Primary ovarian insufficiency quality of life scale
�
�
�
O R I G I N A L R E S E A R C H
Effects of multidisciplinary Internet-based program on management of heart failure
Machiko R Tomita1
Bin-Min Tsai2
Nadine M Fisher1
Neeraj A Kumar1
Greg Wilding3
Kathy Stanton1
Bruce J Naughton4
1Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA; 2Department of Occupational Therapy, I-Shou University, Taiwan; 3Department of Biostatistics, University at Buffalo, Buffalo, New York, USA; 4Department of Medicine, University at Buffalo, Buffalo, New York, USA
Objectives: To develop and test the effectiveness of an Internet-based self management program
by multidisciplinary health care professionals for patients with heart failure (HF).
Methods: The comprehensive educational material for HF was created and posted on a website.
A computer with Internet connection and computer training were provided first. A secure and
simple web-based recording system of vital signs and health behaviors and a mechanism for
feedback regarding each participant’s record were developed. A randomized controlled trial
with a one-year intervention was conducted using a total of 40 patients who were assessed three
times in their homes. An intention-to-treat analysis used multivariate statistics.
Results: The treatment group had a high (85%) adherence to the intervention. Only the
treatment group showed a significant improvement in the knowledge level (p 0.001), amount
of exercise (p = 0.001), and quality of life (p = 0.001), and reduction in HF related symptoms
(dyspnea, p = 0.001; fatigue, p = 0.003; functional emotion, p 0.001), blood pressure
(systolic, p = 0.002; diastolic, p 0.001), frequency of emergency room visit, and length of
hospital stay (both p = 0.001).
Conclusions: An effective program to change one’s behaviors in managing HF takes a
multidisciplinary approach to create and provide feedback regarding a patient’s daily record,
which can be accomplished through Internet use.
Keywords: e-health, self-management, Internet, heart failure, older adults, exercise
Correspondence: Machiko R Tomita 515 Kimball Tower, UB, 3435 Main Street, Buffalo, NY 14214, USA Tel +1 716 829 6740 Fax +1 716 829 3217 Email machikot@buffalo.edu
Introduction Heart failure (HF), or congestive heart failure, is a debilitating illness affecting about
five million Americans, with 550,000 new cases diagnosed each year.1 Approximately
79% of adults with HF are over 65 years of age, with a 30%–40% annual hospital-
ization rate.2 This is the most expensive illness among the population 65 years and
over due to recurring emergency room visits and hospitalizations. In 2005, in the US
alone, HF-related costs rose to $27.9 billion, a $4.7 billion increase in three years.3
This rise is likely to continue due to the rapid growth in the aging population along
with a longer life expectancy. HF is a final common pathway of various illnesses and
conditions and is usually chronic without a cure. HF, therefore, is a condition that
greatly impacts the individual and society as a whole.
One strategy for slowing decline with chronic HF is to improve daily healthy
behaviors including reducing and monitoring salt and fat intake, smoking, and
alcohol consumption, committing to regular exercise,1 medication adherence, and
maintaining a positive attitude. This strategy takes a multidisciplinary approach to
develop and individualize. Although effective, the obstacles for this intervention
have been identified: the high cost and the large amount of effort4 for providers as
well as patients.
In order to overcome these limitations, Internet use has been suggested as a means
to change daily health behavior4 by empowering a large number of patients to take
Journal of Multidisciplinary Healthcare 2009:2 13–21 © 2009 Tomita et al, publisher and licensee Dove Medical Press Ltd.This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.
13
�
Tomita et al
more control of their health.5 An early study with HF patients
compared the efficacy of an interactive voice response system
and interactive web-based technologies (e-health group)
to change health behavior.6 After one year of intervention,
exercise and general activities were similar for both groups,
but the e-health group had lower health care costs. A study
using a meta-analysis concluded that Internet-based health
interventions can improve behavioral outcomes such as
increased exercise time, knowledge of nutritional status,
knowledge of asthma treatment, body shape perception, and
was also effective in weight loss maintenance.7
Although Internet access is less common among older
adults than younger adults, once they use, their use pattern is
similar to that of younger adults.8,9 As rapid growth of Internet
use among older adults advances, theoretically, so do both
the opportunity and the tools to improve health practices and
improve health outcomes while reducing health costs.
