A Nurse-Led Model of Care with 2 Telemonitoring to Manage Patients with Heart Failure in Primary Health Care: A Mixed-Method Feasibility Study [Response to Letter]

Dear editor

We thank the authors of the letter to the editor regarding our manuscript entitled “A Nurse-Led Model of Care with Telemonitoring to Manage Patients with Heart Failure in Primary Health Care: A Mixed-Method Feasibility Study.”¹

We appreciate the insightful comments addressing potential biases and weaknesses inherent in our study and proposing implications for future research endeavors.

We would like to engage in further discussion on specific points.

Firstly, challenges in recruitment and the limited sample size were process outcomes of our study, aligning with our intention to conduct a feasibility study rather than a randomized controlled trial assessing the model’s efficacy. The Medical Research Council² outlines distinct phases for investigating complex interventions: development or identification, feasibility, evaluation, and implementation. Our focus on the feasibility phase aimed to evaluate predefined progression criteria, gauging the necessity for modifications to mitigate potential issues, such as uncertainties related to recruitment, acceptability, and adherence, in the subsequent randomized controlled trial.

In evaluating the feasibility of our care model, we adhered to the framework proposed by Bowen and colleagues,³ encompassing eight dimensions: acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited-efficacy testing. For this study, we assessed acceptability, demand, practicality, integration, and limited efficacy testing.

We established a priori feasibility cutoffs to ascertain our care model’s effectiveness in recruitment and adherence rates. Consequently, the observed challenges in recruiting patients and caregivers, along with the small sample size, were considered outcomes necessitating improvements to the model for evaluation in the subsequent randomized controlled trial. It is acknowledged that the limited sample size might have constrained the assessment of the model’s feasibility; however, it is necessary to note that our primary aim was not to evaluate the model’s efficacy on an estimated sample size or its effectiveness in preventing heart failure complications.

Suggestions for enhancing the model include adopting diverse screening strategies to enhance patient detection. Recruitment through general practitioners and outpatient cardiology clinics could identify stable patients, allowing time to educate them on self-care and potentially preventing decompensation events and re-hospitalizations. Alternatively, recruiting patients post-hospitalization for heart failure discharge could facilitate educating patients on self-care since the hospitalization makes self-care relevant to them, potentially reducing re-hospitalization rates in high-risk patients.

Concerning the autonomous completion of the Self-Care of Heart Failure Index, we acknowledge the potential influence of the Hawthorne effect on responses. Nonetheless, it is essential to note that this instrument is widely utilized, even in more extensive randomized controlled trials, to measure self-care abilities.

Lastly, we are cognizant of the study’s limitation regarding the absence of a control group. This will be addressed in our forthcoming experimental study, ensuring the inclusion of a control group to comprehensively evaluate the model’s efficacy on self-care and clinical outcomes, including long-term complications.