
Self-care: HFSCBS
Medication adherence: pill counts
QOL: MLHF
Timeframes: baseline, 3 months
(1) Improved QOL in IG (F = 10.0, P = .006), (P = .002); not CG (P = .113)
(2) Better adherence in IG versus CG (P = NS)

Barnason et al. (2006); USA [20]N = total 50
Gender: males n = 28
Ethnicity not reported
CVD diagnosis: CHD
Attrition not reported
IG: combined intervention of telemonitoring and home visit
CG: usual care
QOL: SF-36
Healthcare utilization: emergency care
Timeframe: baseline, 6 weeks, 3 m
(1) IG had higher QOL general health functioning (F = 8.41, P < .01)
(2) Significant time effects in QOL physical (F = 9.42, P < .01), role-physical functioning (F = 5.74, P < .05) in both groups
(3) CG had more ER visits (NS)

Barnason et al. (2009); USA [21]N = 55
Gender: males n = 46
Ethnicity: White n = 54, nonwhite n = 1
CVD diagnosis: CHD
Attrition not reported
IG: telehealth intervention
CG: usual care
QOL: SF-36
Physical activity/energy expenditure: RT3 accelerometer
Timeframe: baseline, 3 w, 6 w, 3 m, 6 m
(1) Significant main effect by group in energy expenditure/physical activity (F = 4.66, P < .05)
(2) Both groups had significantly improved QOL P < .05)

Brandon et al. (2009); USA [22]N = 20
Gender: males = 9
Ethnicity: Caucasian n = 8, African American n = 12
CVD diagnosis: HF
Attrition not reported
IG: nurse-led telephone intervention (7 telephone calls, 5–30 minutes in length)
CG: usual care with standard education by physician and/or nurse
QOL: MLHF
Self-care: Self-Care Behavior scale
Healthcare utilization: self-report hospitalizations
Timeframe: baseline, 3 m
(1) IG improved self-care behaviors (F = 21.853, P < .001) and reduced hospital readmissions (F = 7.63, P = .013)
(2) QOL in IG improved P = NS; no change in UC

Caldwell et al. (2005); USA [23]N = 36
Gender: males n = 25
Ethnicity: white n = 34, other = 2
CVD diagnosis: HF
Attrition n = 11
IG: combined intervention: focused education and counseling with telephone follow-up
CG: usual care
Self-care: EHFScBS
Biomarkers: BNP
Timeframe: baseline, 3 m
(1) Self-care improved significantly in IG (P = .03)
(2) No significant difference in BNP levels (P = .21)

DeBusk et al. (2004); USA [24]N = 462
Gender: males n = 236
Ethnicity: white n = 386, Black n = 27, Hispanic n = 14, American Indian n = 27, Asian n = 8
CVD diagnosis: HF
Attrition n = 72
IG: telephonic case management
CG: usual care
Healthcare utilization: HF and all-cause hospitalizations medical claims
Timeframe: baseline, 12 m
(1) HF rehospitalization similar in both groups (NS) (proportional hazard, 0.85 (95% CI = 0.46, 1.57))
(2) All-cause rehospitalization NS (proportional hazard, 0.98 (95% CI = 0.76, 1.27))

Dougherty et al. (2005); USA [25]N = 168
Gender: males n = 139
Ethnicity: Caucasian n = 150, American Indian/Alaska n = 3, Asian/Pacific Islander n = 4
CVD diagnosis: arrhythmia
Attrition n = 18
IG: combined intervention: self-care management patient education, telephone, and clinical support
CG: usual care
QOL: SF-36
Depression: CES-D
Healthcare utilization: outpatient visits, hospitalizations, and emergency care
Timeframe: baseline, 6 m, 12 m
(1) Improved mood in IG (P = .04) compared to CG
(2) No statistically significant differences between the groups on total outpatient visits, hospitalizations, or ER visits over 12 months

Gallagher et al. (2003); Australia [26] N = 196
Gender: 196 females
Ethnicity not reported
CVD diagnosis: CHD
Attrition not reported
IG: combined intervention: telephone intervention with behavioral focus
CG: usual care
Depression: Hospital Anxiety and Depression Scale
Timeframe: baseline, 12 w
(1) No significant differences in anxiety (F = 0.15, P = .69) or depression (F = 0.11, P = .74) between groups

Gould (2011); USA [27]N = 154
Gender not reported
Ethnicity not reported
CVD diagnosis: CHD
Attrition n = 25
IG: combined intervention: discharge nursing intervention with telephone follow up (IG, n = 64)
CG: usual care
Adherence: Morisky adherence
Healthcare utilization: urgent care
Timeframe: baseline, 3 days
(1) No significant group differences were found on medication adherence, or use of urgent care

