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Journal of Cardiovascular Nursing Vol. 22, No. 5, pp 382Y389 x Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Weight and Symptom Diary for Self-monitoring in Heart Failure Clinic Patients Cathy A. Eastwood, BN, MN; Lucille Travis, PhD, RN, CNA, BC; Tanya T. Morgenstern, MSN, MPH; Erin K. Donaho, RN, BSN Background: For people with chronic heart failure, self-monitoring has been linked with improved body awareness and better communication with health professionals. Cognitive theory and the concept of somatic awareness help explain self-monitoring behaviors. This study compares the clinical and hospital outcomes of heart failure patients who are using and not using a diary to record weight, vital signs and, symptoms and evaluates the diary format. Methods: All patients enrolling in an outpatient heart failure clinic were given a Heart Health Diary. Seventy patients used the diary and 54 did not. A review of these 124 patients (82 men and 42 women) was completed 6 months after enrollment. Results: Diary nonusers were more likely to be younger women with a lower ejection fraction and worse functional status. Those using a diary had 35% and 47% more contacts via telephone and clinic, respectively. Both groups had significant functional and B-type natriuretic peptide improvement. If hospitalized after enrollment in the heart failure clinic, average length of stay for all hospital admissions for diary users decreased by 58% (P G .002) and average cost per case decreased by 56% (P G .011). Length of stay and cost per case did not significantly change for those not using diaries. Conclusion: Diary users showed evidence of improved clinical and hospital outcomes. Further investigation is needed to clarify the characteristics of a diary user and the effect of diary use on self-management and outcomes. KEY WORDS: diary, heart failure, outcomes, self-monitoring, somatic awareness I ntensive outpatient clinical follow-up and education have been well documented to reduce hospitalizations for people with chronic heart failure (HF).1Y4 In a review of posthospitalization nursing interventions in the HF population, HF clinics that included nursing interventions effectively reduced admissions, emergency visits, and overall costs; decreased mortality; and improved self-care and Cathy A. Eastwood, BN, MN Lecturer, School of Nursing, Memorial University, St. John’s, Newfoundland and Labrador, Canada. Lucille Travis, PhD, RN, CNA, BC Associate Dean and Director, School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC. Tanya T. Morgenstern, MSN, MPH Family Nurse Practitioner, Private Practice, Otolaryngology and Allergy, Mark S. Robertson, DO, Albany, Ore. quality of life.5 Reduced hospitalizations have been linked to the patient’s ability to effectively detect and report worsening HF symptoms.6 Research on nursing interventions that enhance detecting and reporting of symptoms in HF patients is limited. The outpatient Heart Failure Clinic and Program (HFC) at St. Luke’s Episcopal Hospital/Texas Heart Institute in Houston offers private-practice cardiologists the option of added multidisciplinary support for HF patients when enrolled in the hospital-based outpatient program. Cardiologists, nurse practitioners, and specialized nurses ensure that medications are optimized based on current practice guidelines. Nursing interventions in the HFC include a 90-minute HF education class, a weight and symptom diary, regular telephone monitoring, and frequent clinic visits provided by nursing personnel between medical visits. Erin K. Donaho, RN, BSN Heart Failure Coordinator, Heart Failure Department, Heart & Lung Transplant Treatment Center, Houston, Tex. Purpose The authors have no conflicts of interest to declare. Weight monitoring and symptom monitoring have become standard topics for outpatient HF education. Practice guidelines suggest that the patient and family be educated to demonstrate understanding of the early signs of fluid retention by documenting Corresponding author Cathy A. Eastwood, BN, MN, School of Nursing, Memorial University, Prince Philip Drive, PO Box 4200, St. John’s, Newfoundland and Labrador, Canada A1C 5S7 (e-mail: [email protected]). 