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Volume 1 Issue 4 1000123J Cardiovasc Dis Diagn

ISSN: 2329-9517 JCDD, an open access journal

Research Article Open Access

Anane, J Cardiovasc Dis Diagn 2013, 1:4

http://dx.doi.org/10.4172/2329-9517.1000123

Review Article Open Access

Journal of Cardiovascular Diseases & Diagnosis

Keywords: Advanced Heart ailure; Re-hospitalization; Quality olie; NYHA unctional class

Introduction

Te burden o advanced heart ailure includes debilitatingsymptoms, requent rehospitalization and high rates o mortality.Te most common causes o this preventable rehospitalization arepatients ailure to adhere to prescribed medicines and diet regimen. Itis imperative that any medication counseling and educational programseeks to assess the patients understanding o their medical conditionsand ability to appreciate the importance o medication compliance totheir condition [1].

Methodology

A prospective cohort study involving 583 patients aged 30 yearswho met clinical criteria or presence o advanced heart ailure onadmission was done to assess the outcome o the program on mortality

and rehospitalization. 498 patients were discharge to the cardiacclinic or a 6-month ollow up. Tese patients were taken throughmedication counselling and education on the management o theirdisease condition as ollows:

Medication compliance

Compliance is oen seen as one o the most important outcomeo patients education. Tereore, all the patients were counselled andeducated to comply with the prescribed treatment and to adapt tohealth-promoting behaviors like healthy diet and moderate or mildexercise depending on age. Te underlying philosophy o compliancewas that the illness could be controlled i the patient complied withprescribed therapy. Tey were taught that non-compliance increasesmorbidity and mortality and rehospitalization [2].

Medications: Te patients were educated on the name o eachmedicine and its purpose, dosage, requency and signicant side-

eects likely to be encountered. For example, patients who weretaking -blockers were counselled that they may experience atigue,lightheadedness or dizziness. Tey were urther instructed thattheir -blockers would be up-titrated slowly as tolerated, that side-

eects would minimize over time and that they should report ithey experienced any adverse eects. In addition, the patients wereinstructed to bring all their medications with them to each clinic visit.Tat served two purposes; rst, inormation about each drug could bereviewed and the patients knowledge assessed. Secondly, conusionabout medicine doses and interactions could be addressed.

In addition, patients were asked about over-the-counter andalternative medications example homeopathic or herbal products theymight be taking. Tey were advised to avoid such products so long asthey remained on their cardiac drugs.

Patients were counselled to avoid taking non-steroidal anti-inammatory drugs not prescribed because they could lead to renaldysunction and renal ailure.

Smoking: All the patients were strongly discouraged rom cigarettesmoking i they were smokers.

*Corresponding author: Charles Anane, Clinical Pharmacist, Cardiology and

Critical Care, Medicine Directorate, Head, Clinical Pharmacy, Komfo Anokye

Teaching Hospital, Ghana, Tel: 233-1313803; E-mail: [email protected]

Received July 10, 2013; Accepted September 5, 2013; Published September

12, 2013

Citation: Anane C, Buabeng KO, Sarpong K, Owusu IK (2013) The Impact of a

Comprehensive Medication Counseling and Education on Rehospitalization and

Mortality of Advanced Heart Failure Patients in Ghana. J Cardiovasc Dis Diagn 1:

123. doi:10.4172/2329-9517.1000123

Copyright: 2013 Anane C. This is an open-access article distributed under theterms of the Creative Commons Attribution License, which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author and

source are credited.

Abstract

The burden of advanced heart failure includes debilitating symptoms, frequent re-hospitalization and high

rates of mortality. The most common causes of this preventable rehospitalization are patients failure to adhere to

prescribed medicines and diet regimen. It is imperative that any medication counseling and educational program

seeks to assess the patients understanding of their medical conditions and ability to appreciate the importance of

medication compliance to their condition. A prospective cohort study involving 583 patients aged 30 years who

met clinical criteria for presence of advanced heart failure on admission was done to assess the outcome of the

program on mortality and re-hospitalization. 497 patients were discharge to the cardiac clinic for a 6-month followup during which period they were taken through medication counseling and education on; Medication Compliance,

Smoking, Alcohol, Diet and Nutrition, Salt restriction, Fluid intake, Weight loss and Exercise. The study showed

97.6% decrease in re-hospitalization rate and 12.4% decrease in mortality. Patients had also signicantly improved

in subjective and objective indices to functional status. 93.8% were classied within NYHA function class II and

6.2% in function class III. None of the patients remained in functional class IV as compared to 46.5% of the patients

before discharge. The study showed that management of heart failure patients based on well structured medication

education and counseling modalities can contribute to improved patients outcomes, including reduced morbidity and

mortality rates, improved functional status and quality of life.