Harrison et al. (2002); Canada [28]N = 192
Gender: males n = 105
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 8
IG: combined intervention: transition/discharge care: educational materials, telephone, and home visits
CG: usual care included home visits
QOL: MLHF, SF-36
Healthcare utilization: emergency care, readmission rates (medical records)
Timeframe: baseline, 6 weeks, 12 weeks
(1) IG: improvement in QOL (27.2 ± 19.1) compared to the CG (37.5 ± 20.3; P = .002)
(2) Less emergency room use in transitions group compared to CG (P = .03) but no change in readmission rates

Holmes-Rovner et al. (2008); USA [29]N = 525
Gender: males n = 191
Ethnicity: Non-Hispanic white n-443, African American n = 60, Hispanic White n = 12
CVD diagnosis: CHD/acute coronary syndrome
Attrition n = 152
IG: telephonic intervention with behavioral focus
CG: usual care
Functional status/physical activity: Duke Activity Status Index
BP
Timeframe: baseline, 3 m, 8 m
(1) IG showed higher physical activity (OR = 1.53, P = .01) during the first three months
(2) No significant differences in functional status or QOL

Jaarsma et al. (2000); the Netherlands [30] N = 179
Gender: males n = 79
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 47
IG: combined intervention of education, telephone, and home visits (6 encounters)
CG: usual care
Self-Care: HFSCBS
QOL: Cantril’s Ladder
Timeframe: baseline, 1 m, 3 m, 9 m
(1) Self-care behaviors improved in IG (1 m (t = 3.3, P < .001), 3 m (t = 2.9, P < .005) but not sustained at 9 m (t = 0.7, P = .47))
(2) QOL in both groups at 3 m not sustained at 9 m
(3) Limited effect of self-care on QOL (r = 0.24, P < .05)

Kutzleb and Reiner (2006); USA [31]N = 23
Gender: males = 8
Ethnicity not reported
CVD diagnosis: HF
Attrition not reported
IG: combined intervention: individualized education and counseling with telephone follow-up
CG: usual care: protocol driven medical care
QOL: Ferrans and Powers QOL Index
Functional status: 6-minute walk test
Timeframe: baseline, 12 m
(1) IG: improved QOL (F = 3.569, P <.000)
(2) IG: functional capacity NS (F = 0.228, P = .949)
(3) Between-group NS

LaFramboise et al. (2003); USA [32]N = 90
Gender: males = 45
Ethnicity: Caucasian n = 75, African American n = 12, other n = 3
CVD diagnosis: HF
Attrition not reported
Combined intervention
Group 1: Telephonic only
Group 2: Home visit only
Group 3: Telemonitoring
Group 4: Home visit and Telemonitoring
*All groups also received structured HF disease management 5 encounters
Functional status: 6-minute walk test
Self-efficacy: BEES-HF
Depression: Geriatric Depression Scale
QOL: SF-36
Timeframe: baseline, 2 m:
(1) Group by time effect significant (P = .0027) in self-efficacy only
(2) Improved functional status (P < .01), HRQL (P < .05), and depression (NS) in all groups

Lorig et al. (2003); USA [10]N = 551
Gender: males n = 113
Ethnicity: U.S. born n = 31 Mexican born n = 353, Central American born n = 121, South American born n = 36
CVD diagnosis: CHD
Attrition not reported
IG: group-based, peer-led community-based program
CG: usual care
Healthcare utilization: emergency care, hospitalizations,
Timeframe: baseline, 6 w, 4 m, 12 m
(1) IG had fewer emergency room visits (P < .05) at 4 m and 1 year (P < .001)

Maric et al. (2010); Canada [33]N = 20
Gender: males n = 11
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 3
IG: combined intervention: web-based education and monitoring with telephone follow-up
CG: usual care
Self-care: SCHFI
Functional status: 6-minute walk test
Biomarkers-BNP
Timeframe: baseline, 6 m
(1) Improved self-care (P = .039)
(3) no change in QOL, (P = .337), 6-minute walk test (P = .124), and BNP (P = .210)

Mårtensson et al. (2005); Sweden [34]N = 153
Gender: males n = 83
Ethnicity not reported
CVD diagnosis: HF
Attrition not reported
IG: combined intervention: individualized education and counseling with telephone follow up
CG: usual care
QOL: MLHF, SF-36
Depression: Zung self-rated depression scale
Timeframe: baseline, 3 m
(1) No significant difference in QOL; but IG preserved QOL while UC deteriorated in QOL (P = .035), vitality (P = .029)
(2) No significant differences in depression