382 Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Self-monitoring in Heart Failure Clinic Patients 383 daily weights and monitoring symptom changes.7,8 These guidelines also suggest that, when possible, individuals be taught to self-adjust diuretics in response to fluid retention.8 Although the HF literature2,5,6,9 suggests that patients record their weight as an intervention, the use of a symptom diary in this population has limited research. This article discusses the methods and results of a study comparing the clinical and hospital outcomes of people with HF who chose to document their weight, vital signs, and symptoms in a daily diary with those of people with HF who did not document. A secondary purpose of the study was to evaluate the format of the Heart Health Diary as a self-monitoring tool. Theoretical Concepts The complex work of self-monitoring is an important behavior for self- management required for various chronic illnesses such as diabetes, hypertension, and HF. Coping strategies for chronic illness include obtaining knowledge and skill for ongoing self-care that involves developing Ban awareness of body cues, interpreting physical changes accurately, and taking appropriate action either to alter therapy or to seek help from health-care resources to prevent a crisis.^10(p29) Becoming aware of body cues and taking appropriate action are part of the decision-making process that is described by cognitive theory.11 Riegel et al12 describe HF patients’ decision making regarding symptoms within the cognitive theory stages as involving the patient recognizing that a body cue or symptom is related to the illness, acting to address the symptom, and then evaluating the effectiveness of the action taken to relieve symptoms. The concept of somatic awareness, defined as sensitivity to physical sensations secondary to physiological change, may also play a role in symptom reporting.13 Jurgens13 hypothesized that symptom monitoring is impaired by poor somatic awareness. Both HF somatic awareness and a sudden onset of symptoms independently predicted delays in seeking care. Jurgens13 concluded that variability in the type and severity of symptoms might be responsible for patients’ difficulty developing a reliable cognitive meaning upon which to make decisions about seeking care. Interventions focusing on developing somatic awareness and cognitive symptom experience were suggested as potentially helpful to reduce delay in seeking treatment. Given somatic awareness and cognitive theory, a diary is a tool that may focus attention on the body’s physical patterns and changes. The conscious effort of noting symptoms and writing them down may improve the ability of patients to do the following: know their body in relation to their chronic illness, link symptoms with behaviors, report symptoms early, and potentially prevent unnecessary hospitalizations. Self-monitoring by patients with chronic conditions has been linked to improved body awareness, better communication with health professionals, and an improved sense of self-efficacy in controlling HF.3,14 Literature Review Health diaries described in the literature can be broken down into 2 major types: ledger and journal formats. In the ledger format, occurrences such as weights, blood pressure readings, healthcare visits, and episodes of pain are recorded as they occur. The advantages of ledger-type diaries are that they usually contain few pages and they are written in only when an event occurs. Conversely, journaltype diaries usually require daily entries, whether or not an event has happened. With the journal format, the researcher is able to obtain more detailed information and can more easily determine if data are missing.15 Both in the chronic illness and cardiovascular literature, symptom diaries are frequently used solely to collect research data.16,17 These diaries are often ledger style with Likert-scale check boxes. When diaries are mentioned for data collection, it is not clear to what degree the patients are encouraged to actively evaluate and report symptoms for improved self-management. Basilicato et al18 used a ledgertype diary to determine if it would assist cardiac patients in providing a more complete report of their angina. They found that after using the diary, patients were able to give a more concise report of symptoms. The diary was advocated as a useful tool for patient education and data collection about angina symptoms. Most medical or nursing articles describing the outcomes of outpatient HF programs mention that they educate patients on weighing daily and monitoring symptoms.19Y21 A weight and symptom record may have been encouraged, but most often, it is not described. Several authors state that a diary is used for weight and medication monitoring but include it as one of many program interventions.22Y25 These interventions included medication and diet education, a focus on medication adherence, and telephone contact with nurses. Only 1 article focused specifically on outcomes that may be related to diary use. Wright et al26 found that 76 of 197 patients used the diary that was encouraged to everyone in their HF intervention group. Those who used the