The Impact of a Comprehensive Medication Counseling and Education

on Rehospitalization and Mortality of Advanced Heart Failure Patients inGhanaCharles Anane*, K Ohene-Buabeng, K Sarpong and IK Owusu

Clinical Pharmacist, Cardiology and Critical Care, Ghana
http://dx.doi.org/10.4172/2329-9517.1000123http://dx.doi.org/10.4172/2329-9517.1000123



Citation:Anane C, Buabeng KO, Sarpong K, Owusu IK (2013) The Impact of a Comprehensive Medication Counseling and Education on Rehospitalization and Mortalityof Advanced Heart Failure Patients in Ghana. J Cardiovasc Dis Diagn 1: 123. doi:10.4172/2329-9517.1000123

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Alcohol: All the patients were counselled to restrict alcoholconsumption to moderate levels given the myocardial depressantproperties o alcohol.

Diet and nutrition: All the patients were taken through dietand nutrition lessons by the dieticians at the hospital and made tounderstand that diet and nutritional measures were as important inheart ailure to ensure adequate and appropriate nutritional balance[3]. Poor nutrition could contribute to cardiac cachexia. Tey wereadvised by the dieticians at the hospital as ollows; to avoid commonlyconsumed processed oods that have high sodium content such ascheese, sausages, salted peanuts, tinned meat e.g. corned bee andtinned sh e.g. sardines, salmon and tuna.

Salt restriction: Te patients were educated to restrict their saltintake substantially. All the patients were counselled to avoid oodsthat are rich in salt and were told not to add salt to their ood at thedining table. Tey were advised to take resh produce such as ruits,

vegetables, eggs and sh which have relatively low salt content.

Fluid intake: Patients with severe symptoms, those requiring highdose diuretics and those with a tendency towards excessive uid intakewere counselled to restrict their uid intake to 1.5-2 litres daily.

Weight loss: Obese patients were taken through a comprehensiveprogram with the nutritionist to reduce weight.

Exercise: All the patients in stable condition were encouraged totake to light exercising like walking as regular as possible. Althoughbed rest may be appropriate in patients with acute heart ailure, regularexercise was encouraged. Nevertheless, the patients were advised toknow their limits and avoid excessive atigue or breathlessness duringmild or moderate exercise [4,5].

Data processing and analysis: Te data collected using the DataCollection Forms were coded, transerred to Microso ofce Exceland then entered separately into SAA version 11 statistical sowareor analysis. Descriptive statistics were used to characterize the studypatients. Data were presented as means Standard Deviations (SDs) orrequencies and percentages. Te baseline characteristics o the threetreatment interventions were compared using t-test and chi-squarestatistics.

Results

Te patients recorded 100% in attendance during the 1st threemonths and 96.6%, 95.4% and 94.3% attendance during the 4th, 5thand 6th months respectively when 12 patients were re-hospitalized

(able 1). However, the table shows in addition the percentages opatients who did not attend the clinic in those months i.e. 1.3%, 2.5%and 3.6% during the 4th, 5th and 6th months respectively. During therst 3 months o ollow-up, patients scored 100% in terms o regularattendance, knowledge and compliance o medications and ollowedall the instructions given them on diet, salt restriction, uid restrictionand the others as showed on the table.

NYHA functional status

Out o the 498 patients discharge to the cardiac clinic or the ollow-up program, 12 patients were re-admitted and 6 died. Te remaining492 patients completed the ull 6-month ollow-up counseling andeducation program at the cardiac clinic. At the end o study period,

unctional status o the patients had improved rom 92.1% in NYHAclass II to 97.1% in NYHA class II. Only 2.9% had remained in NYHAclass III as compared to 7.9% beore the program. Te 2.9% o the

patients who remained in Class III at the end o the study period neededsome orm o device intervention or valve repairs i.e. pacemakers andmitral valve repair or replacement.

