Optimizing online–offline education

This invited commentary refers to ‘The impact of online-offline integrated out-of-hospital education on patients with heart failure: a systematic review and meta-analysis’ by Z. Zhu et al., https://doi.org/10.1093/eurjcn/zvag126. Increased rates of ageing, heart failure (HF) prevalence, and multimorbidity lead to socioeconomic burden, rising healthcare expenditures, and resource demands. The objectives of prescribing guideline-directed medical therapy (GDMT) in HF care are to improve cardiac workload and enhance contractility, leading to better management of HF, fewer acute events, and improved health-related quality of life (HR-QoL).1,2 GDMT in HF seems to remain poor, and even when medical therapy is appropriately applied, underdosing is common, especially in women, older people, and people with lower health literacy, highlighting existing sociocultural inequality issues.3 The management of HF has changed markedly following the COVID-19 pandemic and the introduction of new clinical guidelines.4,5 The 2021 European Society of Cardiology (ESC) guidelines recommend telemonitoring at class IIb. This shift reflects the growing use of digital health solutions in routine clinical practice. Adoption depends on patient and caregiver acceptability and levels of digital literacy. Digital health solutions involve several ways, including telephone calls, SMS text messages, mobile apps, websites, videoconferencing, and wearables (e.g. activity trackers). The potential advantages of digital health solutions provide convenience in terms of minimizing distance, time, and cost, and enabling personalized and person-centred interventions. Such personalized care empowers people to manage their health, increases health care efficiency, and reduces health care costs.2,6 Digital health interventions to improve management in HF, including online–offline integrated post-discharge patient education, have grown over the last two decades. Zhu et al.,7 aiming to provide a more comprehensive approach to clinicians and decision makers, established a systematic review and meta-analysis to evaluate the effects of integrated online–offline education on patients with HF in the health management of patients with HF by quantifying the outcomes of the studies included. It is the first systematic review with that primary focus. The results and analysis showed significant improvements in all-cause mortality, left ventricular ejection fraction, QoL, and self-care ability. But, even though findings sufficiently support that they improve survival and reduce mortality, they may require additional components beyond patient education and monitoring, such as structured multidisciplinary coordination, social support interventions, and healthcare system integration. The value of online–offline integrated education extends beyond its technological aspects. Its significance lies in the establishment of a continuous care loop, wherein patients are systematically monitored, supported, and empowered outside of the hospital environment.8,9 Continuous monitoring facilitates earlier identification of clinical deterioration, while individualized education and nurse-led support may enhance patients’ confidence, symptom recognition, adherence to treatment, and capacity to respond effectively to changes in their health status.2,9 Accordingly, digital tools should be conceptualized as facilitators of ongoing self-management and prompt clinical intervention, rather than as replacements for direct contact with healthcare professionals.4,8 Furthermore, the heterogeneity of existing studies and interventions, as well as additional disparities, should be carefully considered in future research. Physical performance outcomes were not found to be statistically improved, most probably due to missing structured exercise rehabilitation components. Likewise, NT-ProBNP results were found to be null, indicating that the intervention intensity or follow-up duration was insufficient to induce measurable changes in neurohormonal status or that the included patient populations had relatively stable disease at baseline.7 Another reason is the population of patients with HF. The ageing population has an increased risk of multimorbidity and frailty, complicating clinical outcomes and treatment. Frailty is also common among the population of patients with HF. These characteristics make routine assessment and personalized care strategies, including medication adjustments and holistic symptom management, necessary components when developing digital interventional programmes.10,11 Multimorbidity challenges the implementation of clinical guidelines, requiring healthcare systems to move beyond single-disease models towards integrative care approaches.10 Digital health solutions as a delivery method may provide effective physical activity interventions in patients with HF and can make these types of interventions available for more people at a lower cost. Practical barriers, such as limited consultation time, insufficient training, communication difficulties, and fragmented services, hinder patient-centred care. Nurse liaisons play a key role in improving continuity of care. Health inequalities significantly affect HF care across Europe, with variable access to specialized HF health professionals, multidisciplinary teams, and advanced treatments.6,12 Contributing factors include socioeconomic status, the geographical distribution of services, sex differences that span throughout the overall spectrum of HF, language and cultural barriers, and differing healthcare policies. For example, socioeconomic disadvantage increases the risk of multimorbidity and frailty, which in turn affects HF outcomes. They also affect health literacy and access to care and digital health solutions. Multiple strategies of action are strongly warranted to improve the future approach in the treatment of women with HF and address all disparities, to develop cultural sensitivity, build advocacy skills, promote health literacy, and use remote monitoring technologies.3,12 Digital health may improve access for some but widen inequalities for others. These include patients with low digital literacy, cognitive impairment, frailty, language barriers, poor internet access, or weak social support.12,13 Therefore, online–offline models should not assume all patients can use digital tools. The offline part is not secondary; rather, it can be essential for equity, especially when digital solutions target diverse patients and settings2 and remote monitoring. HF nurses are a crucial component of interprofessional, multidisciplinary, and patient-centred care. They provide structured programmes on self-care education and optimization of GDMT. They have a pivotal role in the development of tailored self-care strategies and empowerment of patients and their caregivers, mental well-being, remote monitoring, including online–offline integrated interventions, transitional care from hospital to home, and supportive and palliative care. They are often involved in the design, implementation, and evaluation of HF programmes and services, and they are well-positioned within the health care system to drive change and improve clinical outcomes. Competencies associated with these key and leadership roles are well described in the updated Curriculum for Heart Failure Nurses developed by the Heart Failure Association and the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology.14 Online–offline integrated digital solutions are promising for improving GDMT, clinical outcomes, and HR-QoL. HF nurses address human challenges using interdisciplinary, person-centred approaches. These strategies promote health, improve care quality, and optimize HF outcomes. Nurse engagement may be vital to developing integrated, person-centred pragmatic studies. Zhu et al.7 move the debate from just digital vs. face-to-face education. They focus on how to meaningfully integrate both. Their findings suggest that online tools alone are unlikely to suffice. Benefits arise when digital contact connects to structured clinical review, timely responses, self-care support, and personalized offline assistance. Ekaterini Lambrinou (Conceptualization, Project administration, Writing—original draft, Writing—review & editing [lead]) and Martha Kyriakou (Writing—review & editing [supporting]) No funding is declared.