diary were on more medication; were more likely to attend education Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 384 Journal of Cardiovascular Nursing x September/October 2007 sessions, HF clinic, or primary care visits; and had lower symptom and mortality rates. checkbook, so that it could fit in a purse or pocket for ease of transport to clinic visits. Objectives Methods Based on the body of research about health diary use in monitoring patients, we developed a combination ledger- and journal-format diary. The hypotheses for this study were the following: (1) Diary users would have improved communication with providers, as evidenced by more contact by telephone and clinic visits during the first 6 months in HFC; and (2) Diary users would have improved clinical and hospital outcomes comparing pre- and post-HFC enrollment. The Heart Health Diary was developed with an expert panel of nurses and cardiologists from cardiology, cardiac rehabilitation, and the outpatient HFC. The type of diary in this study is a combination of ledger and journal format, with columns for data and space for personal comments. Using the Agency for Health Care Policy Research guidelines for HF,27 the expert team identified the salient vital signs and symptoms for the patient to note and record. The diary contained instructions, 6 pages for noting current medications, and space for 6 months of daily information (Figure 1). Weight, blood pressure, pulse, fatigue, trouble breathing, cough, swelling/bloating, and chest pain were the essential columns. Blood sugar was included because many people with cardiovascular disease also have diabetes and could keep 1 record, not 2. The incision/ wound column was added for postoperative cardiovascular patients or those in postprocedure (heart catheterization) to document any problems. The size chosen for the diary was 3 8 inches, the size of a This study was a retrospective descriptive design. A review of 124 patient records between January 2001 and August 2002 was completed, collecting data on the 6 months after patients were enrolled in the HFC. All clinical data were collected and saved in CHF Manager, a commercial computer database. At all times during the study, patient information and privacy were protected by limiting access to charts and the database only to departmental personnel. All patients signed a hospital-wide consent to treatment form before enrollment in the program. Institutional review was not required at the time for this retrospective study. Frequency of patient telephone contacts and clinic visits with clinic staff was counted. At each visit, a nurse and a physician examined the patients and determined the New York Heart Association (NYHA) functional class as a subjective measure of HF severity (Table 1).28 Left ventricular ejection fraction (LVEF), a measure of the amount of blood pumped from the left ventricle with each beat, was measured by echocardiogram as a part of routine care. Left ventricular ejection fraction is measured as the percentage of blood ejected from the left ventricle with each contraction, with 60% being normal and less than 40% considered dysfunctional. B-type natriuretic peptide (B-NP) blood levels were measured at each patient clinic visit using the Biosite Point of Care Assay. The B-NP level correlates with left ventricular end diastolic pressure.29 Hospitalization FIGURE 1. Heart Health DiaryB. Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Self-monitoring in Heart Failure Clinic Patients 385 TABLE 1 New York Heart Association Functional Class28 Class I Class II Class III Class IV No limitations of activities; no symptoms with ordinary activities Slight or mild limitation of activity; comfortable with rest or mild exertion Marked limitation of activity; comfortable only at rest Any physical activity brings on discomfort, and symptoms occur at rest data were captured using the hospital’s financial accounting system, including the number of admissions, length of stay (LOS), and cost per case 6 months before and after enrollment in the HFC. The Heart Health Diary was given to all patients upon enrollment in the HFC. Diary users are defined as those who regularly recorded their weight and symptoms. Diary nonusers chose not to keep a record. Any form of symptom record was counted as a diary because a few patients preferred to track their information on a computer, calendar, or other small booklet. All documentation behavior was encouraged and commended. Patients received instruction for use of the diary from the HFC nurses during their initial clinic visit and education session. The importance of recording in the Heart Health Diary was reinforced during subsequent visits and during telephone contacts