McKinley et al. (2008); Australia and USA [35] N = 3522
Gender: males n = 2,393
Ethnicity: white n = 3,207, other n = 315
CVD diagnosis: CHD
Attrition n = 386
IG: combined intervention: individual one-on-one education provided with structured education with counseling
CG: usual care
Mood: Multiple Affect Adjective Check List
Timeframe: baseline, 3 m, 12 m
(1) Knowledge increased significantly from baseline in IG compared to CG at 3 months and sustained at 12 months (P = .0005 for all)
(2) Higher state anxiety was associated with lower levels of knowledge (P < .05)

Otsu and Moriyama (2009); Japan [36]N = 96
Gender: males n = 61
Ethnicity not reported (Japanese study)
CVD diagnosis: HF
Attrition n = 3
IG: individualized (face-to-face) case management
CG: usual care
QOL: Macnew health-related quality of life
Functional status: NYHA Biomarkers; BNP
Mortality: records
Timeframe: baseline, 3 m, 6 m, 9 m, 12 m
(1) Statistically significant differences between groups: BNP at 3 m (P = .032) and 6 m (P = .002)
(2) IG: improved QOL in IG improved (F = 26.157, P < .000)
(3) No significant difference in NYHA but deterioration in symptom in the UC group (NS)

Paradis et al. (2010); Canada [37]N = 30
Gender: males n = 22
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 5
IG: combined intervention: motivational interview (3 encounters—1 in person; 2 telephone)
CG: usual care
Self-care: SCHFI
Timeframe: baseline, 1 m
(1) No significant results in self-care behaviors
(2) IG: improved self-care confidence (P = .005)

Prasun et al. (2005); USA [38] N = 66
Gender: males n = 43
4) Ethnicity: white n = 58, African American n = 7, other n = 1
CVD diagnosis: HF
Attrition not reported
IG: supportive education about flexible diuretic titration
CG: usual care
QOL: MLHF
Functional status: 6-minute walk test
Biomarkers: BNP, norepinephrine
Healthcare utilization: emergency care, hospitalizations, mortality
Timeframe: baseline, 3 m
(1) IG: improved 6-minute walk test (646 ± 60 ft versus 761 ± 61 ft, P = .01) and total QOL score (53 ± 5 versus 38 ± 5, P = .001), no change in CG group
(2) Significantly fewer emergency care in the IG compared to CG (3% versus 23%, P = .015)
(3) No differences in hospitalizations or mortality
(4) No differences were found between baseline and 3-month biomarkers

Riegel et al. (2006); USA [39]N = 134
Gender: males n = 62
Ethnicity: Hispanics n = 134 (109 Spanish-speaking)
CVD diagnosis: HF
IG: telephonic case management with self-care education
CG: usual care
Self-care: SCHFI
Depression: Patient Health Questionnaire-9
Healthcare utilization: hospitalizations, cost, mortality—medical records
Timeframe: baseline, 3 m, 6 m
(1) No significant group differences were found in HF readmission rate, HF days in the hospital, HF cost of care, all-cause hospitalizations or cost, mortality, or depression

Scott et al. (2004); USA [40] N = 88
Gender: males n = 39
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 22
Group 1: individualized counseling and usual care
Group 2: supportive-educative and usual care
Group 3: usual care and placebo
QOL: SF-36
Depression: Mental Health Inventory
Timeframe: baseline, 6 m
(1) IG (groups 1 and 2) improved QOL (F = 4.632, P = .01) and depression (F = 6.27, P = .003) and over a 6-month period
(2) between-group comparisons (NS)

Sethares and Elliott (2004); USA [41]N = 70
Gender: males n = 33
Ethnicity: white n = 63, black n = 6
CVD diagnosis: HF
Attrition n = 18
IG: combined intervention, individualized/tailored message intervention
CG: usual care
QOL: MLHF
Healthcare utilization: hospitalizations
Timeframe: baseline, 1 w, 1 m
(1) No significant differences in HF readmission rates or QOL

Shearer (2007); USA [42]N = 90
Gender: males n = 56
Ethnicity: white n = 81, black n-2, Hispanic n = 3, Native American n = 1
CVD diagnosis: HF
Attrition n = 3
IG: telephonic intervention with behavioral focus
CG: usual care
Self-care: self-management heart failure
QOL: SF-36
Timeframe: baseline, 3 m
(1) IG improved self-care compared to CG (F = 6.19, P < .001)
(2) QOL NS

Shively et al. (2005); USA [43]N = 116,
Gender: males n = 110
Ethnicity: Caucasian n = 87, African American n = 11, Hispanic n = 9, Asian/Pacific Islander n = 6, mixed n = 3
CVD diagnosis: HF
Attrition = 15
IG: combined intervention: behavioral management with telephone follow up
CG: usual care
QOL: SF-36, MLHF
Functional status/exercise capacity: 6-minute walk test
Timeframe: baseline, 4 m, 10 m, 16 m
(1) IG improved QOL compared to UG (F = 7.04, P = .009)
(2) No group differences in exercise capacity