A conceptual framework, Model Toward Optimal
Independence through Technological Adoption
(M-TOMITA) was formed for this study based on the Trans-
theoretical Model (TTM),10 social support theory,11 and a
mass communication theory called Uses and Gratifi cations.12
The M-TOMITA works best when individuals are already
aware of their chronic conditions and are contemplating
doing something to manage their illness but are not sure
what to do (the contemplation stage). If someone has little
knowledge of their illness and is not aware that changing
health behavior may help them, this model may not be effec-
tive. The model is an empowerment process that progresses
through stages from contemplation, preparation, and action,
to maintenance. Using the Internet method, four types
of support by health care professionals can be provided.
Informational support or education of chronic illness and
suggested health behaviors is especially important in the
initial stage but should continue all the stages. Among the
recommended health behaviors, patients will choose an
activity to focus on. Once the first activity is successfully
implemented, additional activities will be added, one by one.
After the decision regarding a particular health behavior
is made, Instrumental support should be provided via the
Internet. Through the online record-keeping system the
participant can track their own vital signs and health behav-
iors so that they can become aware of a cause (life style)
and effect (symptom and general health) relationship. The
website also provides participants and nurse monitors the
record with alerts for critical measures so that health care
providers can be notified. This record is shared with their
health care providers at office or home visits for the purpose
of monitoring as well as appraisal support to reinforce patient
motivation. Internet use, especially in the initial stage,
boosts older adults’ self-esteem. They realize their ability
to learn something new and feel they are up to date with their
children and their grandchildren. The Internet is so versatile;
it provides not only opportunities for education, but also for
frequent communication with families and friends, leisure
through playing games to stimulate and challenge the mind,
and can improve instrumental activity of daily living (IADL)
by participating in online shopping on drugs, books, and
even groceries. Mastering Internet technology, therefore,
improves the quality of life of older adults. Throughout this
process, emotional support from health care professionals is
important to keep the participants motivated until the time
that their illness prevents them from using the computer. Its
application to Internet use is described in the intervention
section of this study, and is illustrated in Figure 1.
The objectives of this study were to develop and test an
e-health intervention using a multidisciplinary approach to
improve health behavior and outcomes among older adults
with HF. Hypotheses in this study are that the treatment
group will: (1) adhere to the intervention program at a high
rate ( 75%)13; (2) improve in knowledge of HF and related
healthy behaviors; (3) reduce specific HF symptoms and
sick days, and improve blood pressure (BP), (4) improve
in perceived quality of life; and (5) reduce frequency
of emergency room visits and length of hospital stays.
Participants’ subjective evaluation of the program was also
sought. It included satisfaction/dissatisfaction, reasons for
the rating, benefit, improved or not improved HF, the most
liked/disliked part of the method, and suggestions for the
program.
Methods Study design The study employed a randomized controlled design with a
one-year intervention. Three assessments (baseline, and fol-
low-ups at six and 12 months) were conducted in participants’
homes. The control group received usual care. Usual care
for home-based patients in the US is a three-month regular
check up with their physicians. If they are hospitalized, they
may have nurse visits, physical or occupational therapists’
home care, and phone calls from their insurance company
to report their weight and blood pressure for three months.
None of the partisans were receiving nurse visits due to
hospitalization. The treatment group received the e-health
intervention in addition to usual care, and process measures
were collected daily.
Journal of Multidisciplinary Healthcare 2009:2 14
�
/~ r
/ ~
"' r ~r r r ,,
--+ --+ ~ ~
Effects of e-health in patients with heart failure
Health care professional
Emotional support
Informational support
Instrumental Support
Appraisal support
E-Health
Precontemplation Contemplation Preparation Action Maintenance
Figure 1 Model toward optimal management of independence through technological adoption.