with the patient. Patients were encouraged to document in the diary and bring it with them to each clinic visit. Patients were also asked to refer to the diary during telephone contacts with the nurses to discuss exact information. Sample This study includes a nonrandomized sample, with the study group being the diary users. One hundred forty-four charts were reviewed. Twenty charts without data on diary use were excluded; 124 records containing data on diary use were included in the study. The sample consists of consecutive patients who were referred to the program for hospitalization in the past year, were classified as NYHA functional class II to IV, had evidence of difficulty TABLE 2 adhering to the recommended medications or 2-g sodium diet, or wait too long to report symptoms. The population ranges in age from 20 to 93 years; is almost equally male and female; and is 40% white, 40% African American, 10% Hispanic, and 10% of other races. Data Analysis Data were analyzed using SPSS version 11.5 to calculate descriptive statistics and comparisons between groups. Paired t test, univariate analysis of variance, and repeated measures analysis of variance were used to explore the hypothesis of this study. The level of significance was set at P e .05. Results The sample consisted of 82 men (50 used the diary) and 42 women (20 used the diary) (Table 2). The mean age of the diary users was 65.0 years (T11.9 years), and the mean age of the diary nonusers was 56.7 years (T15.4 years). Baseline ejection fraction was 5% higher in the diary users. Upon enrollment in the program, there was no significant difference in the mean NYHA functional class between diary users (mean T SD, 3.1 T 0.69) and diary nonusers (2.9 T 0.77). B-type natriuretic peptide level also had no significant difference between groups. Patient Contact As an indicator of active decision making, we reviewed the frequency of telephone calls to the clinic nurses and clinic visits by the subjects over a 6-month period. We compared both variables by diary users and nonusers. The mean number of contacts during the 6 months of the study is shown in Table 3. Diary users had 35% more telephone contacts and 47% more clinic visits than diary nonusers did. Clinical Outcomes A comparison of baseline to 6 months after HFC enrollment indicated that ejection fraction improved Characteristics of the Sample (N = 124): Diary Users Versus Diary Nonusers Subset, no. (%) Age, mean T SD, y Sex, no. (%), M/F Mean baseline LVEF, mean T SD, % Mean baseline NYHA, mean T SD Mean baseline B-NP, mean T SD Diary Users Diary Nonusers P 70 (56) 65 T 11.9 50/20 (71/29) 26.9 T 11.9 3.1 T 0.69 459 T 392 54 (44) 56.7 T 15.4 32/22 (59/41) 21 T 7.0 2.9 T 0.77 430 T 395 G.004 G.074 .769 LVEF indicates left ventricular ejection fraction; NYHA, New York Heart Association; B-NP, B-type natriuretic peptide. Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 386 Journal of Cardiovascular Nursing x September/October 2007 (Figure 3). There was no difference between groups in frequency, LOS, or cost with HF admission. However, the total costs for admissions for reasons other than HF decreased significantly for diary users and increased for nonusers (Figure 4). TABLE 3 Clinical Contacts Over 6 Months Compared Between Diary Users and Diary Nonusers Variable Telephone contacts Total Range Mean T SD Clinic visits Total Range Mean T SD Diary Users (n = 70) Diary Nonusers (n = 54) 525 0Y25 7.5 T 5.24 265 0Y31 4.9 T 5.14 617 3Y25 8.9 T 4.57 273 1Y20 5.1 T 3.37 P Discussion G.007 G.001 more for the diary users (n = 50): 27.0% (T11.2%) to 29.3% (T14.2%), a change of 23% (P G .038). There was no change in the ejection fraction measures of diary nonusers (n = 25): 22.4% (T7.6%) to 22.5 (T7.2%). Change in the NYHA functional class of patients over 6 months is provided in Table 4. Functional class improved significantly for both diary users and nonusers. B-type natriuretic peptide was measured as an indicator of HF severity because high levels of B-NP indicate the greater stretch within the left ventricle.29 For both diary users and nonusers, the B-NP level improved significantly (Table 4). Hospital Outcomes A comparison of all admissions 6 months before and after HFC program enrollment demonstrated no significant difference between the diary users and nonusers in the number of hospitalizations. The mean LOS when admitted for any reason decreased for both diary users and nonusers; however, the decrease in LOS was statistically significant for the diary users: from 9.8 (T9.5) to 4.1 (T6.3) days (Figure 2). Average cost per case decreased significantly for diary users only, whereas it increased for diary nonusers TABLE 4 Variable LVEF, % Baseline 6 Months