Ms. Carroll is a doctoral candidate at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr. Howrey is a postdoctoral fellow at Siteman Cancer Center/Barnes-Jewish Hospital in St. Louis, Missouri. Dr. Payvar is a clinical psychologist, Ms. Deshida-Such is a clinical dietitian, Dr. Kansal is a cardiologist, and Dr. Brar is an acute care nurse practitioner all at the Jesse Brown VAMC in Chicago.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
to a specialty clinic only after being hospitalized for HF. These patients likely were experiencing more advanced disease and/or low adherence, as indicated by the relatively high prevalence of AF diagnoses and pacemakers; these null findings are consistent with those from a randomized controlled trial of a disease management program among veterans with heavy HF symptom burden and impaired functional status. 13 However, integrating self-management programs earlier in HF clinical care (eg, primary care or cardiology clinics) may be more effective in promoting proactive disease management and delaying or preventing initial HF hospitalizations.
For example, a disease management plan implemented by general practitioners for veterans with HF in Australia was associated with a 23% reduction in potentially preventable hospitalization rates. 14 Veterans with HF enrolled in a NP-led disease management intervention, relative to those followed only in primary care, had significantly fewer hospitalizations and nearly half the risk mortality (15% vs 28% after 2 years; HR 0.55). 15 Furthermore, some have suggested that SMAs may be more effective for patients for whom risk of disease is high but current disease burden (ie, symptoms) is low, such as diabetes mellitus management programs. 16 Early intervention also may allow providers to reach more patients more quickly and before they experience advanced symptoms, thereby reducing specialty clinic wait times and overall health expenditures. Developing more effective disease management programs for patients with acute HF and veterans in particular remains a critical matter for future study.
Additional and novel components of HF management programs show promise for future interventions. First, various facets of social support, including emotional support, instrumental/tangible support, informational support, and appraisal support, are associated with improved self-care. 17 For example, the levels of family functioning and family support predict HF outcomes, perhaps because between-appointment monitoring allows patients to report problems that might otherwise go unidentified and receive more external feedback about their disease and symptoms. 18,19 Patients report that family members or especially supportive members of their health care team are invaluable contributors to their successful management of HF. 20 A recently published feasibility trial of a couple-based disease management program observed positive trends in HF management for veterans, as well as improvements in caregiver’s depressive symptoms and burden, indicating that even support from informal caregivers may improve HF outcomes. 21
Advances in technology-delivered disease management programs show promise in improving adherence to chronic disease management programs. 22,23 Specifically for HF, veterans who enrolled in a daily telehealth