Subjects Individuals with HF were recruited from three hospitals and
two health insurance companies in Western New York using
a convenience sampling method. Inclusion criteria were those
who: (1) were living at home and 60 years of age or older;
(2) had at least one emergency room visit or overnight hospital
admission due to HF in the past year; and (3) met the New York
Heart Association (NYHA) Classification of Heart Failure for
Class II (Slight limitation of activity or dyspnea and fatigue
with moderate physical activity) or Class III (Marked limita-
tions of activity or dyspnea with minimal activity).14 Exclusion
criteria were individuals who: (1) were scheduled for any kind
of heart surgery and/or (2) had cognitive impairment (Mini
Mental State Exam [MMSE] 24).15
The sample size, determined by a power analysis to
achieve 80% of power at α 1
= 0.05 with a large effect size
(d = 0.90)16 was 15 in each group. Considering a high attrition
rate anticipated for the control group, 24 in the control group
and 16 in the treatment group were recruited. The sample
size flow-chart is included in Figure 2.
Intervention Technology Participants in the treatment group were provided a standard
PC with Internet access as well as basic computer training.
Publicly accessible and secured websites were created by a
multidisciplinary health care team of a health behaviorist,
a geriatric physician, a geriatric nurse, an occupational
therapist, a physical therapist, and an exercise physiologist.
We used the web creation guidelines published by the National
Institute on Aging and the National Library of Medicine.17
Four types of support (informational, instrumental, appraisal,
and emotional) at suitable stages of behavioral changes were
provided in this e-health intervention.
Informational support included online information on:
HF, drugs used to treat HF, effects of alcohol and smoking,
depression, prescribed home exercise, nutrition, weight
management, and exercise in general using the Flesch–
Kincaid Reading Grade level of eight on average. An exercise
instruction program (walking, breathing, stretching, range
of motion, upper and lower extremity strength training, and
stationary biking) was developed and delivered via streaming
video. This support was provided in the beginning of the
intervention period.
Instrumental support included availability of a secure,
simple, and short online recording system using Lotus
Notes Web Server 6.5. This support was provided after
participants became comfortable with the use of a computer
and Internet. Participants were asked to access the website
daily to record their vital signs and health behaviors. The
site asks questions about blood pressure, pulse, weight,
medication use, type and amount of exercise, levels of
fatigue, intake of salt, sugar, alcohol, and tobacco, health
changes, and HF-specific questions regarding swelling,
Journal of Multidisciplinary Healthcare 2009:2 15
Tomita et al
Assessed for eligibility (N = 262)
Enrolled
Excluded (n = 220)
• Not meeting inclusion criteria (n = 69)
• No response (n = 129)
• Refused to participate (n = 20) • Family’s refusal to participate
Allocated to control (n = 24) Allocated to intervention (n = 16)
Randomized (N = 40)
�
! ) :
l
Lost to follow-up (n = 5)
• Died (n = 2)
• Nursing home placement (n =2)
• Quit: too sick due to CHF (n = 1)
Lost to follow-up (n = 3)
• Died (n = 1)
• Moved to assistive living (n = 1)
• Noncompliant (n = 1)
Figure 2 Flow chart of sample sizes.
fatigue, and dyspnea. Additionally, a webpage containing
their past records with an automatic alerting function for
sudden weight gain was available. Any overnight gain of 3
lbs or more resulted in a red dot display in the record that
signaled participants to contact their physician.
Appraisal support was provided via email every month
from appropriate health care professionals in dealing with
subjects for the purpose of feedback for patients’ records.
This support was provided to encourage participant’s ongo-
ing actions for changing their health behaviors toward a
maintenance stage (beyond six months).
Emotional support was provided on an as needed basis
via email. Since no participants were depressed ( 15 Center
of Epidemiological Study- Disease18) at the time of initial
assessment, an online discussion group was not formed.
Dependent variables A knowledge questionnaire was developed for this study
consisting of 20 questions with a possible total score ranging
from 0 to 60 (all correct responses). Frequency of exercise
was captured on a nominal scale (every day, 2–3 times/week,
less than once/week, rarely and none) for breathing exercise,
Journal of Multidisciplinary Healthcare 2009:2 16
�
�
�
�
Effects of e-health in patients with heart failure
stretching, walking, and mild exercise including stationary Table 1 Baseline demographic and health characteristics (N = 40)
biking, swimming, and golfi ng.
