The effectiveness of computer-based learning in hospitalized adults with heart failure on knowledge, re-admission, self-care, quality of life, and patient satisfaction: a systematic review protocol

Review question/objective In hospitalized adults with heart failure, what is the effect of computer-based learning strategies versus usual care on knowledge, re-admission, self-care, quality of life, and patient satisfaction? Background Heart failure (HF) is a chronic debilitating disease with a poor prognosis.1 A widely accepted definition of HF is “a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of ventricles to fill with or eject blood which includes diastolic as well as systolic heart failure”.2 This disease may present as complaints of dyspnea, fatigue, orthopnea and peripheral edema. Clinical diagnosis can be confirmed with an echocardiogram, demonstrating decreased ejection fraction, structural changes or hemodynamic abnormalities.3 One of the main goals in treatment of HF is to improve quality of life (QOL) and self-care, while minimizing the healthcare expenditure related to this disease.4 HF is a progressive disease that affects approximately 4% of the population worldwide (about 26 million).5 In the United States (US) nearly 5.7 million people are affected with HF.6 In Europe, it is estimated that over 15 million people suffer from HF and in Australia, the incidence is close to 300,000 (1.5-2%).7 It is difficult to appreciate the global impact of HF due to the lack of a consistent means of accurate reporting, especially from countries in Asia and Africa.8 It is also difficult to obtain an accurate assessment of gender differences in HF due to under-representation of women in clinical trials.9 Due to the persistent and growing incidence of HF, changes have occurred in treatment. Redirecting the focus on post-hospitalization care, patient self-management, and QOL has resulted in decreased hospital re-admission.10 Patient education has become an integral component of HF management.10 Despite these efforts, HF often leads to frequent hospitalizations and impaired QOL.1 According to the Centers for Disease Control (CDC), in 2010 there were one million hospitalizations related to HF in the US.11 It is estimated that approximately 25% of these patients will be readmitted to hospital within 30 days of discharge.4 A major goal of Healthy People 2020, a US initiative to improve national healthcare, is to reduce hospital readmission rates due to HF.12 The mortality rate of HF increases with frequent hospitalizations.4 In the Fall of 2012, the Centers for Medicaid and Medicare Services (CMS) implemented a program that aims to reduce reimbursement of services based on readmission rates for HF. Currently CMS provides health insurance to almost 48 million Americans.13 This initiative prompted many hospitals to bring HF to center stage, focusing on the quality of care during hospitalization and meticulous discharge planning. The Joint Commission (TJC), a non-profit organization in the US that accredits health care organizations and programs, has identified the importance of discharge instructions/education for HF by including it as a benchmark core quality indicator for hospitals. Failure to meet benchmarks on quality indicators for HF may demonstrate poor quality of care or missed opportunities of coordination of care for patients.14 One of the main purposes of HF education is to assist the patient in learning and thus gaining the knowledge and skills required to adhere to the treatment plan.15 Patient education can facilitate learning and knowledge acquisition to influence the attitudes and behavior required to improve health.16 Therefore, patients are more likely to remain motivated and involved in self-care decisions.17 The patients’ HF knowledge can be measured with tools such as the Atlanta Heart Failure Knowledge Test (A-HFKT)18or the Dutch Heart Failure Knowledge Scale19 which are valid and reliable tools. Self-care is a decision making process of performing daily activities to maintain health, prevent illness, and manage chronic disease.15,20 HF self-care management is the ability of the individual to adhere to the prescribed regimen, identify the signs and symptoms, and take action when symptoms occur.15,17 Self-care behavior can be measured with tools such as the European Heart Failure Self-Care Behavior Scale (EHFScBS),21 or the Self-Care Heart Failure Index (SCHFI), Both are valid and reliable tools.22 QOL can be improved with patient education on self-care management.23 QOL is a multidimensional concept that includes self-reported measures of physical, emotional, social, and mental health.24,25 Compared to the general population, the QOL in HF patients is more compromised.26 The distressing symptoms of HF may lead to decreased physical activity, poor QOL and an increase rate of hospital readmissions.27 QOL can be measured with tools such as the European QOL-5 Dimensions (EQ-5D),28 the Minnesota Living with Heart Failure Questionnaire (MLHFQ),28,29 or the Nottingham Health Profile (NHP),30 all valid and reliable tools. Patient satisfaction has also been linked to better outcomes. Patient satisfaction is demonstrated by how patients value their care.31 It is a comparison between the patient's subjective standards and their healthcare experiences.32 Satisfied patients are more likely to adhere to the treatment plan.33 One of the main goals in the treatment of HF is to provide education that will enhance the patients’ knowledge and understanding of the disease process and treatments, thereby improving the patients’ ability to engage in self-care and adhere to the treatment plan.34 Adherence to a treatment regimen will improve one's clinical condition which may ultimately lead to greater patient satisfaction.35 Patient satisfaction can be measured by valid and reliable tools such as the Patient Satisfaction Questionnaire (PSQ),36 or the Newcastle Satisfaction with Nursing Scale (NSNS)37 which measures patient satisfaction with nursing care. Hospital readmission is defined as returning to the same hospital or another acute hospital following a prior admission for HF within one year.38 A readmission can be the result of incomplete treatment, providing poor care, poor discharge coordination, or incomplete discharge planning.39,40 Hospital readmission rates can be measured using tools such as the Center for Medicaid and Medicare's Risk Standardized Readmission Rates Model (RSRR).41 The RSRR model is endorsed by the National Health Quality Forum and gives a measure of hospital performance based on readmission rates.41 The American Heart Association (AHA) strongly emphasizes the use of written discharge instructions and educational materials that address diet, activity level, discharge medication use, weight monitoring, and follow-up appointments to be given at the time of discharge.42 Discharge instructions/education facilitates patients and caretakers in their learning process and knowledge acquisition necessary to care for themselves at home. Medical complications and rates of hospital readmission have the potential to be successfully reduced by carefully designed discharge educational interventions.43 Improved patient education at time of discharge may increase knowledge acquisition, decrease hospital readmission, and enhance self-care, QOL, and patient satisfaction. Studies have demonstrated that the addition of illustrations to written discharge instructions can improve patient comprehension and retention of instructions.44, 45 The use of follow-up phone calls 48 hours after discharge in which hospitals call patients to assess their health status and treatment plan is another strategy that has been employed.46 Care transition intervention strategies have been developed utilizing a transition coach to work closely with the patient ensuring that the treatment plan post discharge is effective.47,48,49,50 A relatively new intervention is the use of the computer as a medium to deliver educational materials. Computer-based education, also known as computer-based/assisted-learning, is the application of supportive educational media including simulation, cognitive tools for learning and video-conferencing to aid in knowledge acquisition through teaching, learning and assessment among other modalities.51,52 Computer-based learning considers, facilitates, and integrates the unique needs of the patient population.53,54 Comprehension and retention of knowledge can potentially prevent recurrence of illness and reduce hospital readmission which are dependent on the adaptability of the intervention to the learner's needs.55 HF most often affects older adults who may require specific adaptive educational considerations such as modifications to computer learning including visual and auditory requirements unique to each learner.56 The adaptability of computer-based learning also has the potential to enhance the specific linguistic and cultural preferences for the HF population in order to succeed in building the patient's comprehension.56 A literature review was conducted that focused on computer-based approaches to education for patients with chronic diseases such as diabetes, cancer, cardiovascular disease, and asthma across all age groups. This literature review supports the use of a computer-based approach as an effective strategy for patient education pertaining to knowledge transfer and skill acquisition by patients.51 Furthermore, a randomized controlled trial (RCT) on computer-based learning for patients with chronic HF conducted in heart failure clinics, demonstrated significant outcomes resulting in increased knowledge related to HF.57 It is the intention of this systematic review to determine if computer-based learning will improve knowledge, reduce HF readmission and enhance self-care, QOL, as well as patient satisfaction in adults hospitalized with HF.