Motivational Interviewing as a Strategy to Impact Outcomes in Heart Failure Patients: A Systematic Review
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Heart failure (HF) hospitalization is an expensive healthcare utilization event. Motivational interviewing (MI) has been studied for effects on HF self-management behaviors.
The objective of this systematic review was to conduct an exploration and report of evidence and gaps in the literature regarding the impact of MI on HF outcomes.
A modified Cochrane systematic review was conducted via a literature search in the MEDLINE, CINAHL, Cochrane Collaborative Systematic Reviews, PsycINFO, Health Source: Nursing/Academic Edition, and Google Scholar databases.
Study Eligibility Criteria, Participants, and Interventions
Randomized controlled trials (RCTs) or controlled experimental studies published in English from January 1990 to February 2019 that included adults (18 years and older) diagnosed with HF New York Heart Association (NYHA) class I, II, II, or IV were eligible for inclusion. Interventions evaluated were an MI-based face-to-face communication or telephone-based conversation provided by any healthcare provider type.
Study Appraisal and Synthesis Methods
The Cochrane method for assessing risk of bias was used to analyze the methodological quality of retained studies.
Of 167 initial articles, nine were retained, describing eight unique studies (758 total patients, range 30–241; age range 58–79 years; attrition range 13–36%). The impact of MI was examined for general self-care behaviors (SCBs) (physical activity specifically), quality of life (QoL), and/or hospital readmission prevention. Eight of nine articles reported a positive impact of MI over advice-giving, seven being statistically significant. MI interventions used an initial face-to-face encounter with three to five follow-up telephone encounters.
This systematic review had the following limitations: most retained studies included intervention activities conducted in hospital/clinic settings, which limits generalizability of the intervention in other care settings; intervention fidelity, blinding, selection, interventionist training, and random assignment were not clear in all studies; retained studies did not include potential covariates such as health literacy, patient age, and perception of disease/health risks; and some retained studies relied on patient self-report of outcomes, which may introduce recall or social desirability bias.
Conclusions and Implications of Key Findings
MI demonstrated a positive effect on the SCB hospital readmission prevention factor and on QoL. MI delivered with greater frequency and over a longer duration may improve the immediate risk of hospital readmission as well as long-term outcomes through better medication adherence and SCBs. However, heterogeneity in the methods, design, intervention type, and structure challenged comparisons across studies and further research is warranted.
The authors would like to thank Ms. Adelia Grabowsky, Librarian, Auburn University for her support in the literature search process. And special thanks to Dr. Lindsey Hohmann for her feedback and editing of the manuscript.
Dr Jan Kavookjian, Associate Professor of Health Outcomes Research and Policy in the Harrison School of Pharmacy at Auburn University, is senior author and corresponding author. Dr Kavookjian directed the work, taught the modified Cochrane systematic review process to Nabin Poudel, was the second researcher for the separately conducted full-text review tier and discussion to consensus for retain/reject decisions, wrote a majority of the Methods section, wrote significant portions of the Discussion section, gave writing edits to the entire manuscript, and prepared and conducted the manuscript submission. Nabin Poudel, BPharm and PhD student in Health Outcomes Research and Policy, is first author, having completed the directed formulation of the research question, completed the directed search and review, completed the directed data extraction and results tables preparation, composed the literature review and narrative for the Introduction section, composed portions of the methods section, composed the initial results and discussion sections. Michael J. Scalese, PharmD, BCCP, BCPS, CACP, Cardiology Clinical Pharmacist and former faculty member in the Harrison School of Pharmacy at Auburn University, served as the clinical expert in each step of the project. He directed the clinical aspects of the research question development, wrote portions of the Introduction section, helped interpret and wrote portions of the Results and Discussion sections, and provided edits to the full manuscript.
Compliance with Ethical Standards
No funding contracts or grants, nor honoraria, were received for the completion of this work.
Conflict of interest
Dr Kavookjian discloses that she is on the Merck Speakers Bureau for non-product medical education for the topics of motivational interviewing, shared decision-making, and health literacy communication; she also reports that she serves as a consultant for Merck for motivational interviewing content in the person-centered communication line of education materials; she also consults for MediMergent, LLC for its US Food and Drug Administration (FDA)-funded project in training pharmacists in motivational interviewing for medication adherence in diabetes. Nabin Poudel and Dr Michael Scalese declare that they have no conflicts of interest or financial disclosures.
Data Availability Statement
All data generated or analyzed during this systematic review study are included in this published article and Electronic Supplementary Material 1 Search Strategy Results.
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