HF-specific symptoms (dyspnea during daily activities,
fatigue, and emotional function) were measured using the Con-
gestive Heart Failure Questionnaire (CHFQ).19 Higher scores
are indicators of better conditions. The psychometric of CHFQ
has been tested. It has good reproducibility for the total score
and the three subcategories and responsiveness for change.20
The responsiveness was found to be similar to the Minnesota
Living with Heart Failure21 and better then SF 12.22,23
Perceived quality of life (QOL) was assessed using
a 50-item age relevant questionnaire on diet, health care,
safety, social, communication, psychological health,
activities, and perceived aging, with a higher score indicating
a higher level of wellness.
Statistical methods An intention-to-treat analysis was conducted using mostly a
multivariate linear model. To explain the observed variability
in the data and test for differences within and between
groups, the model was fit to numeric endpoints via restricted
maximum likelihood methods, adjusting to the difference
for the severity of illness. To analyze health care use, actual
data of those whose data were available at follow-up 2, due
to nonnormal distributions, Friedman’s Tests for correlated
samples were used. A significance level of 0.05 was set for
each hypothesis test. SAS version 9.1.3 statistics software
(SAS Inc., Cary, NC) was used for all analyses.
Results Demographic and health information at baseline for
40 participants is summarized in Table 1. The two groups were
equivalent for all characteristics. An overall mean age was
76.2 years, 32.5% were males, 2.5% were Asian, 12.5% were
African American/Black, and 85.0% were Caucasian. Fifty-eight
percent had 12 years of education or less, 36.7% had between
13 and 16 years, and 5.4% had 17 years or more. Mean MMSE
score was 29 of 30. The mean number of comorbidity was
10 and medication taken was 8. The control group was comprised
of 79.2% of patients with NYNA Level II and 20.8% of Level
III while the treatment group had 75% and 25%, respectively.
Although statistically not significant, this difference was adjusted
in the multivariate linear approach. The control group had
5.1 years of HF while the treatment group, 3.6 years.
Adherence to the program (Hypothesis 1) All participants in the treatment group visited the
publicly available website with a mean frequency of 3.5
Variable Control Treatment Difference
(n = 24) (n = 16) values
Age (years) M = 77.5 M = 74.2 t = 1.240
SD = 7.4 SD = 9.7 p = 0.223
Gender
Male 9 (37.5%) 4 (25.0%) χ2 = 0.624
Female 15 (62.5%) 12 (75.0%) p = 0.408
Race
Asian 0 1 (6.3%) χ2 = 1.544
African American/Black 3 (12.5%) 2 (12.5%) p = 0.462
Caucasian 21 (87.5%) 13 (81.3%)
Education
12 years 13 (54.2%) 9 (56.3%) χ2 = 0.430
13–16 years 8 (33.3%) 6 (37.5%) p = 0.806
17 yeas 3 (12.5%) 1 (6.3%)
Living status
Live alone 9 (37.5%) 8 (50.0%) χ2 = 0.614
Live with someone 15 (62.5%) 8 (50.0%) p = 0.433
Income
$10,000 4 (16.7%) 4 (25.5%) χ2 = 0.556
$10,000–$29,999 12 (50.0%) 8 (50.0%) P = 0.757
$30,000 8 (33.3%) 4 (25.0%)
Number of comorbidities M = 9.5 M = 8.7 t = 1.746
SD = 3.1 SD = 3.5 p = 0.099
Number of medications M = 8.4 M = 7.1 t = 1.358
SD = 2.5 SD = 2.9 p = 0.218
MMSE M = 28.9 M = 28.9 t = 0.228
SD = 1.5 SD = 1.3 p = 0.821
NYHA Class
II 19 (79.2%) 12 (75.0%) χ2 = 0.096
III 5 (20.8%) 4 (25.0%) p = 0.757
Years since diagnosed M = 5.1 M = 3.6 t = 1.273
SD = 4.3 SD = 3.0 p = 0.211
times a month and recorded daily vital signs and health
activities a mean of 85% of the days in one year which is
considered high.