Smeulders et al. (2010); the Netherlands [44]N = 317
Gender: males n = 230
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 42
IG: group-based structured education
CG: usual care
Self-care: EHFScBS
QOL: SF36, Kansas City Cardiomyopathy Questionnaire
Depression: HADS
Timeframe: baseline, 26 weeks, 52 weeks
(1) IG improved in self-care (P < .01) and QOL (P = .005)
(2) results not sustained at 6 and 12 months

Sol et al. (2010); the Netherlands [45]N = 314
Gender: male n = 242
Ethnicity not reported
CVD diagnosis: vascular disease
Attrition n = 91
IG: tailored behavioral self-care intervention
CG: usual care
QOL: SF-36
Biomarkers: lipids, BP, waist circumference, BMI
Timeframe: baseline, 1 yr
(1) IG achieved treatment goals for LDL-cholesterol (difference 13%, 95% CI = 1, 26) and HDL-cholesterol (difference 9%, 95% CI = 0, 19) compared to CG
(2) Mean SBP decreased significantly by 5 mm Hg (95% CI = −9, 0) in IG
(3) BMI increased significantly by 0.4 kg/m2 (95% CI = −0.8, −0.1) in CG
(4) No significant differences were seen in waist circumference, smoking, or triglycerides or QOL

Stafford and Berra (2007); USA [50]N = 419
Gender not reported
Ethnicity not reported
CVD diagnosis: CHD
Attrition n = 122
IG: combined intervention: individualized case management with follow-up meetings, telephone call, home visits
CG: primary care
Framingham risk score
Timeframe: baseline, 17 m
(1) IG had statistically significant reduction in mean Framingham risk probability compared to CG (1.6% decrease in 10-year CHD risk, P = .007)

Strömberg et al. (2003); Sweden [47]N = 106
Gender: males n = 65
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 43
IG: combined intervention: group based intervention focused on self-care education and support to patient and family
CG: usual care
Self-care: HFSCBS
Healthcare utilization: hospitalizations, length of stay, mortality
Timeframe: baseline, 12 m
(1) IG: fewer patients with events (death or admission) after 12 months compared to CG (29 versus 40, P = .03) and fewer deaths after 12 months (7 versus 20, P = .005)
(2) IG had fewer admissions (33 versus 56, P = .047) and days in hospital (350 versus 592, P = .045) during the first 3 months
(3) At 12 months, there was a 55% decrease in admissions/patient/month (0.18 versus 0.40, P = .06) and fewer days in hospital/patient/month (1.4 versus 3.9, P = .02)
(4) IG improved in self-care at 3 and 12 months compared to CG (P = .02 and P = .01)

Strömberg et al. (2006); Sweden [48]N = 154
Gender: males n = 109
Ethnicity not reported
CVD diagnosis: HF
Attrition n = 24
IG: multimedia intervention
CG: usual care
QOL: EuroQol
Adherence: study-specific survey
Timeframe: baseline, 1 m, 6 m
(1) NS difference between groups in adherence or QOL

Tonstad et al. (2007); Norway [49]N = 51
Gender: males n = 36
Ethnicity not reported
CVD diagnosis: hypertension
Attrition n = 4
IG: combined intervention: behavioral intervention with telephone follow up focuses on lifestyle counseling
CG: primary care
Biomarkers: lipids, triglycerides
BP, Waist circumference 
Timeframe: baseline, 6 m
(1) Waist circumference increased significantly between baseline and 6 m in CG but not in IG (mean difference 3.1 cm (95% CI 1.2–5.0), P = .04)
(2) Reduced serum triglyceride in IG compared with CG (mean difference 0.56 mmol/L (95% CI 0.22–0.90), P = .03)

Westlake et al. (2007); USA [46]N = 80
Gender: males n = 57
Ethnicity: white n = 58, black n = 8, Hispanic n = 3 other n = 11
CVD diagnosis: HF
Attrition not reported
IG: web-based education (n = 40)
CG: standard education
QOL: SF-36
Timeframe: baseline, 3 m
(1) Between-group improvement in QOL (P < .001)

BMI: body mass index; BNP: B-Natriuretic Peptide; BP: blood pressure; CG: control group; CHD: coronary heart disease; CVD: cardiovascular disease; EHFScBS: European Heart Failure Self-Care Behavior Scale; HF: heart failure; HFSCBS: Heart Failure Self-Care Behavior Scale IG: intervention group; MLHF: Minnesota Living with Heart Failure Questionnaire; NS: not significant; NYHA: New York Heart Association; QOL: quality of life; SCHFI: Self-Care of Heart Failure Index.

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