NYHA Baseline 6 Months B-NP Baseline 6 Months Sample The diary nonuser was more likely to be a younger woman with a slightly lower ejection fraction and functional status (Table 2). Further demographic data are needed to better predict who would use the diary. Patient Contact Diary users had more telephone calls to staff and clinic visits. Diary users may help define a subpopulation of patients who are more likely to be adherent to a health regimen or more actively participate in self-management.26 Diary nonusers may require more focused intervention. Possibly, more frequently scheduled clinic visits and telephone contacts are needed for improved outcomes. Analysis of the telephone call purpose and subsequent interventions would further describe the symptom-reporting behavior of both groups. The diary nonuser group may indicate a group that might benefit the most from electronic monitoring devices when considering cost and benefit. These devices transmit weight and symptom data to the providers who intervene with patients who indicate worsening symptoms. Patients can be provided with daily reminders of appropriate health behaviors and feedback on their progress when more active patient involvement is not attainable.30 Clinical Outcomes Improvement in LVEF for diary users only is marginally useful, given the low sensitivity of the Changes in Clinical Outcomes Over 6 Months Diary Users P Diary Nonusers P 27 T 1.2 (50) 29.3 T 14.2 G.038 22.4 T 7.6 (25) 22.5 T 7.2 ns 3.1 T 0.69 (69) 2.6 T 0.80 (69) G.001 2.9 T 0.77 (50) 2.4 T 0.80 (50) G.001 459 T 392 (42) 351 T 359 (42) G.011 433 T 397 (24) 271 T 277 (24) G.004 LVEF indicates left ventricular ejection fraction; NYHA, New York Heart Association classification (1-4); B-NP, B-type natriuretic peptide (pg/mL). Values are given in mean T SD. Numbers inside parentheses are the number of participants. Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Self-monitoring in Heart Failure Clinic Patients 387 FIGURE 2. Mean length of stay. test and the inconsistent correlation with functional status. NYHA functional class and B-NP levels improved significantly for both groups, indicating clinical improvement for all enrolled in the program. NYHA class is subjective but is widely accepted as a cardiovascular symptom severity measure. Data were not collected on medications prescribed; therefore, it is difficult to separate other factors contributing to the improvements other than the general program effect. Similarly, comorbidities were tracked, but given the limited sample size regression analysis, it was not possible to identify if other disease conditions (ie, hypertension) contributed to the results. Hospital Outcomes Reduction in hospital days and related costs for diary users potentially indicates improved physical health and/or less acute care needs when admitted. Decreased LOS and cost when admitted for other than HF for the diary group, which increased for the diary nonuser group, may indicate better selfmanagement for all comorbidities for the diary users, not just HF. It is not clear if the diary user group might have had reduced hospital stays even without a diary. The characteristics of a diary user need further study including more sensitive measures of self- management, such as the Self-Management of Heart Failure Instrument12 and the Heart Failure Somatic Awareness Scale,13 to determine how different people act on symptoms and the greatest effect on outcomes. In sum, use of the diary was a potential contributing factor toward clinical improvement. A tool that promotes participation in self-monitoring and early reporting of health changes can strengthen a program effect. Diary Format The combination of a ledger and journal format was useful for patients to see patterns and identify related behaviors. The symptoms recorded are included in the list of 12 symptoms measured by Jurgens.13 Daily recordings were most useful when they included a minimum of daily weight, whether it changed or not. Most people recorded daily blood pressure readings. This was encouraged at varied times of the day to capture any fluctuations in blood pressure. The next most frequently recorded data were comments, including brief statements on changes in health, activity, or medications. The symptom columns were often either filled out completely or not at all. The symptom columns serve as a reminder to the patient to reflect on his or FIGURE 3. Mean cost per case. Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 388 Journal of Cardiovascular Nursing x September/October 2007 FIGURE 4. Total admissions cost per case for other than heart failure. her symptoms each day and, although often left blank, are believed to remain valuable. The incision/ wound column is not frequently used for the outpatient HF population and could be excluded. The diary size and format were reported to be portable and functional. Given that adherence to one’s medication regimen is essential for maintaining and improving clinical stability, it is strongly encouraged that all patients come to the clinic with either their medication bottles or a list of medications. Many chose to write their medications on separate pages rather than use the diary pages. This may be because of the frequency of medication changes, making a new page clearer to follow. When a current list of medications and diary data are recorded, it is evident that the person is committed to self-monitoring and communicating health data. Limitations and Recommendations This study was limited by being a retrospective rather than a prospective design. The retrospective review of diary users versus nonusers helps identify those individuals more likely to document and report concerns. The nonrandomized sample of this study limits the generalizability of the results to other populations. If the diary was randomly assigned, some patients may still have not used it, potentially skewing study data. However, a nonrandom design provides information about the diary user and nonuser that might otherwise be lost in a randomized study. The self-selection bias also reduces the ability to determine the strength of the effect of the diary on outcomes compared with the other program interventions. A study design powered for regression analysis might clarify which variable within the program has the greatest effect on outcomes. Also, it was not clear whether it was the patient or a significant other who recorded in the diary. Consequently, recorded information may vary de- pending on the recorder’s perspective. As well, truthfulness was assumed and verified by comparing reported symptoms with physical assessment and interview findings. For consistency, we accepted the data as recorded. The study lacked information on each patient’s cognitive and education level, which might further describe the groups. For future study, a prospective approach is recommended, with data collected to identify the diary recorder and identify the diary user versus nonuser at baseline. Specifically, information on cognitive status, educational level, marital status, race, and socioeconomic background might help identify individuals or groups who might use a diary. Psychological profile and depression measures might also clarify factors influencing diary use. Additional assessment with specialized questionnaires for selfmanagement12 and somatic awareness13 could provide the team with an indication of self-monitoring skill that might need individualized intervention. Health-related quality of life might be a useful outcome to measure. Commending patients when they report symptom changes in a timely manner reinforces their somatic awareness and their positive cognitive decision making for their health. For others, nurses need to highlight the worsening symptoms and clearly describe the appropriate response to model decision making. For example, BWhen your abdomen feels this tight or your weight is up this much, you are retaining fluid and you need to call me.^ Lastly, the potential patient- and system-related barriers to adherence to diary use need further exploration. Literacy, social support, beliefs, cognition, motivation, and accessibility to and response from the HFC staff may affect diary use, self-monitoring, and patient outcomes. Conclusion In conclusion, diary users showed some evidence of improved clinical and hospital outcomes. Diary users maintained closer contact with the health team with Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Self-monitoring in Heart Failure Clinic Patients 389 more frequent telephone calls and clinic visits. Further investigation is needed to clarify the characteristics of HF patients who do and do not practice routine self-monitoring and to determine the effect of diary use on somatic awareness, health decision making, and communication with health providers and outcomes. Understanding differences in self-care practices will help nurses refine monitoring methods and educational approaches for HF patients. Acknowledgments We thank Hope Nora, PhD, for data analysis; Nancy Cole for data collection; and Greg Poulin, MSN, for support for patients in their use of the diary. REFERENCES 1. Edlin M. Healthcare providers empower patients to help monitor their congestive heart failure: length of hospital stays and patient costs can be mitigated with the proper self-care systems. Manag Healthc Exec. 2001;11: 30Y35. 2. 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