The number of exercisers was analyzed using a nominal
binary scale: exercisers (exercising 2–3 times/week or
more) and nonexercisers (exercising 1 time/week or less).
The change in percentage of exercisers for three time
points for various exercises is summarized in Figure 3.
For any exercises, there were no significant changes for
the control group during the study while the treatment
group showed significant increases in all exercises
Journal of Multidisciplinary Healthcare 2009:2 17
�
�
�
. . ·•· . .
■
-" ... - - -- . . . )I( •••
• ••
I , _c._ __ ---+ .. ... .. •· - .
Tomita et al
12 mon.
100
90
80
70
60
50
40
30
20
10
0
Initial 6 mon.
Figure 3 Percent changes in exercisers (2–3/week or more). Abbreviations: C, the control group; T, the treatment group; Breath, breathing exercise;Walk, walking; Mild, mild exercise.
after one year. At 12 months the percentage of exercisers
increased to 92% for both breathing and stretching, 54%
for mild exercise, and 100% for walking. At 12 months,
significant differences were found between the two groups
for all exercises.
Knowledge of HF and related health behaviors (Hypothesis 2) At baseline, the control group had higher knowledge scores
than the treatment group, but at six months, the treatment
group increased their knowledge level surpassing the control
group, and maintained the trend at 12 months. At both six and
12 months, the treatment group was significantly higher than
the control group (both p 0.05). Descriptive statistics, change
scores, and p-values for within-group change and between
group differences for Hypotheses 2 through 5 are presented
in Table 2.
HF-specific symptoms and general health indicators (Hypothesis 3) For dyspnea, the control group, which initially scored better
(23.5) than the treatment group (18.5) worsened gradually.
The treatment group showed improvement with signifi cance
at six and 12 months (both p = 0.001). For fatigue, the control
group showed significantly lower levels of fatigue at six
months, then showed a significant increase at 12 months
(p = 0.011). The treatment group recorded greater fatigue at
C-Breath
T-Breath
C-Stretch
T-Stretch
C-Walk
T-Walk
C-Mild
T-Mild
six months but felt less tired at 12 months as compared to the
baseline (p = 0.002). These changes were both signifi cant.
For emotional function, the control group showed
significant gradual decrease over one year (p = 0.001),
while the treatment group exhibited signifi cant gradual
improvement (p 0.001).
Elevated BP was observed in both groups during the
year. The control group’s systolic BP decreased signifi cantly
initially, but rebounded to significantly higher levels at
12 months relative to baseline readings (p = 0.003). While
initially much higher than the control group, the treatment
group’s systolic BP significantly decreased by six months
and remained lower at 12 months (p = 0.010). Regarding
diastolic BP, both groups decreased signifi cantly.
For the treatment group, the number of people who
were sick less than one week in the past six months was
significantly increased at six months and 12 months.
QOL (Hypothesis 4) Although both groups increased the QOL scores signifi cantly for
the first six months and maintained for another six months, the
treatment group had greater gains at both follow-ups, resulting
in significant between groups differences (p 0.05).