Out o the 583 patients recruited or the study, 14.6% ( 85 patients)had died beore discharge to the cardiac clinic and 85.4% (498)surviving patients began the the 6-month ollow-up program at thecardiac clinic. Out o the 498 patients, 1.2% (6 ) patients died duringthe ollow-up with 98.8% (492) patients remaining alive till the end othe study program (Figure 1).

Out o the 186 patients in the carvedilol group discharged to thecardiac clinic 2 patients had died during the ollow-up period and 184patients in this group were alive till the end o the study period. Out othe 207 patients in the bisoprolol group discharge to the cardiac clinic 1patient died and 206 patients were alive till the end o the study period.With the control group out o 105 patients discharge to the cardiacclinic, 3 patients had died leaving 102 patients alive till the end o thestudy period. Mortality dierence between the 2 intervention groupsdid not reach statistical signicance but compared to the control groupthe mortality dierence was signicant statistically.

Out o the 498 patients discharge to the cardiac clinic, 2.4% (n=12)o patients were rehospitalized and 6 died, however, the remaining 492patients did not need any readmission till the end o the study period(able 2 and Figure 2).

Knowledge level of the patients

Almost 80% o the patients were aware o the importance to limit

Figure 1: Outcome before and after discharge to the cardiac clinic.

Counselling &

education

1st

month

2nd

month

3rd

month4th month 5th month 6th month

Medication Yes Yes Yes Yes Yes Yes

Compliance Yes Yes Yes Yes Yes Yes

Diet & nutrition Yes Yes Yes Yes Yes Yes

Salt restriction Yes Yes Yes Yes Yes Yes

Fluid restriction Yes Yes Yes Yes Yes Yes

Weight loss Yes Yes Yes Yes Yes Yes

Smoking Yes Yes Yes Yes Yes Yes

Alcohol Yes Yes Yes Yes Yes Yes

Exercise Yes Yes Yes Yes Yes Yes

% Attendance 100 100 100 96.6 95.4 94.3

Table 1: Percentage attendance of the patients at the cardiac clinic and counseling

and education sessions
http://dx.doi.org/10.4172/2329-9517.1000123http://dx.doi.org/10.4172/2329-9517.1000123



Citation:Anane C, Buabeng KO, Sarpong K, Owusu IK (2013) The Impact of a Comprehensive Medication Counseling and Education on Rehospitalization and Mortalityof Advanced Heart Failure Patients in Ghana. J Cardiovasc Dis Diagn 1: 123. doi:10.4172/2329-9517.1000123

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their salt intake.

Barriers of learning

Because majority o the patients had little or no ormal education,counselling sessions were time-consuming and most o the processesneeded repetition over again or the patients to understand andappreciate their importance to their disease progression (able 3).

Discussion

37% o the cohort had no ormal education and these patientstook a lot time to understand their disease and medication. With42% having just basic education to some level, their understanding otheir condition was almost the same with those who had no ormaleducational group. Patients with tertiary education (7%) and secondaryeducation (21) were better in their understanding o the diseaseprognosis and its management.

Te goals o the medication counselling and education programwere to assist patients to comply with the therapeutic regimen, tomaintain clinical stability and unction, and to improve quality olie. Tese goals are best achieved when the patient and amily areknowledgeable about every aspect o the condition and treatment andare active participants in the plan o care. With majority o the patientshaving little knowledge about their condition because o illiteracy,education and counselling was simplied to their understandingand appreciation. Furthermore, since the intervention lasted only 6

months, the optimal length o education and support through othermethods like home visits and tele-monitoring is unknown, and theminimum time period necessary or patients to maniest benets

o these interventions is still unknown. Te study has showed thatan integrated approach to the management o heart ailure based onwell structured medication education and counselling can contributeto improved patients outcomes, including reduced morbidity andmortality rates, improved unctional status and quality o lie. Teprogram also enhanced compliance, reduced rates o rehospitalizationand prolonged survival. Tese results, building on the work o others,suggest that all patients with advanced heart ailure should be oeredan education and support program that extends beyond hospitalization[3-5].

Counselling of the patients

It was important to explain to the patients the results he/she should

expect rom adding the -blocker to their conventional therapy andthat clinical improvement was gradual and may only become evidentaer treatment or some months [2].

Tey were urther instructed that the -blocker would be up-titrated slowly, as tolerated; that side eects would decrease over time;and that they should call the healthcare team i they experienced anyadverse eects.

Patients were encouraged to measure their blood pressureand heart rate requently and report to the clinic i these values alloutside the optimal range and/or they develop symptoms particularlybreathlessness, atigue and dizziness.

Patients were taught to understand some level o their condition toinuence compliance and reduce readmission rate.

Tese counselling points were very useul as they reected in theoutcome at the end o the program with less patients being readmittedand in mortality reduction.

Conclusion

Te study also showed that an integrated approach to themanagement o heart ailure based on well structured medicationeducation and counselling can contribute to improved patientsoutcomes, including reduced morbidity and mortality rates, improvedunctional status and quality o lie.

References

1. Strmberg A, Martensson J, Fridlund B, Levin LA, Karlsson JE, et al. (2003)

Nurse-led heart failure clinics improve survival and self-care behaviour inpatients with heart failure: results from a prospective, randomized study. Eur

Heart J 24:1014-1023.

2. Burkhart PV, Sabat E (2003) Adherence to long-term therapies: Evidence of

Action. J Nurs Scholarsh 35: 207.

3. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T (1990) Early

readmission of elderly patients with congestive heart failure. J Am Geriatr Soc

38: 1290-1295.

4. Bennett SJ, Huster GA, Baker SL, Milgrom LB, Kirchgassner A, et al.

(1998) Characterization of the precipitants of hospitalization for heart failure

decompensation. Am J Crit Care 7: 168-174.

5. Ghali JK, Kadakia S, Cooper R, Ferlinz J (1988) Precipitating factors leading

to decompensation of heart failure: traits among urban blacks. Arch Intern Med

148: 2013-2016

NYHA Before Management 6 months after Management

II 92.1 97.1

III 7.9 2.9

IV - -

Table 2: Improvement in functional status after 6 months of the counseling program

for all the 492 patients that remained alive till the end of study compared with their

composite functional status before undergoing the management program irrespec-

tive of intervention.

Table 3: Literacy levels of the patients

Education level %

Tertiary Education 7

Secondary Education 21

Primary Education 42

No Formal Education 37

Figure 2: Percentage of the patients who were readmitted after

discharge to the cardiac clinic for counseling and education program.
http://dx.doi.org/10.4172/2329-9517.1000123http://www.ncbi.nlm.nih.gov/pubmed/12788301http://www.ncbi.nlm.nih.gov/pubmed/12788301http://www.ncbi.nlm.nih.gov/pubmed/12788301http://www.ncbi.nlm.nih.gov/pubmed/12788301http://www.ncbi.nlm.nih.gov/pubmed/14562485http://www.ncbi.nlm.nih.gov/pubmed/14562485http://www.ncbi.nlm.nih.gov/pubmed/2254567http://www.ncbi.nlm.nih.gov/pubmed/2254567http://www.ncbi.nlm.nih.gov/pubmed/2254567http://www.ncbi.nlm.nih.gov/pubmed/9579241http://www.ncbi.nlm.nih.gov/pubmed/9579241http://www.ncbi.nlm.nih.gov/pubmed/9579241http://www.ncbi.nlm.nih.gov/pubmed/3046541http://www.ncbi.nlm.nih.gov/pubmed/3046541http://www.ncbi.nlm.nih.gov/pubmed/3046541http://www.ncbi.nlm.nih.gov/pubmed/3046541http://www.ncbi.nlm.nih.gov/pubmed/9579241http://www.ncbi.nlm.nih.gov/pubmed/2254567http://www.ncbi.nlm.nih.gov/pubmed/14562485http://www.ncbi.nlm.nih.gov/pubmed/12788301http://dx.doi.org/10.4172/2329-9517.1000123

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