Health care utilization (Hypothesis 5) For the control group, health care use did not change. For
the treatment group, the number of visits to an emergency
Journal of Multidisciplinary Healthcare 2009:2 18
�
�
�
�
�
�
�
�
�
Effects of e-health in patients with heart failure
Table 2 Change over one year in heart failure-related symptoms, blood pressure, and weight
Outcome Baseline M and (SD) Changes score Change score p-values for estimated p-values for difference measure in six months in 12 months change for six and between the two groups
12 months at six and 12 months
Knowledge
Control 35.5 (14.0) 1.9 (4.4) 1.5 (5.7) 6: 0.021 6: 0.027
12: 0.022
Treatment 32.6 (12.5) 10.9 (11.0) 13.8 (8.8) 6: 0.001 12: 0.012
12: 0.001
CHFQ
Dyspnea
Control 20.9 (6.6) 1.2 (4.6) 1.4 (5.6) 6: 0.004 6: 0.721
12: 0.004
Treatment 20.3 (6.1) 3.7 (6.2) 4.4 (4.8) 6: 0.001 12: 0.942
12: 0.001
CHFQ
Fatigue
Control 16.2 (3.4) 0.05 (2.3) −0.32 (3.1) 6: 0.009 6: 0.482
12: 0.014
Treatment 15.6 (2.9) −0.13 (3.1) 0.77 (4.0) 6: 0.007 12: 0.446
12: 0.003
CHFQ
Emotion
Control 31.4 (5.3) −0.35 (4.0) −0.79 (4.9) 6: 0.001 6: 0.305
12: 0.001
Treatment 31.8 (4.4) 0.75 (4.6) 2.0 (4.5) 6: 0.001 12: 0.032
12: 0.001
Blood Pressure (mmHg)
Systolic
Control 123.9 (26.9) −0.85 10.6 6: 0.001 6: 0.512
(16.6) (24.0) 12: 0.001
Treatment 136.9 (22.8) −8.7 −10.3 6: 0.001 12: 0.391
(12.8) (15.5) 12: 0.002
Diastolic
Control 76.9 (16.0) −3.7 −6. 5 6: 0.001 6: 0.803
(10.22) (21.2) 12: 0.001
Treatment 83.2 (23.4) −7.6 −13.9 6: 0.001 12: 0.609
(19.53) (23.0) 12: 0.001
QOL
Control 196.0 (18.5) 1.05 6.8 6: 0.005 6: 0.019
(10.7) (22.1) 12: 0.003
Treatment 202.7 (23.6) 9.1 14.2 6: 0.001 12: 0.247
(15.2) (15.3) 12: 0.001
Notes: For weight, McNemar Test was used.The last column presents Z-score and p-value.
Journal of Multidisciplinary Healthcare 2009:2 19
Tomita et al
Table 3 Health care utilization
Baseline Six months 12 months Difference (for six months) (for six months) (for six months) p-value
Emergency Room Use (times)
Control 1.05 ± 1.72 0.58 ± 1.43 0.79 ± 1.32 (0.541)
Treatment 1.31 ± 1.80 0.23 ± 0.60 0.31± 0.63 (0.015)
Hospital Stay (days)
Control 10.74 ± 21.38 0.84 ± 1.89 2.42 ± 5.07 (0.232)
Treatment 6.85 ± 11.83 1.00 ± 2.45 1.23 ± 2.55 (0.040)
room and the length of hospital stay decreased signifi cantly
at six months; this was maintained at 12 months.
Participants’ evaluation of the e-health program At the end of the study period, 100% of the treatment group
reported that they were confident in dealing with HF due to
the e-health program and said that they would recommend
the program to other people who have similar conditions.
Furthermore, 84.6% said that they were very satisfi ed with
the system, 15.4% were satisfied, and 92.3% thought that
their HF was better than one year before. The most often
cited reason for satisfaction was “Monitoring myself for
increased awareness.” The second and third reasons were
“Better health” and “Support from health care providers.”
Two participants reported that the most disliked part of the
program was “Feel guilty when I have to record that I did
not exercise, so I had to do exercise.” Two suggestions were
“Expand the program to diabetes” and “Create a way to fi nd
out how other study participants are doing, so that I know
my relative status.”
Discussion This randomized controlled study tested a e-health method
of self-management of HF for one year in home-based older
adults. Four types of support were delivered via Internet by a
team of multidisciplinary health care professionals. Although
this e-health method may not be effective for all HF patients,
it was beneficial for HF patients with NYHA Class II or III
with respect to increasing knowledge of HF and related health
behaviors, exercise time, emotional function, and quality of
life, and reducing levels of dyspnea, fatigue, blood pressure,
and sick days. The result of exercise was parallel to the fi nding
of the meta analysis by Wantland and colleagues.7 It was also
effective in decreasing the number of emergency room visits
and length of hospital stays. Limitation of the study was that
it did not calculate cost effectiveness of the e-health method,
which is necessary for its practical application. Also many
between-group comparisons were not statistically signifi cant
mainly due to the small sample size. On the other hand, with
this small sample size, most of within-group comparisons
were significant, which is a strong indicator that the interven-
tion was effective. With a larger sample size, it is expected
that many between-group comparisons would be statistically
significant. Vigorous studies with geographical and ethnical
diversity are also needed in the future. Nevertheless, this
study provided evidence that the effective e-health method
in changing health behaviors and improving health outcomes
takes an interdisciplinary approach since changing one’s
health behaviors covers various health care disciplines.
Major e-health strategies that lead to successful health
behavior change identified in this study are that: (1) relevant
information should be provided using easy-to-understand
language in an easy-to-see format; (2) a simple recording
system for vital signs and health behaviors should be available
to allow patients to be aware of their behaviors; (3) patients
should be aware that their health activities are monitored by
a health professional; and (4) feedback should be provided
for continued health behavior change. The strategy was
supported by a conceptual framework, M-TOMITA, which
applied a concept of human social support to the Internet use
by strategically placing the types of support in the stages of
health behavioral change. In this model, a multi disciplinary
team is necessary at the initial stage but once the program is
in place, a nurse may be able to run the program with input
from the team for appraisal. In this study we convened a
regular distance team meeting every month for appraisal
support, but this frequency should be further investigated for
its validity. For a comprehensive self-management program,
it is strongly recommended to include a pharmacist to check
interactions of multiple medication intake and a nutritionist
for better diet.
In this study, emotional support was not independent of
appraisal and instrumental support, but was not provided in
Journal of Multidisciplinary Healthcare 2009:2 20
Effects of e-health in patients with heart failure
a specific manner, such as forming a discussion/chat group.
For patients who are not depressed or believe that they have
control over their illness, the level of emotional support
provided in this study may be sufficient. However, especially
for patients who are depressed, the Internet-based method
has been utilized and its effectiveness has been reported.24,25
Subjective evaluation of this program found that some par-
ticipants wished to know their health behaviors in relation
to other participants’. Providing an average of aggregated
data of all study participants can be easily done via the
Internet. TTM describes a process of behavioral change
called social liberalization as the person’s realization of
changes of social norms. E-health may be able to create a
social norm among study participants and allow them to see
how it is changing.
Finally, evidenced by a very high adherence to the
program, 85% of 355 days (Internet was not available for
10 days), an e-health approach utilizing a multidisciplinary
health care team can be accepted as a tool for self-management
of HF and other chronic diseases in the near future when
technology is more advanced, computer costs are reduced,
and older adults become more computer literate.
Disclosure This study was funded by the National Institute on Aging,
USA.
Reference 1. American Heart Association. Heart Failure. Heart and stroke Statistical
Update [updated 2007]. Cited on Oct 31, 2008. Available from: http:// www.americanheart.org/presenter.jhtml?identifi er=1486.
2. Centers for Education and Research on Therapeutics. Better Treatment for Heart Failure [updated 2003]. Cited on Oct 31, 2008. Available from: http://www.certs.hhs.gov/about_certs/annual_reports/year2/centers/ duke.html.
3. The Joint Commission; The Joint Commission’s Annual Report on Quality. Heart Failure. Improving American’s Hospitals [updated 2007]. Cited on Oct 31, 2008. Available from: http//www.jointcommissionreport. org/conditions/heartfi lure.aspx.
4. Glasgow RE, Emmons KM. How can we increase translation of research to practice? Types of evidence needed. Annu Rev Public Health. 2007;28:413–433.
5. eHealth Institute; eHealth Institute Mission. [updated 2004]. Cited on Oct 31, 2008. Available from: http://www.ehealthinstitute.org?Index. aspx.
6. Ruggerio C, Minassian P, Barr E, et al. Disease management and e-health can be successfully merged. Proceedings of the 2000 Healthcare Information and Management System Society. 2000;2:1–9.
7. Wantland DJ, Portillo CJ, Holzemer WL, et al. The effectiveness of web-based vs non-web-based interventions: A meta-analysis of behav- ioral change outcomes. J Med Internet Res. 2004;6:e40.
8. Fox S. Older Americans and the Internet. 2004. Cited on Oct 31, 2008. Available from: http://www.pewinternet.org/PPF/r/117/report_display.asp.
9. Becker SA. Web accessibility for older adults. 2003. Cited on Oct 31, 2008. Available from: http://cob.fi t.edu/facultysites/abecker/ Accessibility/OlderAdutlsStats/OlderAdultsSats.html.
10. Prochaska JO, Redding CA, Evers KE. The trenstehrotical model and stages of change. In: Glanz K, Rimer B, Lewis FM (editors). Health Behavior and Health Education. 3rd ed. San Francisco, CA: Jossey-Bass; 2002.
11. House JS, Kahn R. Measures and concepts of social support. In: Cohen S, Syme S (editors). Social Support and Health. Orlando, FL: Academic Press, 1985;83–108.
12. Rossi E. Uses and gratifications/dependency theory. 2002. Cited on Oct 31, 2008. Available from: http://zimmer.csufresno.edu/∼johnca/ spch100/7–4-uses.htm.
13. Castro CM, King AC. Telephone-assisted counselling for physical activity. Exerc Sport Sci Rev. 2002;30:64–68.
14. Heart Failure Society of America. The strategy of heart failure. [updated 2006 Sept 26] Cited on Oct 31, 2008. Available from: http://www. abouthf.org/questions_stages.htm.
15. Folstein M, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res.1988;12:189–198.
16. Stewart S, Marley JE. Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. J Lancet. 1999;25;354:1077–1083.
17. The National Institute on Aging and the National Library of Medicine. Making your site senior-friendly. 2002. Cited on Oct 31, 2008. Available from: http://www.nlm.nih.gov/pubs/checklist.pdf.
18. Radloff LS. The CES-D scale: A self report depression scale for research in the general population. Appl Psycholl Measure. 1977;1:385–401.
19. Guyatt GH, Nogradi S, Halcrow S, et al. Development and testing of a new measure of health status for clinical trials in heart failure. J Gen Intern Med. 1989;4:101–107.
20. O’Keeffe S, Lye M, Donnellan C, et al. Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients. Heart. 1998;80:377–382.
21. Rector TS, Cohn JN. Assessment of patient outcome with the Minnesota Living with Heart failure Questionnaire: Reliability and validity during a randomized, double-blind, placebo-controlled trial of pimobendan. Am Heart J. 1992;124:1017–1025.
22. Ware JE Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–233.
23. Bennett SJ, Oldridge NB, Eckert GJ, et al. Comparison of quality of life measures in heart failure. Nurs Res. 2003;52:207–216.
24. Gerhard A. Internet-based self-help for depression: randomised controlled trial. Br J Psychiatry. 2005;187:456–461.
25. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ. 2004;328:265.
Journal of Multidisciplinary Healthcare 2009:2 21
<< /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /CMYK /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo true /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments true /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 300 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 300 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile () /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /Description << /CHS <FEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000410064006f006200650020005000440046002065876863900275284e8e9ad88d2891cf76845370524d53705237300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002> /CHT <FEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef69069752865bc9ad854c18cea76845370524d5370523786557406300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002> /DAN <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> /DEU <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> /ESP <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> /FRA <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> /ITA <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> /JPN <FEFF9ad854c18cea306a30d730ea30d730ec30b951fa529b7528002000410064006f0062006500200050004400460020658766f8306e4f5c6210306b4f7f75283057307e305930023053306e8a2d5b9a30674f5c62103055308c305f0020005000440046002030d530a130a430eb306f3001004100630072006f0062006100740020304a30883073002000410064006f00620065002000520065006100640065007200200035002e003000204ee5964d3067958b304f30533068304c3067304d307e305930023053306e8a2d5b9a306b306f30d530a930f330c8306e57cb30818fbc307f304c5fc59808306730593002> /KOR <FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020ace0d488c9c80020c2dcd5d80020c778c1c4c5d00020ac00c7a50020c801d569d55c002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002e> /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken die zijn geoptimaliseerd voor prepress-afdrukken van hoge kwaliteit. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.) /NOR <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> /PTB <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> /SUO <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> /SVE <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> /ENU (Use these settings to create Adobe PDF documents best suited for high-quality prepress printing. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.) >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /ConvertToCMYK /DestinationProfileName () /DestinationProfileSelector /DocumentCMYK /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >> /FormElements false /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles false /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ] >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice